Before discussing the risks of needlestick and sharps injuries it is important to identify the extent of the problem. This is the first stumbling block, as there is little information relating to the true incidence of needlestick and sharps injuries. The Department of Health (DH) does not currently collect such data, but there are plans to issue guidance to remedy this.
Janice Gabriel, MPhil, PgD, BSc (Hons), RN, FETC, ONC, CertMHS.
Consultant Cancer Nurse, Winchester and Eastleigh Healthcare NHS Trust/ University of Southampton, Hampshire
In 2000, the RCN ran a surveillance programme over a 12-month period that involved 14 hospital trusts supplying data on the number of sharps injuries sustained by their staff. This was the beginning of the RCN’s ‘Be Sharp, Be Safe’ campaign (RCN, 2003a; Trim and Elliott, 2003). Data from the first 12-month monitoring period identified 888 sharps injuries among staff from the participating organisations.
Following on from this the RCN invited organisations to join a second study period, running from January to December 2002. Some 15 sites participated, and they reported a total of 1445 sharps injuries over the 12-month period. The number and types of injuries reported revealed that the use of hollow-bore needles and other sharps as part of everyday work posed a significant risk to staff.
However, this information was collected from only a small percentage of UK trusts, which participated in data collection on a voluntary basis and recorded reported injuries only (RCN, 2003a: Trim and Elliott, 2003).
The US experience
Health-care workers in the USA have access to a range of needle-free systems. Where it is not possible to substitute the use of needles, safety protection systems have been developed. These include cannulas with integral sharps protection and venesection needles that ‘self-blunt’ once venepuncture has been achieved or when the needle is withdrawn through the skin.
Using a data collection system developed by the University of Virginia called EPINet, researchers estimate that between 600,000 and 800,000 needlestick and sharps injuries occur annually among health-care workers in the USA. This equates to about 30 needle-stick injuries for every 100 hospital beds (EPINet, 1999).
The EPINet system not only captures the number of sharps and needlestick injuries, but also seeks information relating to the equipment involved, the professional group of the injured person, the nature of the injury and the action taken. The software package used was the same as that used for data collection by the RCN (EPINet, 1999; RCN, 2003a).
It has been estimated that between 1985 and 1999 there may have been 136 cases of occupationally acquired HIV among US health-care workers. The prime cause of these infections is believed to be the use of hollow-bore needles (NIOSH, 2003).
To reduce the incidence of such injuries, the US Senate introduced legislation aimed at protecting health-care workers (Tan et al, 2002). Employers are required to ensure that staff have access to needle-free and safer sharps systems. In addition to this, it is a requirement for all sharps injuries to be recorded.
The UK experience
Data collected by the RCN has identified that nurses sustain the greatest number of sharps and needlestick injuries of all health-care workers. Some 37% of all nurses sustain a needlestick or sharps injury at some time in their career. Intramuscular (IM) and subcutaneous (SC) injections account for 23% of the reported injuries (RCN, 2003a).
The RCN study identified that 56.4% of sharps injuries are sustained by the the original user of the sharps/needle. Poor disposal of sharps and needles were found to account for a significant percentage of injuries. Data, again from the RCN study, identified that 20% of injuries among health-care workers is the result of sharps/needles protruding from a dedicated sharps disposal container (RCN, 2003a).
In Scotland, it has been estimated that the health service loses £260,000 a year in staff time lost due to injury-related absence, treatment for injures, and legal and compensation costs. An NHS Scotland report (2000) acknowledges that the introduction of sharps and needle safety systems would not only be a cost benefit, but would also significantly reduce the risk to staff of a blood-borne viral infection.
Understanding the problem
Until health-care professionals have directly or indirectly experienced a sharps injury, they are likely to underestimate the potential implications. A study of 100 nurse, undertaken by Leliopoulou et al in 1999, identified that the majority of those surveyed considered the risk of a needlestick injury to be ‘unlikely’ or ‘very remote’. Data from the RCN survey identified a nearly two-fold increase in the incidence of reported sharps between the first and second study periods (RCN, 2003a). The question is, was this a ‘real’ increase in the number of injuries or a case of staff reporting more injuries?
The community perspective
Nurses working in the community, primarily attached to GP practices, have a higher incidence of sharps injuries than colleagues in secondary care.
Community nurses provide care to patients in a variety of settings, for example health centres, community hospitals, patients’ homes, residential and nursing homes. Current government initiatives promote the provision of health care in the community rather than in acute hospitals (Lane, 2000). Liberating the Talents states: ‘90% of patient journeys begin and end in primary care and it is where most contacts with the NHS take place’ (DH, 2002).
It is also important to remember that patients themselves, their family members and carers provide a considerable amount of care in the community. Therefore being ‘sharps safe’ is an issue for community nurses, as well as their hospital colleagues, in terms of clinical practice, education and risk assessment.
Routine procedures such as venepuncture, IM and SC injections, along with the removal of sutures, have been carried out in the community for many years. However, as highlighted by Billingham (2003), demand for more specialist care in the community is increasing and procedures such as intravenous (IV) therapy and cannulation are becoming more common (Kayley, 1999; Kayley and Finlay, 2003).
