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Sharps injuries Lindsey Pearson’s Guidelines on
multiple choice practice profile how to write a
questionnaire on triage practice profile
Review Introduction
All articles are subject to external double-blind peer review and checked On evaluating the safety risks to staff in NHS
for plagiarism using automated software. hospitals, the National Audit Office (2003)
identified that 17% of accidents reported
Online were associated with needlesticks or sharps.
NSIs and sharps injuries are common among
Guidelines on writing for publication are available at healthcare professionals. Following a survey
www.nursing-standard.co.uk. For related articles visit the archive and of more than 4,000 nurses carried out by the
search using the keywords above. Royal College of Nursing (RCN) (2008), it
was estimated that 48% of nurses had received
an NSI or sharps injury. Inoculation injuries
may be subdivided into two categories: those
resulting from percutaneous exposure and
those resulting from mucocutaneous exposure.
Percutaneous exposure occurs as a result of HIV have been calculated (Adams and
a break in the skin caused by a needlestick or Elliott 2006a). The costs were estimated at
sharp contaminated with blood or body fluid. £1,540 for infection with hepatitis B, £235
Mucocutaneous exposure occurs when body for infection with hepatitis C and £938 for
fluids come into contact with open wounds, infection with HIV. These costs include
non-intact skin such as that found in eczema, or serological investigations, post-exposure
mucous membranes such as the mouth and eyes prophylaxis, healthcare consultations
(Haiduven et al 1999). There are more than 20 and assessments, and time associated
blood-borne pathogens that can be transmitted with attending occupational health clinic
following an NSI or sharps injury; the most appointments (Adams and Elliott 2006a).
common are hepatitis B, hepatitis C and human Furthermore, the financial costs associated
immunodeficiency virus (HIV). with the initial treatment of a staff nurse who
Complete time out activities 1 and 2 has seroconverted to hepatitis B, hepatitis C or
HIV following an NSI were also determined
NSIs and sharps injuries can transmit disease (Adams and Elliott 2006b). The approximate
and therefore are a significant occupational financial costs associated with seroconversion
hazard for healthcare professionals. At present to hepatitis B, hepatitis C or HIV following
there is no national surveillance system in place an NSI were £607 for hepatitis B, £7,298 for
to monitor healthcare-associated NSIs and hepatitis C and £938 for HIV. Activities that
sharps injuries in the UK. However, since 1997 incurred these costs included post-exposure
all cases of occupational exposure to hepatitis prophylaxis, serological investigations,
B, hepatitis C and HIV, and all incidents healthcare consultations or assessments
where post-exposure prophylaxis for HIV and time associated with attending clinic
has been commenced as a result of suspected appointments during the initial six to 12
inoculation, must be reported to the Health months of therapy.
Protection Agency (HPA) (Centers for Disease A study of the costs associated with the
Control and Prevention (CDC) 1997). implementation of safety devices to reduce the
One of the largest surveillance systems being risk of NSIs was undertaken in 18 hospitals in
introduced worldwide is EPINet (Exposure Sweden (Glenngård and Persson 2009). The
Prevention Information Network). EPINet study demonstrated that the increased cost of
provides a standardised method for recording the safety device was offset by the reduction
NSIs and mucocutaneous exposure, therefore costs associated with the investigation and
enabling identification of how future injuries treatment of a potential NSI.
of this nature can be prevented. The RCN has
undertaken studies using this system (May and
Churchill 2001). Psychological implications
Between 1997 and 2009, there were 17 The psychological effect of an NSI or sharps
recorded cases of healthcare professionals injury on a healthcare professional can be
developing (seroconverting) hepatitis C in significant. The individual may find waiting
England following percutaneous exposure to a for test results particularly distressing.
patient infected with the virus (NHS Employers Costigliola et al (2012) questioned 634 nurses
2005). Five cases of HIV seroconversions from western Europe and Russia who had
resulting from percutaneous exposure have experienced an NSI associated with diabetes
been reported in healthcare professionals in injections. They identified emotional responses
the UK. However, there have been no cases following such an injury, including depression,
of seroconversion to HIV from percutaneous crying spells, tension in the family, relationship
exposure since 1999 (HPA 2008). issues, panic attacks, excessive anxiety and
inability to work.
