Joanna C. Trim, BSc, RN.
Clinical Skills Trainer, University Hospital Birmingham NHS Trust
The risk of exposure to blood-borne pathogens - in particular hepatitis B, hepatitis C and human immunodeficiency virus (HIV) - has been documented since the mid-1980s following the first reported occupational exposure and subsequent seroconversion to HIV of a health-care worker (Communicable Disease Surveillance Centre, CDSC, 2000). Since that time numerous strategies have been introduced to reduce the risk of exposure to blood-borne pathogens, including hepatitis B vaccination, training, education, universal precautions and, most recently, needle-protective devices. Furthermore, data-collection systems were implemented at both local and national levels in order to audit this occupational hazard.
Needlestick injury incidence
Research studies have evaluated the number of reported needlestick injuries within individual health-care establishments. However, due to varying study methodologies, timescales and denominators, study comparisons were limited (Trim and Elliott, 2003) (Table 1).
Approximately 100 000 needlestick injuries currently occur each year in the UK (Godfrey, 2001) and in Scotland an estimated 2000-2400 such injuries were sustained annually (Short Life Working Group, 2001). More recently, a review of eight studies evaluating more than 7000 health-care workers found that 4% sustained a needlestick injury per year (range 1-6.2%) (Trim and Elliott, 2003). In the USA, the number of needlestick injuries was estimated to be one million per year (Occupational Health and Safety Administration, 2001; Porta et al, 1999). However, the actual number of needlestick injuries remains unknown due to under-reporting.
Unreported needlestick injuries
The non-reporting of needlestick injuries was first identified by Hamory (1983) who commented that as many as 40% were not reported. However, this figure has since risen to as many as 91% (Burke and Madan 1997). The number of unreported needlestick injuries from six UK studies are illustrated in Table 2.
Reasons for not reporting such injuries are varied and include the following:
Inaccurate assessment of source-patient risk factors - Nash and Goon (2000) identified that only 5% of needlestick injuries were reported because the health-care worker’s decision to report was influenced by judgements made about the source-patient’s lifestyle.
Complacency and acceptance - Health-care workers perceived needlestick injuries as an inevitable part of handling sharp devices and therefore injuries were unreported and bad practice tolerated (Connington, 2002; Jeanes, 1999).
Fear of a positive result - The stigma associated with blood-borne pathogens, the fear of a positive result as well as health-care workers’ denial of personal risk prevents the reporting of such incidents (May and Brewer, 2001; Osborn et al, 1999). From anecdotal evidence it seems that many nurses and doctors would rather not know their status following injury for fear of the result because of the potentially devastating impact a positive result could have on their career. Indeed, previous research studies identified that injuries were not reported due to health-care workers’ inability to influence the outcome following injury (Rabaud et al, 2000; Burke and Madan, 1997). Health-care workers may thus perceive reporting a needlestick injury as futile. However, this may be influenced by their knowledge of post-exposure prophylaxis.
The reporting process - Health-care workers’ lack of knowledge of the reporting process was highlighted by Trim et al (2003) who found that only 10% knew how to report a needlestick injury despite a comprehensive training and education programme. This deficient knowledge base may have been due to the lack of a standardised reporting policy across all UK hospitals, in addition to variations in reporting practice during day and night shifts (Trim et al, 2003). Indeed, with health-care workers’ current workload pressures injuries may go unreported if the reporting process is perceived as time-consuming (Connington, 2002; Burke and Madan, 1997). As such, it is essential to ensure that the process of reporting injuries is simple and efficient, incorporating a follow-up mechanism.
To improve the number of reported needlestick injuries it is important to understand health-care workers’ behaviour. Studies should be undertaken to identify reasons and factors that may influence whether an injury is sustained and reported. For example, it has been suggested that a clinical area’s organisational climate may influence whether injuries are both sustained and reported (National Audit Office, 2003).
