ALERT - Centers for Disease Control and Prevention

Preventing Needlestick Injuriesin Health Care Settings

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESPublic Health Service

Centers for Disease Control and PreventionNational Institute for Occupational Safety and Health

ORDERING INFORMATION

To receive documents or more information about occupational safety and healthtopics, contact the National Institute for Occupational Safety and Health (NIOSH) at

NIOSH—Publications Dissemination4676 Columbia Parkway

Cincinnati, OH 45226–1998

Telephone: 1–800–35–NIOSH (1–800–356–4674)Fax: 513–533–8573

E-mail: [email protected]

or visit the NIOSH Web site at www.cdc.gov/niosh

This document is in the public domain and may be freely copied or reprinted.

Disclaimer: Mention of any company or product does not constitute endorsement by NIOSH.

DHHS (NIOSH) Publication No. 2000–108

November 1999


Employers of health care workers shouldimplement the use of improved engineer-ing controls to reduce needlestick injuries:

• Eliminate the use of needles wheresafe and effective alternatives areavailable.

• Implement the use of devices withsafety features and evaluate theiruse to determine which are most ef-fective and acceptable.

Needlestick injuries can best be reducedwhen the use of improved engineeringcontrols is incorporated into a comprehen-sive program involving workers. Em-ployers should implement the followingprogram elements:

• Analyze needlestick and othersharps-related injuries in your work-place to identify hazards and injurytrends.

• Set priorities and strategies for pre-vention by examining local and na-tional information about risk factorsfor needlestick injuries and success-ful intervention efforts.

• Ensure that health care workers areproperly trained in the safe use anddisposal of needles.

• Modify work practices that pose aneedlestick injury hazard to makethem safer.

• Promote safety awareness in thework environment.

• Establish procedures for and en-courage the reporting and timelyfollowup of all needlestick and othersharps-related injuries.

• Evaluate the effectiveness of pre-vention efforts and provide feedbackon performance.

Please tear out and post. Distribute copies to workers. See back of sheet to order complete Alert.

WARNING!

Health care workers who use or may be exposed to needles are at increasedrisk of needlestick injury. Such injuries can lead to serious or fatal infectionswith bloodborne pathogens such as hepatitis B virus, hepatitis C virus, or hu-man immunodeficiency virus (HIV).

Health care workers should take the fol-lowing steps to protect themselves andtheir fellow workers from needlestick inju-ries:

• Avoid the use of needles where safeand effective alternatives are avail-able.

• Help your employer select and eval-uate devices with safety features.

• Use devices with safety features pro-vided by your employer.

• Avoid recapping needles.

• Plan for safe handling and disposalbefore beginning any procedure us-ing needles.

• Dispose of used needles promptly inappropriate sharps disposal contain-ers.

• Report all needlestick and othersharps-related injuries promptly toensure that you receive appropriatefollowup care.

• Tell your employer about hazardsfrom needles that you observe inyour work environment.

• Participate in bloodborne pathogentraining and follow recommended in-fection prevention practices, includ-ing hepatitis B vaccination.

For additional information, see NIOSH Alert: Preventing Needlestick Injuriesin Health Care Settings [DHHS (NIOSH) Publication No. 2000–108]. Singlecopies of the Alert are available from the following:

NIOSH—Publications Dissemination4676 Columbia Parkway

Cincinnati, OH 45226–1998

Telephone: 1–800–35–NIOSH (1–800–356–4674)Fax: 513–533–8573

E-mail: [email protected] site: www.cdc.gov/niosh

U.S. Department of Health and Human ServicesPublic Health ServiceCenters for Disease Control and PreventionNational Institute for Occupational Safety and Health


The National Institute for OccupationalSafety and Health (NIOSH) requests as-sistance in preventing needlestick inju-ries among health care workers.

*These

injuries are caused by needles such ashypodermic needles, blood collectionneedles, intravenous (IV) stylets, andneedles used to connect parts of IV de-livery systems. These injuries maycause a number of serious and poten-tially fatal infections with bloodbornepathogens such as hepatitis B virus(HBV), hepatitis C virus (HCV), or humanimmunodeficiency virus (HIV)—the vi-rus that causes acquired immunodefi-ciency syndrome (AIDS).

These injuries can be avoided by elimi-nating the unnecessary use of needles,

*In this document, the term health care worker in-cludes all workers in the health care setting whouse or may be exposed to needles and other sharpdevices that may contain blood or other potentiallyinfectious materials. Health care workers includephysicians, nurses, laboratory and dental person-nel, pre-hospital care providers, and housekeep-ing, laundry, and maintenance workers.

using devices with safety features, and

promoting education and safe work

practices for handling needles and re-

lated systems. These measures should

be part of a comprehensive program to

prevent the transmission of blood-

borne pathogens.

This Alert provides current scientific in-

formation about the risk of needlestick

injury and the transmission of blood-

borne pathogens to health care work-

ers. The document focuses on needle-

stick injuries as a key element in a

broader effort to prevent all sharps-

related injuries and associated blood-

borne infections. The document de-

scribes five cases of health care work-

ers with needlestick-related infections

and presents intervention strategies for

reducing these risks. Because many

needleless devices and safer needle

devices have been recently introduced

and the field is rapidly evolving, the

Alert briefly describes an approach for

evaluating these devices.

1

WARNING!

