Needlestick Injuries in Nursing and Laboratory Personnel

Needlestick Injuries in Nursing and Laboratory Personnel

by

©Bonita MariaJames.B.Vc e.Ed.

A the sissubmitte d in parti alfulfillment of the requiremen ts forthe'degree of

Master ofScience

Facultyof Medicine MemorialUniversity of Newfoundland

July.1990

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This study was designedto increase understanding of needlestickinjuries in order to make recommendations for appropriatepreventive measures.

Needlestick in j u r y rates for the period 1985-1989 were calculated fOl:nu r s ing and lab or ato r y emp loyeesat three tertiary care hospitals, using staffhealth re cordsand an anonymousself-administeredquestionnaire .

In 1989,hospital-reco rdedne edl e s t i c k ratesranged from 12 to 24 per 100 FTE (full- timeequ i v a l e nts) for nurses 4 to 23 per 100 for laboratory empl oyees in the study hospitals. No declinein rates of reported needles ti cks for all hospitalemployeesor for nurses was seen; a decline in needlestick frequency was seen in two of the three laboratories.

A random sampleof nurses who ordinarilyuse needles in their work and all laboratory employees who reg ularly co l1~,. ...cd were invited to partic ipate in a su r ve y descr..')·J reedIe use patterns and needleinj ur yexpe ri e nces . Responses were received r rcn 86% of nurses and 83% of laboratory employeescont a c t ed, for a total of 342 sur ve y part i cip a nt s.

Ratesof self- reportedneedlesticksforthe prev i o us twelve monthswere 74 per 100nurses and24 per100la bo r a t o r y employees. Forty-onepercent of nursesand 20% of laborato ry

Fac tors i i i empl oy e e shad oneor mor ein j u ri es in the last year. Therisk of needlestick injury wa s notas s o c iate d wit h anemp l o y e e's Sf!X,educ ati on level,jobsta tus, kn owledgean dbeliefsabout ne e d les t ic ks, or pe r s o nal healt h practices. associatedwith having been injure d incl uded:

1) need to carryusedneed l e stoa disposal container, 2) recapping usedne e d l e s using twohands, 3) inconsiste n t discardingofunc ap pednee d l e s, 4) work ar e a ,

5) working expe r-Lcnce , and 6) numbe r of ne ed les us e d.

Mo s t ne e d l e s t i ck injuriesoccurredafterthe needl e had been used: 42%involvedrec a p p i ngth e usedne e d le. Most of the re cen t needle s t i cks experie n ced by nurses involved disposable syri nges or automatic spring -loaded lancets.

Almost all ne e d l e s ti c k s described by laboratory employees involved va cuum-tubeblo od col lect i on eq ui pm e n t .

Pr og r a ms to re d uc e needlestick injur ies shn uld includ e:

1) point-of-usepl a c e me nt of disposalcontainers;

2) attention to equipment an d situati ons re q u i r i n g specialhand ling,e.g.,devicesneedingdisassembly:

3) ed u c a t i on st rat egies targ ete dl'llt groups athigher risk, su chasnewly employed nu r s e s :

4) eval ua t ionofth e efficacy of needlestick prevention programs .

iv ACKNOWLE DGEMENT S

I wi shtothank the manyind iv idua l ~whohav ehe l p e d in theprepara tio n ofthis thesis .

I appr ec i atetheint erest shownbythehund r ed s of hospital employee s who completed questio n na ires, provided backgrou nd informat i on, pr omote dthesurv e yorassistedwith questionna i r e dist r i b u tionan d return.

The fina ncia l suppo r tof theFacul tyofMe d i c ine of Memo ri a l Un ivers i t y, whi ch enabled me to attend the Fi f t h Intern a tional AIDS Confe r e nc e an d th e 1990 New England Epidemio log y ln s t ! tute, is grat e f u ll y ac k no wledg e d.

It has been a pleasu re to be as s o c iate d wit h the fac u l t y , staff and gr ad uate st ude nts of the Di v i s i on of commu n i ty Medi c i n e andBeh a vioura l Scie nces. Th ei rfriendship andexpertass i stan c e throu gho u tthe pa st twoyearswere mUC'!l appreciated.

Thankyou to Dr.KevinHogan , Or.Dor e e nNevi lleand Dr. Jorge segovi a fo r serving on my supe r viso ry committee, readi n gth e thes i s, andmaki ng ma ny help ful sugg estions.

My sinc e r e than ks and appr e ciation go to my supe r v isor, Dr. Sha r on Bue h ler ,whohas beenextraordina ri ly gen ero u s withher ti me, expertiseand sup port.I was inspired byherkindnes s, un failingene rg yandent h us iasm .

Finally , I wo u l d l ik e to thank Jim Mill er , my hu s b and , fo r his confidenc e, su ppo rtand und e r stand i ng .

TABLEOFCONTENTS

ABSTRACT. •.••••••••••• • • ••• .••••• •••••• • • ••••••••• i i

ACKNOWLEDGEMENTS.• ••••• •••••• • •• ••••••• ••• •• ••• ••• iV TABLEOF CONTENTS••••• • •• •• ••••••••••••••• •••••• •• LI ST OFTABLES••••• • •••••••••• •••••••• •• ••••••• ••• LISTOF FIGURES... .. ... ... ... . ... . . xiii CHAPTER 1. INTRODUCTION ••••••• • •• ••• •• • ••••• • ••••

Descr iptionof the problem ..•... Purposeof study•. ... . ... ... . ...• Researc hquestions...•...•.. .... ... CHAPTER2. BACKGROUNDTOTHE STUDy•• • • • ••• • • ••• • •

Consequencesandco s t s of needlestick injuries...•. .. . .... . • ... . ... . ... Medicalc:on s e quc n c es of needlesticks .

HepatitisB .

AI DSj HI V... ... ....•. .. .. . Additional medical consequences....

Financialco s t s related tonee dlestick s. Costsof preventivemeasnres . Costsof needlesticktreatme nt . Costs of needlestick-related

disability... . . .... ... 12 Epidemiology of needlestick injuries.. ... 13

Needlestickinjuries as anoccupational health problem... . . .... .... .. .. 13 Needlestick injuryrates... ... .. 13 proport ionaterates... ... 17 Extentof under-reportingof needles tick

injuries.... ... . . . .•. ... . .. 18 Me c h a ni sms of needlestickinjuries. . . ... . . 20

Activitiesassociatedwith needlestick in j u r i e s .. . . . .... .. .... . . ... 20 Equ i p me nt associated with needlestick

injuries ... .. .. .. ... . .... .... 22 Factorsaf f ecting needlestick injuries.. 23 CDC measuresto prevent needlesticks.... . . ... 24 CDC guidelines... ... .... .... ... .. 24 Effectivenessof CDC guidelines... 26

Critique of CDC guidelines .

Education .

containers .

"No recapping"policies . Acceptanceof universal precautions Mo n i t o r i ng andenforcement . Alternativemeasures to prevent ne e d l e s t i c ks.

Safer needle recapping .

One-handed needle recapping . Safer two-handedrecapping .

Redesigned equipment .

Directionsfor furtherstudy .

CHAPTER3. METHODS .

Target population .

Information providedby hospitals .

Sources of data .

Recorded needlestick injuries .

Survey sample .

Ethical considerations .

Questionnaire .

Pre-test .

pilot study .

Survey method .

Questionnairedistribution .

ccesut cnnad ee return .

First fOllow-up .

Secondfollow-up .

Additionl'l l reminders .

Dataent r y and analysis .

CHAP'l'ER4. RESULTS .

se c tion A: Hospital-recorded needlestick injury

rates .

Availabilityof data .

Calculatedhospital-recordedrates for nurses

and allstatf .

Laboratory data .

Pr opo rti ona t e distribution . Summary of hospital-recorded injury rat e s .

Section B: Survey results .

Survey results I: Responserate . Surveyresults II: Prof ileof participants .

Age and sex .

Qualifications .

vi 26 28 29 30 31 33 J4 35 35 36 38 40

44 45 45 46

"

49 50 50 50 51 52 52 53 53 55

55 55 56 57 57 59 60 60 61 61 62

vii 64 66 67 6B 6B 6.

6.

72 73 7.

B2

83 83 Area ofwork... . ... ..•..••..•.•. Workexp erience... .... . ...•.•.. ....

Le ngth of shi ft .

Job stat us .

Profilesummary .... . . .. ... ..•...

Survey results III: Nee d leuse patterns . Types of equipment... ... •... . ...•. .•. . Numbersof ne e dle s used. . ...••• .. • .•. • Handlingu~ <:ldne edl e s .

Needle dispOsal .

Summary ofne e d l e- u s epat t e rn s . Surveyre su l t s IV: Riska arenessand

management .

Diseasetransmissionby needlest ick

in j ury .

Educat iona l activ i tiesrelated to safe

needle- ha ndling .

Respo J"l"':i bi l i ty fo r re d ucingne e dl e

injuri e s .