Since the mid-1980s surveillance systems have collated information regarding numbers of occupational exposures to hepatitis B, hepatitis C and HIV, use of post-exposure prophylactic treatments and any seroconversions. In the UK the Health Protection Agency (formerly the Public Health Laboratory Service, part of the CDSC) started its national strategy in 1984. This surveillance system relies on voluntary reports from health-care establishments of health-care worker exposures to hepatitis B, hepatitis C and HIV, exposures where the source-patient status was unknown or where the recipient was treated with post-exposure prophylaxis. For exposures to hepatitis C and HIV, recipients are followed up six weeks and six months after the initial report. Approximately 250 departments report to the CDSC (Thomas, 2002). This information can be accessed via their website (www.hpa.org.uk).
Other surveillance strategies have provided data regarding needlestick injuries. In June 2000, the RCN started a sharps injury surveillance pilot study using Exposure Prevention Information Network (EPINet) software. This system provides health-care facilities with a standardised method for recording all inoculation injuries as well as provision of statistical analysis, customised reports and tracking of injuries by job, device and procedure (May and Brewer, 2001).
However, there is currently a paucity of available published evidence evaluating EPINet’s usability in today’s health-care establishments, although results from the pilot study are available at the Safer Needles Network website (available at www.needlestickforum.net).
Surveillance systems were also implemented by individual hospitals. However, as the UK National Audit Office (NAO) reported this year, 5% of hospitals were still unable to provide any information on needlestick injuries. Indeed, systems that are in place frequently lack consistency and co-ordination as well as the time, expertise and financial resources required to collect, manage and analyse meaningful data (Doebbeling, 2003).
It is possible to reduce the risk of exposure to blood-borne pathogens - for example, by adhering to policy and procedure as well as ensuring the provision and attendance of training. A variety of preventive strategies have been implemented to reduce the occupational risk of exposure to blood-borne pathogens and, if exposed, the risk of seroconversion.
Hepatitis B vaccination - The first published guidelines for hepatitis B vaccination were issued in 1993, with subsequent amendment in 1996 (Department of Health, DoH, 1996). Vaccination provides protection for an estimated 90% of recipients. However, a minority group do not develop antibodies (Ramos et al, 2000; DoH, 1998; Boxall and Dennis, 1998). Despite this relatively simple method of risk reduction, health-care workers are complacent with regard to their immunity, frequently unaware of their immunity status or fail to be vaccinated (Brotherton et al, 2003; McGrane and Staines, 2003). Indeed, one study found that 28% of nurses reported incomplete vaccination and only just over half of the 289 participating hospitals provided vaccination for medical staff (Brotherton et al, 2003).
Training and education - Training and education have been identified as integral to developing awareness among health-care workers, as well as improving adherence to good clinical practice (Wang et al, 2003; Heinrich, 2000; Mercier, 1994). Indeed, the DoH recommended training and education to prevent needlestick injuries (DoH, 2002); with medical staff being the most recent focus for training initiatives (NAO, 2003). Numerous studies have found that training and education - for example, in universal precautions and sharps management - not only encouraged safer work practices but improved concordance with policy and procedures (Gerberding, 2003; Connington, 2002; Short Life Working Group, 2001).
Despite this evidence, health-care workers continue to demonstrate inadequate knowledge of universal precautions or fail to comply. Anecdotal reports suggest that health-care workers were frequently unaware that gloves may reduce the volume of blood transferred via a needlestick injury from the source to recipient (Mast et al, 1993); even though this information was highlighted by the DoH (1998) and the Infection Control Nurses’ Association (2003), which both noted that blood may be ‘wiped off’ as the needle passes through the glove, reducing the volume of blood transferred. Reasons for health-care workers’ deficient knowledge base may be due to a lack of investment in staff training or limited understanding of health-care workers’ safe behaviour in the clinical setting or complacency (Twitchell, 2003; Henderson, 2001; Godin et al, 2000).
