Report of the Council on Scientific Affairs: preventing needlestick injuries in health care settings

Needlestick injuries continue to pose a significant risk to health care workers; however, appropriate use of needlestick prevention devices, especially in comprehensive prevention programs, can significantly reduce the incidence of such injuries. Cost analyses indicate that use of these devices will be cost-effective in the long term. To provide more scientific and cost data on the efficacy of needlestick prevention devices, recording of needlestick injuries must be improved. Federal law now requires the use of safety-engineered sharps devises to protect health care workers, and state-level legislation on the use and evaluation of needlestick prevention devices is under consideration. Health care employers should evaluate the implementation of needlestick prevention devices with the participation of employees who will use such devices and, where appropriate, introduce such devices accompanied by the necessary education and training, as part of a comprehensive sharps injury prevention and control program.

Reducing percutaneous injuries in the OR by educational methods

Exposure to bloodborne pathogens (e.g., HIV, hepatitis B, hepatitis C) through percutaneous injuries is an occupational risk for health care workers, especially those in the OR. The incidence of disease continues to rise, although occupational exposures often go unreported. Percutaneous injury prevention methods have included use of safety devices, practice changes, and educational programs. An educational intervention to increase awareness of risk, provide suggestions for injury reduction, and encourage reporting of exposures was performed at a university teaching hospital. Preliminary qualitative results show increased exposure reporting, increased use of personal protective equipment, and increased awareness of disease exposure risk among OR personnel.

Costs and benefits of measures to prevent needlestick injuries in a university hospital

OBJECTIVE

To document the costs and the benefits (both in terms of costs averted and of injuries averted) of education sessions and replacement of phlebotomy devices to ensure that needle recapping did not take place.

DESIGN

The percentage of recapped needles and the rate of needlestick injuries were evaluated in 1990 and 1997, from a survey of transparent rigid containers in the wards and at the bedside and from a prospective register of all injuries in the workplace. Costs were computed from the viewpoint of the hospital. Positive costs were those of education and purchase of safer phlebotomy devices; negative costs were the prophylactic treatments and follow-up averted by the reduction in injuries.

SETTING

A 1,050-bed tertiary-care university hospital in the Paris region.

RESULTS

Between the two periods, the proportion of needles seen in the containers that had been recapped was reduced from 10% to 2%. In 1990, 127 needlestick (12.7/100,000 needles) and 52 recapping injuries were reported versus 62 (6.4/100,000 needles) and 22 in 1996 and 1997. When the rates were related to the actual number of patients, the reduction was 76 injuries per year. The total cost of information and preventive measures was $325,927 per year. The cost-effectiveness was $4,000 per injury prevented.

CONCLUSION

Although preventive measures taken to ensure reduction of needlestick injuries appear to have been effective (75% reduction in recapping and 50% reduction in injuries), the cost of the safety program was high.

Needlesticks: who pays the price when costs are cut on safety

Here is a syringe whose spring-loaded needle automatically retracts into the barrel of the syringe almost quicker than the eye can register--If you've never seen one, you're not alone. Despite the prevalence of needles engineered with safety features to prevent needlesticks, few organizations are using them. The reasons why go far beyond the expense of the syringe.

Accidental needlesticks in the phlebotomy service of the Department of Laboratory Medicine and Pathology at Mayo Clinic Rochester

OBJECTIVE

To determine the change in accidental needlestick rates in the Phlebotomy Service at Mayo Clinic Rochester and to identify safety practices implemented from 1983 through 1996.

MATERIAL AND METHODS

We retrospectively reviewed yearly Phlebotomy Service accidental needlestick rates from 1983 through 1996. Interviews were conducted with representatives of the Infection Control Committee and the management team for the Phlebotomy Service, and minutes of meetings of these two groups were reviewed to identify implemented safety improvements that may have had an effect on accidental needlestick exposures.

RESULTS

Accidental needlestick exposures in the Phlebotomy Service declined from a high of 1.5/10,000 venipunctures to 0.2/10,000 venipunctures. Several safety improvements were made during that time, including the implementation of a one-handed recapping block, change to single-use evacuated tube holders, increased number and improved locations of disposal containers for needles, implementation of resheathing needles and retractable capillary puncture devices, discontinuation of the practice of changing needles before inoculation of blood culture bottles, increased emphasis on safety for new and experienced phlebotomists, and improved exposure reporting tools.

