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Minimizing needle stick injury

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  • During this presentation we will talk about needlesticks and injuries with other sharps. We’ll first discuss why these injuries are a problem, how these injuries occur, and most importantly, how these injuries can be prevented.
  • CDC estimates that approximately 385,000 injuries with contaminated needles and other sharps devices occur annually among hospital-based healthcare personnel. That’s over 1,000 injuries a day! Many more occur in other healthcare settings, such as emergency services, home care, and nursing homes. Injuries with contaminated needles and other sharp devices are an important concern because they pose the risk of transmission of bloodborne viruses, and they are costly to personnel and to the healthcare system.
  • The three bloodborne viruses of primary concern for transmission from sharps injuries are hepatitis B (HBV) and C (HCV) viruses, and human immunodeficiency virus (or HIV), the virus that is associated with AIDS. The average risk of transmission after an occupational percutaneous exposure varies by the type of bloodborne virus. As you can see, one is at a higher risk for being infected with HBV following a sharps injury than for HCV or HIV. Fortunately, for hepatitis B virus, a vaccine and immune globulin are available that can protect healthcare personnel from becoming infected. This is why this vaccine is heavily promoted for healthcare personnel. The average risk for HCV transmission after a percutaneous exposure to HCV-infected blood is approximately 1 in 50 exposures. The average risk for HIV infection after a percutaneous exposure to HIV-infected blood is about 1 in 300 exposures.
  • For all bloodborne viruses, the percutaneous route of exposure (for example, a needlestick injury) carries the greatest risk for transmission of infection. The average risk for HIV transmission after a mucous membrane exposure (for example, blood splashed in the eye) is estimated to be 0.09%, or about 1 in 1,000. Although episodes of HIV transmission after skin exposures have been documented, the average risk for transmission has not been precisely quantified but is estimated to be less than the risk for mucous membrane exposures.
  • Although occupational transmission of HIV or hepatitis is relatively rare, the risks and costs associated with blood exposure are high. Some of the direct costs of sharps injuries are those associated with the initial and follow-up laboratory testing and treatment of exposed healthcare personnel. These are estimated to range between $71 to approximately $5,000, per person depending on the treatment provided. Costs that are harder to quantify include direct and indirect costs associated with potential side effects of antiretroviral therapies and lost time from work, time lost to completion of paperwork and follow-up (including obtaining informed consent for source patient testing), the emotional cost associated with fear and anxiety from worrying about the possible consequence of an exposure, and the societal cost associated with HIV or HCV seroconversion. By societal cost, I’m referring to possible loss of a worker's services in patient care, the economic burden of medical care, any worker’s compensation claims due to injury and exposure, and the cost of any associated litigation. [Note to presenter: Use local cost information if available.]
  • Because of the high burden of sharps injuries, our goal is to prevent – and ideally eliminate – sharps injuries.
  • Data from NaSH show that nurses sustain the highest percentage of percutaneous injuries. However other patient-care providers (such as physicians and specialized technicians), laboratory staff and support personnel (such as housekeeping and maintenance staff) are also at risk. [ NOTE to presenter: Depending on audience, the collective data can be used to elicit discussion on issues that contribute to this distribution: devices, training, staffing, disposal problems, etc. Ask audience members how they think injuries to housekeeping and maintenance staff occur. If the targeted group is primarily laboratory staff, you may want to include other bloodborne pathogens important to lab workers (See Workbook , Overview—Risks and Prevention of Sharps Injuries in Healthcare Personnel, Table 1).]
  • Injuries with needles and other sharp devices can happen at any time during use. NaSH data show that the majority of injuries occur during or immediately after use; 15% occur during or after disposal. During use injuries often occur when the device is being inserted or withdrawn and/or the patient moves. After use injuries occur during cleanup or in transit to another location. Injuries during disposal often involve Placing used sharps into the container or Disposing of a sharps devise inappropriately; that is, when a device is placed in the trash or left at the bedside or other location. In the next few moments, we will look in greater detail at how these injuries occur.
  • Think about all the needles and other sharp devices that are used to provide healthcare. While many different devices that can cause sharps injuries, six types account for nearly 80% of injuries in NaSH hospitals. Hollow-bore needles alone account for 56% of all sharps injuries. Hollow-bore needle injuries, especially from devices used for blood collection or for IV catheter insertion, are of particular concern, since they are likely to contain residual blood and are associated with an increased risk for bloodborne virus transmission. Of the 57 documented cases of occupational HIV transmission to healthcare personnel reported to CDC from June 1995 to December 2002, 50 (88%) involve percutaneous exposure . Of these, 45 (90%) were caused by hollow-bore needles and half of these needles were used in a vein or an artery. Although two scalpel injuries (both in an autopsy setting) caused HIV seroconversions, solid sharps such as suture needles or scalpels, generally deliver a smaller blood inoculum, especially if they first penetrate gloves or another barrier. Therefore these devices theoretically pose a lower risk for HIV transmission. Similar descriptive data are not available for type of devices or exposures involved in transmission of HBV or HCV.
