Avoiding sharps injuries: put prevention before cure

Needlestick injuries (NSIs) are one of the most common injuries for healthcare workers. Clare Tregoning discusses what measures can be taken to protect staff from harm, and what actions should be taken if an injury does occur.

The Health Protection Agency (HPA) defines inoculation exposure as a term to encompass an NSI, sharps injury (SI) and body fluid splashes.

The injuries are subdivided into two categories:

those resulting from percutaneous exposure, such as needlestick and sharps injuries, where a blood or body fluid contaminated object pierces the skin; and
those resulting from mucocutaneous exposure, such as blood or body fluid splashing into an open wound, eye or mouth mucous membrane (HPA, 2008).

Following a survey of 4,000 nurses carried out in 2008 by the Royal College of Nursing (RCN), it is estimated that 48% of nurses have received an NSI, which is identified as one of the most frequently experienced injuries to healthcare workers (Adams, 2012).

According to the RCN (2011), NSIs – through venepuncture and injection – are the most common causes of inoculation exposure (see fig.1, right). This is supported by the HPA (2008), which reports that percutaneous injuries with hollow bore needles remain the most frequently reported inoculation exposure in the healthcare setting.

Those at risk

All workers in the healthcare setting are at risk of an inoculation exposure, which can result from a bite, bloodstained body fluid splash to mucous membrane or a skin puncture through a contaminated sharp. However, the HPA identifies certain groups of workers that are at increased risk due to their role and/or area of work. These are:

doctors;
dentists;
nurses;
healthcare assistants;
phlebotomists;
domestic staff;
porters; and
waste-removal workers.

A number of factors are known to contribute to NSIs. Aziz (2012) suggests the cause is a lack of resources, while Adams (2012) suggests that it is due to tired or busy staff. However, poor practice can also increase the incidence of injury, according to Higginson & Parry (2013).

Legislation

Appropriate training, management and reporting of NSIs is essential, and the employer has a duty of care to protect employees from these injuries.

There are several laws that legislate over the protection of staff against NSIs (RCN, 2011):

The Health and Safety at Work etc. Act (HSW Act, 1974).
The Management of Health and Safety at Work Regulations (1999).
Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR) (1995), although NSIs are not covered by this unless the person is infected as a result of the injury, or the person is absent from work for more than three days.
Control of Substances Hazardous to Health Regulations (COSHH) (2005).
Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

A Directive was published by the European Union (EU) in June 2010, requiring protection for employees from sharps injuries in the hospital and healthcare sector, and stating that the guidelines must be fully implemented in all EU member states by May 2013 (Council Directive EU, 2010). The directive required governments of EU countries to introduce legislation on the management of sharps to improve practice and reduce the risk of NSIs. The UK has implemented the Directive in the form of the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

Sharps management guidance (Council Directive EU, 2010) states that sharps bins should fulfil the following requirements:

Conform to appropriate standards (UN3291 & BS7320).
Be made available where sharps are used.
Never be overfilled.
Have correct labelling and disposal when two-thirds full.
Not be placed on the floor.
Be safely located.
Do not bend, disassemble, break or re-sheathe needles prior to disposal.
Safety needle devices (SNDs) must be assessed before use and indicated as providing a safer system of working before they are introduced.
Staff must be appropriately educated and trained in hand hygiene and the use of personal protective equipment (PPE), such as gloves, aprons and visors.

Prevention of sharps injuries

Historically, the UK has focused on changing individual behaviour and follow-up support after an NSI. However, the EU Directive places priority on prevention. The “Hierarchy of controls” and principles of prevention frameworks (RCN, 2011) highlights measures that can be implemented to prevent NSIs, which are listed in box 1, below, in order of most to least effective.

Box 1: RCN Hierarchy of controls for sharps injury prevention.

Elimination or substitution of hazard:
- Eliminate all unnecessary injections.

Engineering controls:
- Employ safety devices.
- Use sharps bins.

Administrative controls:
- Training programmes.
- Policies.
- Safer systems of work.

Work practice controls:
- Safe handling and disposal of sharps.
- Standard precautions, eg no recapping of needles.

Personal protective equipment:
- Face shields, gloves, masks and gowns.

