Are We Still in the Dark Ages of Sharps Safety?

For as long as there have been sharp medical devices and instruments, healthcare workers have been injuring themselves. But it wasn’t until 1981 that the healthcare community started learning about the extent of these injuries through the efforts of Dennis Maki, MD, and Rita McCormick, RN, CIC, of the University of Wisconsin Hospitals, who were poised to publish the very first systematic study of needlestick injuries (NSIs) in the United States.¹ Maki and McCormick investigated 316 reported NSIs occurring between 1975 and 1979, which represented one-third of the hospitals’ work-related accidents. They examined how the sticks occurred and what could be done to reduce or prevent these injuries, including not recapping used needles, and making widely available (and promoting use of) an efficient needle disposal system.

Maki and McCormick discovered that housekeeping (127 cases per 1,000 HCWs annually) and laboratory personnel (104.7 per 1,000) experienced the highest incidence of NSIs, followed by registered nurses (92.6 per 1,000); physicians rarely reported NSIs. Maki and McCormick found that most of the injuries occurred during disposal of used needles (23.7 percent of all injuries), during the administration of parenteral injections or infusion therapy (21.2 percent), drawing blood (16.5 percent), recapping needles after use (12 percent), or handling linens or trash containing uncapped needles (16.1 percent). Sixty percent of the personnel who reported a needle-puncture injury sought emergency room treatment in which management was variable. The total cost of needle puncture injuries in the hospital over a 27-month period was $6,331.

Ten years later, in 1991, Maki and McCormick² published data from a study they conducted over a 14-year period, at a time when AIDS was becoming pandemic in nature. Using the same reporting system and analyses for the 1981 study, Maki and McCormick revealed that despite significantly increased institutional efforts to prevent sharps injuries, the annual incidence increased more than threefold (60.4 to 187 per 1,000 HCWs), reflecting better reporting and increased exposure. Maki and McCormick found that adjusting for inflation, the direct costs of sharps injuries increased from $5,354 to $37,271 annually. The top personnel sustaining injuries were environmental services staff with 305.8 sharps injuries per 1,000, and nursing staff with 196.5 per 1,000.

Maki and McCormick found that injuries continued to occur mainly during disposal of waste, linen or used procedure trays (19.7 percent of all injuries), administration of parenteral injections or infusion therapy (15.7 percent), surgery (16 percent), blood drawing (13.3 percent), or recapping of used needles (10.1 percent). They noted that making disposal units available at every bedside reduced injuries from needle disposal two-fold since 1975 to 1979. Maki and McCormick also reported that consistent application of a stringent post-exposure protocol and wide acceptance of the hepatitis B vaccine resulted in zero sharps injury-related infections for a three-year period.

Sharps Past and Present: Dark Ages? Middle Ages?

“We have left the dark ages,” McCormick says. “Most facilities have implemented a number of safety devices and workers are apprised of the hazards. The one area that is still problematic is the operating room. Many, many suture needles are used and there is reluctance on the part of surgeons to adopt newer devices, as they often feel different. It is a real hump to get past, as surgery is such a technical endeavor.”

“We have come some way but there is still a long way to go,” says Michael Sinnott of Qlicksmart. “Regulations are in place but there is a lack of resources and priority to regulate safety measures. Users are complacent, thinking, ‘It can’t be me because I have been using the current method for the last 20 years.”

“We may have left the dark ages but we may have only as gotten as far as the middle ages,” says Gareth Clarke, CEO of Inviro Medical Devices.

For the third consecutive year, Inviro Medical Devices is a co-sponsor with the American Nurses Association of the 2008 Study of Nurses’ Views on Workplace Safety and Needlestick Injuries, which provides an eye-opening peek into the opinions, concerns and experiences about workplace safety and NSIs. The independent research of more than 700 U.S. nurses reveals that NSIs and bloodborne infections remain major concerns for 64 percent of nurses. The survey also revealed that 59 percent believe their most recent NSI could have been prevented by improved safety syringe design, with 94 percent identifying specific design improvements.

“The survey was a confirmation that there is still much to be done,” Clarke says. “We certainly are not yet where we need to be in terms of preventing injuries.”

“We have certainly reduced the number of sharps injuries due to newer safety devices, but we are still in the dark ages with respect to the OR and scalpels, as most have not adopted safety scalpels yet in this arena,” observes Craig Fernandes of DeRoyal Industries.