  • You may also know that there are many possible mechanisms for injuries. In NaSH hospitals, 26% of hollow-bore needle injuries occur while the needle is being inserted, manipulated or withdrawn from the patient, and the patient moves or jars the device. Some needle injuries occur when accessing intravenous lines, such as giving an IV flush. With needle-free IV systems now available, these injuries should not be occurring. The same applies to recapping injuries. Why do you think people recap needles when it is so dangerous? [NOTE to presenter: Encourage discussion of this subject if time permits] You can see that many injuries in NaSH hospitals occur after use on the patient, such as during clean up, in transit to disposal, and during disposal. An additional 9% of injuries are due to improper disposal or result from leaving a sharp device on a table, stuck in a mattress, on the floor, or some other location. Another 10% of injuries occur when healthcare personnel collide with each other during a procedure. [NOTE to presenter: Encourage discussion of the different injury mechanisms, including some not mentioned here.]
  • Data from the NaSH system show that most sharps injuries from hollow-bore needles are preventable. A majority (64%) of all hollow-bore needle-related injuries can be prevented by using needles only when necessary, using devices with engineered safety features, properly using the safety features on these devices, following proper work practices (such as not recapping used needles), and properly disposing of needles after use.
  • As stated earlier, the first strategy in the hierarchy of sharps injury prevention is to reduce, if not eliminate, the unnecessary use of needles or other sharps objects when appropriate.
  • There are several ways that needle use can be eliminated or reduced. One way is the implementation of needle-free IV delivery systems that do not require, and in some instances, do not permit needle access. The majority (approximately 85%) of US hospitals have eliminated unnecessary use of needles through implementation of these devices. This strategy has largely removed needles attached to IV tubing, such as those for intermittent (piggy-back) infusion and other needles used to connect and access the part of the IV delivery system. Such systems have demonstrated considerable success in reducing IV-related sharps injures.
  • Here are two examples of needle-free IV delivery systems. As you can see all connections are made without the use of needles. Some systems use blunt cannulae (lower right) that enter the system through pre-pierced ports. Still other systems have recessed needles for system connections. [Note to Presenter: Discuss the safer IV delivery system that is used in your facility. When available, include a picture or have samples of the system on display.]
  • Some needle-free systems have been associated with bloodstream infections in patients. Therefore it is important to understand the infection control measures that should be adhered to, particularly the need for aseptic technique, when handling these systems.
  • The needs of patient care suggest that it will never be possible to eliminate the use of all needles and other sharps devices. Therefore, devices with engineered, or built-in sharps injury protection features aim to reduce the hazard to healthcare personnel.
  • This slide displays a variety of safer sharps devices engineered to prevent sharps injuries. On the left you see a variety of devices with the needle exposed in the before-use position. On the right you see that sharps are protected after use. The safety features include hinged caps [Note to presenter: point to devices #2 and # 7 from the top] , sliding sheaths [Note to presenter: point to devices #3, 4, and 6 from the top] , and retracting needles [Note to presenter: point to devices #1, 5, and 8 from the top] . Another type of safety feature, not shown here, is a bluntable phlebotomy or butterfly type needle. Additional strategies for needle protection are likely to evolve. [Note to Presenter: Identify whether any of these devices are currently in use or being evaluated by your facility. If other products are available, provide samples of them. Alternatively, create a slide with pictures of the devices used in your facility.] [ Disclaimer: The devices pictured in this slide are meant to serve as examples of devices that are currently available. This is not an exhaustive list, nor is it meant to favor one device over another. CDC and OSHA do not approve, endorse, register, or certify any medical devices.]
  • Many injuries related to work practices occur while sharps are being passed between different individuals, or transferred to a different location. Additionally, even though the practice of recapping contaminated needles has been discouraged for more than 20 years, approximately 5% of sharps injuries continue to occur due to recapping. Still other injuries related to work practices occur during collisions between workers and during decontamination or processing of used equipment. Personnel also continue to be injured by the improper disposal of used sharps. These injuries occur when sharps are left in unusual locations such as laundry or linens or are stuck in mattresses, left in pockets, or left on tables, trays, or other surfaces.
