Efficacy of safety-engineered device implementation in the prevention of percutaneous injuries: a review of published studies

Prevention from Sharp Injuries in the Hospital Sector: An Italian National Observatory on the Implementation of the Council Directive 2010/32/EU before and during the COVID-19 Pandemic

Sharp injuries, determining the risk of bloodborne infections and psychological distress in healthcare workers, may be prevented by a set of strategies, legally enforced in Europe through the Directive 2010/32/EU. To assess its level of implementation in Italy, a national survey was conducted in 2017 and again in 2021, evaluating the progress and possible drawbacks of the COVID-19 pandemic. Altogether, 285 safety managers and 330 nurses from a representative sample of 97 and 117 public hospitals were interviewed using a standardized questionnaire. Knowledge of the Directive requirements decreased significantly, with <60% of participants answering correctly in 2021, and nurses' attendance in specific courses dropped to 25% in 2021 compared to 54% in 2017. Over 75% of hospitals introduced multiple safety-engineered devices (SED), though total replacement occurred in <50% of cases; routine SED availability increased for blood collection (89%) and venous access devices (83%). Incorrect behaviors in handling sharps decreased significantly over time. Nurses' HBV vaccination coverage was high (89% in both surveys); in the last year, 97% were vaccinated against COVID, and 47% against influenza. Average annual injuries per hospital did not increase significantly (32 in 2021 vs. 26 in 2017). In 2017, nurses' perceived safety barriers were working in emergency situations (49%) and lack of resources (40%); in 2021, understaffing (73%), physical fatigue (62%), and handling difficulties while wearing full protective equipment (59%). Safety measures were implemented in Italian hospitals, and although the average injuries per hospital did not show a decrease, these measures could have helped protect healthcare workers during the pandemic, mitigating its potential impact on the increase in situations at risk of injury.

Occurrence and Outcome of Blood-Contaminated Percutaneous Injuries among Anesthesia practitioners: A Cross-sectional Study

BACKGROUND

Anesthesia practitioners are at risk for percutaneous injuries by blood-contaminated needles and sharp objects that may result in transmission of HIV and hepatitis viruses. Reporting these injuries is important for early prevention and management of blood-borne infections. We investigated the occurrence, reporting, characteristics, and outcome of contaminated percutaneous injuries (CPI) in anesthesia residents, fellows, and faculty.

METHODS

A cross-sectional anonymous survey electronically distributed to all 214 anesthesia practitioners at a large academic multihospital-based anesthesia practice in Florida, USA.

RESULTS

The overall response rate was 51% (110/214) (60% (50/83) for residents, 50% (8/16) for fellows, 45% (52/115) for anesthesia faculty). 59% (65/110) (95%CI: 50,68) of participants reported having one or more CPI during their years of anesthesia practice (residents 42% (95%CI: 29,55), fellows 50%, faculty 77% (95%CI: 66,88). Numbers of CPI per anesthesia practitioner who answered survey was 0.58 for residents, 0.75 for fellows, and 1.5 for faculty.Within the last 5 years, 35% (95%CI: 26,44) of participants had one or more CPI (39% of residents, 50% of fellows, 29% of faculty. CPI in the last 5 years in faculty older than 45 years of age was 12% (3/25) compared to 44% (12/27) in faculty younger than 45 years of age.Analyzing data from practitioners who had one CPI revealed that 70% (95%CI: 55,85) reported the incident at the time of injury (residents 85%, fellows 100%, faculty 58%). Hollow-bore needles constituted 73.5% (95%CI: 59,88) of injuries. As per participants responses, 17% (18/103) of CPIs received post-exposure prophylaxis and there were zero seroconversions.

CONCLUSION

Based on our study results, most anesthesia practitioners will sustain a CPI during their years of practice. Despite some improvement compared to historic figures, occurrence of CPI continues to be high and reporting of percutaneous injuries remains suboptimal among anesthesia residents. A fifth of injuries in the perioperative setting are from an infected source and require postexposure prophylaxis. Although no infections were reported due to CPI exposure in this study, findings underscore the need for more education and interventions to reduce occupational blood exposures in anesthesia practitioners and improve reporting.

Education and training for preventing sharps injuries and splash exposures in healthcare workers

BACKGROUND

In healthcare settings, health care workers (HCWs) are at risk of acquiring infectious diseases through sharps injuries and splash exposures to blood or bodily fluids. Education and training interventions are widely used to protect workers' health and safety and to prevent sharps injuries. In certain countries, they are part of obligatory professional development for HCWs.

OBJECTIVES

To assess the effects of education and training interventions compared to no intervention or alternative interventions for preventing sharps injuries and splash exposures in HCWs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, NHSEED, Science Citation Index Expanded, CINAHL and OSH-update (from all time until February 2016). In addition, we searched the databases of Global Health, AustHealth and Web of Science (from all time until February 2016). The original search strategy was re-run in November 2019, and again in February 2020. In April 2020, the search strategy was updated and run in CINAHL, MEDLINE, Scopus and Web of Science (from 2016 to current).

SELECTION CRITERIA

We considered randomized controlled trials (RCTs), cluster-randomized trials (cluster-RCTs), controlled clinical trials (CCTs), interrupted time series (ITS) study designs, and controlled before-and-after studies (CBA), that evaluated the effect of education and training interventions on the incidence of sharps injuries and splash exposures compared to no-intervention.

DATA COLLECTION AND ANALYSIS

Two authors (SC, HL) independently selected studies, and extracted data for the included studies. Studies were analyzed, risk of bias assessed (HL, JL) , and pooled using random-effect meta-analysis, where applicable, according to their design types. As primary outcome we looked for sharps injuries and splash exposures and calculated them as incidence of injuries per 1000 health care workers per year. For the quality of evidence we applied GRADE for the main outcomes.

MAIN RESULTS

Seven studies met our inclusion criteria: one cluster-RCT, three CCTs, and three ITS studies. The baseline rates of sharps injuries varied from 43 to 203 injuries per 1000 HCWs per year in studies with hospital registry systems. In questionnaire-based studies, the rates of sharps injuries were higher, from 1800 to 7000 injuries per 1000 HCWs per year.  The majority of studies utilised a combination of education and training interventions, including interactive demonstrations, educational presentations, web-based information systems, and marketing tools which we found similar enough to be combined. In the only cluster-RCT (n=796) from a high-income country, the single session educational workshop decreased sharps injuries at 12 months follow-up, but this was not statistically significant either measured as registry-based reporting of injuries (RR 0.46, 95% CI 0.16 to 1.30, low-quality evidence) or as self-reported injuries (RR 0.41, 95% CI 0.14 to 1.21, very low-quality evidence) In three CCTs educational interventions decreased sharps injuries at two months follow-up (RR 0.68, 95% CI 0.48 to 0.95, 330 participants, very low-quality evidence). In the meta-analysis of two ITS studies with a similar injury rate, (N=2104), the injury rate decreased immediately post-intervention by 9.3 injuries per 1000 HCWs per year (95% CI -14.9 to -3.8). There was a small non-significant decrease in trend over time post-intervention of 2.3 injuries per 1000 HCWs per year (95% CI -12.4 to 7.8, low-quality evidence). One ITS study (n=255) had a seven-fold higher injury rate compared to the other two ITS studies and only three data points before and after the intervention. The study reported a change in injury rate of 77 injuries per 1000 HCWs (95% CI -117.2 to -37.1, very low-quality evidence) immediately after the intervention, and a decrease in trend post-intervention of 32.5 injuries per 1000 HCWs per year (95% CI -49.6 to -15.4, very low quality evidence). None of the studies allowed analyses of splash exposures separately from sharps injuries. None of the studies reported rates of blood-borne infections in patients or staff. There was very low-quality evidence of short-term positive changes in process outcomes such as knowledge in sharps injuries and behaviors related to injury prevention.  AUTHORS' CONCLUSIONS: We found low- to very low-quality evidence that education and training interventions may cause small decreases in the incidence of sharps injuries two to twelve months after the intervention. There was very low-quality evidence that educational interventions may improve knowledge and behaviors related to sharps injuries in the short term but we are uncertain of this effect. Future studies should focus on developing valid measures of sharps injuries for reliable monitoring. Developing educational interventions in high-risk settings is another priority.

