Use of safety-engineered devices by healthcare workers for intravenous and/or phlebotomy procedures in healthcare settings: a systematic review and meta-analysis

Background

The acquisition of needle-stick injuries (NSI) in a healthcare setting poses an occupational hazard of transmitting blood-borne pathogens from patients to healthcare workers (HCWs). The objective of this study was to systematically review the evidence about the efficacy and safety of using safety-engineered intravenous devices and safety-engineered phlebotomy devices by HCWs.

Methods

We included randomized and non-randomized studies comparing safety-engineered devices to conventional/standard devices that lack safety features for delivering intravenous injections and/or for blood-withdrawal procedures (phlebotomy). The outcomes of interest included NSI rates, and blood-borne infections rates among HCWs and patients. We conducted an extensive literature search strategy using the OVID interface in October 2013. We followed the standard methods for study selection and data abstraction. When possible, we conducted meta-analyses using a random-effects model. We used the GRADE methodology to assess the quality of evidence by outcome.

Results

We identified twenty-two eligible studies: Twelve assessed safety-engineered devices for intravenous procedures, five for phlebotomy procedures, and five for both. Twenty-one of those studies were observational while one was a randomized trial. All studies assessed the reduction in NSIs among HCWs. For safety-engineered intravenous devices, the pooled relative risk for NSI per HCW was 0.28 [0.13, 0.59] (moderate quality evidence). The pooled relative risk for NSI per device used or procedure performed was 0.34 [0.08,1.49] (low quality evidence). For safety-engineered phlebotomy devices, the pooled relative risk for NSI per HCW was 0.57 [0.38, 0.84] (moderate quality evidence). The pooled relative risk for NSI per device used or procedure performed was 0.53 [0.43,0.65] (moderate quality evidence). We identified no studies assessing the outcome of blood-borne infections among healthcare workers or patients.

Conclusion

There is moderate-quality evidence that the use of safety-engineered devices in intravenous injections and infusions, and phlebotomy (blood-drawing) procedures reduces NSI rates of HCWs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1705-y) contains supplementary material, which is available to authorized users.

Knowledge, attitudes, beliefs, values, preferences, and feasibility in relation to the use of injection safety devices in healthcare settings: a systematic review

Background

Adopting technologies such as injection safety devices in healthcare settings can enhance injection safety. Developing guidelines for appropriate adoption of such technologies need to consider factors beyond evidence for their health effects. The objective of this study is to systematically review the published literature for evidence among healthcare workers and patients about knowledge, attitudes, beliefs, values, preferences, and feasibility in relation to the use of injection safety devices in healthcare settings.

Methods

We included both qualitative and quantitative studies conducted with the general public, patients, and healthcare workers, administrators, or policy makers. We searched MEDLINE, EMBASE, CINHAL and CENTRAL. We used a duplicate and independent approach to title and abstract screening, full text screening, data abstraction and risk of bias assessment.

Results

Out of a total of 6568 identified citations, we judged fourteen studies as eligible for this systematic review. All these studies were surveys, conducted with healthcare workers in high-income countries. We did not identify any qualitative study, or a study of the general public, patients, healthcare administrators or policy makers. We did not identify any study assessing knowledge, or values assigned to outcomes relevant to injection safety devices. Each of the included studies suffered from methodological limitations, which lowers our confidence in their findings. Based on the findings of six studies, the injection safety devices were generally perceived as easy to use and as an improvement compared with conventional syringes. Some of these studies reported few technical problems while using the devices. In three studies assessing perceived safety, the majority of participants judged the devices as safe. Two studies reported positive perceptions of healthcare workers regarding patient tolerance of these injection safety devices. One study found that less than half the nurses felt comfortable using the insulin pens. Findings from four studies assessing preference and satisfaction were not consistent.

Conclusions

This systematic review identified evidence that injection safety devices are generally perceived as easy to use, safe, and tolerated by patients. There were few reports of technical problems while using the devices and some discomfort by nurses using the insulin pens.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-016-0505-8) contains supplementary material, which is available to authorized users.

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.