Health care workers who use or may be exposed to needles are at increasedrisk of needlestick injury. Such injuries can lead to serious or fatal infectionswith bloodborne pathogens such as hepatitis B virus, hepatitis C virus, or hu-man immunodeficiency virus (HIV).

NIOSH requests that workers, employ-ers, manufacturers, editors of profes-sional journals, safety and health offi-cials, and labor unions implement therecommendations in this Alert andbring them to the attention of all healthcare workers who use or may be ex-posed to needles in the workplace.

BACKGROUND

More than 8 million health care workers inthe United States work in hospitals andother health care settings. Precise nationaldata are not available on the annual num-ber of needlestick and other percuta-neous injuries among health care workers;however, estimates indicate that 600,000to 800,000 such injuries occur annually[Henry and Campbell 1995; EPINet 1999].About half of these injuries go unreported[Roy and Robillard 1995; EPINet 1999;CDC 1997a; Osborn et al. 1999]. Datafrom the EPINet system suggest that at anaverage hospital, workers incur approxi-mately 30 needlestick injuries per 100 bedsper year [EPINet 1999].

Most reported needlestick injuries involvenursing staff; but laboratory staff, physi-cians, housekeepers, and other healthcare workers are also injured. Some ofthese injuries expose workers to blood-borne pathogens that can cause infection.The most important of these pathogensare HBV, HCV, and HIV. Infections witheach of these pathogens are potentially lifethreatening—and preventable.

The emotional impact of a needlestick in-jury can be severe and long lasting, evenwhen a serious infection is not transmitted.This impact is particularly severe when theinjury involves exposure to HIV. In onestudy of 20 health care workers with an

HIV exposure, 11 reported acute severedistress, 7 had persistent moderate dis-tress, and 6 quit their jobs as a result of theexposure [Henry et al. 1990]. Other stressreactions requiring counseling have alsobeen reported [Armstrong et al. 1995]. Notknowing the infection status of the sourcepatient can accentuate the health careworker’s stress. In addition to the exposedhealth care worker, colleagues and familymembers may suffer emotionally.

HIV

Between 1985 and June 1999, cumulativetotals of 55 “documented”† cases and 136“possible”‡ cases of occupational HIVtransmission to U.S. health care workerswere reported to the Centers for DiseaseControl and Prevention (CDC) [CDC1998a]. Most involved nurses and labora-tory technicians. Percutaneous injury(e.g., needlestick) was associated with 49(89%) of the documented transmissions.Of these, 44 involved hollow-bore needles,most of which were used for blood collec-tion or insertion of an IV catheter.

HIV infection is a complex disease that canbe associated with many symptoms. Thevirus attacks part of the body’s immunesystem, eventually leading to severe infec-tions and other complications—a conditionknown as AIDS. Despite current therapies

†Health care workers who had documented HIV af-ter occupational exposure or had other laboratoryevidence of occupational HIV infection.

‡Health care workers who were investigated and(1) had no identifiable behavioral or transfusionrisks, (2) reported having had percutaneous ormucocutaneous occupational exposures to bloodor body fluids or to laboratory solutions containingHIV, but (3) had no documented HIV seroconver-sion resulting from a specific occupational expo-sure.

2 Needlestick Injuries

that delay the progression of HIV disease,most health care workers who become in-fected with HIV are likely to eventually de-velop AIDS and die.

HBV

Information from national hepatitis surveil-lance is used to estimate the number ofHBV infections in health care workers. In1995, an estimated 800 health care work-ers became infected with HBV [CDC un-published data]. This figure represented a95% decline from the 17,000 new infec-tions estimated in 1983. The decline waslargely due to the widespread immuniza-tion of health care workers with the hepati-tis B vaccine and the use of universal pre-cautions and other measures required bythe Occupational Safety and Health Ad-ministration (OSHA) bloodborne patho-gens standard [29 CFR§ 1910.1030].

About one-third to one-half of persons withacute HBV infection develop symptoms ofhepatitis such as jaundice, fever, nausea,and abdominal pain. Most acute infectionsresolve, but 5% to 10% of patients developchronic infection with HBV that carries anestimated 20% lifetime risk of dying fromcirrhosis and 6% risk of dying from livercancer [Shapiro 1995].

HCV

Hepatitis C virus infection is the most com-mon chronic bloodborne infection in theUnited States, affecting approximately 4million people [CDC 1998b]. Although theprevalence of HCV infection among healthcare workers is similar to that in the gen-eral population (1% to 2%) [CDC 1998b],

§Code of Federal Regulations. See CFR in refer-ences.

health care workers clearly have an in-creased occupational risk for HCV infec-tion. In a study that evaluated risk factorsfor infection, a history of unintentionalneedlestick injury was independently asso-ciated with HCV infection [Polish et al.1993]. The number of health care workerswho have acquired HCV occupationally isnot known. However, of the total acute HCVinfections that have occurred annually(ranging from 100,000 in 1991 to 36,000 in1996), 2% to 4% have been in health careworkers exposed to blood in the workplace[Alter 1995, 1997; CDC unpublished data].

HCV infection often occurs with no symp-toms or only mild symptoms. But unlikeHBV, chronic infection develops in 75% to85% of patients, with active liver diseasedeveloping in 70%. Of the patients with ac-tive liver disease, 10% to 20% develop cir-rhosis, and 1% to 5% develop liver cancer[CDC 1998b].

