The emotional toll of needlesticks and sharps injuries to healthcare workers often is overshadowed by the sheer numbers and statistical analysis.
Terry Grimmond, FASM, BAgrSc, GrDpAdEd, a microbiology consultant and one of the principal investigators in the EXPO-S.T.O.P. (EXPOsure Survey of Trends in Occupational Practice), recently shared a story. The ongoing study of sharps injuries and exposures in healthcare workers is supported by The Association of Occupational Health Professionals in Healthcare (AOHP).
“You can’t put a cost on the emotional impact of sharps injuries,” he said at a recent AOHP webinar. “I will never forget a healthcare worker came to me just suffering after she sustained a deep, penetrating injury with a bloody needle. She sobbed and sobbed. She had just been married. She and her husband were trying to have children, and she kept on saying to me, ‘They tell me we’ve got to stop trying until I know my results. How am I going to tell my husband?’”
Grimmond was joined at the webinar by Linda Good, RN, PhD, COHN-S, manager of occupational health services at Scripps Health in San Diego. They discussed trends and preliminary data from the 2018 EXPO-S.T.O.P. survey.
Grimmond and Good suggested the increase in needlesticks in recent years may be due in part to the use of the number of hospital beds as a denominator. As an alternative, the survey is moving to the number of full-time equivalent (FTE) staff, which they think will be a more accurate reflection of sharps injury rates.
“We believe beds or average daily census may no longer be the most suitable denominator because of changing hospital admission patterns,” Grimmond said. “There are now more day patients in our hospitals and fewer overnighters. Your workload increase is not being reflected in occupied beds.”
More than half of all patients are now seen on an outpatient basis, Good added. “That is a lot of patients, a lot of healthcare personnel taking care of them, and probably a fair number of sharps injuries,” she said. “But these are no longer being properly captured when we use average daily census because they are not there overnight.”
With occupied beds decreasing throughout the United Sates, it can give a false impression that sharps injury rates have risen markedly since 2001. “If you use FTE it actually shows that sharps injuries have decreased since 2001, at least somewhat,” Grimmond said.
600 Exposures Daily
Still, the current rate shows there are 600 exposures daily in U.S. hospitals. “Only 27% of U.S. healthcare workers work in hospitals,” he said.
While the investigators are improving the survey to get a more accurate read, they emphasized that needlsticks remain a large problem that has not been mitigated by various new treatments for bloodborne infections like HIV and hepatitis.
“There are 60 pathogens that can be transmitted by needles — 26 viruses, 18 bacteria, three fungi, and 13 parasites,” Grimmond said. “Two HCWs in the last eight years have died of malaria from a needlestick injury.”
Presenting 2018 data from 174 hospitals in 33 states, Grimmond said, “We are relieved to say that 2018 is showing a leveling. If you use FTE, it shows the rates have decreased this year compared to last year.”
Overall, it appears that small hospitals and large hospitals at opposite ends of the spectrum experience high rates, while those in the middle tend to report fewer exposures.
“We think the smaller hospitals — under 1,000 FTE — probably report more injuries,” he said. “Everybody knows each other; no shame, no blame. But in larger hospitals, there truly is a higher risk because of more sharps being used.”
In 2018, nurses represented 38.9% of all sharps injuries. “Overall, nurses’ sharps injury rates are lower than in 2015, and we believe this suggests greater access to safety devices in clinical units as distinct from the OR,” Good said.
Indeed, 42.8% injuries occurred in the OR, but physician rates are difficult to determine because many are not hospital employees and do not necessarily have to report.
“In OR procedures, the percent of sharps injuries are actually rising,” Grimmond said. “In 2018, for the first time, it was above 40%. Twenty years ago, surgery was about 20-25% of all reported injuries because there were so many sharps injuries in clinical units. Now, with greater use of safety-engineered devices, there are less injuries in those units and the OR is proportionally going up.”
Most injuries in surgical procedures are sticks with suture needles. There has been a push in recent years to use blunt surgical needles, but many surgeons prefer standard sharps over the safety designs.
“Occupational health practitioners need to be better partners with OR managers, infection preventionists, and surgical leaders in assisting with device evaluation for alternatives,” Good said.
Good also reminded that healthcare workers remain vulnerable to blood splash exposures to the eyes and other mucous membranes. Many eye exposures occur because the healthcare worker is not wearing eye protection.
While many sharps devices are designed to prevent needlesticks, many of them are not activated before disposable, Grimmond said. In research for an upcoming paper, he opened 2,000 sharps containers at 29 U.S. hospitals. He found that 11% of hollow-bore needles were conventional and did not include safety features. Of those with safety designs, 4% were not activated to protect the worker. In addition, 5% of needles were recapped before disposing, which is no longer recommended because it can lead to needlesticks.
“We are still using far too many standard, hollow-bore needle devices,” he said. “Also, more than half of injuries related to sharps safety devices occurred during or after activation of the device. We need to use safety devices that are less dependent on manual activation. We need to be looking annually at better devices.”
When a sharps injury occurs, take a close look at the worker and the circumstances of the accident. “Make sure workers know how to properly use safety devices, including new staff, interns, residents, students, and agency personnel. Is there a safer, next-generation alternative?”
Never accept the common explanation that exposures are just part of the job. “I push back on that,” Good said. “If exposures were just inevitable or part of the job, we would see pretty much the same rates in all hospitals. This study refutes that by allowing us to identify hospitals with very low exposure numbers. Each year, we reach out to the occupational health professionals at these hospitals and ask them to tell us what they are doing to get such exemplary results.”
Some common themes at these successful institutions include personalized coaching for someone who has been injured, transparency and communication about the program, and sharing success stories with administration. By the same token, if poor practices are observed, they are discussed at a staff meeting in case other workers are doing the same.
“Make sure the devices you are using have been evaluated by the staff,” Grimmond said. “They will be more likely to use them correctly if they were involved in their selection. Secondly, try to move away from mechanically activated devices and toward semi-automatic and automatic devices.”