Avoiding the Point:

September 1, 2005

Avoiding the Point:

Sharps Safety best Practices for HCWs

By Jennifer Schraag

Sharps safety goes beyond theinfection control (IC) team, encircling every aspect of todays healthcaresystems. Reducing the risks presented by occupational exposure begins withawareness, proper compliance, education, and special care in handling anddisposal of sharps.

Sharps include needles, syringes, razorblades, slides, scalpels, pipettes, broken plastic or glassware, and otherdevices capable of cutting or piercing the skin.1

Needlestick injuries in the United States are decreasing, froman 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 (formerlythe Emergency Care Research Institute), points out, it is unlikely thatnurses will ever not be the majority since they bear the brunt of patient care.

Sharps injuries can occur in all aspects of clinical andoperating room (OR) duties as well as when emptying trash containers, replacingoverfilled sharps disposal containers, picking up glass or sharps from thefloor, or processing laundry or linens in which sharps have been placed by otherhealthcare personnel. In addition, many injuries have occurred from one workeraccidentally injuring another with an exposed sharp.

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

Data from the International Healthcare Worker Safety CentersEPINet Multihospital Surveillance Network indicate that syringes cause thegreatest number of sharps injuries. Moreover, the Center for Disease Control andPrevention (CDC)s National Surveillance System for Health Care Workers (NaSH)identified the six devices responsible for the majority (80 percent) ofneedlestick 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), andphlebotomy 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 therisks presented by sharps is achievable, and the initial step is by firsteliminating the many myths that abound.

First of all, many HCWs still act or appear to believe thatthey wont get hurt or suffer an injury, says Ballard. The immortal facadesome younger workers may mistakenly take on appears to increase this idea. Supporting this theory is a Duke University study which foundhigher 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 misplacedtrust in safety products. A safety product doesnt necessarily meanthat needlesticks cant occur, warns Kelli Rosenthal, MS, RN, BC, CRNI,ANP, APRN, president and CEO of ResourceNurse Continuing Education, Inc. Vigilanceis still required for their use.

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

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

Ballard explains why this is a good plan. It is surprisingto me how frequently in injury reports, device failure reports, and inconversations with HCWs, that safety devices were not used properly thesafety 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 thinkit 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 theirpracticality within your facility is a positive step in the right direction,says Poulos. The prevalence of todays use of safety items to reduceexposure and percutaneous injuries are fortunately ever-increasing. Ballard sayssafety syringes, safety phlebotomy devices, and needleless IV systems are themost widely implemented safety devices.

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

Rosenthal agrees, adding, The needlesticks I see arerelated to either failing to activate an engineering control, or during theactual 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 aperipheral IV in an obtunded patient in shock, who then became agitated duringthe stick. When she moved, the stylet with cannula intact came out of her veinand 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 cannulastill on it) would have been able to prevent this kind of occurrence.

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

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

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

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

Jan D. Harris, MPH, director of environment and occupationalhealth and safety with Sharps Compliance, Inc., takes it a step further andadvises HCWs to interview suppliers, attend seminars, and read up on journalarticles concerning safety products.

When evaluating a sharps safety device for use; ease of use,passive activation of safety features, and features that enhance patientsatisfaction (i.e., sharpness of IV catheter stylets) all are importantconsiderations, 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 oremployee in a position where an incident could occur?

Other questions to ask, according to Ballard, are How welldoes it work under usual conditions? Does it require a change intechnique? How well does it work under adverse conditions such aslighting 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 thatsafety is a partnership and needs to work with employees to create the safestwork environment possible. Hospitals should provide the tools, such as safetydevices, personal protective equipment (PPE), and disposal containers; while employees need to follow established policies andprocedures.

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

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

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

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

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

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

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

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

Hand passing of sharps instruments is a known hazard in theOR, according to Pugliese, and eliminating the hand-passing of instruments(e.g., use of transfer basin) during surgical procedures has been found toreduce risk. One study evaluated the impact of a hands-free technique for passing instruments in the OR. In surgeries with a highblood loss (greater than 100 cc) the sharps injury rate was 0.04 percent whenthe 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 safetyrecommendations including double gloving. Double gloving can further protectHCWs in the OR by providing longer lasting and stronger protection for high blood loss surgeries, and will work to remove more blood froma sharp as it penetrates both layers of gloving before reaching the skin site.

