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Preventing Needlestick Injuries

2 Contact Hours
This peer reviewed course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN), Respiratory Therapist (RT)
This course will be updated or discontinued on or before Thursday, April 14, 2022
Outcomes

≥ 90% of participants will be able to identify risk factors associated with increased risk of needlestick injuries and how to respond to needlestick injuries, including a brief review of pre-and post-exposure prophylaxis.

Objectives

After completing this continuing education course, the participant will be able to meet the following objectives:

  1. List the top three healthcare professionals who are most at risk of experiencing a needlestick injuries
  2. Identify the three most commonly transmitted diseases associated with contaminated needlestick injuries
  3. Identify the role the OSHA plays in preventing work-related injuries
  4. List two interventions which could decrease the risk of needlestick injuries
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Berthina Coleman (MD, BSN,RN)

Introduction

Percutaneous injuries amongst clinicians and other healthcare professionals remains a significant concern given the associated increased risk of contracting blood-borne pathogens. Note that 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.

Epidemiology

It is difficult to get an exact number on the global incidence of needlestick injuries among clinicians and other healthcare workers due to the underreporting of the incidents. The actual 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 a total of 148 studies were reviewed from 4 continents. The pooled 1-year incidence globally of studies published during the ten period between 2008 - 2018 is 35.1%.1 Of all the percutaneous injuries, needlestick injuries were the most common type to occur.

According to the CDC, 52% of all percutaneous injuries occur during the use of the device while 23% of the injuries occur before or after use or during steps in a multi-step procedure.2

The devices most commonly involved in a sharp injury among healthcare workers include2:

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

High-Pressure Injection Type Injuries

High-pressure injection injuries are caused by industrial equipment designed to force liquids at high pressures through a small diameter nozzle. Depending on how close the nozzle is positioned with respect to the skin surface, the liquids can penetrate intact skin and dissect along fascial planes leading to an inflammatory response, which is not only determined by the type of substance injected but also the amount and viscosity of the material. High-pressure injection injuries happen most commonly with the injector in the nondominant hand of the operator, especially using a trigger activated gun.

The severity of symptoms may not become apparent until hours after the initial injury. Most symptoms related to this injury tend to resolve spontaneously over a few hours.3

Specific Transmission of Diseases with Needlestick Injuries

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).1, 4

The landmark study by Prüss-Üstün et al. noted that every year an overwhelming number of infections were diagnosed after the occurrence of percutaneous injuries. In that study, there were 1000 cases of HIV, 16,000 cases of HCV infections, and 66,000 cases of HBV infections.1

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

Common Blood-Borne Infections

The most common fear associated with percutaneous injuries, especially needlestick injuries, is the risk of transmitting a blood-borne infection. The most common blood-borne diseases are hepatitis B, hepatitis C, and human immunodeficiency virus infection.

Sharing contaminated needles and other equipment used for injections is a risky behavior that increases the risk of blood-borne transmission of diseases.

Hepatitis B Virus Infection

According to Coppola et al., there are up to 350 million people chronically infected with Hepatitis B virus in the world.5 Each year approximately 800,000 people die from advanced cirrhosis and liver cancer.6

The progression to a chronically infected state depends on the age at the time of infection. Babies born to Hepatitis B antigen-positive mothers progress to chronicity in 90% of cases, while adults who contract hepatitis B only progress to a chronically infected state in 2 - 5%.5

Increased prevalence and stringency of screening procedures have significantly decreased the risk of HBV transmission through transfusion of blood and blood products.5

Hepatitis C Infection

According to the World Health Organization (WHO), there are around 130-150 million people who are chronically infected with HCV.7 In 70% of cases, the HCV infection progresses to a state of chronic infection, which may eventually lead to cirrhosis.

Human Immunodeficiency Virus

HIV is transmitted by exposure to or exchange of blood and other bodily fluids from which may occur with exposure to contaminated sharps, including needles.

Experiencing accidental percutaneous injuries amongst healthcare workers is also considered a risk factor for contracting a blood-borne disease.8

Modes of Exposure and Factors Associated with Blood-Borne Pathogen Transmission in Healthcare Workers

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.4

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.5

In general, the chance of being infected depends on the amount of blood or bodily fluids the healthcare worker is exposed to, as well as the depth of the injury. In general, intravenous exposure is more likely to transmit pathogens compared to subcutaneous or intramuscular exposure.5

Risk Factors Associated with Needlestick Injuries

To prevent needlestick injuries, it is first essential to understand the circumstances under which these injuries occur.1

Auta et al. noted that the highest prevalence of needlestick injuries in healthcare professions was amongst surgeons, nurses, and laboratory staff workers.1

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 getting an injury compared to healthcare workers with more than five years of working experience.

When comparing male and female healthcare workers, there was no difference in the incidence of needlestick injuries. Healthcare workers who received training on the prevention of 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 who work in the hospital setting are at increased risks of percutaneous injuries compared to those who work 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.1

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.9

As previously mentioned, the healthcare workers most at risk for experiencing percutaneous injuries secondary to sharps are surgeons, nurses, and 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 the use of hollow-bore needles are related to increased risk of transmission of disease.

What is the Toll Associated with Needlestick Injuries?