RISK OF INFECTION AFTER ANEEDLESTICK INJURY

After a needlestick exposure to an infectedpatient, a health care worker’s risk of infec-tion depends on the pathogen involved,the immune status of the worker, the se-verity of the needlestick injury, and theavailability and use of appropriate post-exposure prophylaxis.

HIV

To estimate the rate of HIV transmission,data were combined from more than 20worldwide prospective studies of healthcare workers exposed to HIV-infectedblood through a percutanous injury. In all,21 infections followed 6,498 exposures foran average transmission rate of 0.3% per

Needlestick Injuries 3

injury [Gerberding 1994; Ippolito et al.1999]. A retrospective case-control studyof health care workers who had percu-taneous exposures to HIV found that therisk of HIV transmission was increasedwhen the worker was exposed to a largerquantity of blood from the patient, as indi-cated by (1) a visibly bloody device, (2) aprocedure that involved placing a needlein a patient’s vein or artery, or (3) a deepinjury [Cardo et al. 1997]. Preliminary datasuggest that such high-risk needlestick in-juries may have a substantially greater riskof disease transmission per injury [Bell1997].

Post-exposure prophylaxis for HIV is rec-ommended for health care workers occu-pationally exposed to HIV under certaincircumstances [CDC 1998c]. Limited datasuggest that such prophylaxis may con-siderably reduce the chance of becominginfected with HIV [Cardo et al. 1997].However, the drugs used for HIV post-exposure prophylaxis have many adverseside effects [CDC 1998c]. Currently novaccine exists to prevent HIV infection,and no treatment exists to cure it [CDC1998d].

HBV

The rate of HBV transmission to suscepti-ble health care workers ranges from 6% to30% after a single needlestick exposure toan HBV-infected patient [CDC 1997b].However, such exposures are a risk onlyfor health care workers who are not im-mune to HBV. Health care workers whohave antibodies to HBV either from pre-exposure vaccination or prior infection arenot at risk. In addition, if a susceptibleworker is exposed to HBV, post-exposureprophylaxis with hepatitis B immune glob-ulin and initiation of hepatitis B vaccine is

more than 90% effective in preventingHBV infection.

HCV

Prospective studies of health care workersexposed to HCV through a needlestick orother percutaneous injury have found thatthe incidence of anti-HCV seroconversion(indicating infection) averages 1.8%(range, 0% to 7%) per injury [Alter 1997;CDC 1998b]. Currently no vaccine existsto prevent HCV infection, and neither im-munoglobulin nor antiviral therapy is rec-ommended as post-exposure prophylaxis[CDC 1998b]. However, recommendationsfor treatment of early infections are rapidlyevolving. Health care workers with knownexposure should be monitored for sero-conversion and referred for medical follow-up if seroconversion occurs.

Summary

Although exposure to HBV poses a highrisk for infection, administration of pre-exposure vaccination or post-exposureprophylaxis to workers can dramaticallyreduce this risk. Such is not the case withHCV and HIV. Preventing the needlestickinjury is the best approach to preventingthese diseases in health care workers, andit is an important part of any bloodbornepathogen prevention program in the work-place.

HOW DO NEEDLESTICKINJURIES OCCUR?

Devices Associated withNeedlestick Injuries

Health care workers use many types ofneedles and other sharp devices to


provide patient care. However, data fromhospitals participating in the CDC NationalSurveillance System for Hospital HealthCare Workers (NaSH) and from hospitalsincluded in the EPINet research databaseshow that only a few needles and othersharp devices are associated with the ma-jority of injuries [International Health CareWorker Safety Center 1997; EPINet 1999;CDC unpublished data 1999]. Of nearly5,000 percutaneous injuries reported byhospitals participating in NaSH betweenJune 1995 and July 1999, 62% were asso-ciated with hollow-bore needles—primarilyhypodermic needles attached to dispos-able syringes (29%) and winged-steel(butterfly-type) needles (13%). Figure 1shows the extent to which these and othersharp devices contributed to the burden ofpercutaneous injuries in NaSH hospitals.Data from hospitals participating in EPINetshow a similar distribution of injuries by de-vice type [EPINet 1999].

Activities Associated withNeedlestick Injuries

Whenever a needle or other sharp deviceis exposed, injuries can occur. Data fromNaSH show that approximately 38% ofpercutaneous injuries occur during useand 42% occur after use and before dis-posal. Causes of percutaneous injurieswith hollow-bore needles are shown in Fig-ure 2.

The circumstances leading to a needle-stick injury depend partly on the type anddesign of the device used. For example,needle devices that must be taken apart ormanipulated after use (e.g., prefilled car-tridge syringes and phlebotomy needle/vacuum tube assemblies) are an obvioushazard and have been associated with in-creased injury rates [Jagger et al. 1988]. In

addition, needles attached to a length offlexible tubing (e.g., winged-steel needlesand needles attached to IV tubing) aresometimes difficult to place in sharps con-tainers and thus present another injuryhazard. Injuries involving needles attachedto IV tubing may occur when a health careworker inserts or withdraws a needle froman IV port or tries to temporarily removethe needlestick hazard by inserting theneedle into a drip chamber, IV port or bag,or even bedding.

In addition to risks related to device char-acteristics, needlestick injuries have beenrelated to certain work practices such as

— recapping,

— transferring a body fluid betweencontainers, and

— failing to properly dispose of usedneedles in puncture-resistant sharpscontainers.

