Although incremental gains continue, needlestick and sharps injury prevention efforts overall have plateaued and there is a risk of complacency in healthcare settings due to the perceived diminished threat of the major bloodborne pathogens, according to an expert on the issue.
Terry Grimmond, FASM, BAgrSc, GrDpAdEd, an Australian microbiologist with 50 years of experience as a consultant on sharps injury prevention, finds some troubling trends.
“We used to be very concerned about sharps injuries, but in my opinion sharps injuries have fallen off the radar somewhat,” he said recently in Portland at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC).
Although transmission via needlestick remains a rare but real risk, Grimmond cited the general perception that HIV has become a chronic, treatable condition and patients typically are not hospitalized for care. Similarly, although there is a large population of HCV carriers, there are now treatments for the infection. Of course, there is a vaccine for hepatitis B, which healthcare workers are routinely administered if they don’t exhibit evidence of existing immunity. Still, that leaves a wide variety of bloodborne threats that can be injected by a needlestick.
“Do you know how many pathogens are capable of being transmitted [by sharps injury]? Sixty,” Grimmond said. “Six years ago, a nurse in South Africa died from a needlestick injury. Malaria was transmitted from a patient. It was a mosquito without wings.”
In addition, the emergence of Ebola and Zika underscores that the next bloodborne threat via sharps injury may be looming on the horizon. “The organisms are cleverer than us. There are others around the corner,” he said.
While the 2001 U.S. Needlestick Safety and Prevention Act resulted in a 38% reduction of sharps injuries the year after it became effective, only incremental progress has been made since then.
Using multiple denominators and surveillance data, Grimmond said many U.S. healthcare facilities are finding it exceedingly difficult to significantly lower their injury rates. Predictions that sharps injuries were on their way to extinction after the needlestick act was passed now seem particularly farfetched.
“We’re not achieving it, guys — we’re nowhere near it,” he said. “We actually have had a decrease. It was 2.7 per 100 FTE [full-time equivalent employees] in 2001. Now, it’s 2.1 — 16 years later. It fell 38% in one year. We have not even matched that 38% 16 years later — 1.4% a year reduction. I am passionate about trying to reduce injuries among healthcare workers, and we are not doing it enough yet.”
Rising Risk in Home Care
There are high-achieving “sharps-aware” hospitals that typically run about 70% below the national average of sharps injuries, he said. However, too many settings have insufficient systems in place to reduce the estimated 320,000 sharps injuries that occur annually in the United States.
“That’s 800 a day,” he said. “Half of those injuries occur in hospitals, but half of all the healthcare workers in the U.S. don’t work in hospitals. The biggest growth industry at the moment is home healthcare — it is rising so rapidly.”
Indeed, home health is on the expanding frontier of care delivery, and it is likely that many sharps injuries are not being reported or captured in formal surveillance systems.
In one study, a questionnaire survey was administered to aides hired by home care agencies and directly by clients. Overall, 1,178 aides completed questions about sharps injuries and potential risk factors occurring in the 12 months before the survey. Aides had a 2% annual risk of experiencing at least one sharps injury. Client-hired aides, men, and immigrants had a higher risk than their counterparts. Risk factors among all home care aides included helping a client use a sharp device, observing used sharps lying around the home, and caring for physically aggressive clients.
“We calculated a 2% annual sharps injury risk among healthcare aides, corresponding to an annual rate of 6.5 SI/100 FTE,” the authors concluded.1 “Although the risk may appear low, this is the annual risk among a large and expanding population of home care workers who generally have limited access to healthcare.”
No Data, Big Problem
In the most recent hospital surveillance collected by Grimmond and colleagues for the AOHP’s EXPO-S.T.O.P. survey, 45.6% of sharps injuries were reported by nurses, he said. However, he expressed concern that the total sharps injuries reported by physicians (32.8%) and those working in surgery (38.3%) are trending downward.
“What worries me is that these two numbers are down from previous years,” he said. “I have a fear that doctors are reporting fewer of their injuries. Remember, these are only reported injuries.”
The concern, in part, is that the same emerging complacency about the threat of bloodborne pathogens could result in fewer reported injuries. One of the hazards of underreporting and lax surveillance systems is that the dearth of data will translate to inaction. Thus, the adage, “no data, no problem, no action,” Grimmond said.
To counter these trends, establish sharps injury reporting systems that are fully transparent to all staff. Provide regular updates of exposures to decision-makers so a safety culture permeates, he urged.
“Make your sharps injury reduction goals part of your institution’s strategic plan,” Grimmond said. “You can’t use a benchmark. Zero has to be your benchmark for sharps injuries. You won’t do it on your own. Find a champion. There is always one on every unit — even the OR.”
While leadership support is critical, one must bridge the gap and ensure frontline staff are directly involved, he said.
“Do not assume new staff know what they’re doing in your hospitals,” he noted. “The sharps-aware hospitals that brought their injury rates down — if they know that a new staff member is going to handle sharps, they don’t let them on the unit until they’ve demonstrated they can [use the needle devices] safely on manikins. That’s called competency-based training, not ‘see one, do one, teach one.’”
Workers should return for training if they suffer a sharps injury or if a new engineering device is introduced.
Grimmond recommended using a safety script with patients prior to a sharps procedure, citing this example: “I’m about to use a sharp. For your safety and mine, I need you to try and be as still as you can.” Likewise, door signs can be posted before the procedure, warning, “Do not enter. A sharps procedure is in progress,” he said.
For investigations, Grimmond advocates “no blame, no shame” to encourage reporting of every incident. “When there is a trend or problem, ask the users for their opinion,” he said. “Involve the unit manager, leadership, and the employees. Investigate every incident. Confirm they had a safety-engineered device available and they knew how to use it.”
Remember that it is required by OSHA that new sharps prevention devices be evaluated annually, he emphasized.
“People say to me, ‘I’m using safety-engineered devices for almost every procedure,’” Grimmond said. “‘Is there a better one?’ They don’t know. The OSHA law says that, on an annual basis, you must evaluate the other technology that may be better than the technology you’re using.”
Celebrate safety milestones and recognize worker achievements, he added. “When they know this is backed from the top, it’s a safer hospital,” he said.
Another idea is to hold safety forums that open with a thought-provoking question like, “If you arrived at work today and it was a safer environment, what would it look like?”
Don’t assume sharps protection devices are being used correctly — or used at all, for that matter. “I’ve emptied sharps containers and counted every single item,” he said. “I have seen safety devices not activated at all. I was shocked at the number of safety devices that were used that were not activated. Why would you pay more money for a safety device that you are not going to use?”
Although the use of sharps safety-engineered devices is mandatory, shrinking healthcare resources make it difficult for facilities to make the best and safest devices available. Grimmond argued that efforts to reduce healthcare-associated infections (HAIs) in patients have resulted in fewer resources for employee health efforts to reduce needlesticks.
“We need to renew our focus,” he said. “We are concentrating — as we should — on the patients with HAIs, but we forget about our own colleagues who are being injured. Eight hundred a day. Guys, let’s care for the carers.”
- Brouillette NM, Quinn MM, Kriebel D, et al. Risk of sharps injuries among home care aides: Results of the Safe Home Care survey. Am J Infect Control 2017;1;45:377-383.