DropSafe safety pen needle helps to prevent accidental needlesticks after injections: results of a simulated clinical study

Background

Most needlestick injuries (NSIs) result from unsafe needle devices. DropSafe safety pen needle (SPN) was designed to help prevent such injuries before, during and after use through a built-in sharps injury prevention feature (SIPF).

Methods

A two-phase study was undertaken. For the pilot study, five non-healthcare users (NHCUs) performed evaluations. For the validation study, 30 evaluators comprising 10 healthcare professionals (HCPs) and 20 NHCUs performed evaluations. The aim of the study was to validate the performance of the SIPF of the SPN and to collect feedback from the evaluators on several aspects of the safety device. Participants performed simulated injections into an orange.

Results

The results show that no device failures were observed, and all manipulations were performed without a needlestick or without contact with the needle after injection. The safety feature of the SPN was activated successfully. It was shown that: the label on the seal was legible; the SPNs were easy to attach to the pen injector; injections were easy to perform; it was clear when safety feature was activated; removing the SPN from the injection pen was easy; and the written instructions were easy to understand.

Conclusion

The performance of the safety feature of SPN was successfully evaluated in terms of the prevention of NSIs. User feedback demonstrate that the device's ease of use, handling and instructions for use ensure safety and effectiveness of the SPN when used as intended.

Microbial colonization of intravascular catheter connectors in hospitalized patients

BACKGROUND

Central line-associated bloodstream infections may be due to catheter connector colonization and intraluminal migration of pathogens. We assessed the colonization of the split septum catheter connector system, and subsequently the luer lock catheter connector system.

METHODS

This was a prospective, 2 phase, quality improvement study at a tertiary referral center. Each phase of the study was performed over 3 consecutive days in hospitalized patients receiving an active infusion; first with a split septum lever lock connector and second with a luer lock connector and alcohol port protector. The connectors were inoculated onto blood agar plates and incubated. Plates were assessed for microbial growth after 48-72 hours.

RESULTS

In phase I, 98 (41.9%) of 234 split septum connectors yielded microbial growth. In phase II, 56 (23.1%) of 243 luer lock connectors yielded microbial growth. In phase II only, there was a significant increased rate of contamination in peripheral catheters compared with all other catheters, and the rate of contamination on the acute care wards was significantly higher when compared with the intensive care units.

CONCLUSIONS

Bacterial colonization of the lever lock system was unacceptably high among all catheter types and hospital locations. Transition to luer lock catheter connectors and alcohol port protectors decreased the colonization; however, colonization still remained substantial. Causation of colonization cannot be determined with these results.

Needlestick prevention devices: data from hospital surveillance in Piedmont, Italy-comprehensive analysis on needlestick injuries between healthcare workers after the introduction of safety devices

OBJECTIVE

Needlestick and sharps injuries (NSIs) involving healthcare workers (HCWs) are worldwide under surveillance since long time; the implementation of the European Directive 32/2010 regarding the mandatory use of safety-engineered devices (SEDs) seems to have reduced the number of these accidents. Our surveillance investigated the frequency and the modality of SED-related NSIs in the Piedmont region to verify changes in the epidemiology of these events.

METHODS

We analysed the exposure records of NSIs, device usage data and structural data of 42 acute care hospitals and compared conventional and safety devices. We calculated the accident rates per 100 000 needles and, as a measure of SED efficacy, the relative risk between the use of safety and non-safety devices with a 95% CI. We also described the dynamics of the NSIs and the most involved professional groups of HCWs, procedures and devices.

RESULTS

Total and specific device accident rates for 100 000 needles were lower with the use of SEDs. In 2015-2016, there were 1640 NSIs, with a decreasing absolute number during the observation period; 18% were SEDs related. Half of the total accidents with SEDs occurred in the patient's room, and nurses were involved in 78% of the cases. The most involved devices were the butterfly needles and peripheral venous catheters, and the most involved procedures were venous sampling (40%) and phlebotherapy (16%). The exposures occurred mostly during the procedure, and 45% of the SED-related injuries occurred during the disposal of the device; 92% of the SEDs involved had a manual activation mechanism.

CONCLUSION

In agreement with the results of other European studies, our results show that SEDs reduce the risk of percutaneous exposure of HCWs, but in introducing SEDs, we must select those with a higher level of safety (with a passive activation mechanism) and improve the healthcare staff training programmes.

UK safety-engineered device use: changes since the 2013 sharps regulations

BACKGROUND

The 2013 UK sharps safety regulations require healthcare facilities to use safety-engineered devices (SEDs) to protect staff. The recent increase in UK-reported occupational exposures could indicate increased reporting or increased exposures from suboptimal SED use.

AIMS

To ascertain SED use through examination of sharps container contents in a sample of UK hospitals.

METHODS

Reusable sharps containers (RSCs) were selected from seven UK hospitals in 2013 and seven different hospitals in 2016. At licensed processing facilities, the operator, wearing protective apparel, decanted RSCs, separated hollow-bore needles (HBNs) from other sharps and enumerated HBNs into capped/uncapped non-SEDs, activated/non-activated/tampered SEDs, and blunt draw-up SEDs. Probability, risk ratios (RRs) and 95% confidence limits (95% CLs) were calculated using WinPepi v2.78.

RESULTS

In 2013 and 2016, respectively, 2545 HBNs were categorized from 22 RSCs versus 2959 HBNs from 33 RSCs; 70% of HBNs were SEDs versus 93% (P < 0.001; RR 1.33; CL 1.30-1.37); 32% of activatable HBNs were not activated versus 22% (<0.001; 0.67; 0.60-0.76); 41% of HBNs were discarded 'sharp' versus 20% (<0.001; 0.48; 0.44-0.52); 25% of HBNs were uncapped needles versus 6% (<0.001; 0.22; 0.19-0.26); 5% of HBNs were capped needles versus 1% (P > 0.05); and 1% of SEDs were tampered with in both years (P > 0.05). Hospital practices varied widely.

CONCLUSIONS

SED use and activation have increased significantly since 2013. Of concern is that in 2016, 22% of SEDs were non-activated and 20% of sharps were discarded 'sharp'. Increased training in SED handling, assiduous adherence to safe sharps work practices and a higher level of individual safety-ownership are indicated.

Safety-Engineered Syringes: An Intervention to Decrease Hepatitis C Burden in Developing Countries-A Cost-Effectiveness Analysis From Egypt

INTRODUCTION

To assess the cost-effectiveness of introducing the safety-engineered syringe (SES) to decrease hepatitis C burden resultant from unsafe injection practices in healthcare settings.

METHODS

A Markov process model for a hypothetical study cohort was developed over a 30-year time horizon to compare the adoption of SES use with the current strategy, conventional syringes (CS), in the Egyptian healthcare settings. The national treatment program was applied in both groups. Health benefits and total direct medical costs were estimated in both strategies.

RESULTS

The SES use demonstrated a reduction in the burden of injection-associated HCV infection because of unsafe practices in the Egyptian healthcare settings. The probability of HCV infection was 1.4% in the SES group and 40% in the CS group. Adoption of the SES use averted 177 hepatitis C cases and 157 hepatitis C-related deaths per 10 000 individuals. Introducing SES as a preventive strategy resulted in better quality-adjusted life-years (QALYs) (difference; 0.95 QALYs) and lower costs (difference; $-1712).

CONCLUSIONS

Adoption of SES in the Egyptian healthcare settings is a more effective and cost-saving strategy. Our results are consistent with the WHO Injection Safety Program and Safe Injection Global Network initiatives, which call for adoption of smart syringes. The introduction of SES as one of the most urgently needed interventions is mostly encouraged to decrease hepatitis C burden in similar resource-limited settings. The use of SES as a prevention strategy may bring substantial population-level health gains and governmental cost savings in developing countries.