Past studies of needlestick injuries haveshown that 10% to 25% occurred when re-capping a used needle [Ruben et al. 1983;Krasinski et al. 1987; McCormick and Maki1981; McCormick et al. 1991; Yassi andMcGill 1991]. Although recapping by handhas been discouraged for some time andis prohibited under the OSHA bloodbornepathogens standard [29 CFR 1910.1030]unless no alternative exists, 5% of needle-stick injuries in NaSH hospitals are still re-lated to this practice (Figure 2). Injury mayoccur when a health care worker attemptsto transfer blood or other body fluids from asyringe to a specimen container (such as avacuum tube) and misses the target. Also,if used needles or other sharps are left inthe work area or are discarded in a sharpscontainer that is not puncture resistant, aneedlestick injury may result.



Otherhollow-bore

needle10%

Phlebotomyneedle

4%

IV stylet6%

Winged-steelneedle13%

Hypodermicneedle29%

Othersharp6%

Sutureneedle15%

Glass17%

Figure 1. Hollow-bore needles and other devices associated with percutaneous in-juries in NaSH hospitals, by % total percutaneous injuries (n=4,951), June 1995–July 1999. (Source: CDC [1999].)

Cleanup11%

Handling/transferringspecimens

5%

Other4%

Manipulatingneedle inpatient27%

IV line-relatedcauses

8%

Recapping5%

Handling/passingdevice during or

after use10%

Collisionwith healthcare worker

or sharp8%

Disposal-relatedcauses

12%

Improperlydisposed

sharp10%

Figure 2. Causes of percutaneous injuries with hollow-bore needles in NaSHhospitals, by % total percutaneous injuries (n=3,057), June 1995–July 1999.(Source: CDC [1999].)

OSHA, FDA, AND STATEREGULATIONS

**

OSHA

The current Federal standard for address-ing needlestick injuries among health careworkers is the OSHA bloodborne patho-gens standard [29 CFR 1910.1030; 56 Fed.Reg.†† 64004 (1991)], which has been ineffect since 1992. The standard applies toall occupational exposures to blood orother potentially infectious materials. No-table elements of this standard require thefollowing:

• A written exposure control plan de-signed to eliminate or minimize workerexposure to bloodborne pathogens

• Compliance with universal precau-tions (an infection control principlethat treats all human blood and otherpotentially infectious materials as in-fectious)

• Engineering controls and work prac-tices to eliminate or minimize workerexposure

• Personal protective equipment (ifengineering controls and work prac-tices do not eliminate occupationalexposures)

• Prohibition of bending, recapping, orremoving contaminated needles andother sharps unless such an act isrequired by a specific procedure orhas no feasible alternative

**Because of recent changes and pending legisla-tion in the area of needlestick injury prevention,readers are urged to check with current Federalas well as State regulations.

††Federal Register. See Fed. Reg. in references.

• Prohibition of shearing or breakingcontaminated needles (OSHA de-fines contaminated as the presenceor the reasonably anticipated pres-ence of blood or other potentially in-fectious materials on an item orsurface)

• Free hepatitis B vaccinations offeredto workers with occupational expo-sure to bloodborne pathogens

• Worker training in appropriate engi-neering controls and work practices

• Post-exposure evaluation and fol-lowup, including post-exposure pro-phylaxis when appropriate

OSHA also intends to act to reduce thenumber of injuries that health care workersreceive from needles and other sharpmedical objects [OSHA 1999a]. First, theagency has revised the compliance direc-tive (guidance to be used in the field) ac-companying its 1992 bloodborne patho-gens standard [29 CFR 1910.1030] toreflect newer and safer technologies nowavailable and to increase the employer’sresponsibility to evaluate and use effective,safer technologies [OSHA 1999b]. Second,the agency has proposed a requirement inthe revised recordkeeping rule that all inju-ries resulting from contaminated needlesand sharps be recorded on OSHA logsused by employers to record injuries andillnesses. Finally, OSHA will take steps toamend its bloodborne pathogens standardby placing needlestick and sharps injurieson its regulatory agenda.

FDA

Under the regulations of the Food and DrugAdministration (FDA) application clearanceprocess [FDA 1995], the manufacturers of


medical devices (including needles usedin patient care) must meet requirementsfor appropriate registration and for listing,labeling, and good manufacturing prac-tices for design and production. The pro-cess for receiving clearance or approval tomarket a device requires device manufac-turers to (1) demonstrate that a new deviceis substantially equivalent to a legally mar-keted device or (2) document the safetyand effectiveness of the new device forpatient care through a more involvedpremarket approval process. FDA hasalso released two advisories pertaining tosharps and the risk of bloodborne patho-gen transmission in the health care setting[FDA 1992; FDA et al. 1999].

State Regulations

Currently, three States have adopted andmore than two dozen are considering leg-islation to require additional regulatoryactions addressing bloodborne pathogenexposures to health care workers. The re-cent California standard [State of Califor-nia 1998] has several requirements that gobeyond those currently required by OSHA.These requirements include stronger lan-guage for the use of needleless systemsfor certain procedures or (where needle-less systems are not available) the use ofneedles with engineered sharps injury pro-tection for certain procedures.

CASE REPORTS

The following case reports briefly describethe experiences of five health care work-ers who developed serious infections afteroccupational exposures to bloodbornepathogens. Their cases illustrate a numberof the preventable hazardous conditions

and practices that can lead to needlestickinjuries.