Indeed, concordance may be affected by health-care workers’ perception that their workload is increased by adhering to universal precautions and therefore these procedures were impossible to accommodate due to current clinical pressures (Cutter and Jordan, 2003). Other, more practical, reasons for non-concordance have included perceived reduction in dexterity when wearing gloves, unavailable equipment or not wanting to bother (Stein et al, 2003; Nelsing et al, 1997).
Knowledge and adherence to taught practice may still be deficient despite training and education due to insufficient information retention (Trim et al, 2003; Stein et al, 2003; Twitchell, 2003; Nobile et al, 2002; Doig, 2000). Induction programmes have been highlighted as a forum for initiating education, but owing to the large volume of information presented on such days, health-care workers do not retain all the information. For example, Doig (2000) found that the importance of sharps management literature provided during induction was not realised and therefore not retained by staff.
The degree of information retention following training programmes is currently unclear. One study found only immediate improved concordance post-training (Moongtui et al, 2000).
Methods of training and educating health-care workers with an aim to improve concordance, raise awareness of the risks associated with handling sharp devices and improve clinical practice are varied. Practical training sessions should be available for all health-care workers in their own local hospital environment - for example, training and update sessions on universal precautions, the process of reporting needlestick injuries and preventive measures to be undertaken in the clinical environment. However, health-care workers are also able to access educative conferences where expert practitioners share their experiences, research and expertise, giving attendees the opportunity to question, seek advice and potentially return to their own clinical areas with new ideas.
The most recent preventive strategy to reduce the risk of occupational exposure to blood-borne pathogens has been the development of needle-protective devices. These are products that can be used to protect health-care workers from accidental needlestick injury via contaminated sharp devices. Numerous products are currently available. However, few published studies have evaluated these products for usability and acceptability or efficacy in reducing associated needlestick injuries.
One procedure that increases the risk of transmission of blood-borne pathogens if a health-care worker sustains a needlestick injury is inserting a peripheral intravenous catheter because it directly accesses a vein and utilises a hollow-bore needle to penetrate the skin, both of which have been found to increase the risk of transmission of blood-borne pathogens following injury (Goldmann, 2002; Culver, 1997). Using needle-protective peripheral intravenous catheters may reduce this risk. This paper will discuss six published studies that evaluated needle-protective peripheral intravenous catheters; two each in the UK, Japan and the USA.
Needle-protective device studies
Watters et al (1995) study - Watters et al evaluated the usability and acceptability of BD Safelon by four medical staff in an A&E department. Ninety-five per cent of insertions were successful on first attempt and 93% of insertions were easier or comparable with their conventional device. Blood was found to leak from the distal end of the catheter before connection or during attachment of the luer lock cap (10%). The safety feature activated in 98% of insertions, the failures being due to incorrect operator technique rather than the product.
Asai et al (1999) study - BD Insyte Autoguard was compared with its conventional counterpart BD Insyte in Japan. First-attempt success rates were similar for both products and no significant difference with ease of insertion was noted. However, handling of the withdrawn needle was perceived as significantly safer with the needle-protective device when compared with its conventional counterpart. Blood leak was reported in both study groups when removing the introducer needle and connecting an infusion. However, blood contamination was significantly reduced with BD Insyte Autoguard (p=<0.0001). No needlestick injuries were sustained during the study.
Mendelson et al (2000) study - Mendelson et al. undertook a clinical trial to evaluate BD Insyte Autoguard and Protectiv Plus (Johnson & Johnson). BD Insyte Autoguard significantly reduced associated needlestick injuries by 89%; however, no results were reported for Protectiv Plus (Mendelson et al, 2000). In 2001 Mendelson et al presented further findings of this study, reporting a 95% associated reduction in needlestick injuries with BD Insyte Autoguard.
