Effect of the introduction of an engineered sharps injury prevention device on the percutaneous injury rate in healthcare workers

Safety interventions for the prevention of accidents at work: A systematic review

BACKGROUND

Limited knowledge regarding the relative effectiveness of workplace accident prevention approaches creates barriers to informed decision-making by policy makers, public health practitioners, workplace, and worker advocates.

OBJECTIVES

The objective of this review was to assess the effectiveness of broad categories of safety interventions in preventing accidents at work. The review aims to compare effects of safety interventions to no intervention, usual activities, or alternative intervention, and if possible, to examine which constituent components of safety intervention programs contribute more strongly to preventing accidents at work in a given setting or context.

DATE SOURCES

Studies were identified through electronic bibliographic searches, government policy databanks, and Internet search engines. The last search was carried out on July 9, 2015. Gray literature were identified by searching OSH ROM and Google. No language or date restrictions were applied. Searches done between February and July of 2015 included PubMed (1966), Embase (1980), CINAHL (1981), OSH ROM (NIOSHTIC 1977, HSELINE 1977, CIS-DOC 1974), PsycINFO (1806), EconLit (1969), Web of Science (1969), and ProQuest (1861); dates represent initial availability of each database. Websites of pertinent institutions (NIOSH, Perosh) were also searched.

STUDY ELIGIBILITY CRITERIA PARTICIPANTS AND INTERVENTIONS

Included studies had to focus on accidents at work, include an evaluation of a safety intervention, and have used injuries at work, or a relevant proxy, as an outcome measure. Experimental, quasi-experimental, and observational study designs were utilized, including randomized controlled trials (RCTs), controlled before and after (CBA) studies, and observational designs using serial measures (interrupted time series, retrospective cohort designs, and before and after studies using multiple measures). Interventions were classified by approach at the individual or group level, and broad categories based on the prevention approach including modification of: Attitudes (through information and persuasive campaign messaging).Behaviors (through training, incentives, goal setting, feedback/coaching).Physiological condition (by physical training).Climate/norms/culture (by coaching, feedback, modification of safety management/leadership).Structural conditions (including physical environment, engineering, legislation and enforcement, sectorial-level norms). When combined approaches were used, interventions were termed "multifaceted," and when an approach(es) is applied to more than one organizational level (e.g., individual, group, and/or organization), it is termed "across levels."

STUDY APPRAISAL AND SYNTHESIS METHODS

Narrative report review captured industry (NACE), work setting, participant characteristics, theoretical basis for approach, intervention fidelity, research design, risk of bias, contextual detail, outcomes measures and results. Additional items were extracted for studies with serial measures including approaches to improve internal validity, assessments of reasonable statistical approaches (Effective Practice of Organization of Care [EPOC] criteria) and overall inference. Random-effects inverse variance weighted meta-analytic methods were used to synthesize odds ratios, rate ratios, or standardized mean differences for the outcomes for RCT and CBA studies with low or moderate levels of heterogeneity. For studies with greater heterogeneity and those using serial measures, we relied on narrative analyses to synthesize findings.

RESULTS

In total 100 original studies were included for synthesis analysis, including 16 RCT study designs, 30 CBA study designs, and 54 studies using serial measures (ITS study designs). These studies represented 120 cases of safety interventions. The number of participants included 31,971,908 individuals in 59 safety interventions, 417,693 groups/firms in 35 safety interventions, and 15,505 injuries in 17 safety interventions. Out of the 59 safety interventions, two were evaluating national prevention measures, which alone accounted for 31,667,110 individuals. The remaining nine safety interventions used other types of measures, such as safety exposure, safety observations, gloves or claim rates. Strong evidence supports greater effects being achieved with safety interventions directed toward the group or organization level rather than individual behavior change. Engineering controls are more effective at reducing injuries than other approaches, particularly when engineered changes can be introduced without requiring "decision-to-use" by workplaces. Multifaceted approaches combining intervention elements on the organizational level, or across levels, provided moderate to strong effects, in particular when engineering controls were included. Interventions based on firm epidemiologic evidence of causality and a strong conceptual approach were more effective. Effects that are more modest were observed (in short follow-up) for safety climate interventions, using techniques such as feedback or leadership training to improve safety communication. There was limited evidence for a strong effect at medium-term with more intense counseling approaches. Evidence supports regulation/legislation as contributing to the prevention of accidents at work, but with lower effect sizes. Enforcement appears to work more consistently, but with smaller effects. In general, the results were consistent with previous systematic reviews of specific types of safety interventions, although the effectiveness of economic incentives to prevent accidents at work was not consistent with our results, and effectiveness of physiological safety intervention was only consistent to some extent.

