Study Shows Needlestick Injuries...On the Gradual Decline
By Kelly M. Pyrek
The Centers for Disease Control and Prevention (CDC) estimated that the nation's approximately 10 million healthcare workers (HCWs) face as many as 384,000 percutaneous injuries (PIs) annually. A Government Accounting Office (GAO) report estimated several years ago that at least 69,000 needlesticks in hospitals could be eliminated through use of sharps safety devices.
"Gradual but steady" is the way experts are characterizing the adoption by healthcare facilities of these safety-engineered sharp medical devices in an ongoing effort to reduce the occurrence of PIs. Making use of sharps safety devices mandatory were the Needlestick Safety and Prevention Act of 2000 and the Occupational Safety and Health Administration's revised Bloodborne Pathogen Standard. Clinical trials comparing safety devices to conventional devices have demonstrated various benefits of the new technology and have shown downward trends in the number of needlesticks reported nationally.
June 2003Experts say this is encouraging, but there has been a lack of documentation showing the impact of the needlestick act and the safety-engineered devices in a multi-hospital sharps injury surveillance network. To that end, the International Healthcare Worker Safety Center (IHWSC) at the University of Virginia looked at data from its EPINet Multi-hospital Sharps Injury database and compared needlestick injury rates from 1993 and 2001 from a network of participating EPINet hospitals. The study, published in the IHWSC's Advances in Exposure Prevention (Vol. 6, No. 3, 2003), focused on nurses' needlestick reporting actions and data from teaching hospitals
"Nurses represent the occupational group sustaining the most needlestick injuries and the most stable group in terms of reporting patterns," says Jane Perry, director of communications at the IHWSC. "We found an overall 51 percent decrease in sharps injuries for conventional and safety devices."
According to the study, the overall PI rate declined from 19.5 PIs per 100 occupied beds in 1993 to 9.6 PIs per 100 occupied beds in 2001.
"From 1999 to 2001 there was a 35 percent decline in needlesticks, which is good news, but there's always more to be done," Perry adds. "But this definitely shows the right trend. It shows that hospitals have gotten the message and are taking the need to convert to safety devices seriously.
Perry says that although the Needlestick Safety and Prevention Act and OSHA's revised Bloodborne Pathogen Standard have continued to raise awareness and ensure compliance, the trend toward elimination of PIs began early in the 1990s.
"The downward trend started with OSHA's 1991 Bloodborne Pathogen Standard," Perry says. "At the time there was some movement on safety devices but healthcare facilities pretty much saw them as being optional. In 1999 OSHA revised its compliance directive for bloodborne pathogens and that's when the agency stated for the first time safety devices were mandatory and compliance was enforceable. Current data reflects a cumulative effect of the three actions: OSHA's revised directive in 1999, the Needlestick Safety and Prevention Act in 2000 and the revised BBPS in 2001. Congress and OSHA have made it clear it is not optional and facilities are getting that message."
In a study that examined the prevalence of safety needle devices and factors associated with their adoption, National Institute for Occupational Safety and Health (NIOSH) researcher Raymond Sinclair, PhD, and colleagues collected and analyzed data on the adoption of safety engineered devices in 494 U.S. hospitals from 1999 to 2000. The study showed that although 83 percent of the sample reported adopted some kind of safety device, this adoption was inconsistent across types of devices. All of the units in 52 percent of the facilities had adopted needleless intravenous delivery systems, but the hospitals used other types of engineered safety devices less often. Predictors of adoption, according to Sinclair's study, was cost, as well as the size of the hospital and the presence or absence of state legislative activity on the PI issue.
The researchers concluded that smaller hospitals may require special encouragement and assistance from outside sources to adopt expensive risk-reduction innovations such as engineered sharps safety devices. The researchers said that although safety devices are the mandated and preferred way to protect HCWs from needlesticks, complete adoption of this technology depends on the support of the social systems in which it is used and the people who use it.
While just one needlestick is too many, Perry says there must be an appreciation of just how much effort goes into sharps safety compliance and how change is gradual.
"I think we should remain very optimistic and not look it as still having too many needlesticks," she adds. "We want to reduce them as much as possible but when you talk to people who are actually trying to do so in their facilities, you realize how complicated it is -- especially when involving frontline healthcare workers. Ideally, they should have been doing this 10 years ago, not in the last year or two; however, it takes time for facilities to do a full-scale conversion to sharps safety devices. There will be some residual needlesticks that occur during use, and needlesticks can occur with safety devices, especially ones where the safety device isn't activated. These numbers are very good and we think we will continue to see a decline."
