Occupational Health Experts Call for Greater Commitment to Sharps-Injury Prevention

By Kelly M. Pyrek

The Centers for Disease Control and Prevention (CDC) defines a sharps injury as a penetrating stab wound from a needle, scalpel or other sharp object that may result in exposure to blood or other body fluids. Sharps injuries are typically the result of using dangerous equipment in a fast-paced, stressful and understaffed environment. These conditions can increase the risk of injury and infection for healthcare workers.

The CDC estimates that about 385,000 sharps-related injuries occur annually among healthcare workers in hospitals. More recent data from the Exposure Prevention Information Network (EPINet) suggest these injuries can be reduced, as sharps-related injuries in non-surgical hospital settings decreased 31.6 percent during 2001 through 2006 following the Needlestick Safety and Prevention Act of 2000. However, injuries in surgical settings increased 6.5 percent in the same period, where adoption of safety devices was limited compared to non-surgical settings. It has been estimated about half or more of sharps injuries go unreported. Most reported sharps injuries involve nursing staff, but laboratory staff, physicians, housekeepers, and other healthcare workers are also injured.
Healthcare workers may also incur injuries from improper procedures, such as passing sharps hand-to-hand between team members, placing sharps in a disposal container, or failing to use a safer sharps device. A report from the Exposure Prevention Information Network (EPINet) found that nearly half of all sharps injuries occurred during use of the sharp, and of the nearly 40 percent of needle injuries which involved a safety designed needle, the majority occurred before activating the safety device. Moreover, the report also showed that many sharps injuries occurred in patient rooms among nurses and operating rooms among surgical team members. (EPINet 2009)

The cost of a sharps injury can be a compelling reason to use safer sharps practices. One sharps injury can cause a number of direct and indirect costs for the healthcare facility, including:
- Loss of employee time
- Cost of tying up staff to investigate the injury
- Expense of laboratory testing
- Cost of treatment for infected staff
- Cost of replacing staff

In addition to costs incurred by the healthcare facility, the stress on the affected worker and the worker’s family can be enormous. In addition to the initial concern, testing for bloodborne pathogens can last for months, producing feelings of anxiety and distress for an extended period of time.
In addition to the use of sharps devices, injuries are also closely associated with certain work practices that can pose an increased risk of bloodborne pathogen exposure. These work practices include:
- Disposal-related activities (11%)
- Activities after use and prior to disposal, such as item disassembly (30%)
- Recapping a used needle (3%)

Injuries are also closely associated with certain devices that can pose an increased risk of bloodborne pathogen exposure. These devices include:
- Disposable Syringe (31%)
- Suture Needle (24%)
- Winged Steel Needle (5%)

Globally, Prüss-Üstün, et al. (2003) modeled the incidence and fraction of HBV, HCV and HIV infections that were attributable to a workplace percutaneous injury with a needle or sharp contaminated with bloodborne pathogens. The model was based on probabilities for the occurrence of joint events or states, including the probability of injury, the prevalence of active infection in the population, the susceptibility of the worker, and the percutaneous transmission potential. The model assumed that the risk of infection increased almost proportionally to the number of infectious individuals in the population, and was applied to 14 geographical regions, grouped on the basis of the World Health Organization (WHO) region and mortality strata. For developed regions, the effects of PEP for HBV and HIV were included in the model. The researchers found that the proportion of healthcare workers in the general population varied substantially by region (0.2 percent to 2.5 percent), as did the average number of injuries per health-care worker (0.2–4.7 sharps injuries per year). The annual proportions of healthcare workers exposed to bloodborne pathogens was 2.6 percent for HCV, 5.9 percent for HBV and 0.5 percent for HIV, corresponding to about 16 000 HCV infections and 66 000 HBV infections in healthcare workers worldwide. According to the model, 200 to 5,000 HIV infections would also be caused (with an expected value of 1,000 HIV infections). In developing regions, 40 percent to 65 percent of HBV and HCV infections in healthcare workers were attributable to percutaneous occupational exposure. In developed regions, by contrast, the attributable fraction for HCV was only 8 percent to 27 percent, and that for HBV was less than 10 percent, largely because of immunization and PEP. The attributable fraction for HIV in the various regions ranged from 0.5 percent to 11 percent.