Lessons learned from a community based intervention to improve injection safety in Pakistan

BACKGROUND

A national study in 2007 revealed that in Pakistan the prevalence of hepatitis B is 2.5% and for hepatitis C it is 5%. Unsafe injections have been identified as one of the reasons for the spread of these infections. Trained and untrained providers routinely perform unsafe practices primarily for economic reasons i.e. they reuse injection equipment on several patients. The patients, do not question the provider about the need for an injection because of social barriers or whether the syringe is coming from a new sterile packet due to lack of knowledge. The present paper represents an intervention that was developed to empower the community to improve unsafe injection practices in rural Pakistan.

METHODS

In a rural district of Pakistan (Tando Allahyar, Sindh) with a population of approximately 630,000 a multipronged approach was used in 2010 (June to December) to improve injection safety. The focus of the intervention was the community, however providers were not precluded. The organization of interventions was also carefully planned. A baseline assessment (n=300) was conducted prior to the intervention. The interventions comprised large scale gatherings of the community (males and females) across the district. Smaller gatherings included teachers, imams of mosques and the training of trained and untrained healthcare providers. The Pakistan Television Network was used to broadcast messages recorded by prominent figures in the local language. The local FM channel and Sunday newspaper were also used to disseminate messages on injection safety. An end of project assessment was carried out in January 2012. The study was ethically reviewed and approved.

RESULTS

The interventions resulted in improving misconceptions about transmission of hepatitis B and C. In the baseline assessment (only 9%) of the respondents associated hepatitis B and C with unsafe injections which increased to 78% at the end of project study. In the baseline study 15% of the study participants reported that a new syringe was used for their most recent injection. The post-intervention findings showed an increase to 29% (n=87).

CONCLUSION

It is difficult to assess the long-term impact of the intervention but there were several positive indicators. The duration of intervention is the key to achieving a meaningful impact. It has to be at least 18-24 months long.

Reuse prevention syringes for reconstitution of lyophilized vaccines: Operational study and UNICEF plans for expanding introduction

Since the 1990s, the United Nation's Children's Fund has encouraged injection safety for immunizations through bundling vaccines with appropriate amounts of supporting equipment and by supplying autodisable (AD) syringes for injections. However, poor vaccine reconstitution practices continue to be reported worldwide. By 2009, UNICEF will begin to phase out the distribution of standard disposable syringes for vaccine reconstitution and replace them with reuse prevention (RUP) syringes, with a full transition expected by the end of 2010. A field evaluation in Indonesia was conducted to identify introduction requirements, issues with healthcare worker training and acceptance, and RUP syringe performance and safety. Managers and health workers felt that RUP syringes improved injection safety and fit easily into country logistical systems. Healthcare workers felt they were intuitive to use, but recommended special training. The integration of RUP reconstitution syringes by UNICEF could increase injection safety by preventing the reuse of syringes and reducing vaccine contamination.

Monitoring of adverse events during the 2003 mass vaccination campaign with a trivalent meningococcal A/C/W135 polysaccharide vaccine in Burkina Faso

During a mass campaign with a newly licensed meningococcal polysaccharide ACW135 vaccine in Burkina Faso, adverse events following immunization (AEFI) were monitored up to 4 weeks after the campaign. Eighty-six AEFI cases (5.9 cases per 100,000 vaccine doses distributed) were reported. Among 22 serious events, 4 severe local reactions were considered very likely and 4 severe allergic reactions were considered probably related to the vaccination. One fatal case in a child followed protracted seizures of undetermined cause. In a setting with no prior surveillance system, adverse events were reported at rates comparable to documented rates for meningococcal polysaccharide vaccines in other settings. The findings confirm the benefits of the vaccine in the control of meningococcal meningitis.

Improved injection safety after targeted interventions in the Syrian Arab Republic

OBJECTIVES

Concerns about unsafe injection practices and possible infections with blood-borne pathogens in the Syrian Arab Republic motivated an assessment of the injection safety situation in the country in July 2001. In light of the recommendations from this assessment, the Ministry of Health of Syria, with the assistance of WHO, implemented a set of activities under the 'Focus Project', which aims to ensure immunization safety. The first phase of the project ran from May 2002 to February 2004, and consisted of the improved provision of injection safety equipment and supplies, the elaboration and wide distribution of national guidelines on injection safety and safe waste management, a behaviour change and communication campaign targeting the general public, and comprehensive training of healthcare workers. A follow-up survey was carried out in February 2004, 2 years after initiation of the project.