CONCLUSION

We believe that the decrease in our accidental needlestick exposure rate is correlated with the changes in education, practices, and products that we have implemented.

Reducing the risk of needlestick injury associated with implanted ports

Implanted ports give many of our patients a sense of freedom that they have not known since they have been sick. Between infusions, they do not have to be reminded constantly of their illness through an external vascular access device. However, this patient advantage does carry some degree of risk for the nurse working with the patient and the device. Needlestick injuries are serious and expensive. There is a financial and emotional toll that cannot be measured. Each employer is required by OSHA to have an exposure control plan for eliminating or minimizing employee exposure to bloodborne pathogens (OSHA, 1991, 1994). Inventions such as the HuberLoc meet the criteria for devices that can reduce the risk of injury through engineering controls. Agencies need to know that OSHA-mandated worker protection can be both easy to use and cost effective. Home care nurses need to be more proactive in informing agencies about such devices and lobbying for their use.

[Costs of accidental punctures in hospital health personnel]

OBJECTIVES

The aim of this study was to calculate the average cost of each hepatitis B, C and HIV follow-up carried out in the health personnel that have suffered an exposure to blood and body fluids and to estimate the cost for each of the different types of sources as well as to identify the items that account for the main part of the cost.

METHODS

A cost analysis was carried out. The post-exposure programme was modelled in a decision tree combining probabilities (percentage of each type of source in dependence of its positivity for the three viruses and immunization state of the health personnel against hepatitis B) and monetary costs (pesetas from 1994). Costs included: salaries, laboratory, chemist, energy, cleaning, telephone, medical and office equipment, amortization and lost productivity. A sensitivity analysis was carried out with the real fulfillment of the programme.

RESULTS

The average cost was 39,564 ptas. (29,750 ptas. applying the sensitivity analysis), with a range from 86,864 ptas. (source positive for the three viruses and injured subject not immunized) to 23,074 ptas. (source negative for the three viruses). If the source was hepatitis B positive, the average cost was 86,093 ptas. when the injured subject was not immunized and 53,232 ptas. if he was immunized. Serologic tests account for the main part of the cost (range from 72.8% to 87.7%).

CONCLUSIONS

High cost suggests an appropriate risk evaluation in order to avoid unnecessary follow-ups. The model used allows to know the cost of each potentially avoided episode and it could be used for any hospital in order to make an economical evaluation of new preventive devices.

Do protective devices prevent needlestick injuries among health care workers?

OBJECTIVES

To determine the effectiveness and direct of two protective devices-a shielded 3 ml safety syringe (Safety-Lok; Becton Dickinson and Co., Becton Dickinson Division, Franklin Lakes, N.J.) and the components of a needleless IV system (InterLink; Baxter Healthcare Corp., Deerfield, Ill.)--in preventing needlestick injuries to health care workers.

DESIGN

Twelve-month prospective, controlled, before-and-after trial with a standardized questionnaire to monitor needlestick injury rates.

SETTING

Six hospital inpatient units, consisting of three medical units, two surgical units (all of which were similar in patient census, acuity, and frequency of needlesticks), and a surgical-trauma intensive care unit, at a 900-bed urban university medical center.

PARTICIPANTS

All nursing personnel, including registered nurses, licensed practical nurses, nursing aides, and students, as well as medical teams consisting of an attending physician, resident physician, interns, and medical students on the study units.

INTERVENTION

After a 6-month prospective surveillance period, the protective devices were randomly introduced to four of the chosen study units and to the surgical-trauma intensive care unit.

