Reducing the rate of paramedic needlesticks in emergency medical services: the role of self-capping intravenous catheters

Efficacy and Ease of Use of an Intravenous Catheter Designed to Prevent Blood Leakage: A Prospective Observational Trial

Purpose

Conventional safety intravenous (IV) catheters prevent blood exposure during catheter placement but blood leakage from the unconnected catheter still frequently occurs. In the current study a new safety IV catheter equipped with a blood leakage control septum was assessed under routine clinical conditions.

Methods

This prospective observational trial was conducted at the KKRN (Katholisches Klinikum Ruhrgebiet Nord), Germany, September/October 2012. Peripheral IV access was established in presurgical patients using either the investigational (“IS3”) or a conventional safety IV catheter (“IS”). Incidence of blood leakage during placement and subsequent (dis-)connection procedures, duration of placement as well as handling conditions were compared.

Results

A total of 200 IV accesses were established (n(IS3) = 102 and n(IS) = 98). Blood leakage during catheter placement (4.9% (IS3) vs. 61.2% (IS); p<0.001) and blood contaminations (3.9% (IS3) vs. 14.3% (IS); p = 0.01) were significantly reduced for IS3. All blood leakages observed with IS3 were due to improper technique. No blood leakage occurred during repeated (dis-)connections of IS3 (blood leakage IS: 74%). Using IS3, vein compression was not required (no compression: 98%) and duration of catheter placement was significantly shorter ( t(IS3) = 69.6 ± 22.4 s vs. t(IS) = 85.2 ± 28.2 s; p<0.001).

Conclusions

The investigational IV catheter effectively prevented blood leakage, thereby reducing contamination risk and workload associated with cleaning. Omission of vein compression facilitated and shortened IV catheter placement.

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.

Occupational Injuries among Emergency Medical Services Personnel

BACKGROUND

Emergency medical services (EMS) personnel treat 22 million patients a year in the United States, yet little is known of their injury risks.

OBJECTIVES

To describe the epidemiology of occupational injuries among EMS personnel, calculate injury rates, and compare the findings with those for other occupational groups.

METHODS

This was a retrospective review of injury records kept by two urban agencies. The agencies submitted all 617 case reports for three periods between January 1, 1998, and July 15, 2002. The agency personnel worked an estimated 2,829,906 hours during the study periods. Cases were coded according to U.S. Department of Labor (DOL) criteria.

RESULTS

Four hundred eighty-nine cases met the DOL inclusion criteria. The overall injury rate was 34.6 per 100 full-time (FT) workers per year (95% confidence interval [CI] 31.5-37.6). "Sprains, strains, and tears" was the leading category of injury; the back was the body part most often injured. Of the 489 cases, 277 (57%) resulted in lost workdays, resulting in a rate of 19.6 (95% CI 17.3-21.9) per 100 FT workers; in comparison, the relative risks for EMS workers were 1.5 (95% CI 1.35-1.72) compared with firefighters, 5.8 (95% CI 5.12-6.49) compared with health services personnel, and 7.0 (95% CI 6.22-7.87) compared with the national average.

CONCLUSIONS

The injury rates for EMS workers are higher than rates reported by DOL for any industry in 2000. Funding and additional research are critical to further defining the high risks to EMS workers and developing interventions to mitigate this serious problem.

The impact of U.S. policies to protect healthcare workers from bloodborne pathogens: the critical role of safety-engineered devices

In the United States (U.S.), federal legislation requiring the use of safety-engineered sharp devices, along with an array of other protective measures, has played a critical role in reducing healthcare workers' (HCWs) risk of occupational exposure to bloodborne pathogens over the last 20 years. We present the history of U.S. regulatory and legislative actions regarding occupational blood exposures, and review evidence of the impact of these actions. In one large network of U.S. hospitals using the Exposure Prevention Information Network (EPINet) sharps injury surveillance program, overall injury rates for hollow-bore needles declined by 34%, with a 51% decline for nurses. The U.S. experience demonstrates the effectiveness of safety-engineered devices in reducing sharps injuries, and the importance of national-level regulations (accompanied by active enforcement) in ensuring wide-scale availability and implementation of protective devices to decrease healthcare worker risk.

A prospective randomized trial of two safety peripheral intravenous catheters

BACKGROUND

To reduce the risk of accidental needlestick injuries, first active then passive safety devices were developed on IV catheters. However, whether these catheters are easy to implement and really protect personnel from accidental needlestick is untested.

METHODS

In this prospective randomized survey, we compared a passive safety catheter with an active safety catheter and a nonsafety classic catheter. The main objective was to evaluate the difficulty of inserting the catheters in terms of the number of insertion failures, difficulties introducing the catheter and withdrawing the needle, and the normality of the blood reflux in the delivery system. The second objective was to determine the degree of exposure to patients' blood evaluated as the number of exposures of the staff and blood splashes of the environment, and the staff's sense of protection.

RESULTS

Seven hundred fifty-nine assessment cards were collected. The number of failures for the three catheter groups was similar and not statistically different. Introduction of the catheter was more difficult with the active safety catheter. Needle withdrawal was more difficult with the passive safety catheter. The blood reflux was abnormal more often with the safety catheters. The staff's exposure was more frequent with the active safety catheter. The number of blood splashes was more common with the safety catheters.

