Sharps injuries: Continuing professional development

According to the National Audit Office (NAO) report A Safer Place to Work (2003),1 needlestick injuries are the second highest cause of occupational injury in the NHS, and the numbers are increasing.

Needlestick or sharps injuries occur when a needle or other sharp instrument accidentally penetrates the skin. If the needle or sharp is contaminated with blood or other body fluid, there is the potential for the transmission of infection. The NAO reported that 16% of all staff injuries suffered within acute hospital trusts in England are a result of needlestick/sharps accidents, resulting in staff exposure to blood-borne viruses. NHS staff report approximately 40,000 incidents each year, and it is suggested that the same number go unreported.2

 

The Safer Needles Network3 aims to minimise the number of needlestick injuries by promoting preventive measures and safer systems of working, such as the provision of safer needles, as well as improved training and use of standard precautions.

 

The Public Audit Committee4 has recommended to the Department of Health that NHS trusts adopt a comprehensive strategy for dealing with needlestick injuries. Trusts should aim to reduce unnecessary use of needles, upgrade their training for safer working practices, and evaluate the effectiveness of preventative measures.

 

This article discusses how the West Suffolk Hospital NHS Trust is managing the reduction of sharps injuries. Data gathered by the risk office within the trust enabled the OH department to identify areas of particular concern.

 

West Suffolk Hospital

 

Epinet5 results indicate that 40% of healthcare workers who were injured were not the original user of the ‘sharp’, and employees are injured very often through no fault of their own due to the thoughtless disposal of the sharp by others. A breakdown of incidents at the West Suffolk Hospital NHS trust reported for 2004 and 2005 identified approximately 30% were due to inappropriate disposal, ie, left on the bed, locker, floor, disposed of in wrong bin, etc, and a further 30% occurred after use, prior to disposal.

 

The results (see tables 1 and 2) indicated that there was a definite need for control measures to be introduced to reduce the risk of needlestick injuries and exposure to blood-borne viruses.

 

Health risks

 

The Management of Health, Safety and Welfare Issues for NHS Staff2 indicates that the major blood-borne pathogens of concern associated with needlestick injury are:

 

 

  • Hepatitis B (HBV)
  • Hepatitis C (HCV)
  • Human Immunodeficiency Virus (HIV).

 

There are also other infectious pathogens, which have the potential for transmission.

 

The risk from needlestick injuries is generally accepted2 at the following sero-conversion rate:

 

 

  • Hepatitis B 30% or 1 in 3
  • Hepatitis C 3% or 1 in 30
  • HIV 0.3% or 1 in 300

 

The Occupational Health & Safety Strategy Implementation Group6 reported that the greatest risk occurs when the skin is pierced by a hollow bore, blood-filled needle during cannulation (see below).

 

Reducing risk

 

The following methods were being used to reduce the risk of needlestick injuries at the trust:

 

 

  • Induction training
  • Clinical skills training
  • Policy on management of contaminated sharps injury and accidental exposure to body fluids
  • Management of HIV contaminated sharps injury and accidental exposure to body fluids of HIV infected-patient
  • Protecting HCW and patients from Hepatitis B
  • HIV/AIDS policy for the protection of staff and patients
  • Policy for the guidance of Hepatitis C infected healthcare workers
  • Safe needle products currently in use, as follows
  • Safety lock for taking blood cultures
  • Blue Butterfly needles for sub-cutaneous medication
  • Blue twin safety system (needleless connection system)
  • Pre-set safety arterial blood sampling set
  • Sharpsmart disposal bin
  • Recording accident data.

 

A project team was convened to tackle the problem. This included the OH nurse manager (lead), the risk manager, clinical skills manager, purchasing manager, infection control nurse, manager of the emergency admissions unit, senior sister in paediatrics and representatives from companies that provide products to manage needlestick injuries.

 

The project team agreed, in the first instance, that the greatest risk was posed by hollow-bore needles which had been placed in a patient’s vein and contained blood, ie, cannula. A review of products on the market was carried out and two very different cannula were chosen to be piloted, and the sales representatives invited to discuss this. Data provided by the risk office, along with usage figures from the purchasing department, shaped the decision to pilot the safety products in the accident and emergency (A&E), emergency admission, paediatric and oncology units.

 

Needle/sharps management

 

At the start of the pilot, users were asked about their feelings about safety in relation to the risk of blood-borne viruses. The same question was asked again at the end of the pilot.