Clinical guidelines issued by the National Institute for Clinical Excellence (2003) make five recommendations relating specifically to the safe use and disposal of sharps. NICE states: ‘Needle safety devices must be used where x there are clear indications that they will provide safer systems of working for health-care personnel.’
The issue for community nurses is that they do not always have easy access to safety devices and needle-free systems or, indeed, resources to buy them. In relation to IV therapy, community nurses often have to rely on supplies being provided by the acute hospital when a patient is discharged to the community, such as provision of needle-free injection ‘bungs’. This can often mean that an inadequate supply is provided, an inappropriate alternative is supplied or nothing is provided (Kayley, 1999). Community nurses are less likely than their hospital colleagues to be approached by product specialists and so may be unaware of the range of needle-free and safety devices available.
Many problems related to being ‘sharps safe’ are common to both community nurses and hospital staff - so, whatever the work setting, it is essential to address issues such as education, safe practice, raising awareness and reporting of all needlestick injuries.
The hospital perspective
Hospital staff working in a multidisciplinary environment have to be able to trust their colleagues to be ‘sharps safe’. In the RCN study, 43.6% of injuries occurred to people who were not the original user of the needle or sharps (RCN, 2003a).
Needlestick injury prevention is one of the main priorities of infection control teams. The education of staff and safe practice are essential to ensure a safe working environment (Mahoney, 2001). Although the re-sheathing of needles has not been taught in the UK for some years, a number of staff still undertake this practice and breaking this habit is difficult.
One of the challenges of the infection control team is to have user-friendly sharps polices. This is to ensure that when an incident occurs everyone is aware of their responsibilities and the individual(s) affected are rapidly assessed and appropriate action taken without delay.
Infection control link nurses have an important role of protecting their colleagues, and ultimately their patients, by reminding staff how to be ‘sharps safe’. Sharps awareness campaigns using posters and presentations all help to raise awareness about the risks, consequences and preventive measures. However, as with handwashing, we all know what we are supposed to do but what we actually do is sometimes quite different (RCN, 2001).
Wards are busy places, with more dependent patients being cared for than ever before and more staff working in areas with which they are unfamiliar. This can lead to carelessness and shortcuts being taken, including the overfilling of sharps boxes. As professionals, we have a responsibility to practise safely and to protect our colleagues and patients (NMC, 2002). Being ‘sharps safe’ and taking time to consider the consequences of our own actions is essential if we are to prevent the spread of blood-borne infections.
Reducing the risks
In 2003, the RCN IV Therapy Forum issued a comprehensive set of standards relating to infusion therapy (RCN, 2003b). These aim to minimise the complications associated with this aspect of a patient’s care. To reduce the risk of infection and sharps injury, the standards advocate the avoidance of ‘routinely’ suturing midline, peripherally inserted central catheters and non-tunnelled catheters and advocate the use of self-adhesive anchoring devices where possible. In the critical care setting, suturing of lines accounts for 20% of reported sharps injuries (RCN, 2003b).
A number of medical device manufacturers now supply needles with integral sharps protection. These can include self-blunting needles or manually activated protection sheaths. Such devices still require careful disposal. The Standards for Infusion Therapy (RCN, 2003b) offer evidence-based information on their safe disposal, specifying the type of containers to be used and stressing the fact that needles should not be re-sheathed (RCN, 2003b). For staff generating small volumes of ‘used’ sharps, such as community nurses, specifically designed containers are available. We should question our current practice and seek to identify whether there are safer alternatives.
Raising awareness among all health-care professionals of the potential dangers of a sharps injury will ensure that appropriate assessment and action is not delayed for the individual(s) affected. In addition, raising awareness of the importance of reporting such events will help to ensure that the true incidence of such injuries is recorded. This will allow for the investigation of the incident to take place and identify if training is required or if alternatives to the needles/sharps involved can be sought.
A safe working environment for our colleagues and patients, regardless of the clinical setting, depends on all health-care professionals taking responsibility for their own actions and having respect for the safety of others.
NICE infection control guidance on reducing the risk of sharps injury
Handling of sharps to be kept to a minimum
- Never re-sheathe, bend, break or disassemble needles before disposal
- Sharps bins must conform to UN3291 and BS 7320 standards
- Sharps bins must be available where sharps are used and must never be overfilled
- Sharps bins in public areas must be safely located and never be positioned on the floor
- Needle-safety devices must be used where there are clear indications that they provide safer systems of working, but must be thoroughly evaluated before they are introduced
- The guidance also emphasises the importance of education to reduce risk of infection for patients, carers and staff, hand hygiene and the use of personal protective clothing.
The RCN Standards for Infusion Therapy (2003) provide the first comprehensive set of standards for infusion therapy in the UK, covering the following topics:
- Education and training for staff and patients/carers
- Infection control and safety compliance
- Products and documentation
- Infusion equipment
- Site selection and placement
- Site care and maintenance
- Infusion therapies
- Infusion-related complications.
Source: NICE, 2003; RCN, 2003b
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