The Danger Zones: Data from Epi-Net

National data from more recent years indicates that sharps injuries should remain at the top of the HCW safety agenda. The Exposure Prevention Information Network (Epi-Net)’s most current numbers for needlestick and sharp-object injuries (2004; 1,155 total cases and an average daily census of 4,328) indicate the following for selected categories:³

Job category

Nurses sustained 462 injuries/40.3 percent of total injuries

Physicians sustained 131 injuries/11.4 percent of total injuries

Surgery attendants sustained 90 injuries/7.9 percent of total injuries

Location of the injury

Operating room: 355 injuries/31 percent

Patient room, general ward: 330/28.8 percent

Intensive/critical care unit: 97/8.5 percent

When the injury occurred

During use: 469/40.8 percent

After use, before disposal: 169/14.7 percent

Between steps of a multi-step procedure: 140/12.2 percent

Purpose of the sharps

Injection: 265/23.1 percent

Suturing: 246/21.4 percent

Drawing venous blood sample: 149/13 percent

Type of device

Disposable syringe: 392/35 percent

Suture needle: 239/21.3 percent

Reusable scalpel: 43/3.8 percent

Contamination of the sharps

Yes: 726/63.6 percent

No: 388/34 percent

Unknown: 6/0.5 percent

“When the legislation was passed and then the move to safety syringes happened in hospitals, I think there was a significant early reduction in injuries,” Clarke says. “There is an interesting absence of any decent statistics on this, but many people said that injuries were reduced by half, and then we plateaued. If the number was 800,000 to 1 million injuries out there when the legislation was enacted, that still means there are at least 400,000 to 500,000 injuries still occurring. The latest Epi-Net data published in 2004 reported 27 injuries per 100 occupied beds, the annual injury rate for all hospitals. Again, multiply that by 5,000 or so hospitals in the U.S. and you get some big numbers.”

Clarke says he is troubled by the Epi-Net data suggesting that numerous NSIs are being caused by HCWs using non-safety syringes. “For example, if the injury was caused by a needle, 55 percent reported that it wasn’t a safety syringe being used at the time,” Clarke says. “If the safety feature was activated, 78 percent of HCWs who sustained an injury by a safety device didn’t activate the safety feature! Is it a HCW behavioral issue, or is it a safety product design issue? There’s so much in the Epi-Net data that points to these two issues, so we keep coming back to the fact that there are still too many non-safety devices used in hospitals.”

Jeanne Barry-Dimech of St. Mary’s MedicalCenter in San Francisco reports that she has seen an improvement in sharps injuries reporting for 2006 to 2007, explaining that she conducted an ambitious educational campaign in 2006, as well as “fixed a lot of process problems and pushed for disciplinary action when the employee totally did not use the safety device.” Barry-Dimech reports that in 2006, there were 31 total exposures, including 11 needlesticks, another 15 sharp injuries in surgery, and two splashes.

In 2007, there were 20 total exposures, including six needlesticks, five sharps injuries in surgery, and six splash exposures. So far in 2008, Barry-Dimech reports there have been 13 total exposure, including six needlesticks, three splash exposures and three sharps injuries in surgery.

Barry-Dimech comments that St. Mary’s employees usually activate the safety devices, but notes, “I find they do not activate soon enough. Some do not activate, while some activate after they remove the needle from the skin and they use the alcohol wipe.” Barry-Dimech says that in terms of injuries while activating safety devices, of the 11 needlesticks in 2006, two injuries were related to disposal, two injuries were related to used lancets not immediately disposed of, two injuries were related to recapping, and five injuries were related to the safety devices not being activated or not activated soon enough. For the injuries reported in 2007, Barry-Dimech says one injury was related to disposal after blood draw, one was related to ABG, one was related to blood draw, one injury occurred after injection (the device did not activate immediately), one injury was related to an insulin pen, and one injury related to a PICC line insertion. And for the injuries reported so far in 2008, Barry-Dimech says one injury was related to recapping, one was related to an IV insertion, one was related to ABG, and one was related to post-injection.

