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Study Shows Needlestick Injuries...On the Gradual Decline
By Kelly M. Pyrek
The Centers for Disease Control and Prevention (CDC) estimatedthat the nation's approximately 10 million healthcare workers (HCWs) face asmany as 384,000 percutaneous injuries (PIs) annually. A Government AccountingOffice (GAO) report estimated several years ago that at least 69,000needlesticks in hospitals could be eliminated through use of sharps safetydevices.
"Gradual but steady" is the way experts arecharacterizing the adoption by healthcare facilities of these safety-engineeredsharp medical devices in an ongoing effort to reduce the occurrence of PIs.Making use of sharps safety devices mandatory were the Needlestick Safety andPrevention Act of 2000 and the Occupational Safety and Health Administration'srevised Bloodborne Pathogen Standard. Clinical trials comparing safety devicesto conventional devices have demonstrated various benefits of the new technologyand have shown downward trends in the number of needlesticks reportednationally.
June 2003Experts say this is encouraging, but there has been a lack ofdocumentation showing the impact of the needlestick act and thesafety-engineered devices in a multi-hospital sharps injury surveillancenetwork. To that end, the International Healthcare Worker Safety Center (IHWSC)at the University of Virginia looked at data from its EPINet Multi-hospitalSharps Injury database and compared needlestick injury rates from 1993 and 2001from a network of participating EPINet hospitals. The study, published in theIHWSC's Advances in Exposure Prevention (Vol. 6, No. 3, 2003), focused onnurses' needlestick reporting actions and data from teaching hospitals
"Nurses represent the occupational group sustaining the most needlestickinjuries and the most stable group in terms of reporting patterns," saysJane Perry, director of communications at the IHWSC. "We found an overall51 percent decrease in sharps injuries for conventional and safetydevices."
According to the study, the overall PI rate declined from 19.5 PIs per 100occupied 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, whichis good news, but there's always more to be done," Perry adds. "Butthis definitely shows the right trend. It shows that hospitals have gotten themessage and are taking the need to convert to safety devices seriously.
Perry says that although the Needlestick Safety and Prevention Act and OSHA'srevised Bloodborne Pathogen Standard have continued to raise awareness andensure compliance, the trend toward elimination of PIs began early in the 1990s.
"The downward trend started with OSHA's 1991 Bloodborne PathogenStandard," Perry says. "At the time there was some movement on safetydevices but healthcare facilities pretty much saw them as being optional. In1999 OSHA revised its compliance directive for bloodborne pathogens and that'swhen the agency stated for the first time safety devices were mandatory andcompliance was enforceable. Current data reflects a cumulative effect of thethree actions: OSHA's revised directive in 1999, the Needlestick Safety andPrevention Act in 2000 and the revised BBPS in 2001. Congress and OSHA have madeit clear it is not optional and facilities are getting that message."
In a study that examined the prevalence of safety needle devices and factorsassociated with their adoption, National Institute for Occupational Safety andHealth (NIOSH) researcher Raymond Sinclair, PhD, and colleagues collected andanalyzed data on the adoption of safety engineered devices in 494 U.S. hospitalsfrom 1999 to 2000. The study showed that although 83 percent of the samplereported adopted some kind of safety device, this adoption was inconsistentacross types of devices. All of the units in 52 percent of the facilities hadadopted needleless intravenous delivery systems, but the hospitals used othertypes of engineered safety devices less often. Predictors of adoption, accordingto Sinclair's study, was cost, as well as the size of the hospital and thepresence or absence of state legislative activity on the PI issue.
The researchers concluded that smaller hospitals may require specialencouragement and assistance from outside sources to adopt expensiverisk-reduction innovations such as engineered sharps safety devices. Theresearchers said that although safety devices are the mandated and preferred wayto protect HCWs from needlesticks, complete adoption of this technology dependson the support of the social systems in which it is used and the people who useit.
While just one needlestick is too many, Perry says there must be anappreciation of just how much effort goes into sharps safety compliance and howchange is gradual.
"I think we should remain very optimistic and not look it as stillhaving too many needlesticks," she adds. "We want to reduce them asmuch as possible but when you talk to people who are actually trying to do so intheir facilities, you realize how complicated it is -- especially when involvingfrontline healthcare workers. Ideally, they should have been doing this 10 yearsago, not in the last year or two; however, it takes time for facilities to do afull-scale conversion to sharps safety devices. There will be some residualneedlesticks that occur during use, and needlesticks can occur with safetydevices, especially ones where the safety device isn't activated. These numbersare very good and we think we will continue to see a decline."