Numerous barriers to sharps injury prevention exist and have been documented in the literature. Rapiti, et al. (2005) outline some of the determinants of sharps injuries:
- Overuse of injections and unnecessary sharps
- Lack of supplies, such as disposable syringes, safer needle devices, and sharps disposal containers
- Lack of access to, and failure to use, sharps disposal containers immediately after an injection
- Poorly-trained staff or a shortage of staff
- Recapping needles after use
- No engineering controls, such as safer needle devices
- Passing instruments from hand to hand in the operating suite
- Lack of hazard awareness and training

The inherent challenge of determining the number of sharps injuries is partly due to unreported incidents. As Zuraw, et al. (2013) acknowledge, "Despite the potentially serious consequences of percutaneous injuries (PCIs), practitioners in training often downplay the occurrence of PCIs and do not report exposures. Current literature implies that under-reporting of needlestick injuries is multifactorial. By not seeking care after needlesticks occur and thereby delaying treatment, residents incur more risk from exposures."

Zuraw, et al. (2013) sought to understand the underlying issues that might contribute to this lack of reporting needlestick injuries. Using an anonymous survey, the researchers collected information from emergency medicine residents regarding factors that contributed to sustaining a PCI as well as perceived barriers that prevented residents from reporting these exposures. Overall, 55.3 percent of respondents had at least one PCI, with an average of 1.73 sticks per resident. Of all residents with a needlestick injury, 36.5 percent did not report the exposure (42 of 115). Significantly more residents failed to report the PCI when the perception was that the patient was at low risk for communicable diseases (90.2 percent vs. 40.3 percent). Factors that were not found to influence the decision to report an exposure were potential negative repercussions and lack of comfort with the procedure.  Universal precautions were used “always” by 14 percent of residents and “most of the time” by 60.9 percent of residents. If a patient was thought to be associated with a high risk of communicable disease, 93.2 percent of residents responded that they would more thoroughly use universal precautions.

A lack of a cohesive national agenda for sharps injuries prevention in the wake of the Needlestick Safety and Prevention Act (NSPA) has hurt clinicians.  Phillips, et al. (2013) assessed the impact of the legislation on hospital worker percutaneous injuries by analyzing injury data from 85 hospitals. Injury rates were calculated per 100 full-time equivalents, 100 staffed beds, and 100 admissions each year from 1995 to 2005. They compared changes for each denominator, as well as measured the proportion of the injury rate attributed to safety-engineered devices. They also estimated a national change in injuries and associated costs. For all denominators, Phillips, et al. (2013) noted a "precipitous drop in injury rates of greater than one-third occurred in 2001, immediately following the legislation. The decrease was sustained through 2005. Concomitant with the decrease in rates, the proportion of injuries from safety-engineered devices nearly tripled across all denominators. We estimated annual reductions of more than 100,000 sharps injuries at a cost savings of $69 million to $415 million."

As Phillips, et al. (2013) explain, "The most frequently cited national estimate of annual hospital needlestick injuries is 384,325, calculated using EPINet and CDC–National Surveillance System for Healthcare Workers data from 1997 to 1998 (pre-legislation). Using the most conservative (lowest) injury rate reduction among the three denominators examined, 36 percent, we estimate that 138,357 needlestick injuries were prevented in each year of the post-NSPA period. Follow-up costs of reported percutaneous injuries, according to the U.S. General Accounting Office, range from $500 to $3,000. These costs do not include treatment costs of infected healthcare workers, wages and time lost, emotional distress, or loss of life." They concluded that "While the data cannot demonstrate cause and effect, the evidence suggests a reduction in hospital worker injury rates related to the NSPA, regardless of denominator. It also suggests an association between the increase in safety-engineered devices and the reduction in overall injury rates. The decreases observed translate into significant reductions in injuries and associated costs."

One of the outcomes of the NSPA was an uptick in the number of safety-engineered sharps devices available in the market. Laramie, et al. (2011) allude to the fact that sharps with engineered sharps injury protections (SESIPs) have been found to reduce risk of sharps injuries (SIs). They examined trends in SI rates among employees of 76 acute-care hospitals in Massachusetts, including the impact of SESIPs on SI trends from 2002 through 2007. Data on sharps injuries in acute-care hospitals collected by the Massachusetts Sharps Injury Surveillance System were used to examine trends in SI rates over time by occupation, hospital size, and device.

