Needlestick injury rates stuck in limbo

OR, nonsafety devices may be culprit

Hospitals are stuck in a holding pattern in their sharps safety programs. Injury rates dropped dramatically after the implementation of safer sharps in 2001, but many facilities have since reached a plateau.

In about half the cases, the safety mechanisms were not activated, according to sharps injury databases, which indicates that either health care workers haven't been instructed how to use the devices properly or they don't feel comfortable activating them. Conventional devices still are commonplace, as well, the data indicate.

For example, for Massachusetts hospitals, the rate was 19.7 sharps injuries per 100 licensed beds in 2002. It dropped to 18.4 per 100 licensed beds in 2003, but then stayed the same in 2004. Massachusetts is the only state that requires all acute and chronic care hospitals licensed by the Department of Public Health to report their bloodborne pathogen exposures annually.

Among hospitals in the EPINet network of the International Health care Worker Safety Center at the University of Virginia in Charlottesville, needlesticks declined significantly from 1999 to 2001, but then remained stable since then.

While the operating room continues to be a challenge, many of the injuries occur with blood collection devices and syringes for which there are many safety options available. In Texas, which requires public facilities to report their bloodborne pathogen exposures, 47% of sharps injuries in 2006 occurred with devices that lacked safety features. In Massachusetts, more than half of the injuries involve devices without safety features.

"With hypodermic needles and syringes, in 2005 while we saw half of the injuries occurring with devices with safety features, we saw almost a third occurring with devices without safety features," says Angela K. Laramie, MPH, epidemiologist with the Sharps Injury Surveillance Project in the Massachusetts Department of Public Health in Boston.

"These devices with safety features have been available for a long time," she says. "There's no question that they should be used."

Moving forward to reduce needlesticks may require a renewed national focus, says June M. Fisher, MD, director of the TDICT (Training for Development of Innovative Control Technologies) Project in San Francisco.

"A number of people agree that we're at a plateau. I think we need to seek a national consensus that looks at why we're at that plateau and what needs to be done," she says. "We need to think of an agenda overall for health care worker health and safety."

One in five sticks from suture needles

If sharps injury rates are hardly budging, employee health professionals can look to one major culprit: the operating room.

It's clearly impossible to completely remove the risk in the operating room, where surgeons work in small spaces with sharp instruments. But suture needles account for a high portion of sharps injuries - 21% in the Texas data and 22% in EPINet. In surgical settings, according to 2006 EPINet data, 45% of injuries occurred while suturing.

Blunt suture needles could be substituted for sharp ones in as many as 60% of those cases, reducing the risk to surgeons, says Jane Perry, MA, associate director of the safety center. The quality and selection of suture needles has improved, but many surgeons remain reluctant to use them.

"There's hardly been any change in the market for blunt suture needles over the last five years," she says. "Until there is a change in OR injury rates, you will see relative stability in the [overall sharps injury] rates.

"With regards to needlestick injury rates, there are two important facts to keep in mind," she continues. "First, OR settings account for more than a third of sharps injuries in hospitals overall. What does or doesn't happen in ORs in terms of safety devices and health care worker protection will have a sizeable impact on institutional needlestick rates.

"Second, while there was a large decline in injury rates for most clinical settings after the Needlestick Safety and Prevention Act, there was no change in rates for surgical settings. Until compliance with implementation of safety devices - and specifically blunt suture needles - improves in ORs, we're unlikely to see further declines in rates," she says.

The OR poses some unique challenges for sharps safety; there still are procedures for which no safety device exists, Perry notes.

Yet too often, surgery personnel open pre-packaged kits and discover syringes with a fixed, conventional needle.

"[Employers] need to go through an inventory of what's used in the kits, then negotiate for kits with safety devices," says Laramie.

Some hospitals choose to purchase the less expensive kits with nonsafety devices and to switch the devices with their own safety versions. Yet as long as less expensive kits are available with conventional devices, there is a chance that some workers may not replace them with a safety device, says Gina Pugliese, vice president of the Premier Safety Institute, part of the Charlotte, NC-based Premier Inc. health care alliance.

Sometimes, health care providers receive their orders and discover the devices don't have safety features or a way to attach a safety needle - as was the case with Fluvirin pre-filled syringes manufactured by Novartis Vaccines.

"One of the biggest challenges in needle safety is circumstances in which hospitals can't control the sharps safety," says Pugliese.

Unsafe safety sharps?

Still, there's plenty of room for improvement that hospitals can influence. Most sharps injuries that occur after the use of the safety device indicate that the safety mechanism wasn't activated. That can be a training problem, a lack of safety culture, or employee dissatisfaction with the device.

Employers need to monitor the use of devices, especially after a new device is selected, says Kathryn Gardner, DrPH, RNC, CIC, CPHQ, bloodborne pathogen nurse consultant with the Texas Department of State Health Services in Austin.

"When a worksite begins to use a new device, it's critical for them not only to provide the education but to follow up to make sure that the employees know how to use it correctly - and they actually use it correctly," she says.

For example, in Texas public facilities, 75% of injuries with winged steel needles occurred with devices that had safety features. "The winged steel needle [butterfly], even if safety-engineered, is obviously a device with sharps injury risks," Gardner concluded in her analysis.

In Massachusetts hospitals in 2005, 18% of reported injuries involving hypodermic needles attached to disposable syringes with safety features occurred while the worker was activating the safety device." If it's not intuitive how to use the safety feature, people may not activate it, or they may get injured while activating it," says Laramie. "Is that a problem with the design of the device, or do people need more training?"

That is a question that employers should ask as they reevaluate their devices and track their injury rates, she says.

Meanwhile, there's one other issue that can confound the trends in needlestick rates: Underreporting. Needlesticks are notoriously underreported, despite the need for evaluation and follow-up. A focus on sharps safety should include an emphasis on reporting - but that also can affect a hospital's rates.

"It's not unusual when you start to tackle an issue within a facility to even see a small climb in the number of injuries," says Laramie.

Ultimately, that better reporting can point to weaknesses in the sharps safety program - and can lead to improvements and a real reduction in needlestick rates, she says.