Preventing Needlestick Injuries

Percutaneous injuries amongst clinicians and other healthcare professionals remain a significant concern given the increased risk of contracting blood-borne pathogens. Transmission of pathogens through human bodily fluids such as blood or mucosal secretions can occur when a sharp object penetrates the skin or when the contaminated blood and secretions are exposed to non-intact skin. Although transmission usually occurs more with penetrating injuries compared to mucosal exposures. In the healthcare setting, most transmissions commonly occur after needlestick injuries.

It is difficult to get an exact number of the global incidence of needlestick injuries among clinicians and other healthcare workers due to the underreporting of the incidents. The global prevalence of needlestick injuries among healthcare workers is difficult to estimate. There are very few robust recent studies published with global estimates.

Auta et al. conducted a systematic review and meta-analysis in 2018 in which 148 studies were reviewed from 4 continents. The pooled 1-year incidence globally of studies published during the ten periods between 2008 - 2018 is 35.1% (Auta et al., 2018). Of all the percutaneous injuries, needlestick injuries were the most common.

According to the CDC, 52% of all percutaneous injuries occur during the use of the device, while 23% occur before or after use or during steps in a multi-step procedure (CDC, 2019).

The devices most commonly involved in a sharp injury among healthcare workers include:

• a disposable syringe (27%)
• suture needle (25%)
• scalpel blade (6%) (CDC, 2019)

The three primary blood-borne pathogens of concern from exposure to human blood and other bodily fluids in the healthcare setting are human immunodeficiency virus (HIV), Hepatitis B (HBV), and Hepatitis C (HCV) (CDC, 2019).

The landmark study by Prüss-Üstün et al. noted that an overwhelming number of infections were diagnosed every year after percutaneous injuries. In that study, there were 1000 cases of HIV, 16,000 cases of HCV infections, and 66,000 HBV infections (Auta et al., 2018). 

Several factors can influence the risk of transmission of blood-borne infections after a percutaneous injury, including the type of device involved, such as a needle versus a scalpel.

Healthcare workers are at increased risk of transmission of blood-borne infections due to constant exposure to human blood and other bodily fluids. The exposure could be percutaneous or mucosal. Up to 75% of the exposures in healthcare are percutaneous injuries caused by sharps, including needles (Arias-Guillén et al., 2014).

Although exposure to blood and blood products is associated with the highest risk of acquiring HBV, HCV, and HIV, non-blood bodily fluids can also transmit pathogens such as cerebrospinal fluid, ascites, or infected fluid collections (Coppola et al., 2016).

In general, the chance of being infected depends on the amount of blood or bodily fluids the healthcare worker is exposed to and the depth of the injury. In general, intravenous exposure is more likely to transmit pathogens than subcutaneous or intramuscular exposure (Coppola et al., 2016).

To prevent needlestick injuries, it is first essential to understand the circumstances under which these injuries occur (Auta et al., 2018). 

Auta et al. noted that the highest prevalence of needlestick injuries in healthcare professions was amongst surgeons, nurses, and laboratory staff workers (Auta et al., 2018). 

In addition, they examined the prevalence of needlestick injuries based on work experience. They also noted that healthcare workers with less than five years of working experience had a higher risk of injury than healthcare workers with more than five years of working experience.

There was no difference in the incidence of needlestick injuries when comparing male and female healthcare workers. Healthcare workers who received training on preventing needlestick injuries were less likely to experience injuries.

Burnout and anxiety can increase the risk of experiencing a needlestick injury secondary to distraction while performing tasks. Healthcare workers in the hospital setting are at increased risk of percutaneous injuries compared to those in the non-hospital environment.

Given that the risk of healthcare workers experiencing a percutaneous injury is approximately 1 out of every 3 (35.1%), it is essential to decrease and prevent the risk of injury (Auta et al., 2018). 

Several factors influence the risk of transmission of diseases. These include the viral load of the infected blood source, the volume of blood the healthcare worker is exposed to, the type of percutaneous injury, the vaccination status of the healthcare worker in certain conditions such as HBV as well as the post-exposure prophylaxis after the needlestick injury has occurred (Gropper & Miller, 2020).