Case 1

A hospitalized patient with AIDS becameagitated and tried to remove the intrave-nous (IV) catheters in his arm. Severalhospital staff members struggled to re-strain the patient. During the struggle, anIV infusion line was pulled, exposing theconnector needle that was inserted intothe access port of the IV catheter. A nurseat the scene recovered the connector nee-dle at the end of the IV line and was at-tempting to reinsert it when the patientkicked her arm, pushing the needle intothe hand of a second nurse. The nursewho sustained the needlestick injurytested negative for HIV that day, but shetested HIV positive several months later[American Health Consultants 1992a].

Case 2

A physician was drawing blood from a pa-tient in an examination room of an HIVclinic. Because the room had no sharpsdisposal container, she recapped the nee-dle using the one-handed technique.While the physician was sorting waste ma-terials from lab materials, the cap fell offthe phlebotomy needle, which subse-quently penetrated her right index finger.The physician’s baseline HIV test wasnegative. She began post-exposure pro-phylaxis with zidovudine but discontinuedit after 10 days because of adverse sideeffects. Approximately 2 weeks after theneedlestick, the physician developed flu-likesymptoms consistent with HIV infection.She was found to be seropositive for HIVwhen tested 3 months after the needlestickexposure [American Health Consultants1992b].


Case 3

After performing phlebotomy on a patient

with AIDS, a health care worker sustained

a deep needlestick injury with the used

phlebotomy needle. Blood from the collec-

tion tube also spilled into the space be-

tween the wrist and cuff of the health care

worker’s gloves, contaminating her chapped

hands. The health care worker removed the

gloves and washed her hands immedi-

ately. She had a negative baseline HIV test

and refused zidovudine prophylaxis. Be-

cause her patient was not known to have

HCV infection and did not have clinical evi-

dence of liver disease, the health care

worker did not receive baseline testing for

exposure to HCV. Eight months after the

incident, the health care worker was hospi-

talized with acute hepatitis. She was found

to be seropositive for HIV 9 months after

the incident. Sixteen months after the inci-

dent, she tested positive for anti-HCV anti-

bodies and was diagnosed with chronic

HCV infection. Her clinical condition con-

tinued to deteriorate, and she died 28

months after the needlestick injury [Ridzon

et al. 1997].

Case 4

During bronchoscopy to determine the

cause of shortness of breath in a patient in-

fected with HBV, a health care worker sus-

tained a percutaneous injury with a

25-gauge needle while extracting tissue

from biopsy forceps. The worker did not re-

ceive post-exposure prophylaxis with hep-

atitis B immune globulin or hepatitis B vac-

cine. Approximately 15 weeks after the

needlestick injury, the worker noted fa-

tigue, malaise, and jaundice. Later, he was

found to have abnormal liver enzymes and

a positive test for hepatitis B surface anti-

gen, consistent with acute hepatitis B in-

fection. The patient who underwent bron-

choscopy was diagnosed with Pneumo-

cystis carinii pneumonia and died 8 months

later after he was diagnosed with dissemi-

nated Kaposi’s sarcoma and overwhelm-

ing opportunistic infection. The injured

worker had an uncomplicated medical

course, and his liver enzymes and his

health eventually returned to normal. He

later tested negative for hepatitis B surface

antigen and positive for hepatitis B surface

antibody, indicating recovery from his HBV

infection. On followup 15 months after the

needlestick injury, the worker also tested

HIV negative; serum from the deceased

patient was not available for antibody test-

ing [Gerberding et al 1985].

Case 5

In 1972, a nurse sustained a needlestick

injury to her finger while removing a hypo-

dermic needle from a patient’s arm. At the

time of the injury, the source patient had

apparent acute non-A, non-B hepatitis.

The nurse developed hepatitis 6 weeks af-

ter the needlestick injury. Her liver en-

zymes remained elevated for nearly a

year. Later examination of serum samples

from the nurse and the source patient

showed that both persons were infected

with HCV. The initial serum sample from

the nurse in 1972 was negative for

anti-HCV antibody, but the sample ob-

tained 6 weeks after the needlestick injury

was seropositive. Although the nurse was

clinically well at the time of the report, she

remained seropositive for HCV [Seeff

1991].


USE OF IMPROVEDENGINEERING CONTROLS INA PREVENTION STRATEGY

Comprehensive Programs toPrevent Needlestick Injuries

Safety and health issues can best be ad-dressed in the setting of a comprehensiveprevention program that considers all as-pects of the work environment and thathas employee involvement as well asmanagement commitment. Implementingthe use of improved engineering controlsis one component of such a comprehen-sive program. Since many devices withneedlestick prevention features are new,this section primarily addresses their use,including desirable characteristics, exam-ples, and data supporting their effective-ness. However, other prevention strategyfactors that must be addressed includemodification of hazardous work practices,administrative changes to address needlehazards in the environment (e.g., promptremoval of filled sharps disposal boxes),safety education and awareness, feedbackon safety improvements, and action takenon continuing problems. Several authorshave noted the importance of a compre-hensive approach [Krasinski et al. 1987;Hanrahan and Reutter 1997; DeJoy et al.1995; Ramos-Gomez et al. 1997; Gershonet al. 1995]. The critical role of appropriatetraining has been emphasized by severalrecent reports of increased patient blood-stream infections associated with impropercare of needleless IV systems, primarily inthe home health care setting [Cookson etal. 1998; Danzig et al. 1995; Do et al. 1999;Kellerman et al. 1996]. These data empha-size the need for patient safety surveillanceand thorough training as well as occupa-tional injury surveillance when implement-ing the use of a new medical device.