LIMITATIONS

Acute musculoskeletal injuries and injuries from more long-time workplace exposures were not always clearly distinguished in research reports. In some studies acute and chronic exposures were mixed, resulting in inevitable misclassification. Of note, the classification of these events also remains problematic in clinical medicine. It was not possible to conduct meta-analyses on all types of interventions (due to variability in approach, context, and participants). The findings presented for most intervention types are from limited sources, and assessment of publication bias was not possible. These issues are not surprising, given the breadth of the field of occupational safety. To incorporate studies using serial measures, which provide the only source of information for some safety interventions such as legislation, we took a systematic, grounded approach to their review. Rather than requiring more stringent, specific criteria for inclusion of ITS studies, we chose to assess how investigators justified their approach to design and analyses, based on the context in which they were working. We sought to identify measures taken to improve external validity of studies, reasonable statistical inference, as well as an overall appropriate inferential process. We found the process useful and enlightening. Given the new approach, we may have failed to extract points others may find relevant. Similarly, to facilitate the broad nature of this review, we used a novel categorization of safety interventions, which is likely to evolve with additional use. The broad scope of this review and the time and resources available did not allow for contacting authors of original papers or seeking translation of non-English manuscripts, resulting in a few cases where we did not have sufficient information that may have been possible to obtain from the authors.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Our synthesis of the relative effectiveness of workplace safety interventions is in accordance with the Public Health Hierarchy of Hazard Control. Specifically, more effective interventions eliminate risk at the source of the hazard through engineering solutions or the separation of workers from hazards; effects were greater when these control measures worked independently of worker "decision-to-use" at the worksite. Interventions based on firm epidemiological evidence of causality and clear theoretical bases for the intervention approach were more effective in preventing injuries. Less effective behavioral approaches were often directed at the prevention of all workplace injuries through a common pathway, such as introducing safety training, without explicitly addressing specific hazards. We caution that this does not mean that training does not play an essential function in worker safety, but rather that it is not effective in the absence of other efforts. Due to the potential to reach large groups of workers through regulation and enforcement, these interventions with relatively modest effects, could have large population-based effects.

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.

Efficacy of a Novel Intraoperative Engineered Sharps Injury Prevention Device: Pilot Usability and Efficacy Trial

Background

The American College of Surgeons reports 88,320 intraoperative needlestick injuries (NSIs) per year, resulting in US $376 to US $2456 in costs per NSI. Engineered sharps injury prevention (ESIP) devices protect against NSIs. To our knowledge, no study has been published to date to demonstrate clinical effectiveness of an intraoperative ESIP device. Operative Armour is a wearable arm cuff that can be donned during surgical closure to allow surgeons to keep a suture pack and sharps protection container on their forearm.

Objective

We characterize Operative Armour’s ESIP device effectiveness in a tertiary hospital, hypothesizing that this device will decrease NSI risk by decreasing behaviors associated with NSIs: needle passing and handling.

Methods

A prospective case-control study was conducted with institutional review board quality improvement designation in which authors observed skin closures of plastic surgery procedures. To ensure accuracy, one surgeon was observed at a time. Control surgeries were purely observational; intervention cases involved surgeon use of the device during skin closure. Outcomes of interest included needle passing, needle handling, lost needles, and loaded waiting needles.

Results

Surgeons were observed in 50 control and 50 intervention cases. Operative Armour eliminated needle passing during skin closure. One NSI occurred in one control case; no NSIs were observed in intervention cases (P=.36). The mean number of loaded and unprotected waiting needles was also significantly decreased in the intervention group from 2.3 to 0.2 (P<.001). Furthermore, a multivariable linear regression established that Operative Armour significantly decreased the number of needle adjustments by hand per stitch observed (F_{4, 21.68}=3.72; P=.01). In fact, needle adjustments by hand decreased overall (1 adjustment per 10 stitches vs 1 adjustment per 5 stitches, P=.004), and adjustments occurred half as frequently with use of Operative Armour in free flap reconstruction (1 adjustment per 10 stitches vs 1 adjustment per 5 stitches, P=.03) and a quarter as frequently in other breast reconstruction cases such as mastopexy (1 adjustment per 20 stitches vs 1 adjustment per 5 stitches, P=.002).

