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Published on 1 September 2003

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Needlestick injuries can be prevented

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Ron Stoker
Executive Director
International Sharps Injury Prevention Society
E:ron@isips.org

The danger of sharps injuries from hollow-bore needles has been a challenge for healthcare workers since the first syringe was used in 1845. An estimated 12 billion injections are given to patients globally each year. The United States accounts for approximately 800,000 needlesticks each year. There are an estimated 100,000 needlesticks in the UK a year, with 4,000 in Scotland. One in six of all reported occupational incidents in UK hospitals are from needlestick injuries. Compensation claims brought by hospital workers in Ireland who accidentally pierce themselves with dirty needles are now being settled out of court at a rate of one every two weeks. In Amsterdam, a needlestick injury was reported for every five surgeries. Overall, on a global basis, it is estimated that almost two million people are injured with needlesticks and other sharps injuries each year.

Healthcare workers can develop a variety of serious infections from these needlesticks, including life-threatening illnesses such as hepatitis C (HCV), hepatitis B (HBV) and HIV. There are 350 million individuals with HBV in the world, and an additional 500 million individuals with HCV. There are an estimated 42 million people with HIV in the world, the vast majority of these patients living in sub-Saharan Africa. The average risk of HIV infection after a needlestick exposure to HIV-infected blood is 0.3%, or 1 in 300. The chance of infection with HBV from a single contaminated needlestick is 30%; transmission risks for HCV following a needlestick are 3%.

So why isn’t more being done to stop this global occupational epidemic? Unlike many injuries, most needlestick and other sharps injuries can and should be prevented. The Occupational Safety and Health Administration (OSHA) has estimated that over 80% of needlestick and other sharps injuries can be prevented through the use of safer devices. The bulk of these needlesticks occur to nurses and physicians, but they also occur to cleaning staff, housekeeping staff, EMS/paramedics, law enforcement officials, correctional officers, firefighters and family members.

In the United States, the cost of testing healthcare workers for bloodborne pathogens following a needlestick ranges from $500 to $3,500 ($1=e1), and that is without seroconversion to a serious bloodborne disease. The total annual cost of testing without seroconversion in the USA approaches $2.4billion. The individual cost for treatment and testing of an injured healthcare worker increases dramatically, with costs approaching a million dollars depending on the age of the worker that contracts hepatitis or HIV. Younger healthcare workers that have seroconverted from a needlestick injury take more funds for testing and treatment than older workers.

Hospitals, physician offices and other clinics should evaluate and use sharps safety equipment. However, not all safety products are “good” products. In order to be effective in preventing accidental needlestick injuries, a product must easily protect the healthcare worker from injury. The primary prevention of sharps injuries is the replacement of needles and other sharps with alternative modalities. Primary prevention is always the preferred method whenever possible. Not all needles and other sharps, however, can be replaced. Secondary prevention is a method of adding active or passive shielding features to standard needles and other sharps, thus rendering them safer.

So what is the difference between passive and active protection? Passive protection schemes do not require the intervention of the healthcare worker but “happen naturally in use”. These passive devices are considered by many to be superior because the protective feature works automatically without any intervention by the healthcare worker. This is important in reducing accidental sharps injuries. CDC data indicate that about one-quarter of all needlestick injuries occur in situations in which a safety feature of a safety product is not activated.

The following suggestions can help healthcare facilities focus on their most valuable resource – their workers.

Replace unnecessary needles and other sharps with needle-free products

  • Use needle-free connectors instead of standard hypodermic needles to access IV administration set ports or injection sites that connect several IV lines: for example, an intermittent access or “piggyback” system (see Figure 1).

[[HPE10_fig1_59]]

  • Use blunt-needle cannulas to access specialty IV access valves.
  • Sharp suture needles should be replaced with blunt-tipped needles in as many procedures as possible. Blunt-tipped suture needles are less likely to cause percutaneous injuries.
  • Many wounds can be closed using adhesive strips or “superglue”-type products instead of suturing.
  • Wound irrigation can be accomplished by using specialty plastic shields that not only replace a sharp needle, but also shield the physician from bloodborne pathogen exposure.

Replace glass products with plastic ones whenever possible

  • Never use conventional glass capillary tubes. The breakage of glass capillary tubes can result in penetrating wounds.
  • Always use plastic blood collection tubes instead of glass.

Use safety sharps injury protection products whenever they are available
Use retractable or shielded scalpels and safety lancets. They will accomplish the same purpose as standard cutting products without putting healthcare workers or others at risk.

Dispose of all sharps properly

Make sure that sharps disposal containers have an appropriate-sized opening large enough to accept the sharps used during the procedure. Containers should always be within arm’s reach.