A cost-effectiveness analysis of the use of safety-engineered syringes in reducing HBV, HCV, and HIV burden in Egypt

INTRODUCTION

The objective of this study was to estimate the effects and costs of safety-engineered syringes (SS) as a prevention strategy from HBV, HCV, and HIV infections versus conventional syringes (CS).

METHODS

A decision-analytic model with five health states was constructed. The clinical parameters and utilities were derived using published data. Direct medical costs from the health care system perspective were sourced from national data. All costs and effects were discounted at 3.5% annually.

RESULTS

The estimate of total quality adjusted life years (QALYs) while using SS were 10.87 compared to 9.20 for the use of CS in the Egyptian population exposed to unsafe injection practices. The total costs for using SS and CS were EGP2,870 and EGP81,794 (I$1,130 and I$32,202), respectively, per 5.9 injections per person per year. Adopting SS resulted in better outcomes (difference; 1.66 QALYs) and total savings (EGP-78,924/I$-31,073) per person.

CONCLUSION

Introducing SS in the Egyptian health care system might help in preventing transmission of blood-borne infections that are acquired through health care settings. The overall benefit of investing in this technology is far more than CS. These findings encourage the urgent adoption of SS by health care delivery institutions in similar resource-limited settings.

Use of safety syringes for administration of local anaesthesia among a sample of UK primary care dental professionals

Background

Safer sharps devices (SSDs) are commercially available and their use is mandated through UK legislation.

Aim

To identify the current usage of SSDs in UK primary care dentistry.

Method

A cross-sectional survey was administered to delegates at the 2017 British Dental Association (BDA) Conference and Exhibition in Manchester, and at the 2017 BDA Scottish Conference and Exhibition in Glasgow. The survey covered a range of questions relating to sharps injuries and use of traditional and safety syringes for delivery of local anaesthesia. Statistical analyses were conducted using SPSS Version 22 (IBM Corp., 2013) and included chi-square and Fisher's exact tests.

Results

Seven hundred and ninety-six delegates participated, of whom 396 (49.7%) were using safety syringes for delivery of local anaesthesia. Of the 166 participants who had experienced a sharps injury in the past year, 76 (45.8%) worked in facilities that most commonly used SSDs for delivery of local anaesthesia.

Conclusion

Our results indicate that a significant number of dental practices in our sample have not adopted SSDs and suggest sharps injuries are still being sustained in some practices using SSDs. Further epidemiological research is required to provide strong evidence for the effectiveness of SSDs and reasons why SSDs have not been fully adopted in UK primary dental care.

Devices for preventing percutaneous exposure injuries caused by needles in healthcare personnel

BACKGROUND

Percutaneous exposure injuries from devices used for blood collection or for injections expose healthcare workers to the risk of blood borne infections such as hepatitis B and C, and human immunodeficiency virus (HIV). Safety features such as shields or retractable needles can possibly contribute to the prevention of these injuries and it is important to evaluate their effectiveness.

OBJECTIVES

To determine the benefits and harms of safety medical devices aiming to prevent percutaneous exposure injuries caused by needles in healthcare personnel versus no intervention or alternative interventions.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, NHSEED, Science Citation Index Expanded, CINAHL, Nioshtic, CISdoc and PsycINFO (until 11 November 2016).

SELECTION CRITERIA

We included randomised controlled trials (RCT), controlled before and after studies (CBA) and interrupted time-series (ITS) designs of the effect of safety engineered medical devices on percutaneous exposure injuries in healthcare staff.

DATA COLLECTION AND ANALYSIS

Two of the authors independently assessed study eligibility and risk of bias and extracted data. We synthesized study results with a fixed-effect or random-effects model meta-analysis where appropriate.

MAIN RESULTS

We included six RCTs with 1838 participants, two cluster-RCTs with 795 participants and 73,454 patient days, five CBAs with approximately 22,000 participants and eleven ITS with an average of 13.8 data points. These studies evaluated safe modifications of blood collection systems, intravenous (IV) systems, injection systems, multiple devices, sharps containers and legislation on the implementation of safe devices. We estimated the needlestick injury (NSI) rate in the control groups to be about one to five NSIs per 1000 person-years. There were only two studies from low- or middle-income countries. The risk of bias was high in 20 of 24 studies. Safe blood collection systems:We found one RCT that found a safety engineered blood gas syringe having no considerable effect on NSIs (Relative Risk (RR) 0.2, 95% Confidence Interval (95% CI) 0.01 to 4.14, 550 patients, very low quality evidence). In one ITS study, safe blood collection systems decreased NSIs immediately after the introduction (effect size (ES) -6.9, 95% CI -9.5 to -4.2) but there was no further decrease over time (ES -1.2, 95% CI -2.5 to 0.1, very low quality evidence). Another ITS study evaluated an outdated recapping shield, which we did not consider further. Safe Intravenous systemsThere was very low quality evidence in two ITS studies that NSIs were reduced with the introduction of safe IV devices, whereas one RCT and one CBA study provided very low quality evidence of no effect. However, there was moderate quality evidence produced by four other RCT studies that these devices increased the number of blood splashes when the safety system had to be engaged actively (relative risk (RR) 1.6, 95% CI 1.08 to 2.36). In contrast there was low quality evidence produced by two RCTs of passive systems that showed no effect on blood splashes. Yet another RCT produced low quality evidence that a different safe active IV system also decreased the incidence of blood leakages. Safe injection devicesThere was very low quality evidence provided by one RCT and one CBA study showing that introduction of safe injection devices did not considerably change the NSI rate. One ITS study produced low quality evidence showing that the introduction of safe passive injection systems had no effect on NSI rate when compared to safe active injection systems. Multiple safe devicesThere was very low quality evidence from one CBA study and two ITS studies. According to the CBA study, the introduction of multiple safe devices resulted in a decrease in NSI,whereas the two ITS studies found no change. Safety containersOne CBA study produced very low quality evidence showing that the introduction of safety containers decreased NSI. However, two ITS studies evaluating the same intervention found inconsistent results. LegislationThere was low to moderate quality evidence in two ITS studies that introduction of legislation on the use of safety-engineered devices reduced the rate of NSIs among healthcare workers. There was also low quality evidence which showed a decrease in the trend over time for NSI rates.Twenty out of 24 studies had a high risk of bias and the lack of evidence of a beneficial effect could be due to both confounding and bias. This does not mean that these devices are not effective.

AUTHORS' CONCLUSIONS

For safe blood collection systems, we found very low quality evidence of inconsistent effects on NSIs. For safe passive intravenous systems, we found very low quality evidence of a decrease in NSI and a reduction in the incidence of blood leakage events but moderate quality evidence that active systems may increase exposure to blood. For safe injection needles, the introduction of multiple safety devices or the introduction of sharps containers the evidence was inconsistent or there was no clear evidence of a benefit. There was low to moderate quality evidence that introduction of legislation probably reduces NSI rates.More high-quality cluster-randomised controlled studies that include cost-effectiveness measures are needed, especially in countries where both NSIs and blood-borne infections are highly prevalent.

Needlestick and Sharps Injuries Among Nursing Students in Nanjing, China

Needlestick and sharps injuries (NSIs) are a major cause of occupational injuries for health care workers worldwide. In this study, the authors report the prevalence of and risk factors for NSIs among Chinese nursing students. A cross-sectional survey was distributed to 442 nursing students; 393 completed questionnaires were submitted. A total of 237 (60.3%) nursing students reported NSIs, which were more commonly reported by female students, younger students, students who worked frequent night shifts, students without safety training, and students who did not use personal protective equipment. Among those injured, 59.9% were injured by syringe needles, 21.9% by glass items, and 3.4% by scissors. Of those needles and sharps causing injuries, 36.3% of devices had been used on patients, 41% were unused, and 22.7% were unknown. Opening ampoules or vials was the most common injury agent. A total of 86.9% of NSIs were not reported to hospital infection control. Nursing students are at high risk of NSIs in China. Occupational safety training should be developed and implemented to prevent NSIs among this vulnerable population.

Clinical, economic, and humanistic burden of needlestick injuries in healthcare workers

Introduction

Needlestick injuries (NSIs) from a contaminated needle put healthcare workers (HCWs) at risk of becoming infected with a blood-borne virus and suffering serious short- and long-term medical consequences. Hypodermic injections using disposable syringes and needles are the most frequent cause of NSIs.