HepatitisBvac c i n e to reduce risk from needlost i cks... . .... ... .. ... 85 He a l th practices onandoffthejob... 86

Health practicesat work-

gl o v e- we a r i ng.•.• . . .•. . .... ... 87 Personalhe a ltt. prac t ices. . . ... 89 Summary of riskawareness and manag ement 90 Survey results V:Frequencyof need lestick

injuries....•... .•... ... . ... 90 Life t i me inj uries.. ... . ... ... . .. . . .. 90 Rece nt injur ies... . . . .... . .... . . .. 91 Overall injuryrates... .... .. . . ... .. . 91 Nu r si ng inj ury ra t e s . . ... . ... .... 92 Labo ra tory injury ra t e s... 93 Factors affectingin j ury occurrence

in thestudy respondents . . . 94 Summary of needlestick injur y rates.. ... 98 Surveyre sults VI: Descript ionof needlestic k

injuries .... .. .... . . ... . .. ... 99 Typeof equ i p ment .. . ... ... ... . 100 Needle con t a minat i o n... ... ... 101 Act iv ityat thetimeofnee d l e injury. . . 102 Employeesu gg estio ns for inj ury

preventi on .... .. ... . . .• .. . .• ..•. . .. 104 In j uryreporting andmanag e ment .. ... ... . 106 Summary of needlestickinj u ry

descriptions.. ... ... 109

viii

section C: Summaryof resultschapter ... .. 110

Chapter 5. DISCUSSION.•.... . . ... ... l '2 Hos p ita l recorded injuries... ... 112

Hospital-widerates... ... ... .. 113

Departmental rates... . .. ... .. .... .. 114

Nursing... ... .... 114

Laboratory... .. .... . ..•... . .... .. 114

Proportionate distribution... . ... 115

Usefulnessof hospital-recordedinjury ra t e s.... . ... . . . ... ... .. . 115

Needle injuriesreported by questionnaire.... 118

comparison of recorded and self-reported rates... . . . ... 1111

Denomi~ator ~ifferc;nce~... .. 119

Group tncjusLon crJ.ter1a... 11 9 Survey bias... ... .. .. ... 120

Comparison of nursing rates from both sources. ... ... 121

Comparison of laboratory figuresfrom both sources.... .. ... ... 122

Comparison of self-reportedrates with published data... ... . ... ... 124

Factors affecting needleinjury rates... 125 Comparison of laboratory and nursing departments... ... .. 125

Number and types of needles... . 125

Handlingused needles... .... .. 126

Length of working experience. ... 129

Comparisonof nursing sub-groups.. . ... 129

Activities at the time of needle injury... 133

Inj u r i e s priurto plannedprocedure... .. 133

Procedure related injuries.. . ... 134

Injuriesfollowinguse ofne e d l e... 136

Injuries involving colleagues. ... . ... 138

Awarenessand attitudes.. . . .. . . .. .. ... ... 139

Summary... .... .... .. ... . .... .... 140

Chapter 6. CONCWSIONS AND IMPLICATIONS. . ... .... . 141

Conclusions... .... ... ... .. .... 141

Implications of the study... .... . . ... 142

Practice . ... .... ... ... ... . ... 142

Education and training.... ... ... 145

Research... ... .. ... 146

Summary... ... . . ... .. ... .. .. . . 147

BIBLIOGRAPHY.••••••• • • ••• •••••• ••••••••• ••• • •••••• 148

.~PPENOICES

A. Nee dl e s tic kpr ot o c o l forhe p at i t i s B pr eve nti on. .. .. .. ... .... ..•... •... . 156 B. Calculationofnu r s in g sampl esize... 157 c. Questionnaire... . ... ... 159 D. Surveypa c kage ... .. .. ... ... ... 167 E. First remind er... .. ... .... .. .. . .... 170 F. Secondre mind er to nu rses... . .... . ... I'll G. Reminderfor special care un!ts at

Hospi'cal A... .. ... .... . . . .... .. .... 172 H. Second reminde r to la bora t ory employees. 173 1. Outcomeofqu e s t i o nn a i r e return method. . 174 J. Categ ories ofnur s i ngunits _ 176 K. Method for classifying la b or atory

person ne l.. .. ... . .. .•••... . ... .. 177 Notes regardingappendices.. . . ... . .. .... ... .. 179

ix

LIST OFT1I.BLE8

Re po rt edcostsper needlestickinjury.. .... .. 12 Ratesof hospital ne e d l est i c kinj u ri e s ... . ... 15 Proport ionateneedlesti ck injuryra"tes ... 18 categoriesof needlestick injuries. ... .. .. ... 21 An nualneedlest i ckinjuryrat e s per 100FTE.. 56 NeE:!dlestick injuriesto laboratorystaff, as recordedby staf f healthdepartments... .. 57 Pr op o rti ona t e distribution of recorded

ne e d l e s t i c k injuries, by department... 58 Survey response ra t e s... ... ... ... .. 60 Age and sex of survey partiC'i!;Jants. ... 62 10 Qualificati.:lns of participants -nursing... .. 63 11 Qualificationsof participants-Labcr-at.o r-y,, 64 12 Distr ibutionofnu r se s by workarea and

hospita l.... ... ... ... . .. ... 65 13 Number of needles used bynurses.... ... .... .. 72 14 Num:"'er of needles used,by department... 73 15 proportionof two-handedrecapping, by

department ... ... . ... ... .. . .. 75 16 proportionof two-handedrecapping, by

hospital... . . ... .... ... .. 75 17 proportion carryingusedne e dl e s,by

hospital..•... ....•. . . . ... ... . • .. .. .. ... 79 18 pr opo r t ion carrying usedneed l es, by

nursingarea... ... ... .. 81 19 Associationbetweencarryingused needlesand

disposingof uncappedneedles , .. 81

20 Hep a t i t i sBvaccLnatiion, by vc e n are a. . .... .. 86 21 Fa ctors affe ,-t: ingdecis ionto wearglove s... . 88 22 As s oc i ati onbe t ween BSEandgl ove-weari ng.. .. 8S 23 As s o ciat i on betw een carr yi ng used needle s and

ex,?eriencin g recent nee d l esti ck inj ury.... ... 95 24 Assoc i ation betwe en two-handed ne edle

rec a pp ing and experi enc ing re c en t ne e dle s t i ck injur y.... ... ... .. 96 25 Associationbetween discardi nguncapped

ne ed l e s and experi e n cing rec e n t needlestick

injury... 97

Associat ion between nur s i ng areaand exper-Lenci.nq rece nt nee d les t ickinjury.••. •.•

27 aseocLat.tcn for nurses betwee ntimewith pr-esen c emp loye r and experiencingrecent needlestick inj u ry... .. ... . ... ... 98 28 Proportio nof pastand recentinjuriesfrom

each departl'lent... . ... . . ... ... . ... . . 100 29 Equipment associatedwi thpast and recent

ne e d l e sti c k injuries... .. . . . .... .. . 101 30 st ag e ofpro c ed ure at whichin jur y occurred.. 31 Ac ti on fo ll o win g most re cent ne edl e stick

in j ury... . . ... ... .. ... . ... .... ... 107 32 Associatio nbetwee nre portingneem e injuries

to staff hea lthand cond i tionof nee d le. ... 108 33 As s o c ia t i on between reporting ne e dl e Lnju rLe,

to staf f heal thand numberof injur i e s in la st 12mo nt h s ... ... . . ... 109 34 Associationbetwee nrepo rting nee dl e inj u ries

to staff he al th and HBva c c i n a t i on status.... 109 35 Comparisonot:hos pi ta l - r e c o rdedand self-

repo r t e d ne edle sti ck ratesfor nur s ing

depa rt ments in1989... ... . ... 127.

xi

xi i 36 Compariso nof hospital-recordedandsel f-

re po ::rt e dne e dl e stic ks for labo rato r i e s in 1989.. . . . .•••...•••.•.. ••. •.. .• • ....•.•... 123 37 Post-exposureirnmunop rophyl axis... .... 156 38 Nurs ingsamplesize calcu lat i ons.... .. .. ... IS 39 Ques tio n n a i r eretu r n and participant

ident if ication.. . ... . .... ... ... . 17 5 40 categ o r i esofnur s i ng units . . . ... . ... . 17 6

xiii

LI ST OFFI GURES

wo r k i ng experienceof survey respondentsin present hospital... .... . .... ... 67 Equipmentused by nursing and la bo r a t o ry

personnel... ... ... .. ... ... ... 71 t'le e d l e-han dling practices, by department ... 74 Needle-handl ingpractices, by hos pitaL . Numberof needle-stick in j ur i e s in last

twelv emonths . ... ... ... .. .. .. ... .. 93

CHArTER 1 INTRODUCTION

The needles us ed to pe r f orm di a g nostic and therapeutic procedures can be hazardou s to the health professionals ha nd l i ng them. An uncovered nee dlemay pierce the skin, resul ting in an open wound and exposure of the ind i vid u a l to substances present onthe ne ed l e.