Asai et al (2002) study - Asai et al evaluated BD Insyte Autoguard, Protectiv Acuvance (Johnson & Johnson) and the conventional device BD Insyte for intravenous and intra-arterial catheterisation. Both products were more difficult to use when compared with the conventional product. However, BD Insyte Autoguard was reported to be safer when handling the contaminated device, with a lower incidence of blood contamination when compared with BD Insyte. Protectiv Acuvance was evaluated to have an adequate flashback chamber, but the backflow of blood was too slow. Overall, for intravenous catheterisation, BD Insyte Autoguard was preferred. However, for intra-arterial catheterisation conventional catheters were the product of choice. Concurring with their previous study in 1999, Asai et al (2002) found that, while using BD Insyte Autoguard, blood contamination occurred while removing the needle and connecting an infusion line. Indeed, in five incidents blood splashed on the palm or trunk of the operator during retraction of the needle because blood had penetrated the plug at the rear of the chamber. These results were reported to the product company and appropriate modifications were made. Moreover, during the study period no needlestick injuries were sustained.
Mummery (2002) study - In the UK, Mummery evaluated a number of needle-protective devices including Protectiv Acuvance (Johnson & Johnson) and BD Safelon for usability and acceptability. Each product was rated between 1 and 5, 1 being the most favourable. Sixty Protectiv Acuvance products were used, giving an average score of 2.4, whereas 42 BD Safelon scored on average 2.9.
B Braun (2003) study - The most recent study was undertaken in the USA at Mount Sinai Medical Centre and evaluated B Braun’s new product Introcan Safety IV catheter (B Braun, 2003). During the six-month study period no needlestick injuries were sustained compared with the 36-month baseline period where 13 needlestick injuries were sustained. This study is not yet published, but was presented at the Society of Healthcare Epidemiology of America conference in April 2003.
Needlestick injuries are a hazard for all health-care workers in the clinical arena and are a risk of potential transmission of blood-borne pathogens following an inoculation injury. In the UK an estimated 100 000 such injuries occur each year; in the USA it may be as many as one million. However, the true incidence is currently unclear due to under-reporting. Several studies demonstrated that health-care workers did not always report their injuries for a variety of reasons, including fear of a positive result, being unaware of the reporting process, inaccurate assessment of the source patient and complacency.
To improve the reporting of such incidents, it is essential to understand health-care workers’ behaviour, including reasons for not reporting incidents, and to review current reporting processes. Indeed, as highlighted previously, a standardised protocol across all hospitals may reduce confusion among health-care workers who frequently move jobs and therefore have to familiarise themselves with a number of protocols and procedures.Preventive strategies have been implemented to reduce the risk of not only injury but transmission of blood-borne pathogens:
- Hepatitis B vaccination is an effective means of reducing the risk of occupational hepatitis B transmission. However, health-care workers are not conscientious in assuring their immunity
- Training and education has been found to raise awareness and improve health-care workers’ knowledge of the risks associated with needlestick injuries but, despite this, health-care workers continue to demonstrate inadequate knowledge and practical application of safe working practices. Studies should be undertaken to gain insight into information retention and reasons for non-concordance with preventive strategies
- Attendance at educational conferences should be encouraged not only for managers who are able to influence change in the clinical setting but for all clinical staff, to enable exposure to research and current care methodologies. Consequently, this may encourage health-care workers to embrace new technological developments, such as needle-protective devices
- Not all needle-protective devices have been evaluated to date for either usability and safety or efficacy in reducing needlestick injuries. The available research studies reviewing needle-protective intravenous peripheral catheters have, however, demonstrated that these products may be of some value in reducing the incidence of needlestick injuries. Needle-protective devices should be considered as a preventive strategy, but further studies are necessary to evaluate not only the usability and acceptability of these products in a variety of clinical areas, but their efficacy in reducing needlestick injuries.
It is essential for all health-care workers to support advances in technology by encouraging evaluations of these products to identify the degree to which needle-protective devices may assist in the prevention of occupational exposure to blood-borne pathogens.
The author would like to acknowledge the support of Professor T.S.J. Elliott.
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