When it comes to conventional devices, disposable syringes caused thegreatest 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 PIinjuries from needles on IV lines per 100 occupied beds in 1993, while therewere no injuries in 1991, a dramatic decrease some attribute to the widespreadimplementation of needleless and recessed IV systems that were created after the1992 safety alert issued by the Food and Drug Administration.
The study also showed that PIs were reduced for nearly all conventionalneedles that injure nurses, including intravenous catheters (55 percentdecrease), phlebotomy needles (70 percent decrease), prefilled syringes (62percent decrease), winged steel needles (55 percent decrease), and lancets (87percent decrease). PIs caused by suture needles decreased by 5 percent.
These decreases are due in part to manufacturers introducing new and improvedsharps 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. "Wecontinually 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; ofcourse, it is in their best interest that their products be used correctly andsafely. In terms of continuing to develop better safety devices, I think morepassive devices should be considered. (IHWSC director) Janine Jagger has pointedout that we need to see more passive safety designs where appropriate. There aresome devices, like syringes, where you wouldn't want a fully passive designbecause they are used for a lot of different purposes. You have to look atparticular uses, as there is no one blanket answer for passive devices. Ingeneral, passive is good; we see the number of injuries that occur duringdisposal that if the safety mechanism was activated you wouldn't have thoseinjuries. Presumably, passive mechanisms would prevent those injuries. I thinkwe would like to see the trend go toward more passive designs but taking intoconsideration what the devices are used for."
In 1993, when nurses were asked whether the device that injured them was asafety design, 4 percent said yes. In 2001, 25 percent said yes. In 1993, the PIrate for all safety devices was .75 per 100 occupied beds; in 2001 it was 2.3per 100 occupied beds. By contrast, the PI rate for all conventional devicesdeclined from 18.75 per 100 occupied beds in 1993 to 7.3 per 100 occupied bedsin 2001. Perry cautions healthcare professionals not to misinterpret thesefindings.
"It's a matter of correctly interpreting the data," Perry says."It reflects an increased use in safety devices. You have to keep in mindthe total picture and that there has been a decrease in injuries. The data saysbecause there was a decrease in use of conventional devices and an increase insafety devices, the overall sharps injury rate has gone down. We separated theconventional and the safety data in the 1993/2001 comparison and found a sharpdecrease in injuries from conventional devices and an increase in injuries fromsafety devices. You can look at that and say, 'What's the problem there?' butour interpretation is because there's a lot fewer conventional devices beingused, you see this dramatic decrease in the sharps injury rate. As more safetydevices are used, we'll see an increase in injuries from safety devices. Someinjuries will be hard to eliminate even with the use of safety devices -- theinjuries that occur during use. You must look at that data in context with theoverall decline -- that's not to say there are some safety devices that couldn'tbe better designed. Included in that data is the fact the safety mechanismsimply wasn't activated."
According to a separate 2001 study undertaken by the IHWSC, the safetymechanism was not activated in 71 percent of the usage, and 57 percent of theinjuries occurred before the safety mechanism was activated. Perry sayseducation can help cut down on safety device-related injuries.
"When it comes to safety mechanisms causing injury, I wouldn't say it'sanyone's fault; in some cases it may be that a healthcare worker just didn'twant to take the time to activate it," Perry says, "although the timeit takes is miniscule. Some people just haven't received the training theyneed."
Perry recalls her own experience with a nurse who hadn't received training ona safety device. "When I went to my doctor's office for an annualexamination, the nurse who drew my blood used a safety butterfly needle. Aftershe drew the blood she just put the butterfly device into the disposal containerwithout activating the safety mechanism. I pointed out to her that it was asafety device, but she hadn't been there the day they did the training so shehad no idea how to use it. Healthcare facilities pay good money for safetydevices and healthcare workers don't know how to use them. It takes constantinservicing and follow-up for people you missed, plus more follow-up for evenmore people you missed. Facilities should also get rid of conventional deviceswhen they convert to safety devices so HCWs don't have the option of fallingback on the conventional devices."
Perry admits that training can be a formidable process.
"Facilities must make sure that all potential users of the safety devicereceive training. A big facility might use three or four different safetydevices for different purposes or in different clinical settings, so it's a bigjob and it takes time. Of course, you need cooperation from staff. There areHCWs who don't want the training and that's a sizeable hurdle to overcome."