Conclusions

Operative Armour effectively functions as an ESIP device by decreasing intraoperative needle passing and handling. Although sample size prohibits demonstrating a decrease in NSIs during observed cases, by decreasing behaviors that drive NSI risk, we anticipate an associated decrease in NSIs with use of the device.

Education and devices to prevent blood and body fluid exposures

BACKGROUND

Healthcare workers are at risk of blood and body fluid exposures (BBFE) while delivering care to patients. Despite recent technological advances such as safety-engineered devices (SEDs), these injuries continue to occur in healthcare facilities worldwide.

AIMS

To assess the impact of an education and SEDs workplace programme on rates of reported exposures.

METHODS

A retrospective cohort study, utilizing interrupted time series analysis to examine reported exposures between 2005 and 2015 at a 600-bed hospital in Perth, Western Australia. The hospital wards were divided into four cohorts.

RESULTS

A total of 2223 records were available for analysis. The intervention was most effective for the first cohort, with significant improvements both short-term (reduction of 12 (95% CI 7-17) incidents per 1000 full-time equivalent (FTE) hospital staff) and long-term (reduction of 2 (CI 0.6-4) incidents per 1000 FTE per year). Less significant or consistent impacts were observed for the other three cohorts. Overall, the intervention decreased BBFE exposure rates at the hospital level from 19 (CI 18-20) incidents per 1000 FTE pre-intervention to 11 (CI 10-12) incidents per 1000 FTE post-intervention, a 41% reduction. No exposures resulted in a blood-borne virus infection.

CONCLUSIONS

The intervention was most effective in reducing exposures at a time when incidence rates were increasing. The overall effect was short-term and did not further reduce an already stabilized trend, which was likely due to improved safety awareness and practice, induced by the first cohort intervention.

Understanding sharps use in an Australian Emergency Department: A mixed methods organisational case study

BACKGROUND

Despite the introduction of a range of safety policies and sharps equipment designed to protect healthcare workers, rates of percutaneous injuries from occupational exposure to sharps remains high. This study examined the availability and use of various types of sharps devices in a tertiary hospital emergency department, to understand clinician choice between non-safety and safety devices; and to document their safe and unsafe use of sharps.

METHODS

This mixed methods study consisted of areview of stock levels, a survey of staff usage, and a content analysis of semi-structured interview data to explore factors which impact on staff preferences for different sharps devices.

RESULTS

Staff identified a range of sharps risks, as well as barriers and enablers to the use of safety devices. Availability of, and preference for, familiar devices influenced choice of devices used in clinical practice, despite awareness of associated risks.

CONCLUSIONS

This understanding of equipment use and the factors that motivate such use have informed the first stage of the knowledge-to-action cycle. Knowledge translation, should include the development of policies to help reduce the risk of sharps injury. Culture change and ongoing skills development might help to overcome entrenched procedures and increase voluntary engagement with safer sharps.

Needlesticks with safety devices and accident prevention: an integrative review

OBJECTIVE

To identify in the literature the efficacy of needlesticks with safety devices to reduce the occurrence of occupational accidents with exposure to biological material among health workers.

METHOD

Integrative literature review, structured in the stages: Guiding question, search, categorization of studies, evaluation, discussion and interpretation of results, and synthesis of knowledge. Search for original articles and systematic reviews on the main bases of the Health area, published from 2000 to 2016 in Portuguese, English and Spanish, with descriptors: needlesticks injuries, exposure to biological agents, needles, protective devices, occupational accidents, accident prevention and health personnel.

RESULTS

We selected eleven articles, most characterized the passive safety devices as more effective in reducing the occurrence of injuries by needlesticks.

CONCLUSION

The use of needlesticks with safety devices reduces the occurrence of accidents, bringing greater solvency when combined with the training of workers.

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.

Characterisation of occupational blood and body fluid exposures beyond the Needlestick Safety and Prevention Act

OBJECTIVE

To describe the use of mandated safety engineered sharps devices (SESDs) and personal protective equipment in healthcare workers (HCWs) with occupational body fluid exposures (BFE) since the Needlestick Safety and Prevention Act.

METHODS

Two questionnaires were administered, over 3 years, to HCWs who reported sharps or splash BFEs. Descriptive statistics and chi-square analysis were used.