Case Study of a SuccessfulComprehensive PreventionProgram

The value of a comprehensive approach isillustrated by its success in a recent reportby Dale et al. [1998]. Between 1993 and1996, the phlebotomy service at a majorinstitution decreased the needlestick injuryrate among its 200 full-time phlebotomistsfrom 1.5 to 0.2 per 10,000 venipuncturesperformed. In comparison, a national sur-vey from 1990 to 1992 found a medianneedlestick injury rate of about 0.94 per10,000 venipunctures [Howanitz andSchifman 1994]. A retrospective review ofthe events contributing to the success ofthe phlebotomy service included changesin worker education and work practices,the implementation of devices with safetyfeatures, and encouragement of injury re-porting. These interventions as well as theimplementation of CDC published guide-lines and the OSHA bloodborne patho-gens standard were associated with theobserved steady decline in the injury rate.The authors noted that an important factorcontributing to this success was a thor-ough understanding of the injuries that oc-curred among their staff.

Desirable Characteristics ofDevices with Safety Features

Improved engineering controls are oftenamong the most effective approaches toreducing occupational hazards and there-fore are an important element of aneedlestick prevention program. Suchcontrols include eliminating the unneces-sary use of needles and implementing de-vices with safety features. A number ofsources have identified the desirable char-acteristics of safety devices [OSHA 1999c;


FDA 1992; Jagger et al. 1988; Chiarello1995; Quebbeman and Short 1995;Pugliese 1998; Fisher 1999; ECRI 1999].These characteristics include the follow-ing:

• The device is needleless.

• The safety feature is an integral partof the device.

• The device preferably works pas-sively (i.e., it requires no activationby the user). If user activation isnecessary, the safety feature can beengaged with a single-handed tech-nique and allows the worker’s handsto remain behind the exposed sharp.

• The user can easily tell whether thesafety feature is activated.

• The safety feature cannot be deacti-vated and remains protective throughdisposal.

• The device performs reliably.

• The device is easy to use and practi-cal.

• The device is safe and effective forpatient care.

Although each of these characteristics isdesirable, some are not feasible, applica-ble or available for certain health care situ-ations. For example, needles will alwaysbe necessary where alternatives for skinpenetration are not available. Also, asafety feature that requires activation bythe user might be preferable to one that ispassive in some cases. Each device mustbe considered on its own merit and ulti-mately on its ability to reduce workplace

injuries. The desirable characteristicslisted here should thus serve only as aguideline for device design and selection.

Examples of Safety DeviceDesigns

Figure 3 shows examples of syringes withsafety features. These and other exam-ples of safety device designs are listed asfollows:

• Needleless connectors for IV deliv-ery systems (e.g., blunt cannula foruse with prepierced ports and valvedconnectors that accept tapered orluer ends of IV tubing)

• Protected needle IV connectors(e.g., the IV connector needle is per-manently recessed in a rigid plastichousing that fits over IV ports)

• Needles that retract into a syringe orvacuum tube holder

• Hinged or sliding shields attached tophlebotomy needles, winged-steelneedles, and blood gas needles

• Protective encasements to receivean IV stylet as it is withdrawn fromthe catheter

• Sliding needle shields attached todisposable syringes and vacuum tubeholders

• Self-blunting phlebotomy and winged-steel needles (a blunt cannula seatedinside the phlebotomy needle is ad-vanced beyond the needle tip beforethe needle is withdrawn from thevein—see Figure 3)

• Retractable finger/heel-stick lancets


• Safer IV catheters that encase theneedle after use reduced needlestickinjuries related to IV insertion by83% in three hospitals [Jagger1996].

Other studies also document substantialreductions in needlestick injuries with theproper use of needleless systems or newersafety needle devices used in a compre-hensive program to prevent needlestick in-juries [NCCC and DVA 1997; Zafar et al.1997].

Although the focus in this section is onneedle devices with safety features,sharps disposal containers are also impor-tant engineering controls to consider in acomprehensive needlestick injury preven-tion program. NIOSH [1998] recently re-viewed the proper location, use, and bene-fits of sharps disposal containers.

As illustrated by the examples listed here,many devices with safety features de-crease the frequency of needlestick inju-ries, but for many reasons they do notcompletely eliminate the risk. In somecases, the safety feature cannot be acti-vated until after the needle is removedfrom the patient. Or the needle may be in-advertently dislodged during a procedure,thereby exposing the unprotected sharp.Some health care workers fail to activatethe safety feature, or the safety featuremay fail. With some devices, users can by-pass safety features. For example, evenwith some needleless IV delivery systems,a needle can be used to connect parts ofthe system. Understanding the factors thatinfluence the safety of a device and pro-moting practices that will maximize pre-vention effectiveness are therefore impor-tant components in prevention planning.

CONCLUSIONS

Needlestick injuries are an important andcontinuing cause of exposure to seriousand fatal diseases among health careworkers. Greater collaborative efforts byall stakeholders are needed to preventneedlestick injuries and the tragic conse-quences that can result. Such efforts arebest accomplished through a comprehen-sive program that addresses institutional,behavioral, and device-related factors thatcontribute to the occurrence of needlestickinjuries in health care workers. Critical tothis effort are the elimination of needle-bearing devices where safe and effectivealternatives are available and the develop-ment, evaluation, and use of needle de-vices with safety features.