The researchers found 16,158 SIs that were reported to the surveillance system. The annual SI rate decreased by 22 percent, with an annual decline of 4.7 percent. Rates declined significantly among nurses (−7.2 percent per year; ) but not among physicians (−0.9 percent per year). SI rates associated with winged steel needles and hypodermic needles and syringes also declined significantly as the proportion of injuries involving devices with sharps injury prevention features increased during the same time period.

Are small declines but persistent SI rates acceptable? After two extensive surveys of healthcare workers in the U.S., two occupational health experts say that too many personnel are still being injured on the job, despite national legislation and changes to device design to address needlesticks. They emphasize that more than 400,000 healthcare workers annually sustain sharps-related injuries and assert that no decrease in the number of cases since 2001's signing of the Needlestick Safety Act has been identified.

Terry Grimmond, FASM, BAgrSc, GrDpAdEd, director of Grimmond and Associates, Microbiology Consultants in Hamilton New Zealand, and Linda Good, RN, PhD, COHN-s, director of employee occupational services for Scripps Health in San Diego, were concerned about bloodborne pathogen exposure from percutaneous sharps injury (SI) or mucocutaneous (MC) exposure and determined that more data were needed to establish benchmarks.
In 2012 Grimmond and Good worked with the Association of Occupational Health Professionals in Healthcare (AOHP) to administer an Exposure Study of Occupational Practice (EXPO-S.T.O.P.) among its members to establish a nationally representative BE database and benchmark resource. The electronic survey was developed and distributed to AOHP members to ascertain blood exposure incidence and denominator data.

The researchers requested 2011 data on total SI and MC incidence in the respondents' healthcare institutions and during surgical procedures; full-time equivalent (FTE) staff; average daily census, adjusted patient days (APD); teaching status, medical staff inclusion; and state. Incidence rates per 100 FTE, per 100 occupied beds (OB), and per 1,000 APD were calculated and compared with relevant U.S. databases. The researchers also determined the best practices from the top 10 lowest-exposure teaching and non-teaching hospitals. Survey results from 125 hospitals in 29 states were used to calculate a national estimate of BE exposures in hospital and non-hospital settings.

Grimmond and Good found that overall SI incidence rates were: 24.0/100 OB (17.8 in non-teaching and 27.4 in teaching hospitals); 1.89/100 FTE; and 0.53/1,000 APD. Overall MC incidence rates were 9.0/100 OB (7.1 in non-teaching and 10.1 in teaching hospitals); 0.69/100 FTE; and 0.20/1000 APD. Effective reduction strategies in low-incidence, “sharps aware” hospitals include: intense and repeated competency education; monthly institutional emails; easy incident reporting; management involvement; immediate action on ‘trends’; and zero as goal. Extrapolation of survey results indicate that in U.S. hospital and non-hospitals settings, 321,907 HCWs sustain SI and 119,437 sustain MC, thus 441,344 HCWs sustain BE annually.

An updated survey of AOHP members for 2011 and 2012 was conducted by Grimmond and Good, whose results were presented in June at the APIC annual meeting. Using the identical parameters as the aforementioned study, the researchers found 26.3 SI per 100 occupied beds for all hospitals; 2.1 SI/100 Full-time equivalent staff; 0.4 SI/1,000 adjusted patient days; and 43.3 percent for surgical procedure-related SIs. They concluded from this most recent study that the 2012 national estimate is more accurate than 2011 due to more data points as well as more accurate extrapolation; that 400,000 HCWs sustaining sharps injuries per year is unacceptable; and that a new vigor is needed with competency-driven education, more automated technology and zero injuries as a viable target for the future.

In terms of prevention, Rapiti, et al. (2005) state the obvious that "The most effective means of preventing the transmission of bloodborne pathogens is to prevent exposure to needlestick injuries. Consequently, primary prevention of needlestick injuries is achieved through the elimination of unnecessary injections, and the elimination of used needles. If steps are taken, such as implementing education programs and Universal Precautions, eliminating needle recapping, and using containers to safely dispose of sharps, needlestick injuries can be reduced by 80 percent. Additional reductions are possible if safer needle devices are used."