When it comes to conventional devices, disposable syringes caused the greatest number of PIs to nurses in the 1993 (38 percent) and 2001 (40 percent) EPINet data; in 1993 the PI rate was 6.8 per 100 occupied beds, while in 2001, the rate declined by 59 percent to 2.8 per occupied beds. There were 1.78 PI injuries from needles on IV lines per 100 occupied beds in 1993, while there were no injuries in 1991, a dramatic decrease some attribute to the widespread implementation of needleless and recessed IV systems that were created after the 1992 safety alert issued by the Food and Drug Administration.
The study also showed that PIs were reduced for nearly all conventional needles that injure nurses, including intravenous catheters (55 percent decrease), phlebotomy needles (70 percent decrease), prefilled syringes (62 percent decrease), winged steel needles (55 percent decrease), and lancets (87 percent decrease). PIs caused by suture needles decreased by 5 percent.
These decreases are due in part to manufacturers introducing new and improved sharps safety devices, Perry says.
"I think we will continue to see new safety devices flood the market. Not just needles, but new sharps-disposal containers," Perry says. "We continually update the safety device list on our Web site (www.med.virginia.edu/epinet) I also think the manufacturers are doing an amazing job with training; of course, it is in their best interest that their products be used correctly and safely. In terms of continuing to develop better safety devices, I think more passive devices should be considered. (IHWSC director) Janine Jagger has pointed out that we need to see more passive safety designs where appropriate. There are some devices, like syringes, where you wouldn't want a fully passive design because they are used for a lot of different purposes. You have to look at particular uses, as there is no one blanket answer for passive devices. In general, passive is good; we see the number of injuries that occur during disposal that if the safety mechanism was activated you wouldn't have those injuries. Presumably, passive mechanisms would prevent those injuries. I think we would like to see the trend go toward more passive designs but taking into consideration what the devices are used for."
In 1993, when nurses were asked whether the device that injured them was a safety design, 4 percent said yes. In 2001, 25 percent said yes. In 1993, the PI rate for all safety devices was .75 per 100 occupied beds; in 2001 it was 2.3 per 100 occupied beds. By contrast, the PI rate for all conventional devices declined from 18.75 per 100 occupied beds in 1993 to 7.3 per 100 occupied beds in 2001. Perry cautions healthcare professionals not to misinterpret these findings.
"It's a matter of correctly interpreting the data," Perry says. "It reflects an increased use in safety devices. You have to keep in mind the total picture and that there has been a decrease in injuries. The data says because there was a decrease in use of conventional devices and an increase in safety devices, the overall sharps injury rate has gone down. We separated the conventional and the safety data in the 1993/2001 comparison and found a sharp decrease in injuries from conventional devices and an increase in injuries from safety devices. You can look at that and say, 'What's the problem there?' but our interpretation is because there's a lot fewer conventional devices being used, you see this dramatic decrease in the sharps injury rate. As more safety devices are used, we'll see an increase in injuries from safety devices. Some injuries will be hard to eliminate even with the use of safety devices -- the injuries that occur during use. You must look at that data in context with the overall decline -- that's not to say there are some safety devices that couldn't be better designed. Included in that data is the fact the safety mechanism simply wasn't activated."
According to a separate 2001 study undertaken by the IHWSC, the safety mechanism was not activated in 71 percent of the usage, and 57 percent of the injuries occurred before the safety mechanism was activated. Perry says education can help cut down on safety device-related injuries.
"When it comes to safety mechanisms causing injury, I wouldn't say it's anyone's fault; in some cases it may be that a healthcare worker just didn't want to take the time to activate it," Perry says, "although the time it takes is miniscule. Some people just haven't received the training they need."
Perry recalls her own experience with a nurse who hadn't received training on a safety device. "When I went to my doctor's office for an annual examination, the nurse who drew my blood used a safety butterfly needle. After she drew the blood she just put the butterfly device into the disposal container without activating the safety mechanism. I pointed out to her that it was a safety device, but she hadn't been there the day they did the training so she had no idea how to use it. Healthcare facilities pay good money for safety devices and healthcare workers don't know how to use them. It takes constant inservicing and follow-up for people you missed, plus more follow-up for even more people you missed. Facilities should also get rid of conventional devices when they convert to safety devices so HCWs don't have the option of falling back on the conventional devices."
Perry admits that training can be a formidable process.
"Facilities must make sure that all potential users of the safety device receive training. A big facility might use three or four different safety devices for different purposes or in different clinical settings, so it's a big job and it takes time. Of course, you need cooperation from staff. There are HCWs who don't want the training and that's a sizeable hurdle to overcome."