The “Hierarchy of controls” focuses on removing the hazard as the most effective measure for reducing risk, rather than relying on changing work practices, behaviour, training and PPEs. The impossibility of removing all sharps from healthcare environments is recognised, but the hierarchy control measures utilised with risk assessments present a framework for reducing the risks of injury (Aziz, 2012).

Infections transmitted by inoculation exposure

There are more than 20 blood-borne pathogens that can be transmitted following an inoculation exposure (RCN, 2009). Blood-borne viruses (BBVs) such as hepatitis B, hepatitis C and the human immunodeficiency virus (HIV) are the most common.

Examples of infections transmitted by inoculation exposure (HPA, 2008) include:

hepatitis B (HBV);
hepatitis C (HCV);
HIV;
tuberculosis;
syphilis;
malaria;
herpes simplex;
diphtheria;
ebola;
cutaneous manifestations of gonorrhoea;
Staphylococcus aureus; and
Streptococcus pyogenes.

Factors affecting infection transmission

Jack et al (2013) identify that the risk of transmission of a BBV may be affected by certain factors such as:

the type of sharp;
the depth of injury;
the amount of blood or blood-stained fluid on sharp;
how long was the sharp used before inoculation exposure;
whether the sharp was used in a vein or artery; and
the infectiousness of inoculation injury source.

The lifespan of a BBV outside the body can be significant. While HIV is not believed to survive well outside the body (Centers for Disease Control (CDC), 2010), HCV may survive for up to four days (CDC, 2009b) and HBV for up to one week (CDC, 2009a). This has direct implications for injuries sustained from sharps of unknown origins (Hambridge, 2011). These injuries must have assumed risk and the appropriate follow-up care provided immediately (HPA, 2008).

Inoculation exposure injuries not only have potential health consequences for those affected, but also a psychological impact (RCN, 2009). A contributing factor is stress and anxiety, experienced through the uncertainty of infection transmission until the appropriate tests are carried out (Hambridge, 2011). Waiting for test results may prove distressing, as the test result may not only affect relationships and family but also employment (Paton, 2013).

Importance of reporting injuries

Despite the risk of NSIs with contaminated needles having the potential to transmit BBVs, awareness of, and adherence to, local policies of reporting and first aid procedures remains inconsistent (Higginson and Parry, 2013). The Health and Safety Executive (HSE) acknowledges a lack of evidence relating to NSIs, which it attributes to non-reporting of injuries. According to UK law, it is not only the responsibility of the employer to protect their staff from injury, the employee is responsible for following procedures and reporting injuries. Employees may provide numerous reasons for not reporting an injury. However, it is essential that all incidents are recorded to ensure they are managed appropriately.

Reasons for reporting/not reporting NSIs.

Reasons for not reporting an injury:

Unaware of correct reporting procedure.
Embarrassment of sustaining an injury.
Fear of needles involved in follow-up care.
Inaccurate perception of risk associated with contaminated sharps.
Too busy and not enough time to attend for appropriate first aid and follow-up.
Fearful that the injury reflects bad practice.
Transmission of an infection may affect employment.

Reasons for reporting an injury:

Enables correct first aid.
Allows appropriate management to reduce the risk of BBV transmission.
Vaccination history can be checked.
Correct follow-up care can be advised.
Counselling can be offered.
The incident is documented, which is essential for investigation for occupational injury or infection.
Enables investigation into incident and surveillance of safety practices.
Enables audit of safety practices.
Allows employers to meet RIDDOR requirements of reporting appropriate injuries to the HSE.

Action to be taken following an inoculation injury

All healthcare providers should, in line with legislation, provide clear guidance to protect their staff from NSIs and also on the management of an injury should it occur. This is normally in the form of local policies and procedures, which provide guidance on the course of action to take. An example of a local policy is shown in box 2, below.

Box 2: Summary of action to be taken following an inoculation injury (local health board policy)

Are you at risk of contracting a blood-borne virus?

Have you suffered a human bite, a skin puncture, splash of blood or bloodstained body fluid into your eyes, mouth, nose or onto broken skin?