Descriptionof the problem

Pu nc tur e woundscaus e d by needles usedin pa ti e n t are one of the most common occupational inju ries experiencedby hos p i talemployees. Nee d Le in j ur i e s , us u al ly called need lesticks , affect emp l oye e s such as physic ians, nurses and tec h nol og i s t s who routinely use needles when performi ng diagnostic tests or therapeut ic procedures. In addition,othe r categories of health ca re orkerswho do not normally utilize ne e dl e s in th eir work encounter them inadver t ent ly. Forexample,nursingassistants may bein ju r e d when clearing away us e d equipment, laund ry workers occasionally find loose nee dl e s in soil ed linens , and ho usekee ping person nel are endangered when need les ar e di s c a r d e dinto containersnotdas i gna ted for such use.

Mostnee dl e sused in NorthAmerican hospitalsarc single- use, disposable items. Theyar e packaged to main ta i n sterility and to protect the handler before use. The nee dle

ma y be purc ha s ed se pa ratel y oralreadyat tachedtoancillary equi pmen t, for example, a disposab le syringe. Th e ne e d l e shaft is usuall y coveredwi tha plasticcap whichrequires a deli berate twistin gmotionto detach it fr om the base or hub oftheneedl e. Anover-wrapof paper, clearpl ast icor other disposablematerialmay envelope the cappedneedle. Properly capped nee d l e s pose noha z a r d, but from thetime the needle is uncapped untili tis safely removedfrom the work-site,the potential for inju ry is present .

Some injuriesoccur beforethe needle'sintendeduse andmay thereforeinvolvea sterilein s t r u me n t . Used need les may havebeen exposed to drugs or chemicals . to the blood or other body fl uidsof a patient,or tobloodproducts used for transfusionor inject ion. It is th e exposureto human blood which causes gre<:ltest concern , since blood may harbour infectious ag ents. Mos t peo plewho exper iencea needleinjury have no more serious outcomethaT\a sore finger for a few days, butthe~for seriousill n e s s does exist .

It has been reco gnized for many years that needlesticks place health careworke r s at risk for a wide variety of tran s mi s s i b l e diseases . This risk may generate little app re hensio n if the infection is mild, rareor not easily transmi t ted by needlestick. Other infections are widely fea red and do po s e: seriousri s k s tohe a l th workers. Thetwo diseasesre s p on s i b l e for increasedinterestin needle

injuri e s in the pd s t decade are hepatiti s B (HB) and th e acqui red il1lllu nedefi c iency synd rome (AIDS ) .

Bec au s e ofitshigh morbidi tyandit sre lative ea s e oftrans miss i on. hepatitis Bhas long beenaco n cern of thos e expo s e d tohumanbl ood. Adv ance s in te sting andtreateent;

have imp rov ed po st-expos ure man a geme nt fo r th o se repo r ting needj.esufck inj u rie s . Prompt initi ati on of prim a r y and/or secondary prev en tiv e me a su res (he patitis B vac c ine and he p atit i s B immune gl obu li n) can red uc e the likelihood of a need lestick-re l ated in fe c ti on .

Rec og n i t i o nin th emid-198 0'sthatAID Sis ablood- borne diseas e gre a tly he i g h te ne d conce r n abo u t ne e d les t i ck in juries. Healt h profes sionals an d th e ho sp ital admini s t ra t orschargedwith the i r welfa re haveattempted to reducejob-rel ate d AIDS ri sk . Ne ed l estick inj uri e s are th e oc c u pationa l exposur e presenting the llIost serious ri sk of in f e ctionwit h the human immu nod e fi ci ency vi r u s (HIV)I the causa tive agent for AIDS.

Pur pos eof stU dy

The prese nt st ud yhasbeenunderta ke n to inc r e ase knowl ed ge and und e r stand ing of rect.cre contri but i ng to the occ u r r enceofneedl e sticKinjur i esand to su gg e st ap p r op ria te prevent ivemeasu res.

Researchquestions

Th e questions whichthisst udywill addressare:

1. Whatareth e rates of hospi ta l -recordedneedlestick.

in juries for nurses and laboratory employees in th ree selected ho s p i tal s for the years 19 85- l 9 8 9 ? Have rateschangedover thistime period?

2. What are the rates of self-repor ted needlestick in juries fo r th e same groups of employees in a twe lve-mo n t h period, as determined thr oug h ano n ymous, self-administe redquestion na ire?

3. Whi ch of the followi ng fa c t o r s affects the likelihood of an employ eeexp e ri encinga needlestick injury ?

1) ageand sa"

2) edu c a t i on al,_experience, 3) type of servicein whichemployed, 4) numbe r and typesofne e d l e s used, 5) need l eha n d l i ngand disposal pra cti c e s, 6) ri s k awaren e ss andmanagement, 7) self-initi a tedhealt h practices.

CHAPTER 2. BACKGROUNDTOTHESTUDY

co nsequences and costs of needlesti ckinjurie s

Medic al consequ e nce s ofneedlesticJcs

At le a s ttwent y-one differentinfec tiousagentsare known to cause disease in hos pital employees injur ed by needles or ot her "sha r ps", such as metal instrume nt s and broken qLas s (Co ll i n s and Kennedy, 1987). st udies of the medical consequencesofneedlestick injuri e s havefocused on twocrco.i-ccmeviruses,hep atitisB virus(HBV ) and the human immunod eficie ncy virus (HIV).

He patitis B: Expo sure of a non-i mmu ne person to HBV via needlestickcarries a risk of developing hepatitis Bas high as 25-30% (CDC, 1989; Werner and Grady, 1982). Until re c en tl y, the protocolfor manag ingnee dlestickinjuries in ho s p ital employees has co nce ntra ted on the preve nti on of hepat itisB infectio n in theinjuredstaff me mbe r .

~ Recognitio n th at the etiol ogicage ntfor AIDS is trans mi tt ed in blood and other body fluids has enhan c e d interest incorrtrrol LLnq jo b-relatedinfection risks. Results ofprospective studiesmoni tor i ng health careworke r sexposed to HIV-infectedblood and bodyfluids ind ica te wheretherisk

is greatest. The cooperative Needlestic!';SurveillanceGroup of the U.S"Centers for DiseaseContro l (CDC) has identified nee d l e s t i c k exposure to HI V- inf ec t e d blood as the event associated with greatest risk of eeroconversLon (Marcus, 1988)" In this study, the largest of its kind, 80% of exposuresas of July31, J.9 88 wereby ne e dle s t i c k injury; the two occupat ionalgroups with thelargestnumber of exposures were nursesan dlaboratorytechnologists/ph lebotomists.

Inclusion criteria have been modified etnce the project began in 1983 (McCray, 19 86 ) and now include parenteral ,mucosal or non -intactskin exposure to the blood of a HIV-inf ectedindividual. Acanadcan prospective study was initiatedin1985 and had enrolled 336he a lth care workers by May, 1990 (Fede r a l Cen trefor AIDS , 1990). Pa r e nt e r a l , mu c ousmembrane and no n- intac t skinexposuresto HIV-infected bl o o d an d body fluids are included; needlestic); injuries account for 53% of exposures. In a British study (McEvoy at al . , 1987) monitoring the same categories of exposures, ne e d lesti c ks accounted for thir ty~fivepercent of injured he a l th care wor kers (n"150 ) .

Thediffe ren ce s among the studies in proportionof exposu resdue to needlesticksmayberelated to variationsin inclusioncriteriaand methodof da t a collection. Proportions of occupationalgroupsamong enrolleesease vary; for example, San Franc isco Genera l Hospital, which takes a proactive approach to recruiting SUbjects, has a high e r proportion of

phyadc i.ane and, con seque nt l y, lowe r proportio n s of someother occ u pa t i on a l gr oup s than ot herst udies (Ge r b e rd i ng et al.

1987 ) •

Pa r tic i pa t io n in a surveilla nce prog ra m is volunta ry , both for the exp os ed indivi d ua l and for the hospita l. In add i t i on to national programs, ho sp i t a l s treat ingla rge numbersof HIV-i nfecte d pa t ient s mayel e c t to esta bl i s hthe i r ownsurveilla nc e pr ogra ms (Gerbe rdinget al., 1987; str ickler, 19 8 8). st ud y enrollees are tested for evidenceof seroconve rsion at intervalsup to one year after exposureandthey are cou ns e l l e drega rd i ng measuresto prevent HIV transmission (CDC , 1989) . They may be required to completea confident ialquest ionnaireaboutnon-o cc up a t i o na l ri s k factors.