RESULTS

Of the 498 questionnaires completed, nurses completed 262 (53%), house staff 155 (32 %), technicians 63 (13%) and phlebotomists 11 (2%). Four (1%) completers reported 'other' and three (1%) reported unknown. Sharps injuries accounted for 349 (70%) of the BFEs. SESDs were utilised 43% (128/299) of the time with a 54% (70/130) activation rate. Phlebotomists (80%; 8/10) and nurses (59%; 79/267) used SESDs more than doctors (27%; 31/86) and technicians (26%; 10/39) (P <0.0001). Fifty-four percent (185/207) of HCWs reported having had training on SESD use; nurses (64%; 98/154) and phlebotomists (70%; 7/8) significantly more so than house staff (44%; 59/133) and technicians (44%; 21/48) (P <0.05). Most splash BFEs were to the eyes 73% (91/149). Five percent (4/79) of HCWs used protective eyewear.

CONCLUSIONS

Systematic regular training, appropriate protocols and iteratively providing the safest SESDs based on HCW experience and technological advances will further reduce the physical and emotional toll of BFEs.

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.

Reducing needlestick injuries through safety-engineered devices: results of a Japanese multi-centre study

BACKGROUND

Quantitative information on the effectiveness of safety-engineered devices (SEDs) is needed to support decisions regarding their implementation.

AIM

To elucidate the effects of SED use in winged steel needles, intravenous (IV) catheter stylets and suture needles on needlestick injury (NSI) incidence rates in Japan.

METHODS

Japan EPINet survey data and device utilization data for conventional devices and SEDs were collected from 26 participating hospitals between 1 April 2009 and 31 March 2014. The NSI incidence rate for every 100,000 devices was calculated according to hospital, year and SED use for winged steel needles, IV catheter stylets and suture needles. Weighted means and 95% confidence intervals (CI) were used to calculate overall NSI incidence rates.

FINDINGS

In total, there were 236 NSIs for winged steel needles, 152 NSIs for IV catheter stylets and 180 NSIs for suture needles. The weighted NSI incidence rates per 100,000 devices for SEDs and non-SEDs were as follows: winged steel needles, 2.10 (95% CI 1.66-2.54) and 14.95 (95% CI 2.46-27.43), respectively; IV catheter stylets, 0.95 (95% CI 0.60-1.29) and 6.39 (95% CI 3.56-9.23), respectively; and suture needles, 1.47 (95% CI -1.14-4.09) and 16.50 (95% CI 4.15-28.86), respectively. All devices showed a significant reduction in the NSI incidence rate with SED use (P < 0.001 for winged steel needles, P = 0.035 for IV catheter stylets and P = 0.044 for suture needles).

CONCLUSION

SED use substantially reduces the incidence of NSIs, and is therefore recommended as a means to prevent occupational infections in healthcare workers and improve healthcare safety.

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.

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.

epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001(1) and updated in 2007.(2) A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated. These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

Chinks in the armor: percutaneous injuries from hollow bore safety-engineered sharps devices

BACKGROUND

Despite their overwhelming efficacy, safety-engineered sharp devices (SESDs) cause a residual fraction of injuries. Although the fraction of injuries from SESDs is less than that reported for nonsafety devices, it remains a "preventable fraction" and is a sizable target for further advances.

METHODS

A retrospective review of 3,297 percutaneous injuries from hollow bore safety-engineered devices occurring between 2001 and 2009 was conducted examining the Exposure Prevention Information Network (EPINet) needlestick surveillance data.

RESULTS

Nurses sustain 64.6% of all SESD injuries. 42.9% Of SESD injuries occur after device use and are likely preventable through consistent and effective use of safety-engineered technology. Excluding injuries that occurred during device use or between procedural steps, 71.8% (n/N = 28/39) of physician injuries, 58.2% (n/N = 645/1,109) of injuries to nurses, and 45.8% (n/N = 88/192) of injuries to phlebotomists occurred when an available SESD was not fully activated.

CONCLUSION

Passive devices that do not require action on the part of the end user to engage a safety feature currently represent a small portion of the SESD market. Wider dissemination of a broader array of passive SESDs coupled with continual education of end users is essential to an effective sharps injury prevention program.