RECOMMENDATIONS

Selecting and Evaluating NeedleDevices with Safety Features

An increasing number and variety of nee-dle devices with safety features are nowavailable, but many of these devices havehad only limited use in the workplace.Thus health care organizations and work-ers may find it difficult to select appropriatedevices. Although these devices are de-signed to enhance the safety of healthcare workers, they should be evaluated toensure that

— the safety feature works effectivelyand reliably,

— the device is acceptable to thehealth care worker, and

— the device does not adversely af-fect patient care.


As employers implement the use of needledevices with safety features, they can useseveral guidelines to select and evaluatethese products. These guidelines are de-rived partly from publications and other re-sources offering plans, evaluation forms,and related information in this new area[Chiarello 1995; Fisher 1999; SEIU 1998;EPINet 1999; Pugliese and Salahuddin1999]. While health care settings are im-plementing the use of needle devices withsafety features, they should seek helpfrom the appropriate professional organi-zations, trade groups, and manufacturersin obtaining information about devices andprocedures suitable for specific settings(e.g. dental offices). Other informationsources are listed in later sections of theAlert (see References, Additional Informa-tion, and Suggested Readings). In addi-tion, OSHA received nearly 400 responsesto its recent public request for informationabout preventing occupational exposure tobloodborne pathogens from percutane-ous injuries [63 Fed. Reg. 48250 (1998);OSHA 1999c]. This information includesnumerous reports about the successful im-plementation of needlestick injury preven-tion programs, and it may be useful tomedical institutions as they establish injurytracking systems, prevention approaches,and the use of safer devices.

The major elements of a process for se-lecting and evaluating needle devices withsafety features are listed here briefly:

1. Form a multidisciplinary team that in-cludes workers to (1) develop, imple-ment, and evaluate a plan to reduceneedlestick injuries in the institutionand (2) evaluate needle devices withsafety features.

2. Identify priorities based on assess-ments of how needlestick injuries areoccurring, patterns of device use in the

institution, and local and national dataon injury and disease transmissiontrends. Give the highest priority to nee-dle devices with safety features thatwill have the greatest impact on pre-venting occupational infection (e.g.,hollow-bore needles used in veins andarteries).

3. When selecting a safer device, identifyits intended scope of use in the healthcare facility and any special techniqueor design factors that will influence itssafety, efficiency, and user acceptabil-ity. Seek published, Internet, or othersources of data on the safety and over-all performance of the device.

4. Conduct a product evaluation, makingsure that the participants represent thescope of eventual product users. Thefollowing steps will contribute to a suc-cessful product evaluation:

• Train health care workers in the cor-rect use of the new device.

• Establish clear criteria and mea-sures to evaluate the device with re-gard to both health care workersafety and patient care. (Safety fea-ture evaluation forms are availablefrom the references cited earlier.)

• Conduct onsite followup to obtain in-formal feedback, identify problems,and provide additional guidance.

5. Monitor the use of a new device after itis implemented to determine the needfor additional training, solicit informalfeedback on health care worker experi-ence with the device (e.g., using a sug-gestion box), and identify possible ad-verse effects of the device on patientcare.


Ongoing review of current devices and op-tions will be necessary. As with any evolv-ing technology, the process will be dy-namic, and with experience, improveddevices with safety features will emerge.

Recommendations forEmployers

To protect health care workers fromneedlestick injuries, employers must pro-vide a safe working environment that in-cludes safer needle devices and effectivesafety programs. Many types of needle de-vices are associated with needlestick inju-ries, and these injuries can occur in manyways. Thus a combination of preventionstrategies must be considered. Employersshould take the following steps to imple-ment a program for reducing needlestickinjuries and to involve workers in this ef-fort.

1. Employers of health care workers shouldimplement the use of improved engi-neering controls to reduce needlestickinjuries:

• Eliminate the use of needle deviceswhere safe and effective alternativesare available. The most obvious ex-ample of unnecessary needle use isthe use of exposed needles to ac-cess or connect parts of an IV deliv-ery system. For nearly a decade,needleless IV delivery systems andprotected needles have been avail-able to remove or isolate this hazard.Examine information about your owninstitution to identify other unneces-sary needle use.

• Implement the use of needle deviceswith safety features and evaluatetheir use to determine which are

most effective and acceptable. Manydevices are now available withsafety features that isolate an ex-posed needle after use. An evalua-tion approach and references areprovided in this document.

2. Needlestick injury reduction can bestbe accomplished when the use of im-proved engineering controls is incorpo-rated into a comprehensive programinvolving workers:

• Analyze needlestick and other sharps-related injuries in your workplace toidentify hazards and injury trends.Data from injury reporting should becompiled and assessed to identify(1) where, how, with what devices,and when injuries are occurring and(2) the groups of health care workersbeing injured.

• Set priorities and prevention strate-gies by examining local and nationalinformation about risk factors forneedlestick injuries and successfulintervention efforts. Procedures anddevices that have contributed todisease transmission (e.g., devicesused to access a vein or artery)should receive the highest priority forintervention. Look to local and na-tional resources for information aboutthe types of devices and work prac-tices that have been successful in re-ducing injuries.