Ra t e of infection with HIV,as measuredbyinc i de nc e of seroconve rsion(p rod uc ti on of antibodytothevirus), has been es t i ma t e d at 0.4 - 0.5% for pe r s on s exposed through need l.ee t.i.c kto bloodcontai ningthe vi r us (Gerberding, 1987; Marcus , 1988; CDC, 1989). Seroconv e rsio ns following cutane ou s exposure s ha v e not been docume n ted in the prosp ect ive stud ies; the seroconversio n rate has been est i ma ted at<0.13% pe r exposure (Webe r and Ru t ala, 1989 ). Eigh te endo c ume nt e d ins tancesof occupational l y-acquiredHIV in f e c tio nin healthcar e worke rshave beenrep o r t e d worldwide (CDC, 1989);the r e have been no seroconversions repo rted in Cana d a to date (Fed e ral Ce ntre for AIDS, Ma y , 1990).

Publ is h edrep or t s of se roconve rsio n rates andnumbers of work- re lated HIV infec t ions havebeencriticiz e das underestimates (Badd c.o ur,19 87 ; Ke len, 19 88b; Scha f fner, 19 89 ). The critics maintain tita t conservative criteria for classifying work - related HI V infectionres ul t inin fectedhealth carewo r ker s be in g pl a ced intoothe r risk categories.

Additi ona l medical consequences: Detailed ex a mi na t i o n of medicalrisks associated with injur yby needles contaminated wi t h infect ious agents other than HBV or HIV, or with ha zardou s ag en tssuch as chemothera peutic dr ugs hasno t been pub li shed.

The emotional irnrret; of needlestick injuries may inc ludeanxiet yand anger at one'sself (Marrieet a l , , 19 89).

Two we e ks af t e r a!l needlestick injury, 18t of subjects re port e d slee p lo s s due to anxiety and 9%had a chan gein appeti te.

Financialcostsrelated toneedlesticks

Hospital experidicu z-ea related to ne e dl e s t i cks incl ud e costsof preventionmeasures, injurymanagemen t and treatme ntofne ed l e s t ick- rel ate d disab ility. All costs qu ot ed are in u.s. dollars, unlessotherwisespecified.

Costs of preye;ltive measures· Spending on needlestick prevention paysfor special equipmentand supplies plusstaff education and training to introducenew policies . Ribneret a1. (1987) reported that ne w disposal containers in a 72J- bed hos pital cost $8000 per year, about$3100 more than the cardboard boxes usedprev iously ; they estimated a consequent reduction in disposal-re lated needlestickswould save $4000 annually. Contaminated material containers forone year in a 904-bedhospital cost$38,500~point-o f-useplacementofthe containers ineachpatient room was expected to co s t $27,500 (Sanborn et al., 1988). Sanborn anticipated that the hig h costsof the u';'sposal containers could cc offset by a decrease in costs ($62,OOO) oftr e a t i ng needle injuries.

stocket al. (1990) estimated the cost of d Ls.poaa I containers and supplies such as bleach at $30, 770 (Canadian) for a esc-cechospital. Education expenses were placedat

$13,155, which covered partial salary for the infection contro l officer ($6000) and one-half hour lost working time for 1000 employees ($7155).

Costs of needlesticktreatment: Atypicalneedlesti ckfollow- up protocol includessevecejcomponents, as follows:

(1)Basic manageme n t:

immediate care of the injurysite.

io completion of an incident report by the employee, of ten in conj unct i on with the imme diat esu perv i sor ,

an inte rvi ew ofthein j u r ed employee condu c t ed by th e st a f f healthdepa r t men t ,

a review of theemployee' s vacc inat i o nre c o rds to ascertain thenee dfor tetanusprophyl axis , iden t i f ica t i on of the pat i e n t-sou rce (the person on whomthe nee d le wa s used).

(2) Hepat itisBpro p h y l axis :

determination of immuniz ation stat u s of the emp l o yee through records and, if nec es s a r y . bl oodtest ing,

testing the pat i e nt-so u rce for he patit is B surfaceantigen(HBsAg),

adminis tration of hepatitis vacci ne,

hepatit i s B immu n e glalulin (HBIg ) and/or immunese r um glo bul i n (ISG).

Appe n di x A, page 15 6, gives a mor e comp lete des cr ipt i on of post-ex posure proph yl axi s for hepat i tisB.

(3) Human immunodef i ciencyviru s (HIV) testing:

ifthe patient-source isknown orsus p ected to be HIV-anti g e npositive ,th eemp loyee mayelec t to undertak e periodic tes ting for an t i - HIV.

Thiswill necess itatepre-te st c-ou ns e l ling and

may in v o l v e enrolment in

11 external surveilla nceprogram (Federal Centre for AIDS, 1987).

the patient-sourcemay be askedto undergo HIV testing, Whichwill require informed cons-ent;

and pre-test counselling of the patient. Reportedcosts of managingneedlestick inj uriesare high and increasing (Table 1). An unpublished studyat St. Clare'sMercyHo sp i t al inst. Joh n's,Newfound land (S c a nl on, 1990) calculated costs for treating needlestick inj ur ies between January 1987 and April 1988, under the pro t o c ol outlinedin AppendixA, page15 6 . Totalcosts !'>r testingand hepatitis B vaccination following 71 needlesticks were

$9072.95.

Needlestick managementcosts wi l lbl'! affectedbyho w many components of the model protocol are implemented. Routine testing of theinjul'edemployee and the patient-source for hepatitis 8 virus (HBV) markers following needlestick injury is now recomme nded by the CDC (1985) and th e NewfoundlandDepartmentof Health (1989). Testing of eithe r emp loyee or pa t i e nt fo r evidence of HIV exposu re is complicatedby therequirementto provide counselling and to obtain informed consent (Health and Welfare Canada, 1989).

Decisions re gard i ng HIV testing are made on a easecb y- c e se basis.

12 Tab l e 1: Reportedcosts per needlestickinjury

INVESTIGATORS/ AVERAGECOST

TYPEOFHOS P I TAL (Range)

Per needlestick McCormick and Maki, 1979 $33 university hospital.

Reed et al., 1979 $60

Veterans^I hospital.

Kirkman-Lif1.and Dandoy, $92

1984 ($0-496)

Sixnon-federal , 1'101'1- university hospitals.

COMMENTS

HBvaccine and HBI g not administered. HBIgadminister ed, but no t HB vaccine.

In clUd e d ather percutaneous and mucosal exposures as wellasne e d l e s t i ck s. Ribner et al.,1987

Tertiary carehospital. Edmond et a I•• 1988 Teaching hospital.

Sanborn et a L,, 19 8 8 Tertiary ca r e hasp! tal.

Scanlon, 19 9 0 Tertiary care haspi tal.

$95-18 3

$120 ($11-480)

$363

$127*

Amount quoted was most frequent cost of treatment, not an average.

Costsof HBlg, ISG and salary no t in c l u d e d.

*

Costs of needlestick-rela ted disability' Ki rkman-Liff and Dandoy (1!:l84) describe onework -relatedcaseof hepatitis B whichcost $13,376 for medical care, Workers' Compensation paymen tsand 82 cays lost employment . stock and colleagues (1990) estimate the directcc-rt.sof a hypothetical ca s e of work-related AIDS at almost $45,000 cen. forme d i c a l care, andthe indirec t costs resulting from l i fe timewagelo s s e s at

$510,000. Recogni tionofAIDS as a compensable conditi....nby

13 one Wo r k e r s' Compensati on ju r isd i c t i o n is pe n d i ng (He a rd, 1989 ). civil claims against employing hospi t als are cisc likely; one su c h cas e is sai d to have been set t led out-of- court fo r moreth an$1 , 000,00 0U.S. (Al p ert, 19 90).

Epidemiolo g y ofne e d l e s t i c k in1uries

Need le sti c k inj u r i es asan oc ou pat i onal heal th problem

The Nation a l Institutesof Occupatio na l Healt hand Safe ty (NIC SH) in th e United states found that, among occupational Lnjur-Le s tr e a t ed inhospital emergencyrooms In 1982,fing e rswerethemo st commorrLyaffectedsit e,with25.7 % of all in juries (CDC, 1982). Inthe NI a SH stud y, 9.4%of finger injur i e s-anest i mate d77,200-werene e dl e punctures.

Whi l e not al l of tho se inju re d were hos p i t a l wo.rve r-s, the fig u resdo suggest th a t ne e d l e s t i c ks are(I significa ntpublic hea lth conce r n.

Ne edle s t i c k s compriseapproximate lyone th i r d of all work- re l a t e d acc i den tsamo ngho sp ital employees(McCormickand Mak i ,19 8 1 ; Os t erman , 1975).

Ne e dl es t ickin j ury rate s

Avarietyof measure ment s ha v ebeenemployed when calcu l a t ingnee dl estick injur y ra tes inhos pita ls. Whi l e some

14

reported rates have been based on number of beds (for example, Jacobsonetal.I 1983) or number of devices purchased (Jagger et a L,, 1988 ), the mo r e common approach ha s been to use staffingfiquresas denominator. This denominator has evolved fromnumber of employees to number of full-time equivalents (PTE) . The number of PTE is calculated by dividingthe total paid hoursfor an employee group by the normal number of paid ho u rs for 11 ful l-time person; this enables compari sons of gr oup s withvarying compositio ns of full-timeand part-time staf f members. Needlestick inj u r y rates are now us u a lly record ed as nu mb e r of injuriesper 100 FTE per annum.