Sharps products used at home should not be thrown out with the regular trash. The inappropriate disposal of home-created sharps leaves waste management workers potentially exposed to sharps that may be contaminated with HIV, hepatitis viruses or other bloodborne pathogens. Disposal of home-based sharps should be made available to families that require home injection or treatment. For example, the Eureka Sharps Disposal group of Rhode Island, USA, has put together a system that is bolted down in a public place, such as a hospital or pharmacy, which allows for the safe drop-off of home sharps containers. Constructed of 14-gauge steel, the sharps receptacle provides a means to dispose of sharps containers, housing lancets, needles or other home-generated sharps (see Figure 2).

[[HPE10_fig2_60]]

Make sure that waste management and custodial staff are trained to dispose of sharps properly. Teach outpatients that use needles and scalpels at home to dispose of them properly.

Avoiding sharps injuries in hospital pharmacy
Hospital pharmacies are not immune from sharps injuries. Although the concern of bloodborne pathogens is not as critical in pharmacies as it is in other areas of the hospital, it is still important to practise sharps safety so as to not contaminate fellow workers and to avoid exposure to chemotherapeutic agents and other toxic medications. There are a variety of sharps safety products that hospital pharmacies can use that will help to minimise exposure to sharps injuries. These include:

Safety vial adapters
A vial adapter is a connector that allows the user to withdraw medication from a vial without using a needle. It replaces the fill needle, thus making syringe filling completely needle-free. It is designed to fit on standard syringes and can be used to transfer diluent for medication requiring reconstitution without the use of a needle.

Needle-free medication reconstitution
The typical method for reconstitution of lyophilised medication requires the puncture of a rubber vial stopper by a needle filled with diluent. The medication in the vial is mixed and the needle is withdrawn and then used to inject into the patient. The puncture of the rubber septum can dull the tip of the needle before injecting into the patient and provides unnecessary opportunity for a needlestick accident. Newer technologies do not require a needle. One example is the Dispensing-Spike II Reconstitution Device manufactured by Medi-dose. It is designed for medication from multiple-dose IV vials, while providing sterile air filtration. It features a large, 0.2mm hydrophobic air filter to trap aerosolised medications and minimise blowback. The streamlined construction creates short venting and fluid pathways, and the sharp, thin, piercing spike minimises coring and permits easy penetration of rubber stoppered vials. The luer-lock port design maintains a secure closure between the device and the syringe, while the hinged cap and easy-gripping spike sheath help maintain sterilisation before use.

Bottle-to-bottle fluid transfer system
The past practice of using a needle and syringe to pull fluid from one bottle and inject it into another creates opportunities for needlestick injuries. New products allow for the fast transfer of fluid from one bottle to another. These safety spikes provide venting that allows for air displacement simultaneously in both bottles. This eliminates the use of needles, saving both time and money.

Prefilled disposable sterile cartridges
These provide stability during injection and easy, safe disposal of the cartridge after use. The prefilled syringes have a male luer tip allowing easy access to any valve. No needle is attached, nor is it required for use (see Figure 3).

[[HPE10_fig3_61]]

Other considerations
Safe work practices include proper methods of storage, labelling, decontamination and transportation of various sharps. There are some safe alternatives for the safe transportation of hypodermic needles. Can you imagine carrying hypodermics from a prison pharmacy to the infirmary in your hand, or would you prefer a more secure method of carrying them? Many hospitals have similar transportation concerns.

Conclusion
Healthcare workers should use safety products that are available. A new mindset must be used by healthcare workers, hospital administrators, risk managers, infection control managers and others in order to change the status quo. There are alternatives to the unsafe products that have been used in the past. The use of standard needles and sharps is foolhardy because these tools become weapons that can destroy health and lives.

Every needle and sharp instrument should be looked at to determine whether an adequate safety replacement is available, and all alternatives should be evaluated. Standard needles and other sharps should never be used if adequate replacements are available. Hospital administrators should make sure that sharps injury prevention is practised in all departments.

Resources
International Sharps Injury Prevention Society (ISIPS)
Information about ISIPS and sharps safety products.
W:www.isips.org
E:ron@isips.org
ISIPS provides a weekly emailed newsletter that focuses on sharps injury prevention.
The newsletter is available at no cost by registering at W:www.isips.org/register.php
International Healthcare Worker Safety Center
W:http://hsc.virginia.edu/medcntr/centers/epinet/home.html
US National Institute for Occupational Safety and Health (NIOSH)
W:www.cdc.gov/niosh/homepage.html
US Occupational Safety and Health Administration (OSHA)
W:www.osha.gov/



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