Clinical acceptability and ease of use of a safety IV catheter system

OBJECTIVE

Occupational risk of transmission of bloodborne pathogens represents a major challenge in prevention. Even though preventive recommendations to avoid needlestick injuries among healthcare workers include the use of needle protective devices, its use in developing countries is not a standard practice. This study aimed to measure, on experienced nurses, perception of performance characteristics and activation of the safety feature of a safety closed IV catheter system (BD Pegasus*), called catheter P, versus a non-safety device (BD Intima II † ) called catheter I in healthy volunteers.

METHOD

Fifty-two nurses and 205 healthy volunteers participated in a prospective, randomized, controlled study in a simulated setting. Each nurse performed two insertions of each catheter (one in each forearm) in four study volunteers; the order of insertions was randomly assigned. Statistical analyses were performed to compare the performance of the two catheters regarding Overall Perception of Clinical Acceptability and Ease of Use.

RESULTS

Overall acceptance of the device performance characteristics was 90% or more. In all cases, catheter P performed at least as well as catheter I. There were no differences in the insertion success rate between the two devices (93.7% vs. 96.2%). Activation of the safety feature of catheter P occurred 99.4%. Subjects' perception of pain was similar for both devices. Overall perception of clinical acceptability and ease of use were judged better for catheter P than for catheter I (p = 0.006, and p < 0.001 respectively). All clinicians strongly agreed that catheter P would protect them from needle stick injuries.

CONCLUSIONS

Despite the study limitations, mainly its artificial setting and its inability to blind, the results indicate that the Safety Closed IV Catheter System with its safety feature represents a good alternative for IV catheter insertions that can help reduce the incidence of stick injuries in health care workers.

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.

Ongoing use of conventional devices and safety device activation rates in hospitals in Ontario, Canada

This study assessed voluntary compliance with the use of sharp safety devices in lieu of conventional ones and the activation status of these safety devices: VanishPoint syringes, Terumo Surshield butterflies, and Insyte Autoguard IV catheters. Sharps disposal containers from various wards in three private, not-for profit, university-affiliated Ontario hospitals were audited during 9 days in August 2007. In the 149 audited sharps containers, 55% of all syringes found were conventional compared with 45% that were safety syringes. In the three hospitals, the percentages of conventional (non-safety) vs. safety syringes found in used sharps containers were as follows, respectively: (i) 72% conventional and 28% safety, (ii) 55% conventional and 45% safety, and (iii) 65% conventional and 35% safety. In addition, it was found that 77% of 2131 Terumo butterflies, 97% of 1117 Insyte Autoguard IV catheters, and 87% of 4897 VanishPoint syringes in the containers had been activated. This study, carried out approximately 1 year before it was legally required to use safety instead of sharp conventional devices, found that most devices in use were conventional ones. It was also found that only the activation rate for the safety IV device was acceptable.

Evaluation of a new needle catching instrument for suturing simple wounds in the Emergency Department

OBJECTIVES

The Needlecatcher comprises a tissue forceps at one end, with a 'piston and barrel' system, which acts as a needle grasper, at the other end of the instrument. It minimizes exposure of the needle during suturing, potentially reducing risk of injury. We evaluate its effect on operator safety during simple wound closure.

METHODS

Video analysis of 10 clinicians (six junior doctors and four advanced nurse practitioners) closing a standard simulated wound using their normal technique was performed. They were trained in the use of the Needlecatcher, and used it for 10 weeks closing simple wounds in the Emergency Department. Video analysis of wound closure was repeated, using the new instrument. Clinicians filled out a questionnaire for each episode of wound closure, which assessed how they perceived their safety was affected by the device.

RESULTS

Video analysis of clinicians showed that the needle was secured in an instrument and thus unexposed for an average of 60% of the duration of the procedure by standard technique, compared with 95% using the Needlecatcher, with a change of 35% [95% confidence interval (CI): 14-58%, P = 0.005]. Episodes where the needle was grasped by an operator's finger were reduced by 50% (95% CI: 15-85%, P = 0.028). In the questionnaire study of 53 episodes of wound closure, operators perceived their safety to be increased in 38 (71.7%, 95% CI: 66.2-77.2%) episodes, were neutral in 10, and felt their safety was reduced in five.

CONCLUSION

The Needlecatcher showed the potential to reduce the risk of needlestick injury while suturing.