Ta b l e 2 shows the findingsof several studi e s of nee dl e stl ck inj u ri e s . Inaddition to genuinedifferen cesin needlestick injury rate s, thewidevari a t i on in annualrates ma y be in f l u e n ce d by factorssuchas thefoll owi ng:

1) inj u r y reportingand recording procedures, 2) need lestick inj u r y definition (for example,

injuries with cleanneedles incl uded in the rate calcUlation?)•

3) attitudes and beliefs influencing whether an employeereports an injury (Does the in j u r y impose a significant risk? will reporting to st a f f health lead to action s which wi llred u c e that risk ? will there be unpleasant re p e r cu s s i o n sfo rack no wl e d g e d violations of sa f e t y guidel ines?), and

4) meth od of data gathering.

15 Ta})l e 2: Rates of hospi t al need lestickinjuries INVESTIGATO RS AIl. STAFF NURSI NG LABORAT ORY DENOMIN ATOR

Recordedbyst aff health: Mc Cormi ckand

Ha k i , 19 8 1 8.2 9. 3 10 . 5 100staff

Ruben at al., 1983 16 23 12 100staff

Neube rger at al.• 4.9 12.4 6.7 10 0 f'rE 19 8 4

Fishman et a1.,(a) NA' 7.6 NA 10 0staff 19 8 5

{ol ^NA 9.3 8.3 100f'rE

{bl ^NA 14.5 NA 10 0staff

{bl NA 28,0 15.8 100f'rE

Waldron, 1985 NA 3.0 3.9 100staff

Ribner etal., 8.7 23.2 7.6 100 FTE

1987

~ ortedanon y mou sly'

Hama r y, 19 8 3 42 61.1 25.5 10 0staff

,., NA '"not avai lable.

Wide rate ran g e s we re found for all hospital depar t ments;moststudies foundthe highe s t injuryra t e s among Ha mory's self-reportedrates wer e farhi gh e r than those reco rded by staff hea l t h departm ents in all other stud ies. Fishma n'5 re s u l ts (Table 2) illustrate that when injurie s ar e reportedper 100 FTE the rates will be higher tha n when present ed as rat esper 100 (f ull- and part-timo) employe es; the degree of diffe re nc e is no t constant. For

16 exampl e , 7.6inj u r ies per 100nu r s e s in Hospital (a) became 9.3 per 100 FTE, while 14.5 injuries pe r 100 nurses in Ho spit a l (b) arecct;doubled when expressedasne e d l e s t i c k spe r 100 FTE. The more part-timeemployees aho s pita l hasand the fewerhours wo rk ed by each, thegreate rwil l bethe difference betweenthera te pe r 10 0 staffand rateper 100 FTE.

A studyfromBritain (Anan" 1982) was not included inTa b l e 2. Its remar kably low rate of injuries recordedby the occupat iona l health department (1.7 per 100 nurses) was contradicted by a survey which fou nd tha t a small sample of the same nurseshad an inju ryrat ein the previousyear of 50 per 10 0, thi rty times the recorded rate. In addition, need lesticks comprised only 4.5% of injuries to hospital empl o ye e s compared with25-36%re p o rted elsewhere (McCormi ck and Maki, 19811ost erman, 1975 ) . In the Britishstudy, th e onus to reportinj u r i e s to the occupational he al th department fell to the supervisor ;occupationalhealthapparently did not coordina temanageme ntof needlesticks. Th e absence of direct commu nica t ion between injured employees and occupational heal thmay have contributed to under-reporting.

Also excluded from Table2were studieslimitedto special ized occu pational situations, such as blood donor clinics (McGuff and pcpovsky, 1989 ) or the operating room

(Ma nsou r, 19 89 ).

17 Pr,)p orti o na te rate s

Another way needlestick injury rates hav e been evaluated is by determining the proportion of injuries contributed by employees from various haspi tal departments (Table 3). With the exceptionof Waldron'ssmall atuuy, tho proportionaterange ofneedlestickscontributed by the nursing departmentis fairlynarrow,at 60-75 %. The comb i na tio nof a high injury rate for nurses and th e magnitude of thi s occupational group withi n th e hospital makes -rur-sLnq de pa r t ment s the source of mostre p orte d needlestt c kLrrj ur-Lca ,

The proportionaterangefor the laboratory is wi d e , with the percentageof injuriesfr om oneho spita l three ti mes that of another. Needle injury ra t e s may be related in part to whet herornot bloodcollectionis performedby labora t ory employees. Whi lephlebotomyte ams are usually attached to the la b ora t o r y , in some hospitals theyare a separatede p ar t ment andinothers they are affiliated withnursing.

The"ot h e r"category includes all remaininghosp ita l employees reporting needlesticks . Ma ny of these are not act ual users of needles, but are in areas (housekeep ing , central supp l y , laundry) where they enc o u n t e r improp e r ly discarded needles.

18 Ta b l e J: Prop o r t ionateneedl e stickinjury rates.

INVESTIGA'l'ORS NURS ES UBORATORY OT HER

I I I

Mc Corm ickand Maki, 316 60 lS 26

1981

Rancr-y,19 8 3 14 8 66 11 24

Ruben et al., 19 8 3 57. 66 10

Neu berge r etaL,, 19 8 4 286 62 2.

Fi sh man et al., 19 8 5 l1S 63 2.

Ribne r et 81., 19 8 5 238 70 25

Waldron, 198 6 64 45 16 3.

Kra s ins k i et al .• 1987 315 75 i.s

Jagge ret al., 1988 326 64 NA** 35

'" Study totals may not be100%dueto rounding.

**

Studiesby Re ed et a1. (1983) and Jacobson et a r• (1983) we r enot considered appropriate for comparison, since the y inc l ude d in j uriescaused by sharpsotherthan needles.

Extentof under-reportingofnee d les tick injuries

Nee d l estick injuries are not al wa ys reported to staff healthde partm e n ts. Jagger et aL, (19 8 8) in t ervie we d ho spital employees who reportedane e d l e s t i c k injuryand found that 39\ had failed to report apre v i o u s injury.

19 Additional estima t e s of under-reporti ng c.aae from da ta gathered through anonyaous surveys. For ty percent of nurs e s and ph y sic i a n s in a tWO- h o s p ita l su rv e y conductedby Jackson et aL, (1986) said they had do ne noth i n g abo ut needl e stickinjuriesincurr ed in the pastyear. In Ha Dlo ry's 19 8 3 survey of ten hospitaldepartments, 60\ of th o s e who stated on a questionnaire that the y had exper- Lenr--ad a ne e dlesti c kinjur y in thepa s t th r e e months sai dthe yhad not repo r t e dit. Ja c o b s o n at a1. (1983) found thathalf of nurs e s su rv e ye d and92\ oflaboratoryworke r s ddd not see k tr e a t me n t rce punctur e wounds expe r ienced in the preceding year. Empl oyees in the latter two studies exple.ined their failure to reportby the fact th a t thene e d l e inv ol vedwas ster ile , the injurywas con sideredunimportant,thereportingproced ur e wa s inconvenient or the y were unaware of any ere aee en e prog ram.

Par ticipantsin al lfourstudiesWhi ch estimatedthe exte ntof needlestickunder-reporting were sel f - s e l ected in th.atthe yha d reporteda recentneedle sti ck in ju r y (Ja gg eret al., 198 8 ) or had voluntari lyparticipatedin a survey. It is not known whet her th e i r reporting practices representa tiv el, f heal th car ewor kersingeneral .

20 Mechani s msof needlest-1 c kinjuries

Acti v i ties as soci at edwith ne olU e stiek in j ur i es

Early attempts to classify needlest1ck injury necnemeus wereli mi t e d to affixing blame. In 1980, Reed et a1. (and Jacobson et a1., 1983, following their example) divided needlest1ckinjuries into two types:

1) "inno c e n t v letim". those resulting from the actions of someone other than the injured person (e.g.

injuries to housekeeping staff from improperly discarded needles), and

2) "personal carelessness", injuries which occurred to the- ampl cyee in control of the needle.

The latterclassification offered ne i t h e r understanding nor solutions to nu r s e s , laboratory staff and others who were blamed for their misfortune.

More objective attempts at categorization described the activity occurring at the time of injury. Comparisons of studies are difficl'lt since categories have not been used consistentlyand the survey populationsdiffer in composition.

Classifications extrapolated from seven studies aresummarized in Table 4.

