Minimizing Sharps Injuries in the UH: Recessing Safer Sharps and Needle-Free S~stems

Janice Gabriel, MPhil. BSc [Hon5], PgD, RN, FETC, ONC, Cert MHS

Abstract In the United Kingdom (UK) health­

care workers do not have uniform access to safer sharps and needle-free systems in their individual workplaces. The avail­ability of such products is dependent on their budget manager authorizing the purchase of these devices. Tbis can mean that within the same institution one department can be using safer sharps and needle-free systems, while another department does not have access to this equipment. This is partly due to compet­ing priOrities for scarce health care resources and lack of national guidance to employers to provide such safety equip­ment for their employees. At the current time the UK does not have a mandatory reporting system for sharps injuries, so

the true extent of the problem is not fully understood.

Background Unlike the United States (US.) , the

UK has no national guidance on the provision of needle-free and safer sharps products by employers, although the Department of Health (DoH) is expected to produce some guidance in the not too distant future. Budgets for the pur­chase of this type of equipment are usu­ally held at local department level and have to compete with a range of priori­ties. This means that if the department and/or manager do not see the availabil­ity of safer sharps and needle-free sys­tems as a priority, they are not purchased. Finally, the UK can only 'guess' at the true incidence of sharps and needle-stick injuries experienced by healthcare workers each year, as there is

Correspondence concerning this article should be addressed to janice.gabriel@weht.swest.nhs.uk

only a voluntary reporting mechanism at the current time.

In 2000, the Royal College of Nursing (RCN) launched a twelve-month surveil­lance program, where 14 hospitals sup­plied data on the number of sharps injuries sustained by their staff. The data collection tool used was the EPINet sys­tem. This program was developed by the University of Virginia in the US. The EPINet system does not just record the number of needle-stick and sharps injuries for a particular organization, but also records information relating to the equipment involved, professional group of the individual(s) injured, the specific nature of the injury, and the action taken (EPINet 1999). Data from the first twelve-month monitoring period identi­fied 888 sharps injuries among staff from the participating organizations (Figure 1). Following this the RCN invited orga­nizations to join a second study period, running from January to December 2002. On this occasion 15 sites partici­pated and reported a total of 1,445 sharps injuries over the twelve-month study period (Figure 1). The data con­firmed the findings from the initial study period, i.e. there is a significant risk to staff from using hollow bore needles and other sharps as part of their every­day work (Figure 2). However, it must be remembered that this information was collected from only a small per­centage of UK hospitals, who were par­ticipating in data collection on a voluntary basis (RCN 2003a: Trim & Elliott 2003).

Based on data in the USA, using EPINet, it has been estimated that between 600,000 and 800,000 needle­stick and sharps injuries occur annually among healthcare workers. This equates to approximately 30 needle-stick injuries per every 100 hospital beds (EPINet

1999). Between 1985 and 1999 it has been estimated that there may have been 136 cases of occupationally acquired human immuno-deficiency virus (HN) among American healthcare workers. The prime cause of these infections is believed to be the use of hollow bore needles (NIOSH Alert 2003)

To reduce the incidence of such injuries, the USA has passed legislation aimed at protecting all healthcare work­ers (Hadaway 2001; Tan et al. 2002). In November 2000, President Clinton signed The Federal Needle-stick Safety and Prevention Act. Employers are required to ensure staff have access to safer sharps systems where the technol­ogy is available. The Act also stipulates that it should be clinical staff, not man­agers, who are iilvolved in the selection and evaluation of these safety systems. In addition all sharps lfiJunes are required to be recorded and investi­gated (Hadaway 2001).

Healthcare workers in the US. have wider access to needle-free systems compared to their UK colleagues. Where it is not possible to substitute the use of needles, safety protection sys­tems have been developed by manu­facturers for use in clinical care. These include cannula with integral sharps protection and venisection needles that 'self blunt' once venous access has been achieved, or when the needle is with­drawn through the patient's skin.

The United Kingdom (UK) Problem

Data collected by the RCN, have identified that nurses sustain the greatest number of sharps and needle-stick injuries of all healthcare workers, with 37% of all nurses sustaining a needle­stick or sharps injury at some time dur­ing their career (RCN 2003a). The RCN

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Two Studies of Number of Needle Stick Injuries and Sites

1600 -~--- 144~

::::m =:-­I::: /~]~~~ 600 / (/ _

400 ,

200 / - V

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Injuries

IstSt~ No. Sites July 2000 - __________ June 200 I 2nd Study r

Jan 2002 -Oee 2002

Figure I - Results of RCN monitoring

periods.

study has identified that 56.4% of sharps injuries are sustained by the person who was the original user of the sharps/nee­die, with poor disposal of sharps/ nee­dies accounting for a significant percentage of injuries (Figure 2). Twenty percent of injuries among healthcare workers are a result of sharps/ needles protntding from dedicated sharps dis­posal containers (Figure 3) (RCN 2003a).