“I preach to the masses as often as possible,” Barry-Dimech says. “At least they know who I am and for the most part they have stopped reporting the exposure the next day. We have seen a big improvement in surgery after 2006, although it will always be risky.  I now have healthcare workers notifying their supervisor within 30 minutes so we can deal with the exposure immediately (even if it was a stupid thing they did), so that is an improvement. I guess I would say the repeat offenders still have not gotten the message. I would also say that although they activate the device, they often are delayed and that leads to a risky situation. No one should recap, but I still see that. ABGs continue to be an issue because the only safety device is the little plug they put the needle in when they are done. I would also say that for some reason, heparin and insulin sticks have been on the rise. And lastly, I just think they are busy and do not slow down when they are dealing with sharps.”

The Risk of Exposure

One of the most significant occupational hazards faced by HCWs is an injury caused by a contaminated sharp, exposing them to bloodborne pathogens; The Occupational Safety and Health Administration (OSHA) estimates that 5.6 million workers in the healthcare industry and related occupations are at risk of occupational exposure to pathogenic bacteria and viruses such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and others. All occupational exposure to blood or other potentially infectious materials (OPIM) places workers at risk for infection with bloodborne pathogens. OSHA defines blood to mean human blood, human blood components, and products made from human blood. OPIM includes the human body fluids of semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids. OPIM can also mean any unfixed tissue or organ (other than intact skin) from a human (living or dead); and HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions.

The Dawn of Regulatory Protection

In 1991, OSHA issued its Bloodborne Pathogens Standard (29 CFR 1910.1030) to help protect all workers — including healthcare professionals — from this risk. But injuries continued, as did seroconversions, and lawmakers agreed that greater interventions were necessary to stem the tide of sharps injuries.

In 2000, the Needlestick Safety and Prevention Act (NSPA) was signed into law, revising the 1991 Bloodborne Pathogen Standard to require healthcare facilities to implement the following steps:

-- Implement safer medical devices that are appropriate, commercially available, and effective

-- Document consideration and implementation of safer medical devices annually

-- Obtain input for these devices from those responsible for direct patient care; this input must be documented

-- Train employees to use new devices and/or procedures and document training

-- Maintain a log of injuries from contaminated sharps

“Sharps injury prevention has improved significantly since the act was signed into law,” says Peter Rumswinkel, general manager of Sarstedt, Inc. “In addition to more stringent OSHA regulations, HCWs are now more aware of safety hazards and how to prevent them, and industry is continuing to provide more innovative products.”

The Rise of Safety-Engineered Devices

The new requirements of the NSPA and the CDC’s statement that safer medical devices could significantly reduce the number of percutaneous injuries helped launch a movement toward safety-engineered medical devices and the introduction of new words into the infection control lexicon, such as “active” and “passive” safety devices, as well as product category differentiation known as “primary” and “secondary” prevention.

Industry consultant Marilyn Hanchett, RN, PhD, CPHQ, explains, “...devices that use a needle or other sharp component with some sort of protective mechanism to prevent any injury can be described as secondary prevention. That is, the safely technology is secondary to the continued use of the needle or sharp component. Conversely, devices that completely eliminate the use of needles or reduce the frequency with which they must be used are known as primary prevention. The primary focus of this technology is the elimination, or in cases where they cannot yet be eliminated, the reduced use, of the actual needle or sharp component.”⁴

Hanchett observes further, “Unlike the first generation of safety products, the new technology is seeking to eliminate the use of needles and/or sharps. And in cases where current technology cannot yet eliminate needles and sharps, it seeks to reduce the frequency with which they must be used. Specifically, the next generation of safety technology intends to increase safety by removing the potential hazard rather than making contact with the hazard less dangerous.”⁴

Essentially, safety-engineered sharps are considered to be medical devices with protective features that blunt, retract or shield needles or sharps after use. Examples of needles with safety features include protected needle intravenous (IV) connectors; needles that retract into a syringe or vacuum tube holder; hinged or sliding shields attached to phlebotomy needles, winged-steel needles, and blood gas needles; protective encasements to receive an IV stylet as it is withdrawn from the catheter; sliding needle shields attached to disposable syringes and vacuum tube holders; self-blunting phlebotomy and winged-steel needles; and safer IV catheters that encase the needle after use.

But when is a safety device not a safety device?

“Marketers can create a false sense of safety with not-so-safe active devices, confusing ‘safety’ devices as being safe for both patient and staff when it is not necessarily so,” says Sinnot. “Prefixing ‘safety’ to a device does not make it safe.”