Procedural needlesticks are those which happen\··~...re giving an injection, drawing blood or performing another clinical or laboratory technique . Recapping injuries occur

21 whilereplac ingcaps backon the used needle. The disposal category used here is a broad one, includi ng inj uries resul tingfromequi p ment disassemb ly ,carrying usedne e dl e s , inse r t i ng ma teria l into disposal units, and enc o unt e r ing ne e dle s protruding from trash or on a surface or inbedd i n g .

"otn e c" includes injuries Whose circumstances were not on record and activities associated withonl y small pro portio ns of nee dlesticks.

Table 4: Ca t egorie sof needlest i ck in j u ri es.

INVESTIGATCRS/ PROCEDURAL RECAPPING DISPOSAL OTHER

DEPARTMENTS

,

, ,

McCormickand Maki, 19 8 1

Nursi ng and laboratory 61 18 12

Ruben et ai., 1983

Nursi ng 19 25 32 2'

Neubergeret eL,,19 84

Nursing and la bor a t o r y 51 2' 11 14 Kr a si n s k i et aL, 19 a7

Nurs ing 20 13 37 30

Ribneret al.,19 8 7

Nursingand la borator y 5' 26 20 Edmond et al. , 198 8

All departments 55 22 22

Jaggeret aL,, 1988

Allde partme nts 17 30 '7

Me ans 40 21 27 13

*

22 Me a sure s to contro l need le in juries ne ed to take into account the events sur rou ndi ng thos e injuries. Whi le individu a l st ud i es di f f e r conside r a b ly , the calc ul ate dmea ns (Ta bl e4) sugges t that most needl estic ks occ u reit he r du r. og proce duresorinthe processofnee d l edi spo s a l, wit h needle- recappi ngthird infr e qu e nc y . Itmustbenote dtha t employe e s inall atud Leslist e d except tha t of Jaggerat al. (1988)vera provi d ing inj ur y descriptions whirhwou l dbeco me partofthe ho s p i t a l ' s officia l re c o r d s ; whetherthey would have described the circumstances di f f e r en t l y if anonymity was ensured is unknown,

Equipment as s o ciated wit h ne edl esti c:k injur ies

Jag ger at a L, (1988) first do c u me n t e d th a t needl e sti c k. injur y ra t es were different fo r various ty pes of equipment us e d wit h ne e d l e s. Rates per eq u i pmenttypewe r e calculat ed usi ngas denominatorthe number of unitsof that devicepurch a sed bythe hospitaL Disposa b l e syringes, whic h were associatedwit hthe greatestnumb e r ofre por t e d injuries, ha d the lowe s t rateof injuryat 6.9need l esti c k.sper 100 , 000 . Devices involved in far mo r e inj ur i e s on a per- item ba s i s included intravenous tUbi ng ne e d l e assemb lies (36 .7 pe r 100 , 000 ) , vacuum-tube blood collect ion se ts (25.4) , intravenous cathe te rs (18 . 4) and butterf l y -type needle s (18.2). Apar t fr omthe Ja gger study, the contribu t i o nof

23 equipmentty p e to the risk of incurringa needlestick in j u r y ha sre c e ive d little attention.

Topu r s u e this lineof investigation, participants in th e presentstudy were askedto identify the various types of needledins trume nts they ordinaril yuse and state which type had been involved in their most rece nt need l e s tick injury.

Factor s affec t i n gn~ ed le stickinjuries

McCurdyet 211. (1 9 89 ) , in a studyofmucocu t a n eo u s injuries, and Hamory, ex amini ng neec Lee t. I c xs (1983 ), found that recently-employedpersons had more injuries than other hospital employees. McCurdy also found that nurses ...ho

"f l oat" amongvarious nursing areashadhighe r injuryra t e s.

Neube rger an d colleagues (1984) identified part-time and night-shift personnelasha v i ng greater risk of inju ry; they also speculatedthat fa c t o r s cont ribu t ing to high rates in night shift workers might Inc Iude inadequate staff ing, fatigue, poor lighting and less opp o rt uni t y to attend educ atIonaf sessions. On the other han d , injure d and unin j urednursesin a blooddonor clinicdid not differwith resp e c ttoage ,le ng t h of emp loyme nt or timeelapsed in t o work shift (McGuff and popovsky, 1989 ).

24 CDCme asures topre ventneedlesticJcs

Until the lastdecade, it was standard pra c tic e for healthpr o f e s s iona l s to place caps back onto used needles, manually detach the needle from the syringe or oth e r equipment, and dis cardthe needlebyi ts e l f into a designated co nt ai ne r. Manyhospitals cut thetipsoffneedles to render theminope rab le . with increasingconcernabou t hepatitis B and, later, AIDS transmissio n , strategies were sought to reducethenu mbe r ofne e dl e s t i c k in j u r i e s . Needle recapping and disassemblyand thecollection of used needles in easilY - puncturedcontainerswereall believedto contribute to the occurrenceof needlestickinjuries. Needle,:ut t i ng devices were problematicsincetheysometimessplashed th e userwith blood.

CDCguidelines

In August, 1987 , the Centers for Disease Con t r ol (CDC,1987) re c omme n d e d that all pat ientsbetr e ate d with the bloodand body fluid precautionsprev i ous l y reservedfor those known or suspected of carrying blood-borne pathoge ns (Williams, 198 3). This approach, called "Uni vers al Precautions ", hasbe e n endorsed by many agencies, including , in Canada, the Federal Centre tor AIDS , th e Bu rea u of CommunicableDisease Epidemiology andthe LaboratoryCentre

25 for Dis e a se Co nt r o l (Heal th an d We lfare Ca n a d a , 1987). Th e recomme ndat i ons are updated fromti me toti me andincl udethe fol low i n g princi p les relatedto need lehan dli ng (CDC, 19C,I):

1) Needles shoU ld no t bere c appe d , purpose lybent or broken byha n d , re movedfrom dispo s a b l e syri ngesor otherwis ema n ipula t e dby hand.•••shar p items ehouj d be plac ed in pm,"' ··lre-resistant contai ners fo r disposal; th e pu nc ture-resista ntcontainers should be loc ate d as close aspr a c t i c a l to the use area.

2) Ba r rie r preca u tio ns, includi ng gl o v e s , ma s ks and gowns , should be used to prev e n t skin and mucous memb ra ne exp o s u r ewh e n contactwith blood andbody fluidsis anticipated.

3) Gl ovessho ul dalwaysbe available to those who wish to use them for phlebotomyand should bewor nwhen the risk of blood exposure is in c r e a s e d.

Institut i on s in areas with a low prevalence of blood-bo r ne pathog ens whichdo not requiregloves to be worn by skilled phl e b otomi s t s should review th ispolic y par-LodicaLj y ,

Th e CDCdocumentalso statesthat implementatio nof un i v ersa l bl o od and bOdY-fl uid precau tions for .!!llpatients el imina testhe ne e d for ide ntify ingandisolatingthose known or susp ected ofhav ing blood-bornedisease. Itrecommends that employers of heal th car e wor ke rs ensurethat polic i e s

26 ex i s t fo r educati on and traini n g of staf f rega r ding HIV and universa l prec aut i o n s , an d that st aff be mo n itored for adher e nce to recomm endedprocedu res.

The most common appr oa ch to reducing needlestick injuries ,bot hbeforeand af t e rthein troduc t ionof Uni ve r s a l Precau tions, has include d thr e e main aspects:

1) educ a tio n and traini n g sessio ns to introduce changes,

2) provision of puncture-resistantcontainersforused needles, and

3) prohibitionofre c a pp i ng , cutti ng or bending used ne e dl e s.

Krasinski et af. (1987) and Ribner etal. (1987) described studieswhich incorporated all of these elements.

Inbothcases,needlest icks di r e ctlyre l a t e d to the natureof th e dispos a l cont ai ner (for exa mple, those caused by pr o t ru d ing ne ed l es) we rereduced, butno de crease in overall injuryra t e was achieved. Inju r iesdue to recapping of used need les di dno t decre ase ,in spiteofthe educationprogram.

straub et a1. (198 6) reported no significant lasting change in ne edl e st i ck inj u ryrates foll owing the introductionof a rig i d system for ne ed le col l ect ion , accompanied by an

educat io n progra m. In j u r y rates decreased during the year following implementationofthe ne w program,but this tr e nd di d not continue. Inth isstudy, nursing unitswhichplaced needle disposal containersat each bedside reduced injuries by 49% compared to an 18%declinein other units.

Edmond et a1. (1988) and Set a et a1. (1990) ea ch studiedthe effectof an educ ationprogram andimp roved need l e contai nerson the frequencyof needle rec app ing. Th e r e was no change in observed recapping fr e q u e ncy inEdmondIs stud y, ...here part i cip a nts wereunawa r e the ywe r e being mon i to re d.

Set o , however , found that nurses require d to at t e nda li ve, in-service presentation were less li ke l y to be re capping needles £1 ve we e k s la ter than nurses not expos ed to the presentation. Frequen cy of non-re capping behavio ur inth is study was measuredby anonymoussel f-reportsandbyexa mi n i ng discarded need les to determinewhether or not th e y had been recapped. Eighty-fivepercent of thest u dy grouprepo rt edno recapping and57% of th e i r discarded needles we r euncap pe d ; 21%of one control gr oupwere not recappingand27% of the ir di s c a r d ed needles were unc apped .

