Avoiding the Point:

Avoiding the Point:
Sharps Safety best Practices for HCWs

By Jennifer Schraag

Sharps safety goes beyond the infection control (IC) team, encircling every aspect of todays healthcare systems. Reducing the risks presented by occupational exposure begins with awareness, proper compliance, education, and special care in handling and disposal of sharps.

Sharps include needles, syringes, razor blades, slides, scalpels, pipettes, broken plastic or glassware, and other devices capable of cutting or piercing the skin.1

Needlestick injuries in the United States are decreasing, from an estimated 1 million exposures in 1996 to 385,000 in 2000.2 Studies show nurses sustain the majority of these sharps-related injuries, and as Raylene Ballard, MS, MT(ASCP), senior project officer with ECRI (formerly the Emergency Care Research Institute), points out, it is unlikely that nurses will ever not be the majority since they bear the brunt of patient care.

Sharps injuries can occur in all aspects of clinical and operating room (OR) duties as well as when emptying trash containers, replacing overfilled sharps disposal containers, picking up glass or sharps from the floor, or processing laundry or linens in which sharps have been placed by other healthcare personnel. In addition, many injuries have occurred from one worker accidentally injuring another with an exposed sharp.

From such injuries, annual rates of infection weigh in at more than three dozen U.S. healthcare workers (HCWs) contracting human immunodeficiency virus (HIV); 2,000 becoming infected with hepatitis C virus (HCV); and 400 contracting hepatitis B virus (HBV). More than 20 additional types of infectious agents have been transmitted through needlesticks, including tuberculosis, syphilis, malaria, herpes, diphtheria, gonorrhea, typhus, and Rocky Mountain spotted fever.3

Data from the International Healthcare Worker Safety Centers EPINet Multihospital Surveillance Network indicate that syringes cause the greatest number of sharps injuries. Moreover, the Center for Disease Control and Prevention (CDC)s National Surveillance System for Health Care Workers (NaSH) identified the six devices responsible for the majority (80 percent) of needlestick and other sharps related injuries: hypodermic needles (32 percent), suture needles (19 percent), winged steel needles (butterfly) (12 percent), scalpel blades (7 percent), IV (intravenous) catheter stylets (6 percent), and phlebotomy needles (3 percent). 2 Hollow bore needles are most risky because the needle can be filled with blood.

The idealist view is no needle, no risk. Unfortunately, this is not a reality in all healthcare settings. Nevertheless, minimizing the risks presented by sharps is achievable, and the initial step is by first eliminating the many myths that abound.

First of all, many HCWs still act or appear to believe that they wont get hurt or suffer an injury, says Ballard. The immortal facade some younger workers may mistakenly take on appears to increase this idea. Supporting this theory is a Duke University study which found higher rates of risk of exposure among HCWs under age 45 and in those employed one to four years.4

Another common misconception is the overabundance of misplaced trust in safety products. A safety product doesnt necessarily mean that needlesticks cant occur, warns Kelli Rosenthal, MS, RN, BC, CRNI, ANP, APRN, president and CEO of ResourceNurse Continuing Education, Inc. Vigilance is still required for their use.

Brad Poulos, executive director of the National Alliance for the Primary Prevention of Sharps Injuries (NAPPSI) agrees, The myth that, OK, Im going to implement this safety product and it is going to literally eliminate sharps injuries in that field, is unrealistic. Any sharp thats still there even if it is a safety sharp is not a guarantee against sharps safety.

NAPPSIs basic mantra is to exhaust all applicable primary prevention technologies, says Poulos. Primary prevention is the key; no needle, no risk is the way to go.

Ballard explains why this is a good plan. It is surprising to me how frequently in injury reports, device failure reports, and in conversations with HCWs, that safety devices were not used properly the safety feature was never deployed. If the devices were always used as intended, this would surely decrease the number of injuries. Having said that, I do think it unrealistic to expect elimination of every injury, but careful study of the injuries can help to create better, safer work processes and devices.

Searching out technologies and then evaluating their practicality within your facility is a positive step in the right direction, says Poulos. The prevalence of todays use of safety items to reduce exposure and percutaneous injuries are fortunately ever-increasing. Ballard says safety syringes, safety phlebotomy devices, and needleless IV systems are the most widely implemented safety devices.

I believe from statistics at this facility, needleless IV systems with safety IV catheters have been the most effective in reducing occupational incidents, offers Sherry M. McGoldrick, LPN, infection control coordinator at Baxter Regional Medical Center in Mountain Home, Ark.

Rosenthal agrees, adding, The needlesticks I see are related to either failing to activate an engineering control, or during the actual procedure itself, before the clinician can activate the safety mechanism. I have a good friend who is a paramedic in New York City. He was placing a peripheral IV in an obtunded patient in shock, who then became agitated during the stick. When she moved, the stylet with cannula intact came out of her vein and into the palm on his non-dominant hand. Only a passively activating device (i.e., one that is blunted when it comes out of the vein even with the cannula still on it) would have been able to prevent this kind of occurrence.

