Preventing Needlestick Injuries

Working in healthcare is an occupation that has inherent dangers. Needlesticks and other sharps injuries are some of the most common injuries to healthcare workers as there is often exposure to needles and other sharp instruments. Despite having numerous safeguards in place, the National Institute for Occupational Safety & Health or NIOSH (n.d.) estimates that there are 600,000 to 800,000 sharps injuries among healthcare workers annually. A sharps injury is defined as a break in the skin from a sharp object, such as a needle or scalpel, penetrating the skin and exposing the patient's blood or body fluids(Centers for Disease Control and Prevention [CDC], 2019). Needlestick injuries among healthcare providers can result in the transmission of bloodborne pathogens, resulting in considerable monetary and psychological costs. Understanding, preventing, and treating needlestick injuries is critical for the long-term safety of healthcare workers.

Needlestick injuries are a risk to any healthcare provider, though those using needles or other sharps, as in those working in the hospital or in other clinical settings where sharps are used, are at the highest risk. Needles and scalpels are the most common devices that cause injury in a clinical setting (Alsheheri et al., 2023). Needlestick injuries can occur at any point in care, from setup to use to transfer or hand off to another healthcare provider and clean up. Although needlestick injuries are common in healthcare, international evidence on the true incidence is lacking as many needlestick injuries go underreported. A study by Yun et al. (2023) noted that nurses were more likely than other healthcare providers to report needlestick injuries. The reason for underreporting in this study was multifactorial, though many healthcare workers did not recognize reporting as important.

Working in an environment with exposure to needles and other sharp instruments is the greatest risk factor for injuries in healthcare. Additional common risk factors include recapping needles, not using the needle's safety features correctly, and not disposing of sharps in a puncture-resistant container(CDC, 2021). In addition, a study by Alfulayw et al. (2021) noted factors such as insufficient training of staff, lack of appropriate safety needles, lack of personal protective equipment, lack of sharps containers, utilizing sharps more than necessary, and being short-staffed all contribute to increasing the risk of needlestick injuries in healthcare.

The greatest physical risk to nurses after a needlestick injury is the possible exposure to bloodborne pathogens. Although hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) are the most common bloodborne pathogens found with needlestick injuries, there is also a new concern regarding multidrug-resistant pathogen transmission. Here, we will review the most common bloodborne pathogens.

Needlestick injury carries significant costs, both financially and psychologically. The direct monetary cost of a needlestick injury, which includes testing for and the post-exposure prophylaxis treatment for bloodborne pathogens, is estimated at $500 per occurrence. Additional indirect costs include the treatment for the development of any chronic infections, counseling, replacing absent staff, and legal costs (Cooke & Stephens, 2017). The increased cost of safety needles and personal protective equipment (PPE) pales in comparison to the direct and indirect costs of needlestick injury.

The emotional burden of a needlestick injury is more difficult to quantify. Many healthcare workers are fearful of needlestick injuries. Awaiting results from testing for bloodborne pathogens, concern regarding developing a chronic disease, as well as time off work can come with a great emotional toll. Research has noted an association between suffering a needlestick injury and feeling symptoms such as anxiety, stress reactions such as post-traumatic stress disorder (PTSD), depression, and excessive worry(Cooke & Stephens, 2017).

Pre-exposure management of a needlestick injury starts with the prevention of the injury. Policies and protocols within healthcare systems and ongoing staff education and training are integral to preventing needlestick injuries (Alfulayw et al., 2021). Ensuring healthcare workers are up to date on pre-exposure vaccinations, such as the HBV vaccination, can help prevent seroconversion to the HBV virus if a needlestick injury were to occur.The three-step HBV vaccination, as well as standard precautions in healthcare, have been incredibly effective over the years, leading to a 98% reduction in HBV cases among healthcare workers. Healthcare facilities where employees are at risk of exposure to HBV are mandated to offer HBV vaccination to healthcare workers, although not all choose to be vaccinated for various reasons (Schillie et al., 2018). After vaccination is complete, it is recommended to confirm immunity by measuring hepatitis b surface antigens and ensuring the result is >10 milli-international units per milliliter (mIU/mL) (CDC, 2001).

The CDC has specific guidance on how to manage post-exposure needlestick injuries. First, it is recommended to wash the wound with soap and water. The healthcare worker should immediately contact their supervisor to report the injury and seek medical attention so prophylactic testing and treatment can begin. The patient, or source of the exposure, ideally is tested for bloodborne pathogens. State and local laws determine if patient consent is needed for testing.