  • This slide summarizes the steps along the sharps safety continuum that will be reviewed in detail. Work practices to prevent sharps injuries are typically present as a list of specific practices to avoid (for example, recapping used needles) or to use (such as, sharps disposal containers). Data show that the risk of a sharps injury begins at the moment sharps are first exposed and ends once sharps are permanently removed from exposure in the work environment. Therefore, to promote safe work practices, healthcare personnel need to have an awareness of the risk of injury throughout the time sharps are exposed. They should also use a combination of strategies to protect themselves and their coworkers through the handling of the device. We will now review recommended practices that reflect this concept.
  • The recommended work practices that help ensure safety can be simplified into three quick points: Be prepared. Be aware. Dispose with care.
  • Before beginning a procedure that involves the use of a needle or other sharps device you should: ● Ensure that equipment necessary for performing a procedure is available within arm’s reach, and organize the equipment so that the procedure can be done safely. ● Assess the work environment before starting and make sure that you have adequate lighting and work space for the procedure. In cases where low light is needed for the procedure, take steps such as verbal cuing and the use of neutral zones to minimize the risk of injury from passing sharps. ● Ensure that the sharp object being used is always pointed away from the user.
  • Transcript

    • 1. Preventing Needlesticks and Other Sharps Injuries… Everything You Need to Know
    • 2. The Problem CDC estimates ~385,000 sharps injuries annually among hospital-based healthcare personnel (>1,000 injuries/day) Many more in other healthcare settings (e.g., emergency services, home care, nursing homes) Increased risk for bloodborne virus transmission Costly to personnel and healthcare system
    • 3. Risks of Seroconversion due to Sharps Injury from a known positive source  Virus  HBV  HCV  HIV  Risk (Range)  6-30%*  ~ 2%  0.3% (*Risk for HBV applies if not HB vaccinated)
    • 4. What is the Risk for HIV Alone? Percutaneous 0.3% Mucous membrane 0.1% Non-intact skin <0.1%
    • 5. Costs of Sharps Injuries Baseline and follow-up laboratory testing Treatment of exposed personnel $71-~$5,000 depending on treatment provided Lost productivity Time to complete paperwork Loss of income / loss of career Emotional costs Societal costs O’Malley, et. al. Costs of Management of Occupational Exposure to Blood and Body Fluids. ICHE, July 2007, v 28, No. 7.
    • 6. Who Gets Injured? Nurse 43% Technician 15% Student 4% Dental 1% Housekeeping/ Maintenance 3% Clerical / Admin 1% Other 5% Physician 28% Occupational Groups of Healthcare Personnel Exposed to Blood/Body Fluids, NaSH June 1995— December 2003 (n=23,197)
    • 7. When Do Sharps Injuries Occur? During use 41% After use/before disposal 40% During and after disposal 15% Other 4% Source: NaSH, June 1995—December 2003
    • 8. What Devices are Involved in Sharps Injuries? Six Devices Account for 78% of All Injuries  Disposable Syringes 30%  Suture Needles 20%  Winged-Steel Needles 12%  Intravenous Catheter Stylets 5%  Phlebotomy Needles 3%  Scalpels 8% Source: NaSH, June 1995—December 2003
    • 9. How Do Injuries Occur With Hollow-Bore Needles? During Sharps Disposal 13% During Clean Up 9% In Transit to Disposal 4% Handle/Pass Equipment 6% Improper Disposal 9% Access IV Line 5% Transfer/Process Specimens 5% Recap Needle 6% Collision W/Worker or Sharp 10% Manipulate Needle in Patient 28% Other 5% Circumstances Associated with Hollow-Bore Needle Injuries NaSH June 1995—December 2003 (n=10,239) Disposal Related: 35%
    • 10. Sharps Injuries Are Preventable Preventable 64%Nonpreventabl e 18% Undetermined 18% Preventability of Needlesticks in 78 NaSH Hospitals, June 1995--December 2004 (n=11,625)
    • 11. First Strategy:
    • 12. How Can Needle Use Be Eliminated or Reduced? Use needle-free IV delivery systems Use alternate routes for medication delivery and specimen collection when available and safe for patient care Streamline specimen collection systems
    • 13. Needle-Free IV Delivery Systems IV delivery systems use valved ports and connectors, pre- pierced septa using blunt cannulas, or recessed protected needle connectors
    • 14. Use aseptic technique when handling these systems!!! Needle-Free IV Delivery Systems
    • 15. Next Strategy:
    • 16. Safer Sharps Devices Engineered to Prevent Sharps Injuries
    • 17. Injuries Related to Work Practices Injuries occur because of the following: Passing or transferring equipment Recapping contaminated needles Colliding with coworkers Decontaminating/processing used equipment
    • 18. Injuries occur from sharps left in unusual places: Laundry Mattresses Tables, trays, or other surfaces
    • 19. The Sharps Safety Continuum Prepare to use the device the moment the sharps are first exposed Take precautions while using sharps Take precautions during cleanup Take precautions during disposal
    • 20. Sharps Safety Practices Be prepared Be aware Dispose with care
    • 21. Before Beginning a Procedure Be Prepared
    • 22. Organise equipment at the point of use
    • 23. Make sure workspace have adequate lighting
    • 24. Assess the patient’s ability to cooperate and - Get help if necessary Ask the patient to avoid sudden movement
    • 25. Obtain assistance from other staff or a family member to assist in calming or restraining a patient as necessary.