Although Scotland is part of the United Kingdom, it now has its own Department of Health providing guid­ance and regulations on healthcare. The Scotland and Needle-stick Injuries Report (NHSScotland 2000) acknowl­edges that the introduction of sharps safety systems in Scotland would not only be a cost benefit, but would also significantly decrease the risk to staff of a bloodborne viral infection. However, this report falls short in not addreSSing other bloodborne infections or attempt­ing to acknowledge the psychological costs to an injured healthcare worker.

Understanding the Severity of the Problem

In reality, until healthcare profession­als have directly or indirectly experi­enced -§harps injury, they probably underestimate its potential implications. A study of 100 nurses, undertaken by Leliopoulou in 1999, identified that the majority of those surveyed considered the risk of a needle-stick injury to be 'unlikely' or 'very remote'. The RCN sur­vey identified nearly a two-fold increase

in the incidence of repolted sharps between the first and second study peri­ods (Figure 1) (RCN 2003a). This raises the question as to whether this was a 'real' increase in the number of injuries or were staff reporting more injuries? Nurses working in the community, pri­marily attached to general practitioner (family doctor) practices, have a higher incidence of sharps injuries than their colleagues working in hospital settings. Again, putting this into perspective, this group of nurses tends to have more years of nursing experience than those working in hospitals. This means that they have experienced greater exposure to needles and sharps dluing their work­ing life (RCN 2003a). In addition such employees do not benefit from regular education sessions, occupational health surveillance, and equipment purchasing involvement compared to their col­leagues employed by the National Health Service (NHS). This is because General Practitioners independently employ their nurses and they are not covered by NHS employment contracts. Many nurses accept such employment contracts to accommodate their domes­tic corrunitments, or to 'ease' back into employment following a career break.

Community nursing teams in the UK, in conjunction with patients and family members, provide a considerable amount of care away from the hospital environment. Therefore, being 'sharps safe' is an issue for community nurses, as well as their hospital colleagues, in terms of clinical practice, education, and risk management. (Community nurses differ from nurses employed by general practitioners in that they are employed by the NHS and visit patients in their own homes to deliver care.)

Routine procedures such as venipuncture, intramuscular and subcu­taneous injections, together with the removal of sutures, have been carried out in the community for many years. However, the demand for more special­ist care in the community is increasing and procedures such as IV therapy and cannulation are becoming more com­mon (Kayley 2000, Billingham 2003, Kayley and Finlay 2003).

One of the issues for community nurses is they do not always have easy

32 .JAVA Vo I ION 0 200 5

IM & Sf(

Procedure Being Performed When Needle Stick Injury Occurred

Resheathing SI "'.

11 During disposal

• Suturing

Suturing 7'Y. 0 Resheathing

o IH & SIC injectio n

Figure 2 - Incidence of UK sharps injuries.

access to the specific equipment they require. In relation to IV therapy, these nurses are often reliant on supplies being provided by the hospital when discharging the patient into their care, for example needle-free Injection caps/ connectors. This can invariably mean that an inadequate supply is pro­vided, an inappropriate alternative is supplied, or nothing is provided. The nurse has to make do with what she has and can therefore be unfamiliar with its use and/ or limitations (Kayley 1999). Many of the problems related to being 'sharps safe ' are the same for commu­nity nurses as they are for hospital staff and therefore the issues that need to be addressed, such as education, safe prac­tice, raising awareness, reporting of all needle-stick injuries, and how to access safer technology are essential.

The Hospital Environment For hospital statf working within a

multidisciplinary environment they have to be able to trust their colleagues to be 'sharps safe'. In the RCN study, 43.6% of injuries occurred to staff who were not the original user of the needle or sharps (RCN 2003a). Every hospital has an infection control team, consisting of spe­cialist nurses overseen by a consultant physician who is usually from a micro­biology background, who have needle­stick injury prevention as one of their main priorities. The education of staff and safe practice are essential to ensure a safe working environment and is a core function of the hospital infection control team (Ma honey 2001). One of the challenges for the infection control team is to have sharps poliCies that are 'user friendly'. This is to ensure that when an incident does occur everyone

is aware of his or her personal respon­sibilities. In practice this means that the individual(s) affected by a sharps injUly is rapidly assessed and the appropriate action taken without delay. Slu rps awareness campaigns using posters and presentations all help to raise awareness about the lisks, consequences, and pre­ventative measures (RCN 2001). Although re-sheathing of needles has not been taught in the UK for some years, some staff still undertake this practice and breaking this habit is velY difficult to achieve (Figure 2).