HBV – The CDC recommends no further action for healthcare workers with documentation of three hepatitis B vaccinations and post-vaccination anti-HBs ≥ 10 mIU/mL. If the healthcare worker is unvaccinated or has anti-HBs <10 mIU/mL, further serologic testing and treatment are determined based on the patient's hepatitis B surface antigen status. Post-exposure treatment may include additional HBV vaccinations or receiving hepatitis B immunoglobulin (Schillie et al., 2013).

HCV – With no pre-exposure vaccination option for HCV, the CDC recommends, within 48 hours of a needlestick injury, HCV testing for the healthcare worker and patient, if possible. If the patient and healthcare worker have negative HCV antibodies or HCV ribonucleic acid (RNA) negative status, no further action is needed. Further testing for HCV and treatment depends on the patient's and healthcare worker's positive HCV RNA status (Moorman et al., 2020).

HIV – According to the CDC Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for post-exposure prophylaxis by Kuhar et al. (2013), post-exposure prophylaxis should be started after HIV exposure from a needlestick injury. Due to the complexity as well as the needed monitoring for drug interactions and toxicities, post-exposure prophylaxis should be managed by providers experienced in these medications, such as infectious disease specialists. Suppose access to rapid HIV testing is not available, or the patient is unable to be tested. In that case, post-exposure prophylaxis (PEP) should start immediately with three or more antiretroviral medications for a duration of 4 weeks. Follow-up visits for counseling, ensuring medication compliance, and HIV testing are imperative.

As noted previously, the actual prevalence of needlestick injury is unknown due to underreporting. Underreporting causes difficulties in analyzing the root cause, thus causing difficulties in implementing targeted interventions. Agencies such as the NIOSH provide essential information for healthcare workers to understand needlestick safety in the workplace. Occupational Safety and Health Administration (OSHA) is another agency that ensures a safe work environment, including standards for needlestick prevention in healthcare.

Prevention of needlestick injuries in healthcare workers starts with staff education. Continual education and training provide the necessary information on how to prevent needlestick injuries and can simultaneously stress the importance of reporting injuries. Prevention also includes fostering a non-punitive environment of support to create a culture where healthcare workers are not fearful of reporting needlestick injuries. Needless systems using blunt tip cannulas are important for needlestick injury prevention. These systems significantly reduce the frequency at which healthcare workers are exposed to needles. If needles must be used, as with intramuscular or subcutaneous injections, OSHA requires the use of needles with safety devices to reduce the risk of needlestick injury. If a safety needle is not available, recapping needles must be avoided. The needle should be disposed of immediately and in a safe manner. All contaminated needles and other sharps must be disposed of in OSHA-regulated sharps containers. PPE is another aspect of prevention. PPE such as gloves, gowns, and face masks can reduce the risk of exposure to blood or body fluids. Additionally, completing the HBV vaccination series and ensuring an adequate antibody response with post-vaccination anti-HBs ≥10 mIU/mL is key in preventing HBV transmission if a needlestick were to occur.

You are a registered nurse assisting the hospitalist with a central venous catheter (CVC) placement. The CVC kit the physician is using does not include safety covers for the needles. The procedure is completed without complications, and the physician leaves the remains of the kit for you to manage. The needles are placed tip down into the needle holder. There is a scalpel left on the sterile field with a protective cover noted as well as the used guidewire. Another physician finds you in the patient room, asking for assistance with a different patient.

Case Study Discussion

The patient you are caring for is resting comfortably and is sedated on a ventilator. The physician is insistent that you help with another patient without delay for a non-urgent matter. You know the risk of needlestick injury is very high in this scenario. You remember learning in your training never to leave sharps unattended and remember from annual training that there is a risk of exposure to bloodborne pathogens. You politely notify the physician that you will be able to assist once the sharps are managed. You carefully place all sharps into an approved sharps container and clean the remainder of the procedural kit as per institution protocol.

Leaving sharps unattended, even if there is no immediate threat, is never a good idea. If you were to have left the sharps unattended, there would have been a significant risk to the patient, healthcare workers, or visitors. Understanding the importance of sharps safety allowed you to manage the situation confidently and safely dispose of the sharps used in the procedure properly.