This is where the discussion of active versus passive safety devices comes in, Poulos declares. Active vs. passive means the use of a safety device you have to activate yourself (i.e., push a button, force a tube or a lever over) vs. a passive safety device where it automatically does it; you remove a syringe from a patient and it already gets covered. There are various safety products out there that are more passive than others. With the active ones, obviously, you have to rely on two steps: the clinician to activate the mechanism; and the mechanism to actually work.

Keeping up with the ever-changing world of safety products can become a full-time job in itself. Ballard recommends beginning with a search on the Internet to bring a variety of products or names to light. In addition to individual company Web sites, there are several organizations that have product info such as the International Health Care Worker Safety Center, ECRI, and NAPPSI. NAPPSI offers an extensive list of sharp safety devices (www.nappsi.org/safety.shtml). In addition, Training for Development of Innovative Control Technologies (TDICT) offers a full line of safety evaluation forms (www.tdict.org/criteria.html) to aid in selection.

McGoldrick recommends working closely with, and getting information from, your materials management department, clinical educators, and all nurses who have worked at various other facilities.

Discussion with other HCWs while attending meetings, etc., is likely to turn up new products or methods to improve safety, according to Ballard, and make sure that clinicians who actually use the products have as much say over what devices are chosen as the materials managers, adds Rosenthal.

Jan D. Harris, MPH, director of environment and occupational health and safety with Sharps Compliance, Inc., takes it a step further and advises HCWs to interview suppliers, attend seminars, and read up on journal articles concerning safety products.

When evaluating a sharps safety device for use; ease of use, passive activation of safety features, and features that enhance patient satisfaction (i.e., sharpness of IV catheter stylets) all are important considerations, according to Rosenthal.

As far as ease of operation, McGoldrick says to ask yourself, Does the operation interfere with patient care and/or place the patient or employee in a position where an incident could occur?

Other questions to ask, according to Ballard, are How well does it work under usual conditions? Does it require a change in technique? How well does it work under adverse conditions such as lighting changes, wet gloves, aggressive patient, and multiple bystanders? If the device fails to work, how difficult is it to dispose of safely?

I think that hospital administration should realize that safety is a partnership and needs to work with employees to create the safest work environment possible. Hospitals should provide the tools, such as safety devices, personal protective equipment (PPE), and disposal containers; while employees need to follow established policies and procedures.

Keep in mind that the workforce is aging and devices that younger workers find simple to use may not be as easy for older workers or individuals with physical problems, she points out. It is very important that trials for new devices include a representative cross section of employees who will ultimately use the devices.

No matter what you do in evaluating safety instruments, widespread acceptance among HCWs will prove most important. The trick is getting the employee to use the device, Harris asserts. If you do not look at the human factor, behaviors, and consider the values of the employee, they will find a way to avoid safety. Much of this can be accomplished through ongoing training and evaluation. Peer assessment of compliance is also helpful in opening employees eyes to actual employee compliance on a day-to-day basis.

Outdated use of some materials is another aspect to consider. Some facilities are still using glass containers and tubes, for example. The Occupational Safety and Health Administration (OSHA) advises against such use because these products lead to increased risk of exposure, says McGoldrick, whose hospital received a perfect score during a recent unannounced OSHA inspection.

At this time, there is really little reason to still be using glass tubes, Ballard says. There have been published studies indicating that the change to plastic from glass should have little impact on test results. The current saturation of safety devices should guard against such discrepancies.

Taking a look beyond the clinical areas, the OR also is emerging as a site with an increasing proportion of total injuries mostly involving suture needles and scalpels.2 The OR is a high-risk area for contaminated sharps injuries and blood and body fluid exposures,5 increasing the risk of bloodborne pathogen transmission.

Gina Pugliese, RN, MS, vice president of Premier Inc.s Safety Institute, says recent studies are beginning to shed more light on root causes of sharps injuries in the OR which include human factors. One recent study found an association among percutaneous injuries in the OR and the following human factors: anger through conflict with another employee or patient; distractions often from work in a noisy OR or from co-workers performing procedures; rushing a possible link to staffing levels; and fatigue.6

Organizational factors such as nurse staffing ratios and the hospital safety climate have also been shown to relate to the risk of percutaneous injury, Pugliese points out.