Perry likens sharps safety compliance to handwashing compliance -- it's anuphill battle in either situation.
"With handwashing, you must keep doing the training and constantreminders. With sharps safety, if you don't have conventional devices, they areforced to use the safety devices. I have heard stories about hospitals that faceall this complaining about how HCWs can't use safety devices. I recall reading aletter published in a medical journal written by a surgeon infected withhepatitis C. He said that regarding precautions like double gloving, until hewas infected and learned he actually infected a patient, he thought he couldnever 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 riskybehavior, you readjust."
In the 1993/2001 study, PIs to nurses from conventional devices occurred mostfrequently in patient rooms, followed by ORs, intensive care units and emergencyrooms.
"Wherever you have the most needle-related procedures being done, that'swhere you will see the most needlestick injuries," Perry says. "Therealso are disposal-related injuries and injuries that occur in every part of thehospital." The study showed decreases in PI rates for each aforementionedsetting: 65 percent, 50 percent, 79 percent and 54 percent, respectively.
When it comes to procedure-related rates, PIs from conventional devicesoccurred most frequently while giving injections; these rates decreased by 39percent, according to the 1993/2001 comparison. The study showed a 50 percentdecrease for drawing venous blood; a 59 percent decrease for starting IVs, and a96 percent decrease for saline flushes. The 1993/2001 comparison showed that PIsfrom conventional devices occurred most frequently during use or between stepsof a multi-step procedure (32 percent in 1993 for both categories combined and31 percent in 2001). Rates in these combined categories decreased by 61 percentfrom 1993 to 2001.
"It will be interesting to look at the rates again in a year or two andsee what the latest trends are. If this pattern of injury decreases continues,it looks like we are really tackling this problem."
FRANKLIN LAKES, N.J. -- Becton Dickinson and Company (BD) announces plans todiscontinue U.S. sales of many conventional needles and other sharps devicesacross a range of product categories. This action coincided with the secondanniversary of the April 18, 2001 compliance date for the Federal NeedlestickSafety and Prevention Act and reflects the progress made by U.S. healthcarefacilities in transitioning to safety-engineered designs.
"In the past 15 years, the medical device manufacturing industry hasintroduced a continuous stream of safety-engineered sharps device innovationsdesigned to protect healthcare workers from injuries," said Edward J.Ludwig, chairman, president and CEO of BD. "Healthcare facilities have madegreat progress in the change-over to safety-engineered designs. Based on thisprogress, BD is now able to discontinue the sale of many conventional sharpsdevices without disrupting patient care or clinical practice."
BD estimates that U.S. hospitals have transitioned 80 percent of their sharpsproduct usage from conventional to safety-engineered designs in IV catheters,needleless IV connectors, blood drawing needles, winged needle sets and lancetdevices. The level of transition is lower for syringes and needles, surgicalblades, scalpels and other categories of devices utilized for specialty medicalprocedures. Across all product categories, the overall level of transition tosafety designs remains lower in clinics and physicians' offices than inhospitals.
BD sales consultants are prepared to work with healthcare facilities to helpensure a smooth transition.
ABBOTT PARK, Ill.--By this month, Abbott Laboratories will phase out all IVsets that contain or require needles, as part of the company's continuedcommitment to improving patient and healthcare worker (HCW) safety. By no longermanufacturing and marketing these products, the company expects millions ofneedles to be eliminated from the U.S. healthcare system, further protectingHCWs against needlestick injury and blood exposure. Abbott will use aneedle-free technology across its entire line of infusion therapy products.
"Needles cause needlesticks. If you eliminate the needles, you eliminatethe risk," says John Arnott, vice president, hospital business sector,Hospital Products Division, Abbott Laboratories. "For more than fourdecades, HCWs had little, if any, needle-free alternatives. Today, newtechnology allows us to provide innovative products that offer protectionagainst needlestick injuries."
Julie Naunheim-Hipps, a nurse from Glendale, Mo., knows first-hand the risksthat needle-based products pose. In 1999, Naunheim-Hipps contracted hepatitis Cfrom a needlestick injury and has since been actively involved in passing stateneedlestick safety legislation.
"My injury may have been prevented had I had access to products designedto reduce needlesticks," says Naunheim-Hipps. "Abbott's decision tophase-out the use of needles in certain products is a major step forward inprotecting HCWs. Needleless products also help hospitals comply with new federalneedlestick protection regulation."