RESULTS

Forty-seven needlesticks were reported throughout the entire study period, 33 in the 6 months before and 14 in the 6 months after the introduction of the protective devices. Nursing staff members who were using hollow-bore needles and manipulating intravenous lines accounted for the greatest number of needlestick injuries in the pre-intervention period. The overall rate of needlestick injury was reduced by 61%, from 0.785 to 0.303 needlestick injuries per 1000 health care worker-days after the introduction of the protective devices (relative risk = 1.958; 95% confidence interval, 1.012 to 3.790; p = 0.046). Needlestick injury rates associated with intravenous line manipulation, procedures with 3 ml syringes, and sharps disposal were reduced by 50%; however, reductions in these subcategories were not statistically significant. No seroconversions to HIV-1 or hepatitis B virus seropositivity occurred among those with needlestick injuries. The direct cost for each needlestick prevented was $789.

CONCLUSIONS

Despite an overall reduction in needlestick injury rates, no statistically significant reductions could be directly attributed to the protective devices. These devices are associated with a significant increase in cost compared with conventional devices. Further studies must be concurrently controlled to establish the effectiveness of these devices.

Emergency needlestick injury

During the course of a year, there are many healthcare workers nationwide who sustain sharps injuries whilst carrying out their duties. Staff who work in the Accident and Emergency (A & E) units are no different from anyone else in this respect. The emotional cost of such an accident cannot be calculated, whereas the financial costs can. This article aims to show how the cost of an injury to a member of staff can be calculated, thus allowing a manager to assess the financial implications of sharps injuries to their department. In the absence of access to an Occupational Health (OH) department, most A & E units have to respond to sharps injuries to healthcare workers in the hospital. This task must be attended to by the medical staff as well as the nursing staff of the A & E unit. Within the following text the appropriate responses and methods to ensure uniformity of response are discussed. The tables and the calculation figures shown are taken directly from the information held in the St James's University Hospital Trust's OH department. All calculations are based on the middle band of the salary scale for each discipline. Accurate costings for each member of staff injured cannot be shown in this article, but the general principle is laid down and can be easily followed for any situation.

Efficacy and cost-effectiveness of a needleless intravenous access system

BACKGROUND

Needlestick injury has been identified as a major cause of exposure to blood and body fluids. The heparin-lock intermittent intravenous procedure was implicated in the largest number of needlestick-related exposures (26%) at this 1100-bed tertiary care hospital, and replacement of this system was imperative. Cost concerns, however, necessitated that replacement products not increase overall hospital costs.

METHODS

A needleless intravenous access system (Interlink i.v. Access System; Baxter Healthcare Corp., Parenterals Division, Deerfield, Ill.) was introduced. Effectiveness and cost-benefit of this system were analyzed by comparing needlestick injuries and their associated costs, as well as costs of relevant products and procedures, for the year before introduction of the new product with those for 1 year after implementation of the new system.

RESULTS

During the study period, the needleless access system was 78.7% effective in reducing intravenous line-related needlestick injuries. There was an overall reduction of 43.4% in total needlestick injuries from all procedures and events. The incremental cost to this hospital ranged from a 5.3% additional cost to a 5.7% savings, without even considering the less quantifiable benefits associated with avoidance of needlestick injury, time saved by using this product, and decreased infection rate.

CONCLUSION

When used as intended, this system was extremely effective in reducing intravenous line-related needlestick injuries, and the system does pay for itself.

Application of cost-effectiveness methodology to the consideration of needlestick-prevention technology

Data from the study of needlestick-prevention devices in 10 New York State hospitals enabled application of cost-effectiveness analysis techniques for determining relative benefits of various safety interventions. This article introduces to infection control practitioners several economic concepts related to cost-effectiveness methodology and provides two examples of how they may be applied for decision-making purposes. A critical aspect of the analysis described is the determination of a base cost of needlestick injury. By applying decision analysis to experience-based data aggregated from participating institutions, base expected cost of needlestick injury was determined to be $363.

Evaluation and implementation of a needleless intravenous system: making needlesticks a needless problem

A needleless intravenous (IV) system with blunt plastic cannulas and specially designed injection sites was introduced at Olive View Medical Center to reduce needlestick injuries, particularly IV-related needlesticks. IV-related needlestick injuries decreased 72% during the first 8 months of use, costs were reduced $1.85 for a typical IV piggyback administration set-up by revising the IV piggyback procedure, and a staff survey revealed satisfaction with the new system.