One Italian study found incorrect HCW behavior the cause of 74 percent of 439 needlestick-related percutaneous injuries; 26.2 percent of 221 suture needle injuries; and 14 percent of 114 scalpel injuries.7

Hand passing of sharps instruments is a known hazard in the OR, according to Pugliese, and eliminating the hand-passing of instruments (e.g., use of transfer basin) during surgical procedures has been found to reduce risk. One study evaluated the impact of a hands-free technique for passing instruments in the OR. In surgeries with a high blood loss (greater than 100 cc) the sharps injury rate was 0.04 percent when the hands-free technique was used compared to 0.11 percent when it was not a reduction of 64 percent.8

Premier Inc. offers an extensive listing of OR safety recommendations including double gloving. Double gloving can further protect HCWs in the OR by providing longer lasting and stronger protection for high blood loss surgeries, and will work to remove more blood from a sharp as it penetrates both layers of gloving before reaching the skin site.

Other pointers include wearing the proper gowns in relation to level of blood loss and nature of the surgery, neutral and safe zone pointers, and sharp and suture usage alternatives.

The Association for Professionals in Infection Control and Epidemiology (APIC) also offers preventive measures which include careful handling when cleaning used instruments, when recapping by hand, avoidance of purposely bending or breaking by hand, manipulating the sharps by hand, and never removing syringes once they have been disposed.

Whether in the clinical area or the OR, special attention to proper disposal etiquette is imperative. Data from 40 hospitals that participated in NaSH indicate that 16 percent of injuries occur during disposal.9 Furthermore, other hospital studies show as many as one-third of all sharps injuries have been reported to be related to the disposal process.10

One deterrent is to assure safety devices are activated prior to or immediately upon withdrawal from the patient, Harris says. The other concerns all aspects of the sharps disposal container itself and the safety measures to be regarded surrounding these containers.

A report from the National Institute for Occupational Safety and Health (NIOSH) states that focus-group studies suggest there are four major criteria for sharps disposal container safety performance: functionality, accessibility, visibility, and accommodation.

According to Pugliese, OSHA requires sharps disposal units to be closable, puncture-resistant, and leak-proof on sides and bottom; to be accessible, maintained upright, and not allowed to overfill; and be colored red or labeled with the biohazard symbol.

Though not specifically required by law, Pugliese advises managers should also consider the following additional guidelines:

  • Choose containers that are easy to operate, that allow needles to fall into the container unobstructed and that are appropriate in total size and size of opening for the devices being discarded
  • Replace all needle disposal boxes when they are three-fourths full
  • Place needle disposal boxes as close to the patients bed or treatment area as reasonably possible
  • Place boxes at eye level (no higher than 57 inches) so the employee can see the disposal slot before moving his or her hand toward it and
  • Address special placement issues in locations where children may have access.

Newer sharps collector designs are emerging all the time, says Pugliese. Design improvements in wall-mounted sharps containers, for example, have lessened injury rates. Be aware of improvements in safe disposal practices and periodically review and update sharps disposal products, placements, and practices, she advises.

Equally important is the design of the unit to facilitate one-handed placement of the sharp and a clear indication that the box is near full and in need of replacement.

Harris says choosing the correct size sharps collector is crucial to preventing disposal injuries. Test currently used sharps collectors to determine if they are the appropriate size and type needed for disposal of the new devices. NIOSH offers a comprehensive framework for selecting sharps collectors and evaluating their efficacy as part of an overall needlestick injury prevention plan. NIOSH also recommends designation of an individual or group to regularly monitor and maintain sharps collectors, she says.

The Veterans Administration at San Diego Health System (VASDHS) did a little bit of an ergonomics study as far as the height of various placements of the sharps containers because they didnt want short nurses having to reach high into an area that they couldnt see into, Poulos shares.

In addition to height, Ballard advises sharps containers be as near the bedside or wherever a sharp is being used as possible. This is especially important if a patient becomes aggressive or their condition suddenly deteriorates. In the fast pace of healthcare today, personnel should not have to walk far or be searching for the place to dispose of a sharp, she says.

Finally, Hold every person who uses sharps accountable for disposal of any sharps they use, Rosenthal adds. Everyone should be held accountable, because everyone is at risk. As Poulos says, its not just clinicians who get stuck; laundry personnel, dietary personnel, and possibly hospital visitors all are at risk.

According to research from the CDC and NIOSH, sharps injuries related to the disposal process are particularly high when used needles are not disposed of in puncture-resistant sharps disposal containers. Despite a diverse array of available sharps disposal containers, sharps and instruments continue to be rolled in drapes and/or linen and deposited in waste or laundry bags, threatening injury to handlers, haulers, and processors, Pugliese offers. Used syringes and needles such as insulin syringes are also disposed of by patients, such as diabetics, in public waste containers.

As Pugliese clearly points out, safety and education go beyond the clinician realm in any healthcare setting, so facility-wide awareness training is highly advised.