Objective

To perform a systematic literature review on NSI and active safety-engineered devices for hypodermic injection.

Methods

MEDLINE, EMBASE, and COCHRANE databases were searched for studies that evaluated the clinical, economic, or humanistic outcomes of NSI or active safety-engineered devices.

Results

NSIs have been reported by 14.9%–69.4% of HCWs with the wide range due to differences in countries, settings, and methodologies used to determine rates. Exposure to contaminated sharps is responsible for 37%–39% of the worldwide cases of hepatitis B and C infections in HCWs. HCWs may experience serious emotional effects and mental health disorders after a NSI, resulting in work loss and post-traumatic stress disorder. In 2015 International US$ (IntUS$), the average cost of a NSI was IntUS$747 (range IntUS$199–1,691). Hypodermic injections, the most frequent cause of NSI, are responsible for 32%–36% of NSIs. The use of safety devices that cover the needle-tip after hypodermic injection lowers the risk of NSI per HCW by 43.4%–100% compared to conventional devices. The economic value of converting to safety injective devices shows net savings, favorable budget impact, and overall cost-effectiveness.

Conclusion

The clinical, economic, and humanistic burden is substantial for HCWs who experience a NSI. Safety-engineered devices for hypodermic injection demonstrate value by reducing NSI risk, and the associated direct and indirect costs, psychological stress on HCWs, and occupational blood-borne viral infection risk.

Back to Basics: Sharps Safety

Perioperative team members who handle sharp devices or equipment are at risk for sharps injuries. Because sharps injuries can expose individuals to potentially infectious diseases, safety practices should be followed at all times. Health care workers and patients are at risk when a sharps injury occurs, so protocols, including work practice and engineering controls, should be in place at every facility. This article provides guidance on the steps that can be followed to minimize risk of a sharps injury.

Accidental blood exposures among emergency medicine residents and young physicians in France: a national survey

The aim of the present study was to investigate the epidemiological characteristics of blood or fluid exposure (BFE) and occupational infection risk among emergency medicine (EM) residents and young physicians (<35 years old) in France. We led a cross-sectional, anonymous, online survey. 1779 participants were contacted with a response rate of 36 % (n = 633). Among the respondents, 459 (72 %) reported at least one BFE. Among participants with at least one BFE, 35 % (n = 163) never reported the exposure to the relevant medical authorities or support. Among participants who reported exposure, 63 % (n = 232) did it immediately. Among participants who never or not systematically reported their BFE, most of them (62 %, n = 181/289) did not do so because the procedure was too long, and 28 % (n = 82/289) estimated the risk as low even if only one-third (n = 166/458) checked their HIV status even though the BFE was at a transmission risk. Circumstances in which the participants had the most BFE were: suturing 57 % (n = 262/457) and when making precipitated gestures 24 % (n = 111/457). The latest exposures were caused by a solid needle in 42 % (n = 191/455) or hollow-bore needle in 27 % (n = 123/455). Post-exposure reporting rates were low. Reporting procedure itself and self-management were the main reasons for BFE underreporting. Simplifying procedures might increase BFE reporting, and allow appropriate post-exposure counseling and/or prophylaxis.

[Incidence of accidental exposure to blood and body fluids among healthcare professionals in a community hospital]

OBJECTIVE

To determine the annual incidence of healthcare professionals' accidental exposure to blood and body fluids in a community hospital and describe their characteristics, associated situations and follow-up.

METHOD

A longitudinal, retrospective study of biological accidents voluntarily reported on a yearly basis by exposed healthcare professionals at Fundació Hospital de l'Esperit Sant (in Santa Coloma de Gramenet, Barcelona, Spain), between 2005 and 2014. A descriptive analysis of the variables related to the exposed professional, the exposure itself, its production mechanism and the source patient was conducted. The rate of exposure was calculated per 100 occupied beds and by job category.

RESULTS

318 exposures were reported; 89.62% were percutaneous and the remainder were non-intact skin or mucous contamination. The mean percutaneous exposure incidence rate from 2005 to 2014 was 17.6 per 100 occupied beds/year (limits 10.3 in 2013 and 24.5 in 2005). Doctors were exposed to the greatest risk (5.29 exposures per 100 doctors). Over 50% occurred in a surgical setting. 44.2% of exposed healthcare professionals had been working at the centre for 1 year or less on average. Puncture was the most common percutaneous lesion. No cases of occupational viral transmission were reported.

CONCLUSIONS

The rate of percutaneous exposure reported in this hospital fluctuated significantly throughout the analysis period. Risk of exposure is related to job category, work experience, the setting and the activity performed.

A Model-Based Product Evaluation Protocol for Comparison of Safety-Engineered Protection Mechanisms of Winged Blood Collection Needles

OBJECTIVE

To evaluate differences in product characteristics and user preferences of safety-engineered protection mechanisms of winged blood collection needles.

DESIGN

Randomized model-based simulation study.

SETTING

University medical center.

PARTICIPANTS

A total of 33 third-year medical students.

METHODS

Venipuncture was performed using winged blood collection needles with 4 different safety mechanisms: (a) Venofix Safety, (b) BD Vacutainer Push Button, (c) Safety-Multifly, and (d) Surshield Surflo. Each needle type was used in 3 consecutive tries: there was an uninstructed first handling, then instructions were given according to the operating manual; subsequently, a first trial and second trial were conducted. Study end points included successful activation, activation time, single-handed activation, correct activation, possible risk of needlestick injury, possibility of deactivation, and preferred safety mechanism.

RESULTS

The overall successful activation rate during the second trial was equal for all 4 devices (94%-100%). Median activation time was (a) 7 s, (b) 2 s, (c) 9 s, and (d) 7 s. Single-handed activation during the second trial was (a) 18%, (b) 82%, (c) 15%, and (d) 45%. Correct activation during the second trial was (a) 3%, (b) 64%, (c) 15%, and (d) 39%. Possible risk of needlestick injury during the second trial was highest with (d). Possibility of deactivation was (a) 0%, (b) 12%, (c) 9%, and (d) 18%. Individual preferences for each system were (a) 11, (b) 17, (c) 5, and (d) 0. The main reason for preference was the comprehensive safety mechanism.

CONCLUSION

Significant differences exist between safety mechanisms of winged blood collection needles.

Impact of Safety-Engineered Devices on the Incidence of Occupational Blood and Body Fluid Exposures Among Healthcare Personnel in an Academic Facility, 2000-2014

BACKGROUND

Legislative actions and advanced technologies, particularly dissemination of safety-engineered devices, have aided in protecting healthcare personnel from occupational blood and body fluid exposures (BBFE).

OBJECTIVE

To investigate the trends in BBFE among healthcare personnel over 15 years and the impact of safety-engineered devices on the incidence of percutaneous injuries as well as features of injuries associated with these devices.

METHODS

Retrospective cohort study at University of North Carolina Hospitals, a tertiary care academic facility. Data on BBFE in healthcare personnel were extracted from Occupational Health Service records (2000-2014). Exposures associated with safety-engineered and conventional devices were compared. Generalized linear models were applied to measure the annual incidence rate difference by exposure type over time.

RESULTS

A total of 4,300 BBFE, including 3,318 percutaneous injuries (77%), were reported. The incidence rate for overall BBFE was significantly reduced during 2000-2014 (incidence rate difference, 1.72; P=.0003). The incidence rate for percutaneous injuries was also dramatically reduced during 2001-2006 (incidence rate difference, 1.37; P=.0079) but was less changed during 2006-2014. Percutaneous injuries associated with safety-engineered devices accounted for 27% of all BBFE. BBFE was most commonly due to injecting through skin, placing intravenous catheters, and blood drawing.

CONCLUSIONS

Our study revealed significant overall reduction in BBFE and percutaneous injuries likely due in part to the impact of safety-engineered devices but also identified that a considerable proportion of percutaneous injuries is now associated with these devices. Additional prevention strategies are needed to further reduce percutaneous injuries and improve design of safety-engineered devices.