Other pointers include wearing the proper gowns in relation tolevel 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 andEpidemiology (APIC) also offers preventive measures which include carefulhandling when cleaning used instruments, when recapping by hand, avoidance ofpurposely bending or breaking by hand, manipulating the sharps by hand, andnever removing syringes once they have been disposed.

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

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

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

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

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

  • Choose containers that are easy to operate, that allowneedles to fall into the container unobstructed and that are appropriate intotal size and size of opening for the devices being discarded

  • Replace allneedle disposal boxes when they are three-fourths full

  • Place needle disposalboxes 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 seethe disposal slot before moving his or her hand toward it and

  • Addressspecial 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, forexample, have lessened injury rates. Be aware of improvements in safe disposalpractices and periodically review and update sharps disposal products,placements, and practices, she advises.

Equally important is the design of the unit to facilitateone-handed placement of the sharp and a clear indication that the box is nearfull and in need of replacement.

Harris says choosing the correct size sharps collector iscrucial to preventing disposal injuries. Test currently used sharpscollectors to determine if they are the appropriate size and type needed fordisposal of the new devices. NIOSH offers a comprehensive framework forselecting sharps collectors and evaluating their efficacy as part of an overallneedlestick injury prevention plan. NIOSH also recommends designation of anindividual 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 variousplacements of the sharps containers because they didnt want short nurseshaving to reach high into an area that they couldnt see into, Poulos shares.

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

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

According to research from the CDC and NIOSH, sharps injuriesrelated to the disposal process are particularly high when used needles are notdisposed of in puncture-resistant sharps disposal containers. Despite a diverse array of available sharps disposalcontainers, sharps and instruments continue to be rolled in drapes and/or linenand deposited in waste or laundry bags, threatening injury to handlers, haulers,and processors, Pugliese offers. Used syringes and needles such asinsulin syringes are also disposed of by patients, such as diabetics, inpublic waste containers.

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

For example, VASDHS were looking at what you would call downstreamsharps injuries, Poulos recalls. In other words, the housekeeping staffand the kitchen staff. If somebody leaves a sharp in a bed sheet or maybethey actually put the sheet into the basket and then they wheel it down to thelaundry facility somebody could get stuck. Same thing with the food trays;somebody could put the needle underneath a napkin. They (VASDHS) have providedtraining to their housekeeping and dietary staff and if they find a sharp, theyare trained to report it and then try to backtrack it. They backtrack toreeducate. Im sure many hospitals kitchen staff is not trained and iftheres 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 theoverall rate of percutaneous sharps injuries is 27 per 100 occupied bedsannually. 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 199different healthcare institutions, conducted by the California Department ofHealth Services Sharps Injury Control Program, showed housekeeping and laundrystaff to be the fourth most vulnerable worker group, behind nurses, physicians,and phlebotomists. Housekeeping and laundry staff in the study suffered nearly10 percent of all sharps injuries.

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

I think training takes place, but the effectiveness of thattraining session is difficult to judge, she clarifies. I also imagine thatmany people learn how to use a device from a coworker sharing their deviceknowledge. Whether the knowledge that is shared is accurate and the bestway to use a device is another area that is difficult to measure, she pointsout.

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

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

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

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

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

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

References:

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

2. Wilburn, S. Needlestick and Sharps Injury Prevention OnlineJournal 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 Casefor Needlestick Injury Prevention.
www.bbraunusa.com/index.cfm?uuid=A72343ACD0B759A1E3E099509D809577 , and International Sharps Injury PreventionSociety (ISIPS).

4. Dement, JM. Blood and body fluid exposure risks amonghealthcare 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 sharpsinjuries; 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 inhealthcare workers: a case-crossover study. Am J Med. 114(8):688-94, 2004.

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

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

9. Chiarello, LA and Bartley, J. Prevention of bloodexposures 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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