METHODS

Two representative surveys were conducted using a standardized assessment tool. A cluster sampling strategy, with probability proportionate to the population size, led to the inclusion of 80 health facilities in eight districts in 2001 and of 120 health facilities in 12 districts in 2004.

RESULTS

Injection practices had significantly improved 2 years after the start of the project. The 2001 study had pointed to a low, but non-negligible risk to patients (2% unsafe injections), coupled with a high risk to healthcare workers (61% reported needle-stick injuries in the last 12 months) and to the communities owing to unsafe waste disposal (sharps waste found outside 37% of health facilities, waste disposal considered unsafe in 48% of them). The 2004 survey showed that 90% of Syrian healthcare workers had received training in injection safety. All injections observed were given safely (difference to 2001 not significant), although some problems in preparation and reconstitution prevailed. The risk to healthcare workers was significantly reduced as only 14% of the staff reported needle-stick injuries (p < 0.001). The risk to the communities was notably decreased following improvements in sharps waste management (sharps were found in the surroundings of only 13% of health facilities, p < 0.001).

CONCLUSIONS

The example of Syria shows that rapid improvement in injection safety is possible and that the necessary tools and methods to monitor and evaluate progress are at our disposal. Challenges remain in transferring this successful programme from the well-structured immunization programme to the more diverse curative health services.

Progress toward interruption of endemic measles transmission in Tunisia

Measles was the second leading cause of infant mortality in Tunisia prior to introduction of measles vaccination in 1979. The number of reported measles cases has decreased from 3007 in 1981 to 47 cases in 2000 due in part to the high coverage rates achieved after 1992. During 1998, a measles catch-up campaign vaccinated 1,846,657 children (95%) aged 6-16 years, and a follow-up campaign for children aged 9 months to 5 years in 2001 reached 547,766 (94%). During 1999-2001, 1717 cases of rash and fever illness were tested for measles; only 3 (0.2%) were positive for measles. From February to July 2002, an outbreak of measles involving 87 cases occurred in Tunisia in a health care setting and 56 (64%) patients were aged 15-30 years. The low number of laboratory-confirmed measles cases during 1999-2001 suggests endemic measles transmission may have been interrupted.

Association of HLA class II genes with susceptibility to Crohn's disease

BACKGROUND

Published studies on the association between HLA class II genes and inflammatory bowel disease are contradictory perhaps because of the limited size and ethnic heterogeneity of the populations studied.

AIM

To compare the frequencies of HLA class II genes in a large number of French patients with Crohn's disease and in an ethnically matched control group.

METHODS

344 patients (196 F, 148 M, mean age 23.6 years) with Crohn's disease were molecularly genotyped for the HLA-DQB1 and DRB1 alleles. The results were compared with those for an ethnically matched control population of 488 white adults.

RESULTS

There were two significant variations of alleles at the DQB1 locus: an increase in DQB1*0501 allele frequency (chi 2 = 10.6, corrected p value (pc) = 0.01, odds ratio (OR) = 1.61) and a decrease in DQB1*0602/0603 allele frequencies (chi 2 = 8.43, pc = 0.037, OR = 0.66). DRB1 analysis showed associations with three allelic variations: an increase in the frequencies of DRB1*01 (chi 2 = 12.86, pc = 0.003, OR = 1.75) and DRB1*07 alleles (chi 2 = 11.18, pc = 0.008, OR = 1.58) and a very significant decrease in that of the DRB1*03 allele (chi 2 = 19.7, pc = 9.10(-5), OR = 0.46).

CONCLUSION

The alleles DRB1*01 and DRB1*07 are associated with susceptibility to Crohn's disease. The strong negative association between the DRB1*03 allele and Crohn's disease suggests that the HLA-DRB1*03 allele mediates 'resistance' to Crohn's disease.