Safety engineered injection devices for intramuscular, subcutaneous and intradermal injections in healthcare delivery settings: a systematic review and meta-analysis

BACKGROUND

Occupational sharps injuries are associated with transmission of bloodborne viruses to healthcare workers, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Similarly reuse of syringes in healthcare settings might transmit these infections between patients. The objective of this study was to systematically review the evidence about the effects of the use by health care workers of two types of safety engineered injection devices, when delivering intramuscular, subcutaneous, or intradermal injectable medications: sharps injury protection syringes and reuse prevention syringes.

METHODS

We included both randomized and non-randomized studies comparing safety syringes to syringes without safety features. Outcomes of interest included needlestick injuries, and HIV, HBV and HCV infections amongst HCWs (for sharps injury prevention syringes) and patients (for reuse prevention syringes). When possible, we conducted meta-analyses using a random-effects model. We tested results for heterogeneity across studies using the I statistic. We assessed the quality of evidence by outcome using the GRADE methodology.

RESULTS

We included nine eligible studies: six assessed devices that qualify as sharps injury prevention devices, and three assessed devices that qualify as both injury prevention devices and reuse prevention devices. Eight studies were observational while one was randomized. All studies assessed a single outcome: needle stick injuries among healthcare workers. For sharp injury prevention syringes, the meta-analysis of five studies resulted in a pooled relative risk of 0.54 [0.41, 0.71] for the effect on needlestick injuries per healthcare worker. The associated quality of evidence was rated as moderate. For reuse prevention syringes, data from one study provided a relative risk of 0.40 [0.27, 0.59] for the effect on needlestick injuries per healthcare worker. The associated quality of evidence was rated as moderate. We identified no studies reporting on the effect on the reuse of syringes.

CONCLUSIONS

We identified moderate quality evidence that syringes with sharps injury prevention feature reduce the incidence of needlestick injuries per healthcare worker. We identified no studies reporting data for the remaining outcomes of interest for HCWs. Similarly we identified no studies reporting on the effect of syringes with a reuse prevention feature on the reuse of syringes or on the other outcomes of interest for patients.

Prevention of needle-stick injuries in healthcare facilities: a meta-analysis

OBJECTIVE To estimate the summary effectiveness of different needle-stick injury (NSI)-prevention interventions. DESIGN We conducted a meta-analysis of English-language articles evaluating methods for reducing needle stick, sharp, or percutaneous injuries published from 2002 to 2012 identified using PubMed and Medline EBSCO databases. Data were extracted using a standardized instrument. Random effects models were used to estimate the summary effectiveness of 3 interventions: training alone, safety-engineered devices (SEDs) alone, and the combination of training and SEDs. SETTING Healthcare facilities, mainly hospitals PARTICIPANTS Healthcare workers including physicians, midwives, and nurses RESULTS From an initial pool of 250 potentially relevant studies, 17 studies met our inclusion criteria. Six eligible studies evaluated the effectiveness of training interventions, and the summary effect of the training intervention was 0.66 (95% CI, 0.50-0.89). The summary effect across the 5 studies that assessed the efficacy of SEDs was 0.51 (95% CI, 0.40-0.64). A total of 8 studies evaluated the effectiveness of training plus SEDs, with a summary effect of 0.38 (95% CI, 0.28-0.50). CONCLUSION Training combined with SEDs can substantially reduce the risk of NSIs.

Trends in needlestick injury incidence following regulatory change in Ontario, Canada (2004-2012): an observational study

BACKGROUND

A number of jurisdictions have used regulation to promote the adoption of safety-engineered needles as a primary solution to reduce the risk of needlestick injuries among healthcare workers. Regulatory change has not been complemented by ongoing efforts to monitor needlestick injury trends which limits opportunities to evaluate the need for additional investment in this area. The objective of this study was to describe trends in the incidence of needlestick injuries in Ontario prior to and following the establishment of regulation to promote the adoption of safety-engineered needles.

METHODS

An observational study of needlestick injuries obtained from two independent administrative data sources (emergency department records for the treatment of work-related disorders and workers' compensation claims) for a population of occupationally-active adults over the period 2004-2012.

RESULTS

Comparing the year prior to the regulation being established (2006) to three years after the regulation came into effect (2011), needlestick injury rates in the health and social services sector that were captured by workers' compensation claims declined by 31% and by 43% in the work-related emergency department records. Rates of workers' compensation claims associated with needlestick injuries declined by 31% in the hospital sector, by 67% in the long-term care sector and have increased by approximately 1% in nursing services over the period 2004-2012.

CONCLUSIONS

Two independent administrative data sources documented an overall reduction in needlestick injuries in the province of Ontario following a regulatory requirement to adopt safety-engineered needles; however, a substantial burden of occupational needlestick injuries persists in this setting.

Sharps Injuries among Employees of Acute Care Hospitals in Massachusetts, 2002–2007

Objective.

Sharps with engineered sharps injury protections (SESIPs) have been found to reduce risk of sharps injuries (Sis). We examined trends in SI rates among employees of acute care hospitals in Massachusetts, including the impact of SESIPs on SI trends during 2002-2007.

Design.

Prospective surveillance.

Setting.

Seventy-six acute care hospitals licensed by the Massachusetts Department of Public Health.

Participants.

Employees of acute care hospitals who reported Sis to their employers.

Methods.

Data on Sis in acute care hospitals collected by the Massachusetts Sharps Injury Surveillance System were used to examine trends in SI rates over time by occupation, hospital size, and device. Negative binomial regression was used to assess trends.

Results.

During 2002-2007, 16,158 Sis among employees of 76 acute care hospitals were reported to the surveillance system. The annual SI rate decreased by 22%, with an annual decline of 4.7% (P< .001). Rates declined significantly among nurses (—7.2% per year;P< .001) but not among physicians (—0.9% per year;P= .553). SI rates associated with winged steel needles and hypodermic needles and syringes also declined significantly as the proportion of injuries involving devices with sharps injury prevention features increased during the same time period.

Conclusion.

SI rates involving devices for which SESIPs are widely available and appear to be increasingly used have declined. The continued use of devices lacking SI protections for which SESIPs are available needs to be addressed. The extent to which injuries involving SESIPs are due to flaws in design or lack of experience and training must be examined.

Devices for preventing percutaneous exposure injuries caused by needles in healthcare personnel

BACKGROUND

Needlestick injuries from devices used for blood collection or for injections expose healthcare workers to the risk of blood borne infections such as hepatitis B and C, and human immunodeficiency virus (HIV). Safety features such as shields or retractable needles can possibly contribute to the prevention of these injuries and it is important to evaluate their effectiveness.

OBJECTIVES

To determine the benefits and harms of safety medical devices aiming to prevent percutaneous exposure injuries caused by needles in healthcare personnel versus no intervention or alternative interventions.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, NHSEED, Science Citation Index Expanded, CINAHL, Nioshtic, CISdoc and PsycINFO (until January 2014) and LILACS (until January 2012).

SELECTION CRITERIA

We included randomised controlled trials (RCT), controlled before and after studies (CBA) and interrupted time-series (ITS) designs on the effect of safety engineered medical devices on needlestick injuries in healthcare staff.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility and risk of bias and extracted data. We synthesized study results with a fixed-effect or random-effects model meta-analysis where appropriate.

MAIN RESULTS

We included four RCTs with 1136 participants, two cluster-RCTs with 795 participants and 73,454 patient days, four CBAs with approximately 22,000 participants and seven ITS with an average of seven data points. These studies evaluated safe modifications of blood collection systems, intravenous (IV) systems, injection systems, multiple devices and sharps containers. The needlestick injury (NSI) rate in the control groups was estimated at about one to five NSIs per 1000 person-years. There was only one study from a low- or middle-income country. The risk of bias was high in most studies.In one ITS study that evaluated safe blood collection systems, NSIs decreased immediately after the introduction (effect size (ES) -6.9, 95% confidence interval (CI) -9.5 to -4.2) and there was no clear evidence of an additional benefit over time (ES -1.2, 95% CI -2.5 to 0.1). Another ITS study used an outdated recapping shield.There was very low quality evidence that NSIs were reduced with the introduction of safe IV devices in two out of four studies but the other two studies showed no clear evidence of a trend towards a reduction. However, there was moderate quality evidence in four other studies that these devices increased the number of blood splashes where the safety system had to be engaged actively (relative risk (RR) 1.6, 95% CI 1.08 to 2.36).There was no clear evidence that the introduction of safe injection devices changed the NSI rate in two studies.The introduction of multiple safety devices showed a decrease in NSI in one study but not in another. The introduction of safety containers showed a decrease in NSI in one study but inconsistent results in two other studies.There was no evidence in the included studies about which type of device was better, for example shielding or retraction of the needle.