The value of infectious diseases specialists: non-patient care activities

Recent developments in health care have focused efforts on both the national and local levels to reduce unnecessary health care costs and the number of hospital stays while increasing the quality of care, particularly in the context of hospital-associated infections. Infectious diseases specialists who contract to oversee infection-control and antibiotic-stewardship programs are uniquely positioned to play a pivotal role in helping hospitals to prosper in this new environment. This article will detail the available data supporting the value of infectious diseases specialists in their roles of directing antimicrobial-management and infection-control programs, maintaining health care workers' well-being, and minimizing exposure. The evidence in support of the influence of infectious diseases specialists to achieve cost-savings, decrease the length of hospital stays, and improve outcomes is robust and can be used as the framework for negotiating appropriate compensation from hospital management for these activities. Presenting this information in an amicable but definitive framework may be the linchpin to the overall success of the movement to improve quality of care while minimizing hospital costs and antimicrobial use. Developing this ability is critical to infectious diseases specialists' success as they redefine their role in the quality-of-care and risk-management arenas.

Needlestick injuries in a major teaching hospital: the worthwhile effect of hospital-wide replacement of conventional hollow-bore needles

BACKGROUND

Needlestick injury (NSI) with hollow-bore needles remains a significant risk of bloodborne virus acquisition in health care workers. The impact on NSI rates after substantial replacement of conventional hollow-bore needles with the simultaneous introduction of safety-engineered devices (SEDs) including retractable syringes, needle-free intravenous (IV) systems, and safety winged butterfly needles was examined in an 800-bed Australian university hospital.

METHODS

NSIs were prospectively monitored for 2 years (2005-2006) after the introduction of SEDs and compared with prospectively collected preintervention NSI data (2000-2004).

RESULTS

Preintervention hollow-bore NSI rates over 10 years persisted at a constant rate between 3.01 and 3.77 per 100 full-time equivalent employees (FTE) (P = .31). Rates for 2005 (1.93; 95% CI: 1.48-2.47 per 100 FTE) and 2006 (1.50; 95% CI: 1.11-1.97 per 100 FTE) were significantly lower than the average rate for the preintervention years (3.39; 95% CI: 2.7-4.24 per 100 FTE, P = .00004). This represents a fall of 49% (43.1%-55.7%) in hollow-bore NSI, contributed to by the virtual elimination of NSI related to accessing IV lines. More importantly, high-risk injuries were also reduced 57% by retractable syringe use with an overall budgetary increase of approximately US $90,000 per annum.

CONCLUSION

Introduction of SEDs results in an impressive fall in NSI with minimal cost outlay.

Use of safety devices and the prevention of percutaneous injuries among healthcare workers

OBJECTIVE

To study the effectiveness of safety devices intended to prevent percutaneous injuries.Design. Quasi-experimental trial with before-and-after intervention evaluation.

SETTING

A 350-bed general hospital that has had an ongoing educational program for the prevention of percutaneous injuries since January 2002.

METHODS

In October 2005, we implemented a program for the use of engineered devices to prevent percutaneous injury in the emergency department and half of the hospital wards during the following procedures: intravascular catheterization, vacuum phlebotomy, blood-gas sampling, finger-stick blood sampling, and intramuscular and subcutaneous injections. The nurses in the wards that participated in the intervention received a 3-hour course on occupationally acquired bloodborne infections, and they had a 2-hour "hands-on" training session with the devices. We studied the percutaneous injury rate and the direct cost during the preintervention period (October 2004 through March 2005) and the intervention period (October 2005 through March 2006).

RESULTS

We observed a 93% reduction in the relative risk of percutaneous injuries in areas where safety devices were used (14 vs 1 percutaneous injury). Specifically, rates decreased from 18.3 injuries (95% confidence interval [CI], 5.9-43.2 injuries) to 0 injuries per 100,000 patients in the emergency department (P=.002) and from 44.0 injuries (95% CI, 20.1-83.6 injuries) to 5.2 injuries (95% CI, 0.1-28.8 injuries) per 100,000 patient-days in hospital wards (P=.007). In the control wards of the hospital (ie, those where the intervention was not implemented), rates remained stable. The direct cost increase was 0.558 euros (US$0.753) per patient in the emergency department and 0.636 euros (US$0.858) per patient-day in the hospital wards.

CONCLUSION

Proper use of engineered devices to prevent percutaneous injury is a highly effective measure to prevent these injuries among healthcare workers. However, education and training are the keys to achieving the greatest preventative effect.