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Needlesticks, sharps injuries dropping but safety device push must continue
'Until you eliminate the sharp completely, you still have a risk'
Reducing sharps injuries is one of the great success stories of occupational health and infection prevention.
With widespread adoption of safer sharps in hospitals, needlesticks declined by more than half for some of the most hazardous devices. Safety has become the norm in phlebotomy. Needle devices are placed in sharps containers instead of being left on bed linens or carts, where someone else may be stuck.
This month marks the 10th anniversary of the Needlestick Safety and Prevention Act, which is credited with changing the safety paradigm. While many challenges remain to protect health care workers, safety experts are pausing to acknowledge the progress that's been made. They also are touting changes in device design that evolved from simplistic needle shields to passive devices that don't require additional steps to activate safety features.
"If we look back 25 years, before we were so sensitized to the risk of bloodborne pathogen exposure, we can see that all the strategies we've put into place have had a huge impact," says Janine Jagger, PhD, director of the International Healthcare Worker Safety Center at the University of Virginia in Charlottesville and a pioneer in sharps safety.
Market data of medical device sales illustrate that U.S. hospitals have shifted significantly in their purchases. In 2002, less than half (46%) of core hypodermic needles had safety features, according to Global Healthcare Exchange, a Louisville, CO-based collaborative of manufacturers, distributors, hospitals and group purchasing organizations. Today, 95% of core hypodermic needles purchased by acute care hospitals are safety-engineered.
A similar pattern occurred with blood collection needles. More than one-third (38.6%) of blood collection needles in acute care hospitals were conventional devices in 2002, but today, 94% are safety devices.
In fact, Becton, Dickinson and Company of Franklin Lakes, NJ, the world's largest manufacturer of needles and syringes, discontinued sales of conventional blood collection needles in the U.S. market in 2009. The company said it plans to discontinue conventional blood collection sets in 2011. Conventional blood collection wingsets represent less than 1% of wingsets sold by BD in the U.S. market, according to Mike Borlet, senior director of U.S. marketing for BD Diagnostics Preanalytical Systems.
Risk of transmission drops
Advances in vaccination, rapid testing, and post-exposure prophylaxis also have greatly reduced risk for health care workers.
In 1983, the year the hepatitis B vaccine became available, 10,721 health care workers acquired hepatitis B. By 1999, seven years after the U.S. Occupational Safety and Health Administration required health care employers to offer hepatitis B vaccine, the number had dropped to 384.
Vaccination, though widespread, is not universally accepted. A study of data from 2002-2003 found that 81% of nurses and physicians but only 71% of phlebotomists and nurses' aides received the hepatitis B vaccine.1
"We've also made very significant progress in reducing health care workers' risk from HIV," says Jagger. HIV patients are often on medications that lower their viral load, which also lowers the risk of bloodborne transmission, and they receive more care outside the hospital setting.
"We've come a long way and we've made significant progress," says Gina Pugliese, RN, MS, vice president of the Premier Safety Institute, part of the Charlotte, NC-based Premier Inc. healthcare alliance.
Of course, needlesticks continue to occur and now a majority of them are with safety-engineered devices. "Until you eliminate the sharp completely, you still have a risk of injury," says Pugliese.
Nurses still at greatest risk
To evaluate needle safety, it's important to look at both the big picture and the individual event, safety experts say.
Surveillance data reveal the areas of progress as well as gaps. For example, in Massachusetts, where state law requires all hospitals to report needlestick data each year, the rate per 100 beds has declined from 19.7 in 2002 to 17.2 in 2008, a reduction of 13%. Nurses remained at greatest risk of needlesticks, despite overall reductions (41% of needlesticks in 2002 compared to 38% of needlesticks in 2008).2
Sharps injuries vary greatly both within hospitals and from one hospital to another. Operating rooms are the riskiest location, accounting for 38% of needlesticks, according to the Massachusetts data. Large teaching hospitals experience the most needlesticks, and about half (47%) of the sharps injuries to physicians involve medical residents or medical students.
The EPINet system, a voluntary surveillance program with 29 participating hospitals, had similar findings. The overall rate of needlesticks in 2007 was 28 per 100 occupied beds, with greater rates in teaching hospitals (33 per 100 occupied beds) than non-teaching hospitals (16 per 100 occupied beds). Nurses were stuck in 34% of the reported injuries, and medical residents and medical students were more likely to be stuck than other physicians. EPINet is coordinated by the International Healthcare Worker Safety Center.3
While needlesticks have declined, surveillance shows where more work is needed to protect health care workers from bloodborne pathogens. But arguably, the most important data for any hospital comes from the facility's own sharps injury log, safety experts say.