Healthcare workers are at high risk of needlestick injury. Understanding the significance of needlestick injury as well as risk factors aims to decrease the prevalence of injury. Reducing needlestick injury reduces exposure to bloodborne pathogens. Healthcare workers' knowledge of HBV, HCV, and HIV prevention, pre-exposure, and post-exposure prophylaxis is imperative to facilitate reporting of needlestick injuries and reduction of post-exposure chronic disease. Identifying and implementing prevention strategies is key to reducing needlestick injuries in healthcare workers.

• Alfulayw, K. H., Al-Otaibi, S. T., & Alqahtani, H. A. (2021). Factors associated with needlestick injuries among healthcare workers: Implications for prevention. BMC Health Services Research, 21(1), 1074. Visit Source.
• Alsheheri, S., Kayal, M., Alahmad Almshhad, H., Dirar, Q., AlKattan, W., Shibl, A., & Ouban, A. (2023). The incidence of needlestick and sharps injuries among healthcare workers in a tertiary care hospital: A cross-sectional study. Cureus 15(4), e38097. Visit Source.
• Centers for Disease Control and Prevention (CDC). (2001). Updated U.S. public health service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. Morbidity and Mortality Weekly Report, 50(RR11),1-42. Visit Source.
• Centers for Disease Control and Prevention (CDC). (2019). Stop sticks campaign. National Occupational Research Agenda (NORA). Visit Source.
• Centers for Disease Control and Prevention (CDC). (2021). Needlestick injuries are preventable. National Institute for Occupational Safety and Health (NIOSH). Visit Source.
• Centers for Disease Control and Prevention (CDC). (2023a). Hepatitis B surveillance 2021. Centers for Disease Control and Prevention. Visit Source.
• Centers for Disease Control and Prevention (CDC). (2023b). Hepatitis C surveillance 2021. Centers for Disease Control and Prevention. Visit Source.
• Centers for Disease Control and Prevention. (2023c). HIV incidence. Centers for Disease Control and Prevention. Visit Source.
• Cooke, C. E., & Stephens, J. M. (2017). Clinical, economic, and humanistic burden of needlestick injuries in healthcare workers. Medical Devices (Auckland, N.Z.), 10, 225-235. Visit Source.
• Datar, U.V., Kamat, M., Khairnar, M. Wadgave, U., & Desai, K.M. (2022). Needlestick and sharps’ injury in healthcare students: Prevalence, knowledge, attitude and practice. Journal of Family Medicine and Primary Care 11(10), 6327-6333. Visit Source.
• Kuhar, D. T., Henderson, D. K., Struble, K. A., Heneine, W., Thomas, V., Cheever, L. W., Gomaa, A., & Panlilio A. L. (2013). Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infection control and hospital epidemiology, 34(9), 875-892. Visit Source.
• Moorman, A.C., de Perio, M. A., Goldschmidt, R., Chu, C., Kuhar, D., Henderson, D. K., Naggie, S., Kamili, S., Spradling, P. R., Gordon, S. C., Russi, M.B., & Teshale, E. H. (2020). Testing and clinical management of health care personnel potentially exposed to hepatitis c virus — CDC guidance, United States, 2020. Morbidity and Mortality Weekly Report, 69(6), 1–8. Visit Source.
• Occupational Safety and Health Administration. (n.d.). Bloodborne pathogens and needlestick prevention. US Department of Labor. Visit Source.
• Schillie, S., Murphy, T.V., Sawyer, M., Ly, K., Hughes, E., Jiles, R., de Perio, M.A., Reilly, M., Byrd, K., & Ward, J.W., & Centers for Disease Control and Prevention (CDC). (2013). CDC guidance for evaluating health-care personnel for hepatitis b virus protection and for administering postexposure management. Morbidity and Mortality Weekly Report, 62(RR10),1-19. Visit Source.
• Schillie, S., Vellozzi, C., Reingold, A., Harris, A. Haber, P., Ward, J.W., & Nelson, N.P. (2018). Prevention of hepatitis b virus infection in the United States: Recommendations of the advisory committee on immunization practices. Morbidity and Mortality Weekly Report, 67(1),1–31. Visit Source.
• Yun, J., Umemoto, K., Wang, W., & Vyas, D. (2023). National survey of sharps injuries incidence amongst healthcare workers in the United States. International Journal of General Medicine, 16, 1193–1204. Visit Source.