Needlestick injuries among healthcare workers can be very costly both in the testing required after the needlestick as well as 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 they 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, which demonstrated that the average indirect and direct costs of a needlestick injury are around $747.10

The mechanical damage related to needlestick injuries are minimal. The most considerable risk associated with needlestick injuries is the risk of contracting a blood-borne disease such as Human immunodeficiency virus, Hepatitis B or Hepatitis C.4

Preventing Needlestick Injuries

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

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, using 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 using needles and other sharps safely. Employers and overseeing governmental agencies are also responsible for providing safety guidelines or procedures and creating a safe working environment.1

Management of Percutaneous Injuries

Pre-Exposure

Prevention of exposure is the primary method used to reduce percutaneous injuries. Employers must have institutional protocols that elaborate on the safe use of medical devices as well as provide physical, emotional, and organizational support as well as counseling. Education of healthcare workers should include teaching staff how to use devices as well as eliminating unnecessary injections, avoiding needle recapping, disposing of sharp objects in the appropriate containers, using safety devices appropriately, and training new staff adequately.5

Another vital component of pre-exposure management is vaccination specifically as it pertains to hepatitis B virus. The standard vaccination schedule for hepatitis B virus is three vaccination series, and it has been incredibly valuable in reducing the prevalence of hepatitis B among healthcare workers over the past few decades.5

Post-Exposure

According to the 2013 report from the US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis, the risk of infection in a non-immune recipient after a contaminated needlestick is between 37% to 62% for Hepatitis B, 2% for Hepatitis C and 0.3% for HIV.9

Currently, postexposure prophylaxis is recommended for HIV and hepatitis B. Hospitals and other healthcare institutions should have predetermined protocols designed with input from infectious disease specialists that the staff are well educated on and can be easily implemented. In addition, these should be reviewed regularly and updated as appropriate.11

Post-exposure prophylaxis is an integral part of the management of blood-borne pathogens. One of the first steps is to limit the transmission to just the staff exposed.

The Role of the Occupational Safety and Health Administration (OSHA)

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 which have been critical for reducing sharp injuries include avoiding recapping needles when possible or using one-handed recapping technique when appropriate. Also, just wearing gloves or double gloving has been shown to be effective in reducing 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, the use of curved needles with a needle driver has been shown to reduce the risk of a needlestick injury compared to using straight needles.

Clinical Scenario

You are 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.

Clinical Scenario Discussion

Your options are to either call to nurse to immediately dispose of the needle or do it yourself by discarding the used sharp immediately into a sharp-safe container to prevent any potential injury of either the staff or the patient. Given that the device is safety-engineered, it not necessary to worry about needle recapping at this time. However, it is essential to remember to avoid needle recapping as much as possible. If it cannot be avoided, a one-handed technique should be used to prevent and decrease inadvertent needlestick injury.

Conclusion

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 the part to ensure a safe work environment for both the staff and the patients in their care.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
OR
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)

References

  1. Auta A, Adewuyi EO, Tor-Anyiin A, et al. Global prevalence of percutaneous injuries among healthcare workers: a systematic review and meta-analysis. International Journal of Epidemiology. 2018;47(6):1972-1980. doi:10.1093/ije/dyy208.
  2. CDC - Stop Sticks: Sharps Injuries - NORA. Centers for Disease Control and Prevention. Published February 26, 2019. Visit Source.
  3. Quinn J. Puncture Wounds and Bites. In:, . eds. In: Tintinalli JE, Ma O, Yealy DM, et al., eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9th ed. McGraw-Hill New York, NY.
  4. Elseviers MM, Arias-Guillén M, Gorke A, Arens H-J. Sharps Injuries Amongst Healthcare Workers: Review Of Incidence, Transmissions, And Costs. Journal of Renal Care. 2014;40(3):150-156. doi:10.1111/jorc.12050.
  5. Coppola N, De Pascalis S, Onorato L, Calò P, Sagnelli C, Sagnelli E. Hepatitis B virus, and hepatitis C virus infection in healthcare workers. World Journal of Hepatology. 2016;8(5):273. doi:10.4254/wjh.v8.i5.273.
  6. Lavanchy D, Kane M. Global Epidemiology of Hepatitis B Virus Infection. In: Liaw Y-F, Zoulim F, eds. Hepatitis B Virus in Human Diseases. Springer International Publishing, Imprint: Humana Press; 2016.
  7. WHO Guidelines Approved by the Guidelines Review Committee. Guidelines for the screening, care, and treatment of persons with hepatitis C infection. World Health Organization, Geneva. 2014.
  8. Mauss S, Berg T, Rockstroh J, Wedemeyer H, Sarrazin C. Hepatology 2013: A Clinical Textbook. 6th ed. Flying Publisher; 2015.
  9. Gropper MA, Miller RD. Miller's Anesthesia. Elsevier; 2020.
  10. Mannocci A, Carli GD, Bari VD, et al. How Much do Needlestick Injuries Cost? A Systematic Review of the Economic Evaluations of Needlestick and Sharps Injuries Among Healthcare Personnel. Infection Control & Hospital Epidemiology. 2016;37(6):635-646. doi:10.1017/ice.2016.48.
  11. Kuhar DT, Henderson DK, Struble KA, et al. Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis. Infection Control & Hospital Epidemiology. 2013;34(9):875-892. doi:10.1086/672271