AUTHORS' CONCLUSIONS

For safe blood collection systems, we found very low quality evidence in one study that these decrease needlestick injuries (NSIs). For intravenous systems, we found very low quality evidence that they result in a decrease of NSI compared with usual devices but moderate quality evidence that they increase contamination with blood. For other safe injection needles, the introduction of multiple safety devices or the introduction of sharps containers the evidence was inconsistent or there was no clear evidence of a benefit. All studies had a considerable risk of bias and the lack of evidence of a beneficial effect could be due both to confounding and bias. This does not mean that these devices are not effective.Cluster-randomised controlled studies are needed to compare the various types of safety engineered devices for their effectiveness and cost-effectiveness, especially in low- and middle-income countries.

Incidence rate of needlestick and sharps injuries in 67 Japanese hospitals: a national surveillance study

Background

Determining incidence rates of needlestick and sharps injuries (NSIs) using data from multiple hospitals may help hospitals to compare their in-house data with national averages and thereby institute relevant measures to minimize NSIs. We aimed to determine the incidence rate of NSIs using the nationwide EPINet surveillance system.

Methodology/Principal Findings

Data were analyzed from 5,463 cases collected between April 2009 and March 2011 from 67 Japanese HIV/AIDS referral hospitals that participated in EPINet-Japan. The NSI incidence rate was calculated as the annual number of cases with NSIs per 100 occupied beds, according to the demographic characteristics of the injured person, place, timing, device, and the patients’ infectious status. The NSI incidence rates according to hospital size were analyzed by a non-parametric test of trend. The mean number of cases with NSIs per 100 occupied beds per year was 4.8 (95% confidence interval, 4.1–5.6) for 25 hospitals with 399 or fewer beds, 6.7 (5.9–7.4) for 24 hospitals with 400–799 beds, and 7.6 (6.7–8.5) for 18 hospitals with 800 or more beds (p-trend<0.01). NSIs frequently occurred in health care workers in their 20 s; the NSI incidence rate for this age group was 2.1 (1.6–2.5) for hospitals having 399 or fewer beds, 3.5 (3.0–4.1) for hospitals with 400–799 beds, and 4.5 (3.9–5.0) for hospitals with 800 or more beds (p-trend<0.01).

Conclusions/Significance

The incidence rate of NSIs tended to be higher for larger hospitals and in workers aged less than 40 years; injury occurrence was more likely to occur in places such as patient rooms and operating rooms. Application of the NSI incidence rates by hospital size, as a benchmark, could allow individual hospitals to compare their NSI incidence rates with those of other institutions, which could facilitate the development of adequate control strategies.

Estimated risk of HIV acquisition and practice for preventing occupational exposure: a study of healthcare workers at Tumbi and Dodoma Hospitals, Tanzania

Background

Healthcare workers (HCWs) are at risk of acquiring human immuno-deficiency virus (HIV) and other infections via exposure to infectious patients’ blood and body fluids. The main objective of this study was to estimate the risk of HIV transmission and examine the practices for preventing occupational exposures among HCWs at Tumbi and Dodoma Hospitals in Tanzania.

Methods

This study was carried out in two hospitals, namely, Tumbi in Coast Region and Dodoma in Dodoma Region. In each facility, hospital records of occupational exposure to HIV infection and its management were reviewed. In addition, practices to prevent occupational exposure to HIV infection among HCWs were observed.

Results

The estimated risk of HIV transmission due to needle stick injuries was calculated to be 7 cases per 1,000,000 HCWs-years. Over half of the observed hospital departments did not have guidelines for prevention and management of occupational exposure to HIV infections and lacked well displayed health and safety instructions. Approximately, one-fifth of the hospital departments visited failed to adhere to the instructions pertaining to correlation between waste materials and the corresponding colour coded bag/container/safety box. Seventy four percent of the hospital departments observed did not display instructions for handling infectious materials. Inappropriate use of gloves, lack of health and safety instructions, and lack of use of eye protective glasses were more frequently observed at Dodoma Hospital than at Tumbi Hospital.

Conclusions

The poor quality of the hospital records at the two hospitals hampered our effort to characterise the risk of HIV infection acquisition by HCWs. Greater data completeness in hospital records is needed to allow the determination of the actual risk of HIV transmission for HCWs. To further reduce the risk of HIV infection due to occupational exposure, hospitals should be equipped with sufficient personal protective equipment (PPE) and HCWs should be reminded of the importance of adhering to universal precautions.

Evaluating the implementation of health and safety innovations under a regulatory context: a collective case study of Ontario's safer needle regulation

Background

Implementation effectiveness models have identified important factors that can promote the successful implementation of an innovation; however, these models have been examined within contexts where innovations are adopted voluntarily and often ignore the socio-political and environmental context. In the field of occupational health and safety, there are circumstances where organizations must adopt innovations to comply with a regulatory standard. Examining how the external environment can facilitate or challenge an organization’s change process may add to our understanding of implementation effectiveness. The objective of this study is to describe implementation facilitators and barriers in the context of a regulation designed to promote the uptake of safer engineered medical devices in healthcare.

Methods

The proposed study will focus on Ontario’s safer needle regulation (2007) which requires healthcare organizations to transition to the use of safer engineered medical devices for the prevention of needlestick injuries. A collective case study design will be used to learn from the experiences of three acute care hospitals in the province of Ontario, Canada. Interviews with management and front-line healthcare workers and analysis of supporting documents will be used to describe the implementation experience and examine issues associated with the integration of these devices. The data collection and analysis process will be influenced by a conceptual framework that draws from implementation science and the occupational health and safety literature.

Discussion

The focus of this study in addition to the methodology creates a unique opportunity to contribute to the field of implementation science. First, the study will explore implementation experiences under circumstances where regulatory pressures are influencing the organization's change process. Second, the timing of this study provides an opportunity to focus on issues that arise during later stages of implementation, a phase during the implementation cycle that has been understudied. This study also provides the opportunity to examine the relevance and utility of current implementation science models in the field of occupational health where the adoption of an innovation is meant to enhance the health and safety of workers. Previous work has tended to focus almost exclusively on innovations that are designed to enhance an organization’s productivity or competitive advantage.

Needlestick and sharps injuries among housekeeping workers in hospitals of Shiraz, Iran

BACKGROUND

Needlestick and sharps injuries (NSSIs) are one of the major risk factors for blood-borne infections (BBPs) at healthcare facilities. This study examines the current prevalence of NSSIs among housekeeping workers engaged in the handling and disposal of biomedical waste (BMW) at government and private hospitals in Shiraz, Iran, and furthermore, explores strategies for preventing these injuries.

FINDINGS

Using a cross-sectional study design, NSSI's and associated protective measures for housekeeping workers throughout hospitals in Shiraz were evaluated from 2009 onwards. Using a questionnaire, data was collected for 92 workers who had engaged directly with BMW. Data was analyzed using Chi-square, student t-test and where appropriate, SPSS version 12. 90.2 % of housekeeping workers were warned of the dangers associated with waste, 87.5 % in government and 93.2 % in private hospitals (P = 0.0444). 83.7 % had attended educational programs on biomedical waste (BMW) management and injury prevention at their hospital in the preceding year. 16.3 % had not been trained in biomedical waste management (P = 0.0379) and 88.9 % had a sufficient supply of safety wear.