"People need to focus their energies in looking at their own experiences in their own facilities, doing an analysis of why these injuries are happening," says Pugliese. "Even one injury can give you information. That's really where prevention is going to happen."
Employee health professionals should not feel discouraged when they see a higher proportion of injuries occurring with safety devices, says Jagger. That reflects the overall shift to safety devices. However, as safety technology evolves, it's important to evaluate whether your hospital is using the best possible device, she says.
"When you look at the big picture, we should recognize this huge public health success," says Jagger. "Have we implemented as many safety devices as we can? What do we know about the most effective designs of safety devices?"
Better sharps, fewer injuries
A case study at Good Samaritan Hospital Medical Center in West Islip, NY, illustrates how safety design can impact injury risk. When the hospital investigated why phlebotomists continued to be injured with safety-engineered winged steel needles, a pattern emerged of injuries in which the safety feature had not been activated.
The safety mechanism typically required two-handed activation, which was especially difficult when the phlebotomist was also tending to the patient during the withdrawal of the needle, the hospital reported in a 2009 Joint Commission journal. "If two hands are used to activate the safety feature, this series of events would best be accomplished with three hands rather than two," commented Mary Hotaling, MS, MT(ASCP),DLM, a laboratory safety officer.4
The hospital evaluated blunting and retractable devices and ultimately chose a retractable device, even though it was about a third more expensive. The retractable device led to an 88% reduction in needlesticks, Hotaling reported.
That experience was actually reflected in a recent French study, which compared the effectiveness of different types of safety devices. An analysis of 435 sharps injuries at 61 hospitals in France found that passive devices which are activated in use without additional steps by the health care worker were involved in the fewest injuries. Self-blunting needles would be one type of passive device.
"Semi-automatic" devices, in which the user must apply extra pressure to activate the safety mechanism such as some retractable syringes were associated with the next fewest injuries. Those with a "toppling shield" that requires one-handed activation to cover the needle were more effective than sliding shields, which often require two-handed action and were the least effective, the authors said.5
While we celebrate the advances in sharps safety, it's important to continue to work for further improvement, safety experts say. "It's a work in progress. We can't let our guard down," says Pugliese.
Hospitals also should realize that they are setting the standard for safer devices and techniques around the world, says Jagger, who recently was tapped by the European Union to provide input on the U.S. experience on sharps safety legislation. She also has worked to advance sharps safety in Africa, Asia and South America.
"We in the United States have a huge global impact. What we do here is very often looked at as state of the art in other places of the world," she says.
As we develop and introduce better technologies, we also are raising the bar for safety everywhere, she says. "It's very important that we use our influence strategically and wisely to bring better conditions to health care workers around the world," she says.
1. Simard E, Miller JT, George PA, et al. Hepatitis B vaccination coverage levels among health care workers in the United States, 2002-2003. Infect Control Hosp Epidemiol 2007;28:783-790.
2. Massachusetts Department of Public Health Occupational Health Surveillance Program. Sharps injuries among hospital workers in Massachusetts, 2008 and 2002. Available at http://www.mass.gov/Eeohhs2/docs/dph/occupational_health/injuries_hospital_2008.pdf and http://www.mass.gov/Eeohhs2/docs/dph/occupational_health/injuries_hospital.pdf. Accessed on Sept. 26, 2010.
3. Perry J, Parker G, and Jagger J. EPINet Report: 2007 Percutaneous injury rates. Available at healthsystem.virginia.edu/internet/epinet/EPINet-2007-rates.pdf. Accessed on Sept. 26, 2010.
4. Hotaling M. A Retractable Winged Steel (Butterfly) Needle Performance Improvement Project. Joint Commission Journal on Quality and Patient Safety 2009; 35:100-105. Available at www.bd.com/vacutainer/pdfs/JCAHO_Case_Study_article.pdf. Accessed on Sept. 25, 2010.
5. Tosini W, Ciotti C, Goyer F, et al. Needlestick injury rates according to different types of safety-engineered devices: results of a French multicenter study. Infect Control Hosp Epidemiol 2010; 31:402-407.