Perry likens sharps safety compliance to handwashing compliance -- it's an uphill battle in either situation.
"With handwashing, you must keep doing the training and constant reminders. With sharps safety, if you don't have conventional devices, they are forced to use the safety devices. I have heard stories about hospitals that face all this complaining about how HCWs can't use safety devices. I recall reading a letter published in a medical journal written by a surgeon infected with hepatitis C. He said that regarding precautions like double gloving, until he was infected and learned he actually infected a patient, he thought he could never operate with double gloves. After it all happened, somehow he could do it, and I think that's often the case -- when you are forced to change your risky behavior, you readjust."
In the 1993/2001 study, PIs to nurses from conventional devices occurred most frequently in patient rooms, followed by ORs, intensive care units and emergency rooms.
"Wherever you have the most needle-related procedures being done, that's where you will see the most needlestick injuries," Perry says. "There also are disposal-related injuries and injuries that occur in every part of the hospital." The study showed decreases in PI rates for each aforementioned setting: 65 percent, 50 percent, 79 percent and 54 percent, respectively.
When it comes to procedure-related rates, PIs from conventional devices occurred most frequently while giving injections; these rates decreased by 39 percent, according to the 1993/2001 comparison. The study showed a 50 percent decrease for drawing venous blood; a 59 percent decrease for starting IVs, and a 96 percent decrease for saline flushes. The 1993/2001 comparison showed that PIs from conventional devices occurred most frequently during use or between steps of a multi-step procedure (32 percent in 1993 for both categories combined and 31 percent in 2001). Rates in these combined categories decreased by 61 percent from 1993 to 2001.
"It will be interesting to look at the rates again in a year or two and see what the latest trends are. If this pattern of injury decreases continues, it looks like we are really tackling this problem."
BD Plans to Discontinue Conventional Needle Sales in the U.S.
FRANKLIN LAKES, N.J. -- Becton Dickinson and Company (BD) announces plans to discontinue U.S. sales of many conventional needles and other sharps devices across a range of product categories. This action coincided with the second anniversary of the April 18, 2001 compliance date for the Federal Needlestick Safety and Prevention Act and reflects the progress made by U.S. healthcare facilities in transitioning to safety-engineered designs.
"In the past 15 years, the medical device manufacturing industry has introduced a continuous stream of safety-engineered sharps device innovations designed to protect healthcare workers from injuries," said Edward J. Ludwig, chairman, president and CEO of BD. "Healthcare facilities have made great progress in the change-over to safety-engineered designs. Based on this progress, BD is now able to discontinue the sale of many conventional sharps devices without disrupting patient care or clinical practice."
BD estimates that U.S. hospitals have transitioned 80 percent of their sharps product usage from conventional to safety-engineered designs in IV catheters, needleless IV connectors, blood drawing needles, winged needle sets and lancet devices. The level of transition is lower for syringes and needles, surgical blades, scalpels and other categories of devices utilized for specialty medical procedures. Across all product categories, the overall level of transition to safety designs remains lower in clinics and physicians' offices than in hospitals.
BD sales consultants are prepared to work with healthcare facilities to help ensure a smooth transition.
Abbott Laboratories' Infusion Therapy Product Line to Go Needleless This Month
ABBOTT PARK, Ill.--By this month, Abbott Laboratories will phase out all IV sets that contain or require needles, as part of the company's continued commitment to improving patient and healthcare worker (HCW) safety. By no longer manufacturing and marketing these products, the company expects millions of needles to be eliminated from the U.S. healthcare system, further protecting HCWs against needlestick injury and blood exposure. Abbott will use a needle-free technology across its entire line of infusion therapy products.
"Needles cause needlesticks. If you eliminate the needles, you eliminate the risk," says John Arnott, vice president, hospital business sector, Hospital Products Division, Abbott Laboratories. "For more than four decades, HCWs had little, if any, needle-free alternatives. Today, new technology allows us to provide innovative products that offer protection against needlestick injuries."
Julie Naunheim-Hipps, a nurse from Glendale, Mo., knows first-hand the risks that needle-based products pose. In 1999, Naunheim-Hipps contracted hepatitis C from a needlestick injury and has since been actively involved in passing state needlestick safety legislation.
"My injury may have been prevented had I had access to products designed to reduce needlesticks," says Naunheim-Hipps. "Abbott's decision to phase-out the use of needles in certain products is a major step forward in protecting HCWs. Needleless products also help hospitals comply with new federal needlestick protection regulation."