Traditionally, measures to prevent needlestick injuries have been ranked according to a hierarchy of controls, from most effective to least effective (American Nurses Association, 2002):
- Hazard elimination. Rather than use injections, administer medications another way, such as by using tablets, inhalers, or transdermal patches. Needleless intravenous systems, such as jet injectors, can be substituted for syringes and needles. If injections are used, minimize the number by eliminating all unnecessary injections. Remove unnecessary sharps (e.g. towel clips) and needles from the workplace.
- Engineering controls. Examples include needles that retract, sheathe, or blunt immediately after use. The technology of these devices has improved over the last decade, and they are required by law in the U.S.
- Administrative controls. These include policies and training programs aimed at limiting exposure to the hazard, such as Universal Precautions, allocating resources in such a way as to demonstrate a commitment to the safety of healthcare workers, instituting a needlestick prevention committee, formulating an exposure control plan, and having consistent training programs.
- Work practice controls. Examples include rules that prohibit the recapping of needles; placing sharps containers at eye-level and at arm's reach; checking sharps disposal containers on a schedule and emptying them before they become full; and establishing the means for safely handling and disposing of sharps devices before beginning a procedure.
- Personal protective equipment. These are barriers and filters between the worker and the hazard. Examples include eye goggles, face shields, gloves, masks and gowns. A control program to prevent needlestick injuries in health workers can only be effective when it is part of a larger occupational health and safety policy for the healthcare setting. A committed management team is therefore essential for the success of the program. Occupational health and safety committees also play a key role in implementing the strategies.

References

American Nurses Association. Needlestick prevention guide, p. 13. 2002.

EPINet. Activities associated with percutaneous injuries in EPINet hospitals. 2009.

Grimmond T and Good L. EXPO-S.T.O.P.: A national survey and estimate of sharps injuries and mucocutaneous blood exposures among healthcare workers in USA. J Assoc Occ Hlth Prof 2013;33(4):31-36.

Grimmond T and Good L. Presentation at APIC 2014, Publication No. 8-226. EXPO-S.T.O.P.: A National Survey and Estimate of Sharps Injuries and
Mucocutaneous Blood Exposures Among HCW in U.S.

Laramie AK, Pun VC, Fang SC, Kriebel D and Davis L. Sharps Injuries among Employees of Acute Care Hospitals in Massachusetts, 2002-2007. Infect Control Hosp Epidemiol. Vol. 32, No. 6, June 2011.  

Phillips EK, Conaway M, Parker G, Perry J and Jagger J. Issues in Understanding the Impact of the Needlestick Safety and Prevention Act on Hospital Sharps Injuries. Infect Control Hosp Epidemiol. Vol. 34, No. 9. September 2013.

Prüss-Üstün A, Rapiti E, Hutin Y. Sharps injuries: global burden of disease from sharps injuries to health-care workers. Geneva, World Health Organization, 2003 (WHO Environmental Burden of Disease Series, No. 3).

Rapiti, E, Prüss-Üstün, A, Hutin, Y. Sharps injuries: assessing the burden of disease from sharps injuries to health-care workers at national and local levels. Geneva, World Health Organization, 2005. (WHO Environmental Burden of Disease Series, No. 11).

Zuraw J, Sanford G, Winston L and Chan S. Stick and Tell: A Survey of Emergency Medicine Residents and Needlestick Exposures. Infection Control and Hospital Epidemiol. Vol. 34, No. 10, October 2013. 