As previously mentioned, the healthcare workers most at risk for experiencing percutaneous injuries secondary to sharps are surgeons, nurses, laboratory workers, or paramedics. However, when adjusted for full-time equivalent (FTE) units, nurses are at increased risk of percutaneous injuries compared to the other healthcare professions.

One of the main reasons for this increase is that procedures that necessitate using hollow-bore needles are related to an increased risk of disease transmission.

Needlestick injuries among healthcare workers can be very costly in the testing required after the needlestick and the counseling, which may be required for the healthcare staff and their family members.

The consequences of needlestick injuries are not only limited to the physical impacts of contracting a disease but also include significant psychological effects, including the fear of potentially contracting a chronic disease such as Hepatitis and HIV.

Examples of psychological consequences include post-traumatic stress disorder, depression, and anxiety.

Healthcare workers who experience a needlestick injury can incur financial costs associated with the management of needlestick injuries. Mannocci et al. published a systematic review in 2016, demonstrating that the average indirect and direct costs of a needlestick injury are around $747 (Mannocci et al., 2016).

The mechanical damage related to needlestick injuries is minimal. The most considerable risk associated with needlestick injuries is contracting a blood-borne disease such as Human immunodeficiency virus, Hepatitis B or Hepatitis C (Arias-Guillén et al., 2014).

In general, healthcare workers tend to underreport incidents involving needlestick injuries; as such, there is a disconnect between the actual incidence of percutaneous injuries versus the reported incidence.

Reporting percutaneous injuries, including needlestick injuries, into a database or national registry is important. Still, it is also necessary that these incidents get reported to the appropriate supervisors so that they can be appropriately followed up.

Also, an integral part of prevention is discussing why healthcare workers underreport percutaneous injuries and interventions that will increase the number of reported incidents.

In some countries, there is a legislative mandate for the use and implementation of safety devices specifically engineered to prevent percutaneous injuries, specifically needlestick injuries.

Some interventions that could be instituted to prevent percutaneous injuries include; correcting certain behaviors, such as training healthcare workers to stop recapping needles after they are used.

Safety engineered devices such as automatically disabled syringes, needleless intravenous lines, blunt needles, or hollow needles can also significantly decrease the incidence of percutaneous injuries. Furthermore, increasing staff training and reducing their workloads can help prevent further injuries.

Although healthcare workers are responsible for safely using needles and other sharps, employers and overseeing governmental agencies are also responsible for providing safety guidelines or procedures and creating a safe working environment (Auta et al., 2018).

The Occupational Safety and Health Administration (OSHA) is an agency of the US government under the Department of Labor, which is responsible for safety at work. OSHA has worked to create and establish standards that protect health care workers from exposure to contaminated bodily fluids. A landmark act was passed in 2000 called the needle safety and prevention wisdom. OSHA mandates that the employer provides the necessary training, equipment, and timing that the workers require to do their jobs.

Other risk factors that increase the risk of experiencing a needlestick injury include: working the night shift, working long hours, and especially working shifts lasting longer than 24 hours.

Some interventions that have been critical for reducing sharp injuries include avoiding recapping needles when possible or using one-handed recapping when appropriate. Also, wearing gloves or double-gloving effectively reduces the incidence of percutaneous injuries in the healthcare setting.

In some scenarios, the use of specific equipment has been shown to reduce the risk of needlestick injuries. For example, using curved needles with a needle driver has been shown to reduce the risk of a needlestick injury compared to using straight needles.

You are a Nurse Practitioner rounding on an inpatient unit when you notice that one of the nurses administered a subcutaneous Lovenox injection on one of your patients but forgot to discard the needle. The needle is a safety-engineered device with an automatic lock deployed once the medication has been administered.

The prevention of percutaneous injuries, specifically needlestick injuries, is the joint responsibility of the healthcare worker, the employer, and governmental agencies such as OSHA. With each party doing their part to ensure a safe work environment for the staff and patients in their care.

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