Sanborneta1. (1988 ) de scribeda pilot study which provided point-af-us eplace mentof new co n taminated mate rial cont a ine rs in four nursing units in a uni ve r si ty hosp i t al . Educational sessions were provided and sta ff me mbe r s we r e surveyed priorto and during the study . Eig hty-six per cent of nurses whocomp l et e d ques tionnaires before the study began

28 reportedrecapping used needlesallor some of thetime;this was re du c e d to 61\ six months into the study. needlestickinjurieswerereport edto staff healthduring this period comparedto the previous six months.

Mo s t major pub Lfshed studies ofneedlestickin juries were designed to describe th e nee d les t i c k problem in the authors' ho s p i t al , rat he r than report the outcome of a needlestick preventio nprogram (Reed et al., 1980; xccornt.ck andMaki, 19 8 1 1Ha mo r y ,198 ) ; Jacobson et a L, 1983; Ruben et a1.,1983; Neube r'qer-et a1.. 1984). Many conclude by stating that, now th a t more is known about needlesticks in their facility, interventionsare beingplanned inorderto reduce thepr ob l e m. Reports of the outcomes of these programs have not yet beenpub lished.

cri ti qu eof CDCguidelines

It can be seen from th e previous section that limited dataexist to confirmtheeffi cacyof the CDC approach - education. improved disposal containersanl,'l no recapping.

A brief examina t ion of each aspect may help explai n the limitations.

Educational endeavours related to injury prevention "in general hav e consumed la r g e shares of • safety' budq e tie withoutcommensuratebenefits " (Bake r, 1975). It is

29 naive to thi nk that si mp l y info rm ing hea l thcar e wo r k e r s of new regulations will re sult in major be haviou r cha nge s . Decis i on-makers mus t en surethat new equ ipment and policies t ruly meet the needsof thosewho ar e to use them.

Co n t a i n e r s ' Disp osalco ntainersmade of puncture-res i stan t mate ria l (usua llyarig id plastic)havere p laced flimsiErones used pre viou sly. Containers ha ve openingswide enough to ac ceptthe needle an d att ach edequipment , such asadisposable syri ng e , without disassembly. Ma nufacturersnowsupply sturdy conta i ne rs in a range of sizes sui tablefor wall -mou ntingor pl a c ing on medication tr ay s , trolleys, shel ves or nursing sta tions (Po r t er , 1990).

Unc a pp e d need l e satta ch e dto reus a bleequipment,for examp l e,bl oodco l lectionvacuumtubeholders, cannotusually be deta c hed by hand. Some disposal containers allowtho uncapped ne e d l e to be separa t ed from the holderor syringe.

The needlehu bisheld inaslotat thetop of the container whi l e th e hold er is rotated, there by unscr e wi ng the ne e d l e , wh i ch then fa ll s in tothecontainer. Thesecontainers can be qu i te sma l l si nc e the y will hold on ly needl e s ; some bl oo d collectorsuse a pocket -sized de s i gn.

There ar e lim itat i on s to the ability of needle di spo s a l con t ai ne rs to reduce ne edl e sti ck injuries. Unles s disp os a l unitsare loca ted\ar yclose to the siteof ne e dle- use,emplo y e e s may beforced to carryuncapped ne ed l esto the

3D

container, withthe inhe rent risk of pricking themselvesor another indiv i du al en route. Some will ch o o s e insteadto rec ap the needle. Ho st needle contai ne rs wor k we ll for re c e i v ing syringe s , intrave nouscatheter stylets and ot he r dev ices whi c h are sma l l in size and eas y to manipu l ate.

Cu mbers omedevi c e s, su c h as long styletsused for int roduc ing perito neal dialysis catheters, or ne e d l e s attached to intr a ven ou stUb ing , may be tlor a difficultto inser t into the contain e r.

Ne e d l e disposalconta i ners musthave open i ngswhich prov i d e for easy deposition of waste ma t e r i al s without exposing the hea l th care worker to contact with needles already inside. RegUlar re p l ace me n t of conta i n e rs is necessary toavoid ov erfi l ling, wh i c h could ca u se needlesto protrudefrom the op e n i ngor befor cedth roug h the sides .

To summari z e, new disposa lconta i ners offer severa l safe t y advantages, butun l e s s theyare close at ha n d ,ea sy to use andre p la c edbefor eth e y are full,staf fwill not ben e fi t trollthem. Spe ci al pr oblemsnot ad e qua te l y co vered by CDC guidelines,suchashowto discon nectve cuum-ncbeneedles and how to di s p os e of awkwa r d piece s of eq ui p me nt mu st be address ed at th eho s pit al le vel.

"NQ recap p ing" pQl jc j e s· The socie t y of Ho s p i tal Epidemiolog ists ot Ame ri c a (SHEA) believes tha t "it is counte rproductive to flatlyprohibit re c a pping of nee d l e s"

(Weinstein, 199 0 ).

J1 similar views have been expressed frequently by Jagger and colleagues (1987, 1988,19 8 9 ; Anon., 1988a; Anon., 1989). who point out that rather th a n acting ir responsiblywhenre c a pp ing needles, employeesare using the means theyjudqe most appropriate to protect themselvesand others. The CDC"no recapping "directive does not cover every type of needle and every situation. Employees who must manipulate equipmentor who~carry needles through a room or corridor to reach a disposal containerare on theirown.

Needle recapping has been declared unsafe , but strict compliance with "no recapping "policiesalso carries risks.

Acceptance of Universal Precautions : Some hea 1th care wo r k ers believe that use of CDC-recommendedbloodprecautions is necessary onlyforpa t i e n t s known or suspected of carrying a blood-borne pathogen. These employees would like "high- risk" patientsto be identified. Hospitals have cus tomarily used warning labels onpatient beds, room doors,requisitio ns and specimensto alert employe esand visitors to thepresence of in f e c t i ou s diseases. However, in the case of AIDS, th i s typ eofpa t i ent identification r-a Lsec seriousco ncer ns;health ca reworkers,by their own admission, may adopt discriminatory practices towards these patients (Gordin et al.,19a7;Searle , 1987). Labe ls now specify thetype of precautions needed (e.g., bloodand body fluid forHI V infection), racher than

J2 stating whic h disease is present, but any labelling may jeopardize a patient's rightt(J privacy.

Ful l implementationof the principles of Universal Precautionsmeans that all patientsare treated equally and labelling is discontinued. This has proven to be a controversial issue, with some still in favour of knowing whichpatien tspose a risk to health workers (Godfrey, 1988;

Lassen, 1989). According to Le ubb e r t (1990), laboratory technologists who want warning labels for specimens from patients \,lithhe pa t i t i s f.,r HIV infection are in one of two categories. When asked what they would do differently with labelled specimens, tho s e in the first category name procedures whichshould be standard for all patients (e.g., wearing gloves whenth e y have open cuts). Those in the second category would use unnecessaryor redundant procedures (e.g., autoclaving leftover samples, whenthe laboratory already has a policy of incinerating all discarded bloodproducts).

The alleged benefit of divulgingpatient diagnostic information as a protective measure is disputed by findings that many infected patients have not been diagnosed and that health care workers ha v e not be shown to get fewer needlestick injuries when dealing with known AIDS patients.

KeLen et a1. (1988a) foundth a t 92 of 119 patients with HIV infection presenting to a hospital emergency room were not known to be seropositive. In one hospital which used

"b i o ha za r d" warning labels on blood specimens (Hansfield,

3J 1987),astudy found that33% of HIV antibody-positive samp l e s and 72\ of those wit h HBsAg did not carry the ha z a r do us designatio n. Authors of both st u d i e s endorse the us e of Uni versal Pr eca u t i onsforll.!.pat ien t s and their specimens.

Published re po r ts doc ument ingneedlestick injuries among those treating AIDS patients show that knowledge of inf e c t i o nis noassurancethat injuryca n be prevented (Weiss at a L, , 198 5;Wormser a t al., 198 4and19 98; Meltzer, 1989). There are ev e n some who believe tha t health car e workers dealing with known AIDS patients may have an ~ likelihood of injury ,resul t ing fromhe i g h t e ned anxiety (Sande and Cooke,1990; Anon. , 1988b) .

Mon i tori n g andenforc e me n t : WhileCDCrecommendsmonitori ng adh e r e nc e to theirHIV and HBV prevention guidelines, there have beenno reportsdocumenting th e effe ct of mon itor ingon employeecomp lia nce. The twostud ies reportedear lierwhich achieved a measurable red u c tio n in recappin g frequency (Sanborn et al., 19 88; Set a et al. , 199 0) arenotewo r t hy for the continued inv olvement of the investigators with the participants. The requests to compl e t e mu l ti p l e que stionnairesmay in themselvesnave nad animp a ct . Sub j e c t s may havefeltthey werebeingmonitored (th oughrespon s e s were anonymou s) andt.",dbet t e ract as inst ructe d or,alterna tively, they mayha ve simply responded fav o ur a b l y to the atte ntion .