CONCLUSIONS

Safety catheters are not superior with regard to failure rate in the catheter's placement. Users feel better protected, but find the use of safety catheters more difficult, and their handling generates more splashing of blood into the environment. The passive safety catheter is more efficient than the active safety catheter with regard to ease of introduction of the catheter into the vein and the staff's exposure to the patient's blood.

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

Nearly 6 years have passed since the Needlestick Safety and Prevention Act of 2000 was signed into law. We reviewed studies published since 1995 that evaluated the effect of safety-engineered device implementation on rates of percutaneous injury (PI) among health care workers. Criteria for inclusion of studies in the review were as follows: the intervention used to reduce PIs was a needleless system or a device with engineered sharps-injury protection, the outcome measurements included a PI rate, the intervention was evaluated in a defined population with clear comparison groups in clinical settings, and outcomes and denominators used for rate calculations were objectively measured using consistent methodology. All 17 studies reported substantial decreases in device-associated or overall PI rates after device implementation (range of reduction, 22%-100%). The majority of studies (n=12) were uncontrolled before-after trials with limited ability to control for confounding variables. In addition, implementation of safety-engineered devices was often accompanied by other interventions, and direct measurement of outcomes was not performed. Nevertheless, safety-engineered devices are an important component in PI prevention.

Preventing needlesticks in emergency medical system workers

Emergency medical system (EMS) workers frequently use sharp devices in injury-prone circumstances that involve limited visibility, confined spaces, rapidly moving vehicles, and uncooperative victims. This study examined the efficacy of an automatic self-retracting lancet in reducing needlestick injuries and related direct and indirect costs. Subjects were 477 active-duty EMS workers. Counseling, laboratory testing (hepatitis B and C, hepatic function enzymes, and human immunodeficiency virus), antiviral prophylaxis, and immunizations were provided according to US Public Health Service guidelines. Baseline and biennial laboratory testing for hepatitis B and C and liver function enzymes were conducted. After the introduction of a spring-loaded automatic-retracting type glucometer lancet device, needlestick injuries decreased from 16 per 954 EMS worker-years to 2 per 477 EMS worker-years. The annualized cost of treatment declined from $8276 to $2068. The change to a self-retracting device decreased the number of needlestick injuries and was cost-effective with a minimal increase in device cost (annualized $366 per year).

Emergency medical services equipment hygiene practices

OBJECTIVE

To determine whether emergency medical services (EMS) systems adhere to accepted equipment hygiene standards.

METHODS

Mail surveys were sent to the physician medical directors of the EMS systems of the 125 most populous cities in the United States.

RESULTS

Eighty-five surveys (68%) were returned. Seventy-three (86%) of the responding services have a policy addressing equipment decontamination, and 32 of these (44%) have an accompanying quality assurance program. Seventy-nine (93%) utilize either alcohol or a commercial disinfectant (A/CD) on noncritical items when visibly contaminated with blood. However, only 32 of those agencies (41%) use soap and water in addition to A/CD. Another nine (11%) exchange contaminated items at the hospital, one (1%) uses other methods, and two (2%) respondents did not know. Seventy-six (89%) of the responding agencies perform endotracheal intubation. Of the 54 that decontaminate their own blades, 20 (37%) use soap and water in addition to A/CD, 32 (59%) use A/CD alone, and two (4%) use soap and water alone.

CONCLUSION

Adherence to accepted hygiene standards among EMS systems in our most populous cities is poor. Many systems do not use soap and water prior to A/CD. Failure to do so may minimize the effectiveness of disinfection. Several systems use A/CD or soap and water alone, neither of which meets current standards for high-level disinfection recommended for items that will come in contact with mucous membranes, such as laryngoscope blades.

Evaluation of interventions to prevent needlestick injuries in health care occupations

OBJECTIVE

The objective of this study was to evaluate interventions that reduce or prevent needlestick injuries in health care occupations.

METHODS

Cochrane Collaboration search strategies to locate studies that evaluated interventions to reduce needlestick injuries in health care occupations were used. Studies were selected if they met the following criteria: (1) interventions were evaluated in the defined population; (2) interventions were randomized, with a comparison group(s); (3) outcomes were objectively measured and had interpretable data. Eleven studies met inclusion criteria. The main outcomes of interest were changes in the number of glove or skin perforations and changes in amount of skin contamination.

RESULTS

Three studies found a decrease in glove or skin perforations when double gloves or combinations of gloves were used by surgeons and their assistants. One study found an increase in glove perforations but a decrease in hand contamination. Three studies evaluated the effectiveness of specialized needles in reducing needlestick injuries during surgical wound closure with decreases in glove or skin perforations reported. Protective devices were evaluated in three studies and significant reductions in glove perforations were found with the use of a needleless intravenous system and surgical assist device. One study evaluated a "no-touch" technique used by surgeons during wound closure and found a significant decrease in the number of glove perforations compared to the traditional "hand-in" method of closure.

CONCLUSIONS

Few randomized controlled trials have been employed to evaluate the effectiveness of interventions to reduce needlestick injuries in health care occupations. The majority of the studies evaluated interventions during surgical procedures, rather than during patient care on nursing units, probably because the latter is more difficult to observe.