    • 26. Proper placement of sharps container
    • 27. If using a fixed sharps container it should not be fitted higher than 1.4 meter
    • 28. Before the beginning of a procedure that involves the use of a needle or other sharp device: Identify the location of the sharps disposal container; if moveable, place it as near the point-of-use as appropriate for immediate disposal of the sharp. If the sharp is reusable, determine in advance where it will be placed for safe handling after use.
    • 29. Before the beginning of a procedure that involves the use of a needle or other sharp device: If multiple sharps will be used during a procedure, organize the work area (e.g. procedure tray) so that the sharp is always pointed away from the operator.
    • 30. During a Procedure That Involves the Use of Needles or Other Sharp Devices: Maintain visual contact with the procedure site and location of the sharp device.
    • 31. During a Procedure That Involves the Use of Needles or Other Sharp Devices: When handling an exposed sharp, be aware of other staff in the immediate environment and take steps to control the location of the sharp to avoid injury to oneself and other staff.
    • 32. During a Procedure That Involves the Use of Needles or Other Sharp Devices:
    • 33. During a Procedure That Involves the Use of Needles or Other Sharp Devices: If the procedure necessitates reusing a needle multiple times on the same patient (e.g., giving local anesthesia), recap the needle between steps using a one-handed technique or a fixed device that enables one-handed recapping.
    • 34. One handed recapping
    • 35. Locking the cap of the needle
    • 36. Using a one-handed technique recapping
    • 37. Manipulate or remove sharps using a mechanical device
    • 38. Activate the safety feature as the procedure is being completed, observing for audio or visual cues that the feature is locked in place. Safety syringes
    • 39. During Clean-up following a Procedure:
    • 40. During Clean-up Following a Procedure: Do not use bare hands to sort procedure tray
    • 41. Use a mechanical device to pick up the sharp if it cannot be performed safely by hand.
    • 42. After Disposal: Visually inspect sharps containers for evidence of overfilling before removal.
    • 43. Use a mechanical device to remove sharps from overfilled box If a sharps container is overfilled, obtain a new container and use forceps or tongs to remove protruding devices and place them in the new container.
    • 44. During Disposal: If a sharps container is overfilled, obtain a new container
    • 45. Improperly Disposed Sharps: If an improperly disposed sharp is encountered in the work environment, handle the device carefully, keeping the hands behind the sharp at all times.
    • 46. During disposal No recapping
    • 47. During a procedure Do not carry sharps without a tray .
    • 48. Wrong disposal can harm others Do not dispose sharps into regular garbage
    • 49. Improper Disposal
    • 50. Assemble container correctly Do not use sharps box without cover
    • 51. FLOW SHEET FOR NEEDLE STICK/SHARPS INJURY NEEDLE STICK/SHARPS INJURY WASH THE INJURY UNDER RUNNING WATER (DO NOT SUCK/SQUEEZE FROM THE INJURED SITE) COVER INJURY WITH AN IMPERMEABLE DRESSING NOTIFY SUPERVISOR IF INJURY IS SERIOUS GO TO ER FOR APPROPRIATE TREATMENT
    • 52. FLOW SHEET NEEDLESTICK/SHARPS INJURY COMPLETE AN OVA FORM (INCLUDE PATIENT/SOURCE MEDICAL NO.) GO TO EHS WORKING HOURS/AFTER WORKINH HOURS GO TO ER) GO TO GP LAB FOR BLOOD WORKS IF POSSIBLE DO BLOOD WORKS FROM SOURCE PATIENT AFTER CONSENT FROM TREATING PATIENT GO BACK TO EHS AT THE SPECIFIED FOLLOW- UP DATES GIVEN TO YOU FOR BLOOD WORKS
    • 53. THANK YOU !!!