Many NSIs and sharps injuries are
Costs related to needlestick and preventable and employers have a duty to
sharps injuries ensure the safety of their employees. Member
Treatment costs and lost productivity as a states of the European Union have until
result of NSIs and sharps injuries may place May 11 2013 to implement the Council
added financial strain on the NHS. Financial Directive 2010/32/EU Implementing the
costs associated with initial treatment of a Framework Agreement on Prevention from
staff nurse following exposure to a patient Sharps Injuries in the Hospital and Healthcare
infected with hepatitis B, hepatitis C and Sector. The main aims of the directive are to:
Four key factors should be examined when and Elliott 2003). Safety devices are only
evaluating a safety device. These are: safety, as good as the operator using them. If the
usability, compatibility with need and ensuring operator fails to activate a safety feature for
the device does not cause other concerns such any reason then the device is not protected
as splatter on activation (Adams and Elliott and the healthcare worker is at risk from an
2003, 2006c). To assess product safety a NSI or sharps injury.
systematic evaluation should be undertaken. Fahey and Henderson (1999) reported that
Users of the device should also evaluate one reason why these devices sometimes fail to
the product in the clinical setting (Adams reduce NSIs was that they were not accepted
by healthcare professionals. This was because
they had not received comprehensive training
TABLE 1 in their use and their implementation in the
Percentage and rate of needlestick injuries clinical area was poorly managed. Therefore
caused by hollow bore needle devices it is essential that healthcare professionals are
Device % Rate* involved in the selection and evaluation of
Disposable syringe and 35 6.9 safety devices.
needle Several studies have demonstrated the
effectiveness of safety devices in reducing NSIs
Intravenous (IV) tubing and 26 36.7
and sharps injuries. Wolfrum (1994) evaluated
needle assemblies
a needle-free IV system for all inpatients at a
Pre-filled syringe cartridges 12 8.3 394-bed hospital in the US. A 68% reduction in
Winged steel IV sets 7 18.2 NSIs was noted following introduction of the
Vacuum tube phlebotomy 5 25.4
system. The CDC (1997) evaluated three types
assemblies of safety device designed to reduce the risk of
phlebotomy-associated inoculation injuries in
IV stylets 2 18.4
healthcare professionals. A 23-76% reduction
Other devices 13 N/A in NSIs was identified when safety devices
*Rate per 100,000 devices purchased were used, compared with routine products.
(Jagger et al 1988)
In addition, healthcare professionals found the
devices relatively easy to use. Chen et al (2000)
evaluated a safety winged steel needle blood
BOX 1 collection set at a 1,100-bed hospital between
Main features of safety devices
1998 and 1999. The study demonstrated a
59% reduction in reported NSIs.
During use: A four-year study was undertaken in the
Can be activated using a one-handed technique or routine use of the UK to evaluate the effect of the introduction
device causes the safety mechanism to deploy automatically (passively)
of an educational strategy and a range of
immediately after the sharp has been used.
safety hypodermic needle devices on the
Does not obstruct vision of the tip of the sharp.
Offers a good view of any aspirated fluid. number of NSIs. Following the enhanced
Does not require more time to use than a non-safety device. educational strategy, NSIs were reduced by
Works appropriately with a wide variety of hand sizes. 18%. However, when only standard training
Easy to handle while wearing gloves. was provided, the number of NSIs increased
Works with all required syringe and needle sizes. (Adams and Elliott 2006c). The subsequent
Provides a better alternative to traditional recapping. introduction of three safety needle devices
with concomitant training resulted in a
After use: significant reduction (70%) in reported NSIs.
Clear and unmistakable change (audible and/or visible) occurs when the
The Health and Safety Executive (2012) has
safety feature is activated.
recently undertaken a systematic review of
Operates reliably.
Exposed sharp is permanently blunted or covered after use and remains so the efficacy of safety devices and their effect
until and after disposal. on NSIs and sharps injuries. The review
No more difficult to dispose of after use than non-safety devices. found that there was sufficient evidence to
support the use of safety devices to reduce
These criteria represent optimal target features, which may not be the incidence of sharps injuries among
achievable in every device; they do not represent an exhaustive list and may healthcare workers in the UK.
evolve over time. Following the introduction of any safety
(Strauss and WISE Consensus Group 2012) device it is important to ensure that continuing
product reviews are undertaken. This will
Monoject Safety Syringe (Covidien) Nexiva Closed Intravenous Catheter System (Becton Dickinson)
Vacutainer Eclipse Blood Collection Needle (Becton Dickinson) Autoshield Pen Safety Needle (Becton Dickinson)
Surshield Safety Winged Blood Collection Set (Terumo) Retractable Disposable Sterile Scalpel (Swann Morton)
To improve reporting of such incidents, staff HSE is a national independent regulator for
should be educated about the risks associated work-related health, safety and illness issues.
with these injuries and should be aware of local
reporting procedures.
Complete time out activity 5 Measures to be taken following
needlestick and sharps injuries
As identified, there is a lack of evidence Healthcare professionals are potentially at risk
on the actual number of NSIs and sharps from acquiring a blood-borne virus following
injuries (NHS Employers 2005). Employers an inoculation injury. It is therefore essential
have a responsibility to report any exposures that any occupational exposure to blood or
to hepatitis B, hepatitis C or HIV to the body fluid is treated immediately, irrespective
Health and Safety Executive (HSE) under the of whether there is any known risk of infection.
Reporting of Injuries, Diseases and Dangerous The DH (2008) advises encouraging the
Occurrences Regulations (HSE 1995). The wound to bleed as the initial action following a
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