34

The occupational Safety and Health Administration in the United States has developed a Proposed Standard for the Protection of uorkez-s from the Hazards of BloodbornePathogens (OSHA, 1989),which wouldmandate infection control measures in hospitals and other workplaces where there is the potential for blood exposure. The onus placed on hospitals to ensure workplace safety will bring a new dimension to efforts to reduce needlesti c k in j u r i e s. Enforcement of safety regulations, rather than just monitoring, is one expected outcome,as employers strive to demonstratecompliance with OSHA demands.

Densmore (1989) reported the case of aTe xa s nurse fired after she accidentallystuck a co-workerwith a needle used intreating an HIV-infectedpatient. A newspaper story said the nurse was terminated for grossnegligence. She ...as apparently carrying the used ne ed l e across an emergency treatment room to place i t in adi s po s a l container.

Alternat i y e measu res toprevent nee d les tick s

While the approach taken by the CDC to reduce ne ed l e s t i c k injuries ha s been widely pUblicized and endorsed, other strategies have also been proposed. Some of these dispute the merit of theCDC guidelines; others offer changes wh i ch would obviate the need for some current safety practices.

35 Sa fe r needle reoappin a

Re c apping used nee dles wit h two hand s place s the hand hold i ngthe cap at risk. If the ope ra to r miss esthe cap whe n attemptingto insert the need l e,th e contall.i na ted ne e dl e ma y puncturethe handholdingthecap. Needle recapp i ng may be still be reasona b l e when disa s s embly of equipment is re quire d before di s p o s al (fo r exa mpl e , needle holder s for vacuum tu be blood co llection sets are reusa bl e , so needl e s mu s t be detached from the ho l d e r anddisca r d e d separately).

Recapp ingmayalsobe advisable whendis posal co nt a i ne rsare notavailable . Some alter na tives totwo · h a nde dre cappi ng will be described.

One-hand ed ne ed l e recap pi ng: Ne edl e recapping can be acc omp li shedbyillsin g le-handed techn i q ue without any special equi pme n t. When the need l e cap is removed priorto use, it is laid on i ts side near th e opera tor. Aft e r us in g the ne edle , the employee sc oo ps th e cap up and back on to the need l ebyinserti ng the needletipinto th e cap, keepingone hand free. Onc ethe need l e tip is covere d, the seco nd hand se cu re s the cap in place. Th e covere d ne edle may then be discarded along with anyattached eq u i pme nt, or i t may be detachedand di s ca r d ed se p a r a t e l y.

Manyde vice s , both purchas e d and "homemad e" , ha ve beenproposed for faci l it a ti ng one -han d ed nee d l e rec a pp ing .

36 These in clude wooden sta n d s with holes dri l l e d in the to p (Va s a nt, 19 8 6 ). polystyren e foam.bl ocks (Dowker , 19 8 7 ) . towel hol d e rs (Bailey, 19 8 6 ). "h edgehog" pencil holders (Vasant ,1987 ). usedfood cans (Kaufman, 1988) and specially desi gn e d nee d l e cap holde rs (Bessent et a1.. 1987 ; Parker, 1987; Sherwood Medical, 1989 ). All hol d th e cap while the need l eis being used:at the end ofthe procedu re, the needle is inserte d ba c k in to the cap. These devices a l low more con v eni e n t po s i t i on i ng of the ca p tha n la yi n g it on the nearest su r face. Th e gadgets are chea p, reus a bl e and portable. Whil e the y app e a r to pr ovide a sen s ib l e wa y to re c a p ne e d les , thei r effe c tive ness ha s not been studied (Birnba u m, 1988).

Safe r two-h a n d e d needle re c appi ng· Two-handed ne e dl e recapp i n g tQay be safer if the hand holding th e needle is pro t ecte d. Wider needle-ca pshave been prollloted (Huberand Sumne r , 19 8 7 ). as has arigiddisc-shapedshieldwhichhas an ope n i n g at its ce nt e r toenable it to slip over thecap and serve th e salle fu n c t i o n.

Goldwate r ana col l eag ues (Goldwateret al., 1987, 1989a ,1989b;Ni x o n ,1986) havereporte d a fo ur fo l d red uct ion in needlestick injuri e s among phl e b oto mi st s usi ng th ei r pa te n t e d "Needle Guard" shield . Mo st ne edl e s used by the su b j ects were at tached to va c uum - t u be bloo d colle ct i on equi p men t. The resul tswoul d be encouraging if they could be

37

reproduc edelsewhere , but thereare some puz zlingaspe c t s to the reported findings. The nuaberot'vene pu ncture s per f orme d dai l y by thes e"full-timevenepun ctu r i st s " (Goldwat e r et al .• 1989a) appear sto bevery low, fewe rthan t\olent yperperson.

In contrast, the present study found that many blood co l l e ctors usedbetwe en 60and 100 need les pe r shif t. The in j ury frequen c y for gua rd users is reported as 30 for 47 personsin33mo nths, whichc...eve r -es to anannual rate of 23.2 per 100 full-tim e emp loy ee s. Non-user shad arat e of 91. 7per 100. Even the rate achi eved by using thodevice (2 3 .2) is hi ghe rth a n the rang eof3.9 - 15 . 8repo r ted injuriesper 100 laborato ry emplo yee s (Table 2). In anot he r co mpari so n , Goldwater's red u ce d need1esti ck rate of 6.2 per 100,000 ve n e p unctures is similarto the 7.4per 100.000 repo rt ed by Mc Co rm i c k and Ha k i (1 981) in a study pre- da ti ng the CDC gui d e lines.

Gu a r d users inthe Gol dwa te r st udy re ported fewer ne edlestick in jurie s of all typ e s coaperedwi t h no n -use rs, though ther e is no obvio u s reas o n why the incid ence ot pro c e du r a l or dis po s a l inju ries woul d have beenaffecte d by the manner in whic h theca~wa s replac ed . It may be that those who chose to us e the guar d we r e mor e careful in all aspectsof need le-handling tha nno n-us e rs ; it mightaLs c mean theywe r e le s s likelyto reportinjurie s of anytype.

Thecr i te r iabywhich indi v i du als"wer eregarded as non-users" (Gold wateret al. , 19 8 9a) is unclea r. Empl oy e e s

38 feeling some pressure tosupp o r t the study may have declared themselves tobeus ers. Reportinga recappinginjurymayhave led to scrut iny of all aspects of anemp l oye e's technique , includi ng us e orno n- us e of the quaxu.Sinc e uninjuredpersons were no; likely to have been interviewed in depth , a compa r isonofthe prevalenceof guardusageand anestimation of i t s potentia l for reducing riskare not possib le.

RedesignetJ equi pme nt

Long-term approaches to controlling nee dlest i ck inju r iesinclude majo r changes in designand use of needles and related equipment. Ideally, a device to prevent ne edI e s t leks would exert i t s protective ef f ect without requiring any deliberate action on the part of the user.

Passivemea s u re s of injury prevention, fo r exampleautoma ti c air ba g s in automobiles , ....~ more effective than active strategies, such as seat bel t s,which require compliance of theindividual(Haddon,1974 ,Robertson,19 75) . Non-recapping or safer recappingstrategies failbecausethey require he a l th care wo r ke r s tota ke protective actionafter each and every ne ed l e use. A passive safety device wouldcoverthe needle t ipso that the operatorisne v er exposed to a cont a mi na t e d needle.

'9

One l-Lnd of device meeting these criteria is a needle ....hich, in ef f e c t, self-destructs with use. In one model, a solid piston is forced th r o ug h the hollow needle shaft and out through the end, so that the sharp tip is no linger exposed (Zi mme r ma n,1988). Other devices requirethe operator,oncetheneedle is used, to pushor ref ea s e into place a shield whf.ch covers the needle ti p. A search conduct ed in January, 1989 in the U.S. disclosed e Lqrrtee n patents is s u e din the precedingthree years for thistype of needle cov e r i n g device (Imai, 1989). The new products are moreexpensiveth a n those currently in use;theirefficacy in reducing needlesticks has yet to be establ ished .

Reducing the number of needle s used when

administeringdrugs has been suggested (Shu l manand Gorman ,

~988l• Kempen (19 88 and 1989) des cribed a Europ eanca n n u l a which eliminates the use of need Lea for adding drugs to secondary lines during intravenous therapy . Simila r l y , laboratoryuse of needl eand sy ri nge toaspirate and dispense samples has been discontinued wherever pos si bl e (Cal l ins, 1988). Existing manual andmechani calpi pett ingdev ices can replace needles for mostla bo r a t or y purposes .