Nursing Practice Keywords: Needlestick injury/

Safety-engineered medical devices/

Review Education/Legislation
Needlestick injury ●This article has been double-blind
peer reviewed

A new law to protect workers from needlestick injury is being implemented,

but many trusts misunderstand which needles pose the greatest risk

Risk of needlestick injury

from injecting needles
In this article... 5 key
 here needlestick injuries most commonly occur
W
points
The risks associated with injecting needles 1 The 2010 EU
directive on
sharps injury
How to reduce needlestick injuries
prevention will
come into force in
Author Kenneth Strauss is endocrinologist hepatitis C (HCV) and HIV (European Par- May 2013
and director of safety in medicine,
European Medical Association, and global
medical director, Becton Dickinson.
liament, 2010). Many of these incidents,
for various reasons, never get reported.
HBV transmission requires only
2 There is a
business case
for reducing
Abstract Risk of needlestick injury from 1/10,000ml of infected plasma (Wittman needlestick injuries
injecting needles. Nursing Times; 108: et al, 2009), and many times this amount (NSIs) in terms of
40, 12-16 is  resent within the barrel or on the sides improving worker
EU legislation to reduce needlestick injury of medical sharps, even in devices not used safety, reducing
and consequent infections will come into expressly to draw blood or gain vas- the cost of treating
force in May 2013. The law will oblige cular  access. injured staff and
healthcare organisations to take measures A surprising number of NSIs occur avoiding costly
to prevent needlestick injuries to staff, and after use, during disposal. HBV is stable in legal actions
strongly recommends the use of safety-
engineered medical devices.
Some healthcare organisations have
dried blood for at least seven days and HCV
for at least 16 hours (Centers for Disease
Prevention and Control, 1995). Not all
3 Organisations
tend to focus
on safety-
already converted to using safety devices, healthcare workers are vaccinated against engineered devices
recognising the need to improve staff HBV; the European range is 30–90% for blood collection
safety, reduce the cost of treating injured depending on the country and branch of and infusion, rather
workers, and avoid expensive legal actions. medicine (Vos et al, 2006). than medical
The main focus of the directive seems injections
to be on safety-engineered devices for
blood collection and infusion, as healthcare
organisations often ignore or see the risk
Legislation to protect healthcare
workers
Much work has been done since the millen-
4 Nurses need to
be educated
on NSI risks
of injections into tissue as minimal. There is nium by healthcare worker associations to associated with
still a need for further education on the highlight the danger of NSIs. These injuries injecting into tissue
risks of injection.
This article reviews a number of
commonly held views regarding the risk of
have been described by the European Par-
liament as “one of the most serious health
and safety threats in European work-
5 The device
most
commonly
needlestick injury and discusses whether places… estimated to cause one million associated with NSI
the statements are supported by the injuries each year” (EU Commission for is the injecting
evidence. Employment, Social Affairs and Inclu- needle

N
eedlestick injuries (NSIs) are
one of the most frequent occu-
pational hazards faced by
nurses, phlebotomists, doc-
tors and other healthcare workers, as well
as those working in cleaning and waste
disposal. Such injuries are particularly
dangerous in view of their potential for
transmitting life-threatening bloodborne
Alamy
sion, 2010).
The 2010 EU directive on sharps injury
prevention (Council of the EU, 2010) will
become law in all EU countries by May
2013, and oblige healthcare organisations
to take measures to prevent NSIs to their
staff. One measure is the use of safety-
engineered medical devices (SEMDs);
these are needles, phlebotomy devices and Bloodborne viruses
intravenous catheters that incorporate can stay infectious

pathogens, including hepatitis B (HBV), shielding or retraction of the needle. after blood has dried