CONCLUSIONS

NSSIs are a common risk factor for infection among health care workers within hospitals in Iran. For the effective prevention of these injuries, health boards and hospital trusts need to formulate strategies to improve the working conditions of health care workers, discourage the excessive use of injections, and increase their adherence to universal precautions.

Conventional and sharp safety devices in 6 hospitals in British Columbia, Canada

BACKGROUND

Reengineered sharp safety devices have been recommended to reduce occupational percutaneous injury risk in health care facilities. We conducted this study just over 1 year after passage of legislation requiring the use of sharp safety medical devices to assess the frequency of safety and conventional sharp device use and whether safety features were being activated to cover sharp points after safety devices were used and before disposal.

METHODS

Approximately equal numbers of sharps disposal containers from various wards in 6 nonprofit adult and pediatric British Columbia hospitals were audited by paired research assistants, wearing protective clothing.

RESULTS

In the 699 audited sharps containers, 7% (1,690/25,910) of all devices were conventional devices, specifically 2% (96/4,702) of all phlebotomy devices, 7% (1,240/17,705) of all syringes, and 10% (354/3,503) of all intravenous catheters. In addition, 94% (4,344/4,602) of all safety phlebotomy devices, 95% (2,955/3,119) of all safety intravenous devices, and 80% (13,050/16,420) of all safety syringes had been activated before disposal.

CONCLUSION

More than 1 year after legislation was passed mandating the use of sharp safety devices in British Columbia hospitals, the risk from sharps remains excessive because of the ongoing use of conventional sharp devices and nonactivation of safety devices.

Provision and use of safety-engineered medical devices among home care and hospice nurses in North Carolina

BACKGROUND

Nurses who provide care in the home are at risk of blood exposure from needlesticks. Using safety-engineered medical devices reduces the risk of needlestick. The objectives of this study were to assess provision of safety devices by home care and hospice agencies as well as the use of these devices by home care and hospice nurses in North Carolina, and to examine the association between provision and use.

METHODS

A mail survey was conducted among North Carolina home care and hospice nurses in 2006.

RESULTS

The adjusted response rate was 69% (n = 833). The percentage of nurses who were always provided with safety devices ranged from 51% (blood tube holders) to 83% (winged steel needles). Ninety-five percent of nurses who were always provided with safety devices, but only 15%-50% of nurses who were not always provided with safety devices, used a safety device the last time they used that general type of device. Among nurses who did not use a safety device on that occasion, 60%-80% did not use it because it was not provided by the agency.

CONCLUSION

This study suggests that limited access is the primary reason for home care/hospice nurses' failure to use safety devices. The policy goal of providing safety devices to health care workers in all situations in which such devices could reduce their risk of needlestick is not being achieved for home care nurses in North Carolina.

Management practices and risk of occupational blood exposure in U.S. paramedics: Needlesticks

BACKGROUND

The purpose of this study was to present risk estimates for needlestick in U.S. paramedics and estimated risk ratios for selected management practices.

METHODS

A mail survey was conducted among a national sample of U.S. paramedics in 2002-2003.

RESULTS

The adjusted response rate was 55% (n = 2,664). The overall 12-month risk of needlestick was 6.7% (95% confidence interval, 5.4-7.9). Risk ratios for provision of safety-engineered medical devices and two supervisory behaviors that emphasized safe work practices ranged from 2.5 to 3.2. The protective effect of working in an environment that included both of the supervisory behaviors was greater than the protective effect of always being provided with safety devices. A sensitivity analysis indicated that the risk ratio estimates were unlikely to be inflated by nonresponse bias.

CONCLUSIONS

These results suggest that greater provision of safety devices and interventions aimed at management practices that promote worker safety could substantially reduce the risk of needlestick among U.S. paramedics.

Needlestick injury rates according to different types of safety-engineered devices: results of a French multicenter study

OBJECTIVES

To evaluate the incidence of needlestick injuries (NSIs) among different models of safety-engineered devices (SEDs) (automatic, semiautomatic, and manually activated safety) in healthcare settings.

DESIGN

This multicenter survey, conducted from January 2005 through December 2006, examined all prospectively documented SED-related NSIs reported by healthcare workers to their occupational medicine departments. Participating hospitals were asked retrospectively to report the types, brands, and number of SEDs purchased, in order to estimate SED-specific rates of NSI. Setting. Sixty-one hospitals in France.

RESULTS

More than 22 million SEDs were purchased during the study period, and a total of 453 SED-related NSIs were documented. The mean overall frequency of NSIs was 2.05 injuries per 100,000 SEDs purchased. Device-specific NSI rates were compared using Poisson approximation. The 95% confidence interval was used to define statistical significance. Passive (fully automatic) devices were associated with the lowest NSI incidence rate. Among active devices, those with a semiautomatic safety feature were significantly more effective than those with a manually activated toppling shield, which in turn were significantly more effective than those with a manually activated sliding shield (P < .001, chi(2) test). The same gradient of SED efficacy was observed when the type of healthcare procedure was taken into account.

CONCLUSIONS

Passive SEDs are most effective for NSI prevention. Further studies are needed to determine whether their higher cost may be offset by savings related to fewer NSIs and to a reduced need for user training.

Circumstances surrounding occupational blood exposure events in the National Study to Prevent Blood Exposure in Paramedics

More than 20% of U.S. paramedics are exposed to blood each year. Little is known about the circumstances that lead to these exposures. The objective of this study was to describe blood exposure events among U.S. paramedics. A mail survey was conducted in 2002-2003 among a nationally representative sample of licensed paramedics. Eighty percent of needle/lancet sticks involved non-safety devices. A third of mucous membrane exposures occurred even though the paramedic was wearing eye or face protection; in half of the events, the exposures were caused by the patient vomiting, spitting, or coughing up blood; in a third of the events, the patient was being uncooperative or combative. In 83% of the non-intact skin exposures, the paramedic was wearing disposable gloves; the non-intact skin was covered before the call in a third of the events, but the cover did not prevent exposure; 40% of the events occurred when the patient was being uncooperative or combative. These results suggest that blood exposure among paramedics could be reduced through increased use of safety devices and personal protective equipment, improved engineering and design, and increased compliance with Universal Precautions, and that paramedics need techniques for avoiding blood exposure while treating uncooperative or combative patients.

Eliminating the blood: ongoing outbreaks of hepatitis B virus infection and the need for innovative glucose monitoring technologies

BACKGROUND

As part of routine diabetes care, capillary blood is typically sampled using a finger-stick device and then tested using a handheld blood glucose meter. In settings where multiple persons require assistance with blood glucose monitoring, opportunities for bloodborne pathogen transmission may exist.

METHODS

Reports of hepatitis B virus (HBV) infection outbreaks in the United States that have been attributed to blood glucose monitoring practices were reviewed and summarized.

RESULTS

Since 1990, state and local health departments investigated 18 HBV infection outbreaks, 15 (83%) in the past 10 years, that were associated with the improper use of blood glucose monitoring equipment. At least 147 persons acquired HBV infection during these outbreaks, 6 (4.1%) of whom died from complications of acute HBV infection. Outbreaks appear to have become more frequent in the past decade, primarily affecting long-term care residents with diabetes. Each outbreak was attributed to glucose monitoring practices that exposed HBV-susceptible persons to blood-contaminated equipment that was previously used on HBV-infected persons. The predominant unsafe practices were the use of spring-loaded finger-stick devices on multiple persons and the sharing of blood glucose testing meters without cleaning and disinfection between uses.

CONCLUSION

Hepatitis B virus infection outbreaks associated with blood glucose monitoring have occurred with increasing regularity in the Unites States and may represent a growing but under-recognized problem. Advances in technology, such as the development of blood glucose testing meters that can withstand frequent disinfection and noninvasive glucose monitoring methods, will likely prove useful in improving patient safety.

High risk for occupational exposure to HIV and utilization of post-exposure prophylaxis in a teaching hospital in Pune, India

Background

The risk for occupational exposure to HIV has been well characterized in the developed world, but limited information is available about this transmission risk in resource-constrained settings facing the largest burden of HIV infection. In addition, the feasibility and utilization of post-exposure prophylaxis (PEP) programs in these settings are unclear. Therefore, we examined the rate and characteristics of occupational exposure to HIV and the utilization of PEP among health care workers (HCW) in a large, urban government teaching hospital in Pune, India.