Andrew Rose, director of marketing for Smiths Medical, emphasizes that safety devices have achieved a reduction in occupationally acquired injuries. “Just as importantly, the introduction of safety devices has helped to raise the awareness of clinicians in all healthcare settings whereby in the coming years clinicians will only know ‘safety devices’ as the standard of care for protecting HCWs. With the existing range of devices available on the market today, the possibility exists that an HCW can bypass the safety mechanisms of many devices, either intentionally or unintentionally. A line exists with manufacturers and the clinical community where the need to develop and introduce new safety technology that eliminates the ability of the safety mechanism to be bypassed is balanced between the clinical and economic value the new devices will provide to the end user customers.”

According to OSHA, safety devices have their limitations. Many new devices have been developed to reduce the risk of needlestick injuries, but those that have been assessed vary considerably in their clinical efficacy and in their effectiveness in reducing rates of injuries. Also, needles with safety features may not be available or may not be a practical alternative to conventional devices in certain situations; in some cases, these devices have caused needlesticks while in use. Besides these limitations, there are obstacles to the use of needles with safety features, which include their increased purchase price compared with conventional devices, possible staff resistance to changes in the devices used, and the time required to train staff in the use of new devices.

And then there’s the behavioral aspect of getting HCWs to understand how to use safety devices — and actually deploying them correctly. According to 2004 Epi-Net data, of 1,111 records, 38 percent of the injuries caused by needles were by safety devices. The safety mechanism was not activated in 305 or 78.4 percent of 389 total incidents, and in 238 or 65.9 percent of 361 total incidents, the injury occurred before activation of the safety device.

“We don’t get a lot of feedback about inadequacies of systems or supplies,” McCormick says. “Some of the preventable injuries are due to worker error, e.g., failure to inactivate a device as soon as feasible.”

“The devices are there to provide safety, and if they are not used then accidents will happen,” Fernandes says. “Unfortunately, sometimes rules are not followed 100 percent until it hits someone personally with their health or in the pocketbook. In the latter, OSHA has provided enough of a financial incentive to follow their rules. Those who have gotten speeding tickets in the past are more likely to observe the speed limit in the future. If there is no one handing out tickets then everyone tends to speed, and safety is diminished.”

McCormick says that buy-in by key stakeholders in the hospital is important to the success of any sharps safety awareness efforts. “Administrative staff plays a very key role in developing a culture of safety,” she says. “They are doing well in terms of patient safety but employee safety doesn’t get the same attention. I think there still may be an attitude that some injuries are simply part of the job and individual circumstances surrounding the injury are not examined adequately. Employers need to firmly set the expectation that safety devices have been purchased specifically for worker safety and that all workers are expected to do their share in terms of use and proper disposal. We have come a long way and many safer procedures are now simply standard operating procedures.”

“There has been a huge focus on patient safety in the past four or five years, which has resulted in much work around ‘just cultures,’ personal accountability, and holding others accountable for their actions,” says Barbara DeBaun, RN, MSN, CIC, improvement advisor for BEACON, the Bay Area Patient Safety Collaborative. “I wonder if this has had an impact on how staff views their own personal safety and how their behavior affects not only themselves but their colleagues. I don’t know if this has been studied or if there is any evidence around this, but I do think it’s worth exploring. As an example, facilities are expecting staff to ‘speak up’ if they see another staff member not wash his/her hands, or fail to follow ‘the bundle’ when inserting central lines. I wonder if this has had a positive effect on staff who may now feel empowered to hold others accountable to personal safety too.”

Rose is a firm believer in positive change necessitating an institutional culture shift. “We believe that the partnership established prior to and during the legislative years with safety advocacy groups and our clinical end users has demonstrated a significant shift in both attitude and compliance to the selection and use of sharps safety devices, whereby the majority of institutions have created a ‘culture of safety.’ That being said, as a manufacturer monitoring the marketplace and the technology embedded within safety devices, we see areas where the ‘culture of safety’ has not been fully embraced, partly driven by economic considerations or by perceptions that safety is either not needed or the devices available do not meet the clinical needs where a non-safety device may still be in use.”

“Healthcare workers must be provided with the right tools and equipment, but even when they have them, behavioral issues get in the way,” Clarke says. “We see increased workloads impacting worker safety; something we have grown to expect from this is that they put patient safety ahead of their own. If it’s a question of tending to the patient or worrying about their own safety, the patient usually comes first.”