12 Nursing Times 02.10.12 / Vol 108 No 40 / www.nursingtimes.net

 Nursing Practice
Review
Needles used to draw
blood are seen as risky,
injecting needles less
so, although the latter
cause more injuries
Safety-engineered medical devices
NSI costs can be substantial when treat-
ment, lost working time and staff turnover
are taken into account. A number of organ-
isations have introduced full or partial
safety-device policies on the basis of a
measured business case. However, this is
not the only driving force for safety device
conversion. The threat of potentially dam-
aging legal cases, costly compensation
claims and adverse publicity, all of which
divert attention away from core objectives
of delivering high-quality healthcare, may
sometimes be the trigger.
There is an established perceived risk of
NSI with devices that have been in a vein,
whether to draw blood or to infuse medica-
tion, so many healthcare organisations are
focusing on these devices when taking
steps to reduce NSIs.
table 2. ratios of percutaneous injuries among IV catheters, hypodermic
needles and blood-contaminated hypodermic needles
EPINet study Number and percentage of percutaneous injuries
Country (year) All devices
US (1995) 3,003
Italy (1994) 2,915
Italy (1997-99) 6,872
Total/weighted average 12,790
Fotolia
Source: PHASE (2001; 2003)
14 Nursing Times 02.10.12 / Vol 108 No 40 / www.nursingtimes.net
table 1. Factors affecting risk of HIV transmission
Factor for HIV transmission
Deep injury
Visible blood on device
Needle having been directly in a vein or artery
Terminal illness in source patient
Source: CDC (1995)
*All significant at p<0.01
Although there is a definite risk, it is a
common misconception that most NSIs
occur with devices that have been in a vein.
The device most commonly associated
with NSI is an injecting needle. These nee-
dles are used frequently to give medica-
tions (such as insulin or antibiotics), to
aspirate fluids (such as from abscesses) or
to reconstitute drugs (for example, chemo-
therapeutic agents).
Many studies and surveys have placed
the common injecting syringe at the top of
the frequency table of NSI. In the UK, for
example, syringe needles cause more than
25% of NSIs (Watterson, 2005). An over-
view of epidemiological data from several
countries indicates that injection proce-
dures contribute on average to 21% of NSIs
(Valls et al, 2007; Bi et al, 2006; Cullen et al,
2006; Watterson, 2005; Perry et al, 2004;
PHASE study group, 2001; 2003) Injection
procedures are therefore an important
cause of exposure of healthcare workers to
biological and chemical hazards.
Risks posed by injections
Global conversion to safety-engineered IV
catheters and safety-engineered phle-
botomy sets has been faster than conver-
sion to safety-engineered injection devices
(Jagger et al, 2008), even though the last
cause more NSIs.
In the US, where the use of safety
devices has been mandatory since 2000,
the percentage conversion has lagged
IV catheters Hypodermic
needles
6% 33%
5% 30%
10% 44%
8% 38%
Odds ratio
16:1
5:2
5:1
6:4
behind (year on year) for disposable
syringes. There is a lack of perception of
the danger of injection-related NSIs, as
hospital administrators and staff seem to
believe that needles that have been inside
veins are riskier than injection devices.
It is a common view that devices that
have been in veins are more likely to
transmit bloodborne pathogens than
those that have gone into other tissues,
such as muscle or fat. However, while
exposure to blood is a risk factor, there are
factors with even higher risks.
Table 1 shows the odds ratio of HIV sero-
conversion as a function of certain factors
(Centers for Disease Control and Preven-
tion, 1995). An odds ratio of 1 implies that
the event is equally likely in both groups,
and an odds ratio of 16 means that a deep
injury is 16 times more likely to transmit
HIV than a non-deep injury. The depth of
the injury is the most important risk
factor. Table 1 shows that sustaining a deep
injury carries around three times the risk
for transmitting HIV than the presence of
visible blood on the needle, the needle
having been inside a vessel or the HIV posi-
tive patient later dying.
Another study showed similar results
regarding HCV conversion (Yazdanpanah
et al, 2005). Hypodermic needles have the
greatest potential for delivering deep inju-
ries. This is because, for both IV catheters