If yes:

Employee:

1. Follow first aid procedure.
2. Inform manager.
3. Go directly to A&E.
4. Complete incident form.

Manager:

1. Initiate risk assessment relating to type of injury and source patient.
2. Inform A&E.
3. Complete incident form.
4. Coordinate further consideration of source patient investigations.

A&E:

1. Triage to high priority if risk of infection is significant.
2. Review risk assessment.
3. Consider HIV post-exposure prophylaxis (PEP) medication and provide advice sheet if appropriate.
4. Obtain baseline blood tests for BBVs.
5. Consider giving hepatitis B vaccination or immunoglobulin.

Occupational health:

1. Review risk assessment.
2. Review indications for HIV PEP medication.
3. Review need for hepatitis B vaccination or Immunoglobulin.
4. Liaise with infectious diseases, genito-urinary or virology specialists, as appropriate.
5. Review source of patient test results where available.
6. Arrange follow-up monitoring for hepatitis B, C and HIV.
7. Provide confidential support and counselling to employee.

Safe measures

All healthcare workers are at risk of sustaining an NSI and it remains one of the most frequently reported injuries to staff. Considering all factors that affect infection transmission following an NSI, it is imperative that all needlestick injuries and inoculation exposures are reported so appropriate treatment, follow-up care, advice and counselling can be provided.

Historically, the UK has focused on individual behaviour and support following an NSI. However, the new Regulations (HSE, 2013) place priority on prevention, and this is supported by the RCN through its “Hierarchy of controls” for sharps injury prevention (RCN, 2011), which focuses on removing the hazard as the most effective method for reducing risk.

The employer has an obligation to safeguard employees from NSIs (HSW Act, 1974) and ensure that the sharps Regulations are implemented. However, it remains the responsibility of all individuals to follow company policies and procedures and report all inoculation exposures.

References

Adams D (2012). “Needlestick and sharps injuries: practice update”. Nursing Standard; 26 (37), pp.49-57.

Aziz A (2012). “Preventing needlestick injuries”. British Journal of Nursing; 22 (4), pp.32-33.

Aziz A (2012). “Subcutaneous injections: preventing needlestick injuries in the community”. British Journal of Community Nursing; 17 (6), pp.258-64.

Centers for Disease Control and Prevention (2009a). Hepatitis B FAQs for the public. Accessed 18 August 2013.

Centers for Disease Control and Prevention (2009b). Hepatitis C FAQs for the public. Accessed 18 August 2013.

Centers for Disease Control and prevention (2010). HIV transmission. Accessed 18 August 2013.

European Agency for Safety and Health: Council Directive European Union (2010). Implementing the framework agreement on prevention from sharps injuries in the hospital and healthcare sector. Accessed 24 June 2014.

Hambridge K (2011). “Needlestick and sharps injuries in the nursing student population”. Nursing Standard; 25 (27), pp.38-45.

Health and Safety at Work etc. Act 1974: London. The Stationery Office.

Health Protection Agency (2008). “Eye of the needle: United Kingdom surveillance of significant occupational exposure to bloodborne viruses in healthcare workers”. London: HPA.

Health and Safety Executive (1999). Management of Health and Safety at Work Regulations. Norwich: HSE.

Health and Safety Executive (2002). Control of Substances Hazardous to Health Regulations.

Health and Safety Executive (2013). Health and Safety (Sharps Instruments in Healthcare) Regulations 2013. Last accessed 24 June 2014.

Higginson R and Parry A (2013). “Needlestick injuries and safety syringes: a review of the literature”; British Journal of Nursing, 22 (8) pp.4-12.

Jack K, Cooper J and Ryder S (2013). “Hepatitis B virus part 1: risk factors, blood results and nursing care”; Gastro Intestinal Nursing, 11 (3) pp.37-41.

Paton N (2013). “Needlestick injury incidence increasing”; Occupational Health, 65 (1) pp.35-36.

Royal College of Nursing (2008). “Needlestick injury in 2008: results from a survey of RCN members”. RCN: London.

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Royal College of Nursing (2009). “Needlestick injuries: the point of prevention”. RCN: London.

Royal College of Nursing (2011). Sharps safety. RCN guidance to support implementation of the EU Directive 2010/32/EU on the prevention of sharps injuries in the healthcare sector. RCN: London.