• Ensure that health care workers areproperly trained in the safe use anddisposal of needles. Health careworkers and students in the healthprofessions should be trained touse needle devices properly and tomaximize their personal protectionthroughout the handling of these


devices. As safer devices are intro-duced, worker training is essential toensure proper use [Ihrig et al. 1997].

• Modify work practices that pose aneedlestick injury hazard to makethem safer. Hazards that can beeliminated by modifying work prac-tices include injuries due to recap-ping, failing to dispose of a needledevice properly, passing or transfer-ring such a device, and transferringblood or body fluids from a deviceinto a specimen container. Also,specimen collection can be coordi-nated to reduce the number of timesneedles are used on a patient,thereby reducing both worker riskand patient discomfort. In somecases, the use of devices with safetyfeatures will reduce or eliminatethese risks. In all cases, involvinghealth care workers will help identifyand resolve safety issues. Em-ployers should thus review currentprocedures for reporting and ad-dressing hazards related to needlesand other sharps.

• Promote safety awareness in thework environment. Many needlestickinjuries result from unexpected cir-cumstances such as sudden move-ment by a patient or collision with acoworker or needle device. Healthcare workers should be trained to beconstantly alert to the injury potentialwhen an exposed needle or othersharp device is being used. A num-ber of job-related factors influencethe adoption of safety behaviors byhealth care workers [Dejoy et al.1995; Murphy et al. 1996; Gershonet al. 1995]. These workers oftenplace patient needs before their per-sonal safety. They are less likely to

perform a safety measure they per-ceive to interfere with patient care orto require added steps. Therefore,employers must address both thehazards that contribute to needle-stick injuries and the institutionalbarriers and attitudes that affectsafe work practices [Hanrahan andReutter 1997].

• Establish procedures for and en-courage the reporting and timely fol-lowup of all needlestick and othersharps-related injuries. Reporting ofneedlestick injuries is essential to(1) ensure that all health care workersreceive appropriate post-exposuremedical management and (2) providea record for assessing needlestickhazards in the work environment.

• Evaluate the effectiveness of pre-vention efforts and provide feedbackon performance. Employers need toensure that health care workers areadopting the recommended preven-tion strategies and that the changesthey make have the desired effect.Thus they should provide a forum toassess worker perceptions, evaluatecompliance, and identify problems.

Recommendations for Workers

To protect themselves and their cowork-ers, health care workers should be awareof the hazards posed by needlestick inju-ries and should use safety devices and im-proved work practices as follows:

1. Avoid the use of needles where safeand effective alternatives are available.

2. Help your employer select and evalu-ate devices with safety features.


3. Use devices with safety features pro-vided by your employer.

4. Avoid recapping needles.

5. Plan safe handling and disposal beforebeginning any procedure using nee-dles.

6. Dispose of used needle devices prompt-ly in appropriate sharps disposal con-tainers.

7. Report all needlestick and other sharps-related injuries promptly to ensure thatyou receive appropriate followup care.

8. Tell your employer about hazards fromneedles that you observe in your workenvironment.

9. Participate in bloodborne pathogentraining and follow recommended in-fection prevention practices, includinghepatitis B vaccination.

ADDITIONAL INFORMATION

For additional information about needle-stick injuries, call 1–800–35–NIOSH(1–800–356–4674); or visit the NIOSHWeb site at www.cdc.gov/niosh

The following Web sites provide additionalinformation about needlestick injuries andsafer needle devices:

• University of Virginia’s InternationalHealth Care Workers Safety Centerand its EPINet needlestick injurydata collection system:www.med.virginia.edu/~epinet(or call 804–982–0702)

• San Francisco General Hospital’sTrauma Foundation, Training forDevelopment of Innovative ControlTechnology (TDICT) Project:www.tdict.org (or call412–821–8209)

• OSHA Web page: www.osha.gov;for needlestick information,www.osha-slc.gov/SLTC/needlestick/index.html (or call theOSHA Publications Office at202–693–1888)

• CDC Web page: www.cdc.gov; forhepatitis information, www.cdc.gov/ncidod/diseases/hepatitis/index.htm; for hospital infections,www.cdc.gov/ncidod/hip/default.htm; and for HIV informa-tion, www.cdc.gov/nchstp/hiv_aids/dhap.htm

• FDA medical device safety alerts:www.fda.gov/cdrh/safety.html

ACKNOWLEDGMENTS

Principal contributors to this Alert wereThomas K. Hodous, M.D.; Linda A. Chiarello,R.N., M.S.; Scott D. Deitchman, M.D.,M.P.H; Ann N. Do, M.D.; Anne C. Hamilton;Janice M. Huy, M.S.; E. Lynn Jenkins, M.A.;Andrew M. Maxfield, Ph.D.; Edward L.Petsonk, M.D.; Raymond C. Sinclair, Ph.D.;and Angela M. Weber, M.S.

Please direct comments, questions, or re-quests for additional information to the fol-lowing:

Director, Division of Safety ResearchNational Institute for Occupational Safety

and Health1095 Willowdale RoadMorgantown, WV 26505


Telephone, 304–285–5894; or call1–800–35–NIOSH (1–800–356–4674).

We greatly appreciate your assistance inprotecting the health of U.S. workers.

Linda Rosenstock, M.D., M.P.H.Director, National Institute for

Occupational Safety and HealthCenters for Disease Control

and Prevention

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