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This award-winning blog supplements the articles in Hospital Infection Control & Prevention.

Where is the drive for 'zero' needlesticks?

Though the risk of seroconversion to bloodborne infection remains "rare but real," it is striking to see how many health care workers are still enduring the agony and uncertainy of needlesticks and sharps injuries.

The Centers for Disease Control and Prevention estimates that 385,000 sharps injuries still occur annually in the nation’s hospitals, even though the perception is that sharps safety devices have been widely implemented in health care. Each injury represents a health care worker who is at risk of acquiring HIV, hepatitis B or C or another of the 20 or so bloodborne infections.

Why are needlesticks so difficult to prevent? A Massachusetts report -- which includes data from all 97 hospitals licensed by the state -- sheds some light on this persistent problem. Those data -- and a more followup report in the same state -- reveal a complex convergence of issues. Angela Laramie, MPH, epidemiologist with the Massachusetts Department of Public Health Occupational Health Surveillance Program, offers these observations from her analysis of the data:

Too many sharps devices still lack sharps injury prevention features.

In 2010, more than half of sharps injuries (57%) occurred with devices that lacked safety features, including about a quarter (24%) of hypodermic needles/syringes. One major contributor: Conventional needles continue to be placed in pre-packaged kits, such as a central line kit, says Laramie.

Between 2006 and 2010, 55% of the 3,057 injuries that occurred from devices in pre-packaged kits involved devices that lacked sharp injury prevention features. In fact, those conventional devices in pre-packaged kits accounted for one in every 10 sharps injuries reported by Massachusetts hospitals.

Laramie acknowledges that the problem of pre-packaged kits isn’t simple to solve. Health care workers are supposed to have input into the selection of sharps safety technology and they need training if the device differs from the ones they normally use. She recommends that hospitals work with kit packers to obtain kits with safety-engineered devices

Injuries with safety devices indicate a need for better training or selection.

In 2010, 37% of the Massachusetts sharps safety injuries occurred with safety-engineered devices. The most common safety device involved in needlesticks were the sliding sheath (43%) and the hinged arm (28%). There is no data on the number of each device used in Massachusetts hospitals, so the greater number of injuries may be related to more common use, Laramie notes. But she reminds hospitals that they should seek devices that are passive (don’t require an extra step to activate) and easy to use. “If there are a lot of injuries occurring with a particular type of mechanism, the hospital should [ask questions]: Has everyone been trained? Do people feel comfortable using the device? Does the device do the most to protect workers? Is it passive? Is the activation a part of using the device or is there a second step [required to activate it]?”

Injuries are still occurring because there wasn’t safe disposal.

About 12% of injuries occurred because of improper disposal or during disposal, Laramie notes. For example, an unprotected sharp may have been left on a table or tray, or someone was injured while disposing of a device. She advises reviewing the placement of sharps containers. “You want to make sure that they’re as close [as possible] to the point of use and placed at a height that’s easy for people to reach,” she says. Of course, activation of safety devices also decreases the risk of sharps injury after use and before disposal.

Medical trainees are at greater risk of sharps injury. Laramie analyzed 8,268 sharps injuries that occurred among physicians from 2002 to 2009 and found that more than half (4,972 or 60%) were among medical trainees. They were more likely to be injured during the first quarter of the academic year, and they were most often injured by suture needles or hypodermic needles without safety features. In fact, the problem of sharps injuries among medical trainees is likely much worse than that because of underreporting, Laramie says. Attending physicians should model good work practices and use of safety devices, she says.

“Make sure that trainees are aware of the sharps reporting procedure and that reporting of these injuries is part of the safety culture,” she says. Of course, it’s also important to provide adequate training in the use of sharps devices. For example, 14% of injection-related sharps injuries among medical trainees involved recapping of needles – which is expressly forbidden by the OSHA Bloodborne Pathogen Standard.

--Michele Marill