A Q&A with Terry Grimmond

Q: Your EXPO-STOP study revealed a high rate of sharps injuries among US healthcare workers – to what do you attribute this -- lack of safety-engineered devices? Lack of understanding of how to use these devices? Lack of time/hurriedness on the part of HCWs? Other factors?
A: The fact that there has been no reduction in sharps injuries (SI) in the decade since the OSHA Needlestick Safety and Prevention Act (NSPA) is both disappointing and puzzling.  Our 2012 EXP-STOP study estimates that annually, 220,000 SI occur nationally in hospitals and another 170,000 SI occur in no-hospital settings – a disturbing 400,000 SI nationally – a decade after the NSPA. We know incontrovertibly that safety engineered devices (SED) reduce SI. We also know from the large French study and from recently published US studies, that automatic and semi-automatic SED are superior to active SED. In 2013, I asked several hundred occupational health managers what  percentage devices for hollow-bore sharps procedures would be SED – almost unanimously they stated “more than 80%”. It was surprisingly then that the contents of sharps containers in my 2013 small sampling of US hospitals revealed more than half the devices were not SED. The survey also revealed that of the SED, 22% were not fully activated at disposal. Time-pressure is a documented cause of SI but what the above data indicate is that insufficient SED are being used, and of the SED used, a good proportion are not used correctly.
 
Q: Has the Needlestick Safety Act in the US done anything to mitigate injuries overall? And if legislating change won’t work, what will?
A: In 2001 the U.S. incidence of SI fell 38% from the year before – a direct consequence of the NSPA. However our large 2011 Expo-STOP survey published in the Fall 2013 issue of JAOHP, and our larger, yet-to-be-published 2012 EXPO-STOP survey, show that there has been no reduction in the decade since. This is disappointing and puzzling and indicates that legislation is essential but legislation alone is not the answer.  Part of the answer may lay in the fact that some hospitals believe that as long as they adopt an SED, they are OSHA compliant, and although the device may be inferior, they do not change – either because of cost or ignorance of the law. The NSPA is very clear, you must annually examine new technology – whether you are using SED or not.  Put simply, if you have an SI issue, and there is a superior device on the market, and you have not evaluated it, you are breaking OSHA law.  The effect of adopting superior devices was classically revealed by Doris Dicristina’s study at Robert Wood Johnson published in JAOHP in Spring 2014 - they had an issue with venous access SI despite using SED, so they researched, evaluated and adopted a new semi-automatic technology – involving all stakeholders all the way - and their procedure-specific SI rate dropped from 25 to 5. The fallacy is to assume no one has invented a better mousetrap. What works? – Never resting in your quest for better understanding of the root causes and never resting in your search for a better mousetraps. And remember, OSHA state cost cannot be the sole reason for not adopting a better SED.

 
Q: What type of education and training do you think works best to address sharps injuries? What are infection preventionist NOT doing to address the issue and how can this be remedied?
A: The top 5 hospitals with lowest SI rates state that competency-based education, for everyone, doctors included, gets better results. Compulsory at orientation and repeated annually or at the most, every two years. It is NOT “See one, Do One, Teach one” - this has no place in a hospital.

Q: What are those low-incidence hospitals doing right when it comes to injury reduction/prevention? How can these interventions become more endemic among facilities?
A: It is common knowledge Hospital Acquired Infections is the “hot” issue occupying US hospitals. It is also common knowledge that healthcare professionals put patients before themselves. Reducing sharps injuries has slipped off the radar since the NSPA and needs be prominent throughout every hospital. In both our EXPO-STOP surveys we asked the top five lowest-SI hospitals how they did it and these were their answers:
• “Communication – Investigation – Engagement”
• Never rest collecting detailed data and asking Why? Why? Why?
• Never rest in putting SI data overtly in front of staff, frequently.
• Align SI reduction with organizational goals – get the C-suite behind you.
• Don’t stay under the radar. Keep zero as your goal. Push through resistance.
• Make it easy for staff to report SI. Follow-up every SI. Why? Why? Why?
• Present and/or publish your successes – others will want to emulate your success.
• Follow up every SI with compulsory, competency-based SI education.
• Partner with stakeholders
• Hold HCP and management responsible for SI safety – “It’s OUR problem.”

Q: What is your “wish list” for change for the future? What would it take to achieve everything on this list?
A: My wish list:
• Adoption of effective, staff-approved SED for every procedure
• Less use of “Active” SED and more use of automatic and semi-automatic SED
• Development of more automatic and semi-automatic SED by industry
• Inclusion of sharps containers in SED technology assessments
• Cost-reductions in SED matched with “understanding” Purchasing Managers
• Personal ownership of SI safety, including “Slow down with Sharps” campaign
• Compulsory, competency-based, repeated training for all sharps users
What would it take? Passion, commitment and  resources from a top-to-bottom, totally committed facility.