For example, VASDHS were looking at what you would call downstream sharps injuries, Poulos recalls. In other words, the housekeeping staff and the kitchen staff. If somebody leaves a sharp in a bed sheet or maybe they actually put the sheet into the basket and then they wheel it down to the laundry facility somebody could get stuck. Same thing with the food trays; somebody could put the needle underneath a napkin. They (VASDHS) have provided training to their housekeeping and dietary staff and if they find a sharp, they are trained to report it and then try to backtrack it. They backtrack to reeducate. Im sure many hospitals kitchen staff is not trained and if theres a needle there, they just toss it in the trash and thats that they are at risk themselves.

How much at risk are housekeeping and laundry personnel? Pugliese asks HCWs to consider the following statistics: Data from the hospitals participating in NaSH show that the overall rate of percutaneous sharps injuries is 27 per 100 occupied beds annually. About 5 percent of the injuries are incurred by housekeepers (nurses had the most frequent exposures at 49 percent).

A recent study of 1,344 sharps injuries in more than 199 different healthcare institutions, conducted by the California Department of Health Services Sharps Injury Control Program, showed housekeeping and laundry staff to be the fourth most vulnerable worker group, behind nurses, physicians, and phlebotomists. Housekeeping and laundry staff in the study suffered nearly 10 percent of all sharps injuries.

Thorough education and training of all staff on sharps safety is more important than ever, but it is difficult to say if HCWs are being adequately trained in the use of sharps safety devices in todays settings, according to Ballard.

I think training takes place, but the effectiveness of that training session is difficult to judge, she clarifies. I also imagine that many people learn how to use a device from a coworker sharing their device knowledge. Whether the knowledge that is shared is accurate and the best way to use a device is another area that is difficult to measure, she points out.

Unfortunately, training becomes more about documenting its completion than about if it is really working, adds Harris. I think facilities try, but often due to time, fail to evaluate training completely.

Part of the problem is that the majority of available devices require a change in technique on the part of the end user, Rosenthal says. Product conversions are often sabotaged by staff members that hoard their old product, and when they run out, they dont remember the finer points of the safety devices, she says.

A facilitys sharps safety education program should include how to use the device properly, how to dispose of it properly, what to do if it doesnt work correctly, and the reporting process for device failure and dissatisfaction.

It can also be the time to share information on how well the safety program is working share injury rate improvement, or lack of, and talk about the types of injuries HCWs are sustaining, Ballard says. Conversely, discuss who should hear, and how to share information about new devices and satisfaction with current products. This is also the time to discuss injury reporting systems, why it is important all injuries are reported and gather feedback on this most important procedure.

Repeat training and follow-up sessions on how to utilize a device and the need to activate any safety features present, is also important, she said. These sessions should also discuss the types of injuries individuals have sustained and how they might have been prevented.

McGoldrick also recommends staff be educated on distinguishing what items must be placed in sharps containers, biohazard bags, and how and where to dispose of these items properly as well as what PPE is required to use during this process. Make sure each patient care employee is informed of the category of risk in which their position places them.


References:

1. National Institutes of Health. Safety Note Number 8: Proper Handling and Disposal of Sharps. Oct. 27, 1993. www.niehs.nih.gov/odhsb/notes/note8.htm.

2. Wilburn, S. Needlestick and Sharps Injury Prevention Online Journal of Issues in Nursing. 9(3):4, September 2004. www.nursingworld.org/ojin/topic25/tpc25_4.htm.

3. BBraun. Facts About Needlestick and Sharps Safety: The Case for Needlestick Injury Prevention.
www.bbraunusa.com/index.cfm?uuid=
A72343ACD0B759A1E3E099509D809577 , and International Sharps Injury Prevention Society (ISIPS).

4. Dement, JM. Blood and body fluid exposure risks among healthcare workers: results from the Duke Health and Safety Surveillance System. Am J Ind Med. 46(6):637-48, Dec. 2004.

5. Premier Inc. Safer work practices to prevent sharps injuries; recommended safer work practices for the peri-operative setting. www.premierinc.com/all/safety/resources/
needlestick/downloads/16_workpractices.doc 

6. Fisman, DN, et. al. Sharps-related injuries in healthcare workers: a case-crossover study. Am J Med. 114(8):688-94, 2004.

7. Castella, A. Preventability of percutaneous injuries in healthcare workers: a year-long survey in Italy. J Hosp Infect. 55(4):290-4, Dec. 2003.

8. Stringer, B, et. al. Best practices in workplace surveillance: The effectiveness of the hands-free technique in reducing operating room injuries. www.cdc.gov/niosh/sbw/osh_prof/stringer.html.

9. Chiarello, LA and Bartley, J. Prevention of blood exposures in healthcare personnel. Seminars in Infection Control 1(1):30-43, 2001.

10. APIC Prevent Needle Sticks.
www.apic.org/AM/Template.cfm?Section=Search&section=
Brochures&template=/CM/ContentDisplay.cfm&ContentFileID=258

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