and safety-engineered phlebotomy, the
needle is inserted at a shallow angle with
Blood-contaminated
hypodermic needles
5%
6%
12%
9%
Nursing Practice
Review
the intention of entering a superficial vein,
while IM injections are given at 90° with
the intention to reach as deep into the
muscle as possible without going too deep
and into bone or organs.
Contamination of injecting devices
Studies conducted in the US and Italy
(PHASE Study Group, 2001; 2003), before
safety-engineered devices were intro-
duced, found that approximately one in six
hypodermic syringes and needles were
contaminated with blood (Table 2). The
risk of NSIs from blood-contaminated
hypodermic needles is comparable with
the risk from IV catheters.
It is often impossible to tell, simply by
looking, which hypodermic device is con-
taminated and which is not. Not seeing
blood can lure healthcare practitioners
into a false sense of security about NSI
with injecting devices.
The average volume of blood inoculated
in an associated injury via a 22-gauge
needle is approximately 1.0μl and it only
takes minute quantities of blood to
transmit viruses (Wittman et al, 2009).
Table  3 shows the volumes of blood that
are required to transmit HIV, HCV and
HBV; this much blood is frequently present
in used hypodermic needles, and is often
not visible to the naked eye.
Reducing needlestick injuries
No intervention can reduce NSI risk to
zero, but safety-engineered devices reduce
the risk consistently and significantly. A
huge range of independent studies con-
ducted in Europe and elsewhere in the
world show that a combination of training,
safer working practices and the use of
medical devices incorporating safety-
engineered protection mechanisms can
prevent more than 80% of needlestick inju-
ries (De Raeve, 2010).
One prospective study from the Univer-
sity Hospital of Birmingham (Adams and
Elliott, 2006) found that after safety-engi-
neered devices had been introduced along-
side training, NSI rates fell from 20 per
100,000 procedures to six per 100,000.
This study also showed that training and
education alone can achieve a modest NSI
reduction but this reduction is not sus-
tained in the absence of safety-engineered
devices. Significant and sustained NSI
reduction came only when safety-engi-
neered products had been added to
enhanced education.
Further studies showing similar results
have been published from France (Lamon-
tagne et al, 2007), Spain (Valls et al, 2007)
and the US (Jagger et al, 2008).
16 Nursing Times 02.10.12 / Vol 108 No 40 / www.nursingtimes.net
table 3. Viral load and quantity of blood
sufficient to cause one infection
HBV and HCV viruses can be transmitted via a small amount of blood
Viral load per microlitre of Quantity of blood per
blood in a 22G at viral stage infection
HIV up to 10,000 viruses HIV 1ml
HCV 1,000,000 viruses HBV 0.001ml
HBV 1,000,000 viruses HCV 0.001-1ml
Source: Wittman et al (2009)
Healthcare budgets
When considering converting to safety-
engineered medical devices, many pur-
chasing departments take into account
only the additional percentage in costs,
whereas the use of a safety device is an
investment for the institution as a whole.
In a recent study in Belgium, health
economist David Larmuseau has shown
that a conversion to safety-engineered
devices saves nearly half a million euros
per year (Larmuseau, 2007).
Healthcare organisations that have con-
verted recognise that adopting safety-
engineered medical devices is funda-
mental to a safer working environment, to
eliminate the cost of treatment and staff
absence, and to avoid damaging and
expensive legal action.
Conclusion
In contrast to common belief, the risk of
NSIs from injecting needles is greater than
other activities, such as blood drawing and
cannulation.
Now that the EU directive is being
implemented, conversion to safety-engi-
neered devices is swiftly becoming a more
urgent consideration, as healthcare organ-
isations will be obliged to take preventive
and protective measures in all situations
where there is a significant risk of sharps
injury and infection.
Hospitals and other healthcare organi-
sations will need to build strategies so they
comply with the directive, and not to wait
for the May 2013 deadline. These strategies
should definitely include measures to pro-
tect healthcare workers when carrying out
medical injections. NT
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