Literature Review

Fahey BJ, Henderson DK. Reducing occupational risks in the health care workplace. Infect Med 1999; 16:269-270, 273-275, 278-279.

Noting that some current investigations find bloodborne exposures are "device- or product-mediated," authors from the National Institutes of Health in Bethesda, MD, say that improvements in device design should substantially reduce occupational exposures. Safer design characteristics, as well as safer phlebotomy equipment, intravenous (IV) catheter systems, surgical equipment, and sharps disposal containers, are presented in a series of tables.

Safer technology is becoming more available, but the authors warn that specific areas of use within the hospital, with their differences in work conditions, must be considered in device selection. For example, a device that is useful in a structured patient care area may not be appropriate in emergency care settings.

In addition, device failures or occupational exposures may result from inappropriate use of safer devices. One example is an IV catheter safety system containing a plastic sheath that slides over the contaminated needle to help protect the user's hands; however, the sheath makes the catheter so bulky that it often requires two hands for operation. The additional maneuver makes the device difficult to use with uncooperative patients and has resulted in skin exposure to blood, the authors point out.

Studies of new device evaluations show some promising results in the areas of efficacy and cost-effectiveness, but some data are "far from encouraging," they add.

A Centers for Disease Control and Prevention (CDC) study demonstrated efficacy of three phlebotomy devices, and another study showed shielded disposable syringes contributed to a 75% decrease in needlestick injuries. However, another study of safety syringes in an emergency department found no associated exposure reduction.

Studies of needleless IV systems also show mixed results. While four studies concluded that the technology lowered the incidence of device-specific injuries, another study found that needlestick injuries continued despite needleless devices, possibly due to incorrect product use, low user acceptance, and continued use of traditional needle-containing devices in study areas.

A 12-month, three-hospital study of IV catheters found injury rates associated with safety catheters much lower than those related to conventional device use. Investigators concluded that although other factors may have contributed to the lower rates, effective safety devices may produce far more injury reductions than those achieved through education, training, and good needle disposal systems.

For occupational blood exposures in surgery, the authors discuss blunt suture needles. A randomized trial comparing glove punctures using a cutting needle and a blunt-tipped needle showed many fewer perforations with the latter. A CDC study found that blunt suture needles greatly reduced the incidence of needlestick injuries, had minimal adverse effects on patient care, and were well-accepted by surgeons.

The authors also mention puncture-resistant gloves, glove liners, and finger guards, but note that limited information is available to assess their efficacy in reducing blood exposures.

Needle disposal systems have been found to contribute to a rise in needlestick rates. OSHA and the CDC emphasize the importance of effective needle disposal systems, staff education, convenient disposal box location, and appropriate container placement.

The authors conclude that additional safety devices and studies are needed, as is staff education about the rationale and proper use of new technology. Health care facilities' product evaluation must be "consistent and rigorous," accompanied by "intensive education and training of the users of the technology and thoughtful integration into existing institutional policy and procedures."