 

Statement: I feel the procedures and products are sufficient to reduce the risk of HIV, Hepatitis B and Hepatitis C

 

 

  • Pre-pilot: 47% of those surveyed ‘agreed’ or ‘strongly agreed’
  • Post-pilot: 92% of those surveyed ‘agreed’ or ‘strongly agreed’.

 

New needles

 

The first cannula (product A) chosen was a Closed IV Catheter System, which reduces the potential for contamination and risk of infection. This cannula was piloted on the paediatric and oncology units.

 

The second cannula chosen was a straight IV Cannula with injection port (product B), which mirrored the previous non-safety cannula being used within the trust, and was piloted in the emergency admission unit and A&E department.

 

The paediatric staff were very pleased with product A, and it was agreed to continue the pilot for a further two weeks. The response from the emergency admission unit and A&E with product B was also very positive, and the pilot was again extended for a short period.

 

The survey revealed the following views from the users about safety when cannulating before and after the pilot:

 

Statement: I feel there is a risk of sustaining a needlestick injury during cannulation

 

 

  • Pre-pilot: 87% of those surveyed ‘agreed’ or ‘strongly agreed’
  • Post-pilot: 0% of those surveyed ‘agreed’ or ‘strongly agreed’.

 

Although advised that product A was apparently used extensively at a large cancer hospital, the oncology unit appeared to have difficulty adjusting to the slight changes required in practice. But with the majority of staff eager to continue using the cannula, the pilots were deemed to be a success, following evaluation:

 

Statement: I feel the risk of sustaining a needlestick injury would be reduced for all staff by the trust changing to a safety product

 

 

  • Pre-pilot: 42% of those surveyed ‘strongly agreed’
  • Post-pilot: 58% of those surveyed ‘agreed’.

 

Next step

 

The OH manager prepared a business case to propose that the trust make a commitment to change to safer sharps over the following five years. The introduction of the safety cannula (product B) would be the first step in developing a safety culture in relation to the use of needles and sharps within the trust.

 

Product B was the selected safety cannula of choice due to the comments of the users. The business case identifying not only the costs of the cannula, but also the cost of a member of staff sustaining a needlestick injury (see table 4 below), was presented to the Clinical Standards Executive Committee.

 

The principle of introducing safety cannula was accepted as a positive step towards reducing needlestick injuries. However, it was pointed out that the cost of product B was in excess of current costs (product A was even more costly). Taking into consideration the financial constraints the trust was working under, the recommendation was to ask the companies if the price could be reduced.

 

After meetings with the companies providing the products, they agreed to reduce the prices and offer the potential for greater reduction due to agreed discounts for increased sales across the procurement confederation.

 

The proposal was presented to the Trust Management Team (TMT) at the beginning of October 2006 with all the benefits stressed regarding safer sharps, including the decrease in price and predicted savings. There were several questions about usage, other available products and cost. The TMT was advised that a competitive price had been negotiated, which the NHS Purchasing Supply Agency was very pleased to sign up to.

 

Representatives from the Eastern Confederation NHS procurement agency expressed their support, as West Suffolk Hospital was the first trust in the region to give consideration to safer needles. This will not only benefit the region with a greater discount for increases in sales, but will also create a safer working environment.

 

The OH manager and the clinical skills manager met with the sales representative of product B to plan a programme to introduce the new cannulas, on a ward/department basis to ensure an understanding of the positive benefits and need for slight change in practice, as well as to ensure that good practice was maintained.

 

Barriers

 

The process for introducing any change within an organisation will meet with resistance and this project was no different. An oversight was made in not inviting one of the staff groups, which is one of the larger users, to participate in the initial discussions regarding piloting the safety products. This appeared to lead to an apparent antipathy to the chosen safety product, despite several demonstrations and presentations. However, on a positive note, the concept of safety and the need to introduce a safer cannula was conceded.

 

Further safety cannula are being piloted before the final decision is made on the choice of safety product to ensure that there is consistency across the trust, as currently the trust is using various safety cannula in different departments.

 

Conclusion

 

The pilot commenced in June 2006, and the use of safety cannula has continued to a varying degree in different departments. The statistics show a slight increase in needlestick injuries for 2006 (111), but as the use of safety cannula was on a trial basis in only a few departments, the trust will need to monitor statistics and review at the end of 2007 when the use of safety cannula has been embedded in the organisation.