The dependency of hospital patients has increased, with more staff working in areas they are not necessarily familiar with and caJing for more acutely ill indi­viduals. With the overall number of hos­pital beds in the UK decreasing, increasing numbers of patients are being discharged into the care of their commu­nity nurses while still requiring the administration of IV therapy. Histolically, these patients would have remained in hospital for no other reason than to complete the ir presClibed course of IV treatment. Community nurses now con­tinue the patients' treatment, undertaking procedures they have little or indeed no previous experience with. This can lead to inappropriate care and shortcuts being taken, for example overfilling of sharps boxes. Being 'sharps safe' and taking time to consider the consequences of our own actions is essential to prevent the spread of blood borne infections and reduce the emotional stress for all staff.

l. EPINet (1999). Exposure prevention information network data repol1S. Uni­verSity of Virginia: International Hea lth Care Worker Safety Center.

2. Hadaway L C (2001). Safety Legislation passed: H.R.5178. journal q/ Vascular

Access Devices. 6(1); 33-35 3. Kayley J (1999). Intravenous Therapy in

the Community. IN Dougherty Land Lamb J (Eds) Intravenous Therapy in Nursing Practice. London, Harcourt Publishers.

4. Kayley J & Finaly T (2003). Vascular access devices used for patients in the community. Community Practitioner 76(6): 228-231

Reducing the Risks In 2003, the RCN IV Therapy Forum

published a comprehensive set of Stan­dards relating to infusion therapy (RCN 2003b). The aim of these Standards is to minimize the complications associated with this aspect of a patient's care. To reduce the risk of infection and sharps injury, the Standards advocate the avoid­ance of 'routinely' suturing midline, peripherally inselted central catheters (PICCs) and non-tunneled catheters, by using self-adhesive anchoring devices where possible (RCN 2003b). In the crit­ical care setting in the UK, suturing of lines accounts for 20% of repolted sharps injUlies.

A number of medical device manu­facturers/ distributors now supply nee­dles/ cannula with integral sharps protection. These can include self­blunting needles or manually activated protection sheaths. These devices still require careful disposal, but can greatly reduce the potential risk for sharps injuries. However, the range ava ilable in the UK is still very limited compared to what is available in the U.S.

Conclusion Raising the awareness among all

bealtbcare professionals of the potential dangers of a sharps injury will mean that appropriate assessment and action are not delayed for the individual(s) affected. In addition, raising awareness of the inlportance of repolting will help to ensure that tbe true incidence of such

REFERENCES

5. Leliopoulou C, et ai, (1999). Nurses fail­ure to appreciate the risks of infection due to needle stick accidents: a hospital based survey. j OU1"nal q/ Hospital Infec­

tion. 42: 53-59 6. Mahoney C (2001). At the sharp end.

HES International July/August: 29-30 7. NHS Scotland (2000). Needlestick

Injuries Sharpen Your Awareness. NHS Scotland.

8. NIOSH A1el1 (2003). Preventing Needle­stick Injuries in Health Care Settings Publication 2000-108. US Depal1ment of Health and Human Services

9. Royal College of Nursing (2001). Work­ing well initiative. Be sharp be safe.

Figure 3 - Overfilling of sharps box.

injuJies is recorded. Without these accu­rate data we can only estimate the inci­dence of such injuJies. Prompt reporting will allow for the investigation of the inci­dent to take place and identifY if training is required, or if alternatives to the nee­dles/ sharps involved can be sought. We are entitled to a safe working environ­ment and our patients have the right to be cared for by staff that have access to safe equipment, regardless of the politics involved. The teclmology is available to make the provision of healthcare safer for all patients and healthcare workers. •

janice Gabriel is employed as consul­tant cancer nurse at the Royal Hamp­shire County Hospital in Winchester, England. She 'is also a member of the Royal College of Nursing IV Forum, where she has been working with col­leagues 10 raise awareness of the range of safer sharps and needlejree systems that are available, to ensure greater access f or all health care workers in the UK.

RC . London 10. Royal College of Nursing (RCN)

(2003a). Monitoring slurps injuries: what can the RCN EPINet surveillance study tell us? RCN, London

11 . Royal College of Nursing (RCN) (2003b). Standards for Infusion Ther­apy. RCN, London

12. Tan L, Hawk J C, Sterling M L (2002). Report of the Council on Scientific Affairs: preventing needlestick injuries in health care settings. Arch Int Med, 161: 929-936

13. TrinlJ C & Elliott T S J (2003), A review of sharps inju ries and preventative strat~gies , j ournal q/ Hospital Injection, 53(4): 237-242

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