Education about and training in the proper use of safety-engineered devices is critical to ensuring that HCWs can protect themselves concurrently with meeting their patients’ clinical needs.

“We asked ourselves why some institutions were more successful in reducing needlestick injuries than others, and the survey revealed the facilities that provided solid education and training to their personnel was one of the key factors,” Clarke confirms. “As a HCW, if you are getting the right education and training, you are also getting the institution’s commitment to making needlestick prevention a top priority. Because if you identify this as a top priority, you can’t make this kind of statement without facility administration backing it up. And where are you going to start? With education and training of those frontline workers, hopefully you are also getting them involved in the evaluation and selection of safety devices. Facility management must be committed to doing the right thing and not just paying lip service to the needlestick legislation and compliance. Sharps injury prevention is one aspect of employee safety that cannot operate in isolation; it must be part of a broader employee safety mentality in every institution.”

Device Design

While a perfect sharps safety-engineered device may not yet exist, opinions abound as to the components of an ideal device. The National Institute for Occupational Safety and Health (NIOSH) states that improved engineering controls are often among the most effective approaches to reducing occupational hazards such as needlesticks. It provides the desirable characteristics of safety devices:⁵

-- The device is needleless.

-- The safety feature is an integral part of the device.

-- The device does not require activation by the user; if user activation is necessary, the safety feature should be engaged with a single-handed technique and allows the worker’s hands to remain behind the exposed sharp.

-- The user can easily tell whether the safety feature is activated.

-- The safety feature cannot be deactivated and remains protective through disposal.

-- The device performs reliably.

-- The device is easy to use and practical.

-- The device is safe and effective for patient care.

Have safety-engineered sharps devices achieved what they were supposed to?

In general, yes, according to DeBaun, who adds, “The remaining challenge is to design sharps devices that are truly passive, can’t be bypassed, and don’t cause discomfort for the patient.”

“The manufacturers have stepped up to the plate to address the issue,” McCormick says. “We are lacking a few devices but for the most part the needle has been taken out of the picture or safety devices are available. Is enough education and training being provided? Training is an issue because many facilities use different devices. Education is usually good when a major change in supplies is initiated but for new employees coming in continually, they often don’t benefit from the same level of education.”

“Safety-engineered sharps devices will achieve what they were supposed to achieve only if a) they are really safe for the users (staff safety) b) patient safety is not compromised and c) passive devices that need no activation of safety features are used,” says Sinnot. “Have safety scalpels achieved what they were supposed to achieve? No. They are not passive devices and patient safety may be compromised.”

HCWs are looking to industry to evolve their products and advance the national sharps safety agenda, and it is important that they continue to provide feedback to manufacturers.

“We as manufacturers must respond to the feedback we receive from HCWs,” says Rumswinkel. “Products evolve based on solving the problems of HCWs and eliminating specific occupational hazards.

“We can develop products that are improved in the way the safety mechanisms are deployed – making them more automated and also by improving the ergonomics of our products to make them more user friendly,” Fernandes says.

The pressing issues relating to sharps injury prevention that manufacturers hear most are varied.

“Healthcare facilities are trying to balance required engineering controls with cost-effective products,” says Rumswinkel. As manufacturers, we must provide devices that are safe, easy to use, and reasonably priced.”

“For the most part, physicians say the current safety scalpels on the market are too much of a change from their current slab blade and scalpel design – and they will not use them until forced,” Fernandes observes.

“It is imperative that patient safety and quality of care are not compromised in any way,” says Sinnot. “When a device either impedes surgery or restricts quality of care, it should not be used. For example, surgeons are very particular about their implement of choice; they prefer the traditional metal scalpel handle for a reason. Is a ‘safety scalpel’ really the best option for patients when it obstructs the surgeon’s line of sight and restricts the depth of their incision necessary for particular procedures? Is a ‘safety scalpel’ really safe when a surgeon needs to remember to actively slide the sheath over the blade to prevent cutting a nurse during passing, mistaking it as already safe?”

“We often hear about the need for continued support for education and service to maintain the “culture of safety” a specific facility has worked to create, but it is often challenged by staff turnover and cuts in expenditures in their training budgets,” Rose says.