 

My expectations were rather naïve, believing everyone would sign up to a safety product that would reduce the risk of exposure to blood-borne viruses. It would appear that safety with regard to needlestick injuries and reduction of exposure to infections is not given due consideration, and we still have a long way to go. The journey to developing a sharp safety culture has only just begun, but the first steps have been taken.

 

Lessons learned

 

 

  • Be prepared for resistance.
  • Do not assume everyone will be as eager to implement change.
  • It is vital to ensure representation from all departments which are likely to be affected by any change in product and practice.
  • Do be aware that it is important to gain support from a large proportion of users.
  • Stay positive.
  • Believe that what you are doing will improve practice for patients as well as staff.

 

Jenny Saunders is occupational health manager at West Suffolk Hospital NHS Trust

 

Table 1: Reported number of sharps incidents within the trust

 

 Period Number of incidents

 Jan-Dec 2004

130

Jan-Dec 2005

103

 

Table 2: Breakdown of sharps incidents

 

Sharps incident  2004  2005

 Left in inappropriate place

 35

22

 Sharps in rubbish bag

 1

1

 Overfull sharps bin

 3

5

 Re-sheathing

 2

0

 After use before disposal

 41

44

 During surgery

 13

1

 During cleaning process

 2

2

 Other

33

16

 

Table 4: Breakdown of cost per low-risk needlestick injury for year

 

Time lost                                                    £ (approx)

 

 

  • Injured member of staff                                15
  • Occupational health nurse adviser
  • Gum clinic time and doctor’s consultation      132

 

Hepatitis B vaccination

 

 

  • Testing                                                         25
  • Laboratory time                                           17
  • Blood test                                                    110

 

Counselling

 

 

  • Completion of forms                                     20
  • Management Time                                        20
  • Health and safety accident investigation         15

 

Follow-up assessment

 

 

  • Time away from ward/department                 17
  • Occupational health time                               10

 

Estimated cost of a single
low-risk injury = (£a)                                    396

 

Number of low-risk injuries
attending OH = (£b)                                      74

 

Total cost of low-risk
injuries = (£a x b)                                          £29,304
                                                                     (conservative cost)

 

References

 

 

  1. National Audit Office (NAO) (April 2003) A Safer Place to Work: Improving the Management of Health and Safety, p20-21
  2. Department of Health (2005) The Management of Health, Safety and Welfare Issues for NHS Staff, Chapter 19
  3. Department of Health (October 2003) Public Accounts 42nd Report Measuring the extent and impact of accidents to NHS staff,
  4. Occupational Health & Safety Implementation Group, NHS Scotland, Safer Sharps Devices (2003)

 

Continuing professional development quiz

1. What do EPINet results indicate?

a) 20% of injured were drug addicts
b) 10% of injured were not the original user
c) 40% of injured were not the original user
d) 40% of injured were already Hep C positive

2. What percentage of injuries were due to inappropriate disposal?

a) 5%
b) 20%
c) 25%
d) 30%

3. Which of the following is not a blood borne pathogen associated with needlestick injury?

a) H5N1
b) Hep B
c) Hep C
d) HIV

4. Where was product A extensively used?

a) In industry
b) In research
c) In an orthopaedic hospital
d) In a cancer hospital

5. What costs did the business case identify to the Clinical Standards Committee?

a) Cost of the whole package including staff training
b) Cost of the new cannula versus the cost of needlestick injury
c) Cost of new cannula versus cost of old cannula
d) Cost of each individual case

6. What was the cost of a low risk injury?

a) £15
b) £15,000
c) £29
d) £29,000

7. Who made up the team that planned the training programme?

a) OH manager, HR manager and sales representative
b) OH manager, clinical skills manager and sales representative
c) OH manager, clinical skills manager and HR manager
d) HR manager, clinical skills manager and sales representative

8. Why did the author think that he/she had been naïve?

a) He/she believed everyone would sign up to a safety product
b) He/she believed everyone would take part in the pilot research
c) He/she believed everyone would be interested in safety
d) He/she believed everyone would interested in preventative healthcare

9. Who recommended to the Department of Health that NHS trusts should adopt a strategy to deal with needlestick injuries?

a) National Audit Office
b) Public Audit Committee
c) Health Protection Agency
d) Health and Safety Executive

10. Who gathered the data in the Trust?

a) Risk office
b) OH department
c) A&E
d) Infection control officer

Click here for the answers

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