Methods

Demographic and clinical data on occupational exposures and their management were prospectively collected from January 2003–December 2005. US Centers for Diseases Control guidelines were utilized to define risk exposures, for which PEP was recommended. Incidence rates of reported exposures and trends in PEP utilization were examined using logistic regression.

Results

Of 1955 HCW, 557 exposures were reported by 484 HCW with an incidence of 9.5 exposures per 100 person-years (PY). Housestaff, particularly interns, reported the greatest number of exposures with an annual incidence of 47.0 per 100 PY. Personal protective equipment (PPE) was used in only 55.1% of these exposures. The incidence of high-risk exposures was 6.8/100 PY (n = 339); 49.1% occurred during a procedure or disposing of equipment and 265 (80.0%) received a stat dose of PEP. After excluding cases in which the source tested HIV negative, 48.4% of high-risk cases began an extended PEP regimen, of whom only 49.5% completed it. There were no HIV or Hepatitis B seroconversions identified. Extended PEP was continued unnecessarily in 7 (35%) of 20 cases who were confirmed to be HIV-negative. Over time, there was a significant reduction in proportion of percutaneous exposures and high-risk exposures (p < 0.01) and an increase in PEP utilization for high risk exposures (44% in 2003 to 100% in 2005, p = 0.002).

Conclusion

Housestaff are a vulnerable population at high risk for bloodborne exposures in teaching hospital settings in India. With implementation of a hospital-wide PEP program, there was an encouraging decrease of high-risk exposures over time and appropriate use of PEP. However, overall use of PPE was low, suggesting further measures are needed to prevent occupational exposures in India.

Determination of risk of infection with blood-borne pathogens following a needlestick injury in hospital workers

OBJECTIVES

Our paper measures the prevalence of hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) in patients at the University Hospital of Frankfurt/Main, and correlates the prevalence with risk factors for exposure to and infection of healthcare workers (HCWs). Individual risk assessments were calculated for exposed HCWs.

METHODS

Survey of patients admitted to a German University Hospital. Markers for HBV, HCV and HIV were studied and evaluated statistically. Data on needlestick injuries (NSIs) among HCWs were correlated with the prevalence of infectious patients.

RESULTS

The HBV, HCV and HIV prevalence among patients at the University Hospital were 5.3% (n = 709/13 358), 5.8% (n = 1167/20 163) and 4.1% (n = 552/13 381), respectively. Our results indicate that the prevalence of blood-borne infections in patients was about nine times higher for HBV, approximately 15 times higher for HCV and approximately 82 times higher for HIV than in the overall German population. The highest risk of acquiring a blood-borne infection via NSI was found in the department of internal medicine due to increased prevalence of blood-borne pathogens in patients under treatment.

CONCLUSIONS

While accidental NSIs were most frequent in surgery, the nominal risk of blood-borne virus infection was greatest in the field of internal medicine. The study underlines the importance of HBV vaccinations and access to HIV-post-exposure prophylaxis for HCWs as well as the use of anti-needlestick devices.

Needlesticks and surgical residents: who is most at risk?

OBJECTIVE

Exposure to blood-borne diseases remains an occupational risk. Mandates have improved training in how to report exposures for all health-care workers. How exposure rates of surgical residents correlate with experience and mandatory training to reduce risk is not known. It was hypothesized that enhanced training would result in an increased reporting of exposures by surgical trainees and that risk would be greater in the first years of training.

DESIGN

Retrospective review of occupational health records and operative case logs, prospective survey.

METHODS

Occupational Health Services provides both initial and annual training to General Surgery house staff at the Medical College of Wisconsin. Initial training consists of a blood-borne pathogen review and a detailed explanation of exposure reporting. Mandatory annual training is provided during Surgical Grand Rounds. Training was enhanced beginning June 2005 using a videotape outlining surgical risks and specific countermeasures. The numbers of reported exposures per year before and after enhanced training were compared. Exposures were self-reported. As most exposures occurred in the operating room, rate of exposure was calculated for each year of training using the total number of cases done each year reported by the general surgical residents.

RESULTS

Surgical residents reported 118 needlestick injuries over 6 years. Senior and chief residents demonstrated a significantly lower exposure rate than junior residents (nonparametric Mood's median test, p < 0.0001). No significant difference in the injury rate was found per 1000 cases after enhanced training.

CONCLUSIONS

Increasing surgical experience lowered the needlestick injury rate. Assuming no change in self-reporting rates by year, enhanced training and reporting guidelines did not seem to change risk. More specific training for junior residents, as well as passive prevention solutions, may be necessary to positively impact their exposure risk.

Prevalence and prevention of needlestick injuries among health care workers in a German university hospital

OBJECTIVE

Health care workers (HCWs) are exposed to bloodborne pathogens, especially hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV) through job-related risk factors like needlestick, stab, scratch, cut, or other bloody injuries. Needlestick injuries can be prevented by safer devices.

METHODS

The purpose of this study was to investigate the frequency and causes of needlestick injuries in a German university hospital. Data were obtained by an anonymous, self-reporting questionnaire. We calculated the share of reported needlestick injuries, which could have been prevented by using safety devices.

RESULTS

31.4% (n = 226) of participant HCWs had sustained at least one needlestick injury in the last 12 months. A wide variation in the number of reported needlestick injuries was evident across disciplines, ranging from 46.9% (n = 91/194) among medical staff in surgery and 18.7% (n = 53/283) among HCWs in pediatrics. Of all occupational groups, physicians have the highest risk to experience needlestick injuries (55.1%-n = 129/234). Evaluating the kind of activity under which the needlestick injury occurred, on average 34% (n = 191/561) of all needlestick injuries could have been avoided by the use of safety devices. Taking all medical disciplines and procedures into consideration, safety devices are available for 35.1% (n = 197/561) of needlestick injuries sustained. However, there was a significant difference across various medical disciplines in the share of needlestick injuries which might have been avoidable: Pediatrics (83.7%), gynecology (83.7%), anesthesia (59.3%), dermatology (33.3%), and surgery (11.9%). In our study, only 13.2% (n = 74/561) of needlestick injuries could have been prevented by organizational measures.

CONCLUSION

There is a high rate of needlestick injuries in the daily routine of a hospital. The rate of such injuries depends on the medical discipline. Implementation of safety devices will lead to an improvement in medical staff's health and safety.

Sharp-device injuries to hospital staff nurses in 4 countries

OBJECTIVE

To compare sharp-device injury rates among hospital staff nurses in 4 Western countries.

DESIGN

Cross-sectional survey.

SETTING

Acute-care hospital nurses in the United States (Pennsylvania), Canada (Alberta, British Columbia, and Ontario), the United Kingdom (England and Scotland), and Germany.

PARTICIPANTS

A total of 34,318 acute-care hospital staff nurses in 1998-1999.

RESULTS

Survey-based rates of retrospectively-reported needlestick injuries in the previous year for medical-surgical unit nurses ranged from 146 injuries per 1,000 full-time equivalent positions (FTEs) in the US sample to 488 injuries per 1,000 FTEs in Germany. In the United States and Canada, very high rates of sharp-device injury among nurses working in the operating room and/or perioperative care were observed (255 and 569 injuries per 1,000 FTEs per year, respectively). Reported use of safety-engineered sharp devices was considerably lower in Germany and Canada than it was in the United States. Some variation in injury rates was seen across nursing specialties among North American nurses, mostly in line with the frequency of risky procedures in the nurses' work.

CONCLUSIONS

Studies conducted in the United States over the past 15 years suggest that the rates of sharp-device injuries to front-line nurses have fallen over the past decade, probably at least in part because of increased awareness and adoption of safer technologies, suggesting that regulatory strategies have improved nurse safety. The much higher injury rate in Germany may be due to slow adoption of safety devices. Wider diffusion of safer technologies, as well as introduction and stronger enforcement of occupational safety and health regulations, are likely to decrease sharp-device injury rates in various countries even further.