Zero Tolerance for Sharps Injuries

Clinicians and industry members agree that the zero-tolerance mentality being applied to infection prevention in patients ought to be applied to preventing occupational sharps injuries with the same degree of rigor.

“What’s happening with methicillin-resistant Staphylococcus aureus (MRSA) should happen with sharps safety,” Clarke says. “MRSA has moved from reducing to an acceptable level to a more or less zero-tolerance mentality. And that is the attitude we need to take as far as sharp injuries go. Getting it down to 50 percent of what it was before is unacceptable as a stopping point. Think about the individual trauma that goes with one case — so we have to get a mentality which says ‘Hey, our objective should be zero sharps injuries,’ and that is the mentality that’s necessary. That is not the mentality that’s out there right now, except in some facilities that have seen success because they are taking that attitude. I think there is a general acceptance that we’ve got down to a certain level and we can’t go any further — well, we don’t accept that. We think better technology and education and training can continue to drive it down and zero should be the objective. Your chances of getting to 10 percent are much better if your objective is zero than if the objective is 25 percent.”

Clarke suggests the agenda for the future is to find ways to keep the subject of sharps injury prevention current and in front of the healthcare community. “We must eliminate the complacency that is still apparent in some institutions. We must continue to keep the issue alive, as well as bring new and different technologies to the market; we must consider new technology instead of being satisfied with retrofitted devices that have been around for 15 years.”

Infection prevention professionals say they have an important role to play in helping boost sharps safety compliance in their workplaces.

“I feel a shared responsibility between employee health and infection control departments is crucial,” McCormick says. “In our facility, employee health reports the number of injuries and the circumstances surrounding the injuries monthly. Sometimes the data identifies a product that is troublesome and then changes in products are made.

“Keep sharps injuries on scorecards/dashboards,” DeBaun advises. “Be sure data are shared with those at the top, including performance improvement executive councils and hospital boards. If sharps injuries are increasing or have reached a plateau, drill down and ask why, when, where, and how.”

References

1. McCormick RD, Maki DG. Epidemiology of needlestick injuries in hospital personnel. Am J Med. 1981 Apr;70(4):928-32.

2. McCormick RD, Meisch MG, Ircink FG, Maki DG. Epidemiology of hospital sharps injuries: a 14-year prospective study in the pre-AIDS and AIDS eras. Am J Med. 1991 Sep 16;91(3B):301S-307S.

3. Exposure Prevention Information Network (EPINet) Data Reports. International Health Care Worker Safety Center, University of Virginia. 2003.

4. Hanchett M. Why Do We Need to Know About Primary Prevention? Infection Control Today. May 2002.

5. NIOSH Publication No. 2000-108: NIOSH Alert: Preventing Needlestick Injuries in Health Care Settings. November 1999.

Device Selection

 According to NIOSH, the major elements of a process for selecting and evaluating needle devices with safety features are:

Form a multidisciplinary team that includes workers to (1) develop, implement, and evaluate a plan to reduce needlestick injuries in the institution and (2) evaluate needle devices with safety features.

Identify priorities based on assessments of how needlestick injuries are occurring, patterns of device use in the institution, and local and national data on injury and disease transmission trends. Give the highest priority to needle devices with safety features that will have the greatest impact on preventing occupational infection (e.g., hollow-bore needles used in veins and arteries).

When selecting a safer device, identify its intended scope of use in the health care facility and any special technique or design factors that will influence its safety, efficiency, and user acceptability. Seek published, Internet, or other sources of data on the safety and overall performance of the device.

Conduct a product evaluation, making sure that the participants represent the scope of eventual product users. The following steps will contribute to a successful product evaluation:

Train healthcare workers in the correct use of the new device.

Establish clear criteria and measures to evaluate the device with regard to both healthcare worker safety and patient care. (Safety feature evaluation forms are available from the references cited earlier.)

Conduct onsite followup to obtain informal feedback, identify problems, and provide additional guidance.

Monitor the use of a new device after it is implemented to determine the need for additional training, solicit informal feedback on health care worker experience with the device (e.g., using a suggestion box), and identify possible adverse effects of the device on patient care.

Ongoing review of current devices and options will be necessary. As with any evolving technology, the process will be dynamic, and with experience, improved devices with safety features will emerge.

Recommendations from NIOSH

To protect healthcare workers from needlestick injuries, employers must provide a safe working environment that includes safer needle devices and effective safety programs. Many types of needle devices are associated with needlestick injuries, and these injuries can occur in many ways. Thus a combination of prevention strategies must be considered. Employers should take the following steps to implement a program for reducing needlestick injuries and to involve workers in this effort.

Employers of healthcare workers should implement the use of improved engineering controls to reduce needlestick injuries:

Eliminate the use of needle devices where safe and effective alternatives are available. The most obvious example of unnecessary needle use is the use of exposed needles to access or connect parts of an IV delivery system. For nearly a decade, needleless IV delivery systems and protected needles have been available to remove or isolate this hazard. Examine information about your own institution to identify other unnecessary needle use.

Implement the use of needle devices with safety features and evaluate their use to determine which are most effective and acceptable. Many devices are now available with safety features that isolate an exposed needle after use. An evaluation approach and references are provided in this document.

Needlestick injury reduction can best be accomplished when the use of improved engineering controls is incorporated into a comprehensive program involving workers:

Analyze needlestick and other sharps-related injuries in your workplace to identify hazards and injury trends. Data from injury reporting should be compiled and assessed to identify (1) where, how, with what devices, and when injuries are occurring and (2) the groups of health care workers being injured.

Set priorities and prevention strategies by examining local and national information about risk factors for needlestick injuries and successful intervention efforts. Procedures and devices that have contributed to disease transmission (e.g., devices used to access a vein or artery) should receive the highest priority for intervention. Look to local and national resources for information about the types of devices and work practices that have been successful in reducing injuries.

Ensure that health care workers are properly trained in the safe use and disposal of needles. Healthcare workers and students in the health professions should be trained to use needle devices properly and to maximize their personal protection throughout the handling of these devices. As safer devices are introduced, worker training is essential to ensure proper use [Ihrig et al. 1997].

Modify work practices that pose a needlestick injury hazard to make them safer. Hazards that can be eliminated by modifying work practices include injuries due to recapping, failing to dispose of a needle device properly, passing or transferring such a device, and transferring blood or body fluids from a device into a specimen container. Also, specimen collection can be coordinated to reduce the number of times needles are used on a patient, thereby reducing both worker risk and patient discomfort. In some cases, the use of devices with safety features will reduce or eliminate these risks. In all cases, involving health care workers will help identify and resolve safety issues. Employers should thus review current procedures for reporting and addressing hazards related to needles and other sharps.

Promote safety awareness in the work environment. Many needlestick injuries result from unexpected circumstances such as sudden movement by a patient or collision with a coworker or needle device. Healthcare workers should be trained to be constantly alert to the injury potential when an exposed needle or other sharp device is being used. A number of job-related factors influence the adoption of safety behaviors by health care workers [Dejoy et al. 1995; Murphy et al. 1996; Gershon et al. 1995]. These workers often place patient needs before their personal safety. They are less likely to perform a safety measure they perceive to interfere with patient care or to require added steps. Therefore, employers must address both the hazards that contribute to needlestick injuries and the institutional barriers and attitudes that affect safe work practices [Hanrahan and Reutter 1997].

Establish procedures for and encourage the reporting and timely followup of all needlestick and other sharps-related injuries. Reporting of needlestick injuries is essential to (1) ensure that all health care workers receive appropriate post-exposure medical management and (2) provide a record for assessing needlestick hazards in the work environment.

Evaluate the effectiveness of prevention efforts and provide feedback on performance. Employers need to ensure that health care workers are adopting the recommended prevention strategies and that the changes they make have the desired effect. Thus they should provide a forum to assess worker perceptions, evaluate compliance, and identify problems.

Recommendations for Workers

To protect themselves and their co-workers, healthcare workers should be aware of the hazards posed by needlestick injuries and should use safety devices and improved work practices as follows:

Avoid the use of needles where safe and effective alternatives are available.

Help your employer select and evaluate devices with safety features.

Use devices with safety features provided by your employer.

Avoid recapping needles.

Plan safe handling and disposal before beginning any procedure using needles.

Dispose of used needle devices promptly in appropriate sharps disposal containers.

Report all needlestick and other sharps-related injuries promptly to ensure that you receive appropriate followup care.

Tell your employer about hazards from needles that you observe in your work environment.

Participate in bloodborne pathogen training and follow recommended infection prevention practices, including hepatitis B vaccination.