Anaesthesia, 2006, 61, pages 867–872 doi:10.1111/j.1365-2044.2006.04751.

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Needle stick injuries: a comparison of practice and attitudes

in two UK District General Hospitals*
S. Raghavendran,1 H. S. Bagry,2 S. Leith3 and J. M. Budd4
1 Pediatric Anaesthesia & Pain Fellow, Department of Anaesthesia, Montreal Children’s Hospital, 2300, Rue Tupper,
Montreal H3H 1P3, Canada
2 Research Fellow, Department of Anaesthesia, Montreal General Hospital, 1650, Avenue Cedar, Montreal H3G 1A4,
Canada
3 Consultant Anaesthetist, Department of Anaesthesia, Wirral Hospital NHS Trust, Arrowe Park Road, Upton, Wirral
CH49 5PE, UK
4 Consultant Anaesthetist, Department of Anaesthesia, Worcestershire Royal Hospital, Worcestershire Acute Hospitals
NHS Trust, Charles Hastings Way, Worcester WR5 1DD, UK

Summary
Hospital staff are at risk from occupational exposure to blood-borne viruses due to needle stick
injuries. Occupational health departments have invested considerable resources in the prevention of
these injuries, which can be very distressing to the affected individuals. We surveyed health care
workers, i.e. doctors, nurses and operating department practitioners, in the operating theatre and
critical care units of two UK hospitals located in the Midlands and Merseyside to compare attitudes
and experiences. There were significant deficiencies in several aspects of the safe practice of
universal precautions. These deficiencies were similar in the two hospitals surveyed and may reflect
a national trend. We conclude that every individual, department and trust needs to reflect on their
practice and address these deficiencies.
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Correspondence to: Dr Sreekrishna Raghavendran
E-mail: sreeki71@hotmail.com
*Presented as a poster at the 1st National Outreach & Perioperative
Care Symposium, Manchester, UK on the 6th November 2005.
Accepted: 13 June 2006

Needle stick injuries account for 17% of accidents to precautions and prevention of needle stick injuries we
National Health Service (NHS) staff, second only to surveyed health care workers (HCWs) in the critical
injuries related to moving and handling of patients [1]. care, anaesthetic and operating departments of two UK
They also have a major economic impact on individual hospitals. We also aimed to compare responses between
hospitals; the Safer Needles Network estimated the cost to the various groups and the two hospitals.
each NHS hospital trust to be £500 000 a year. Needle
stick injuries cause significant stress and anxiety to the
Methods
affected individual and their families [2]. The Health
Protection Agency (HPA) reported in 2005 on all The survey was conducted simultaneously between April
significant occupational exposures between 1996 and and May 2005 as anaesthetic departmental audits. Iden-
2004 [3]. Percutaneous injury was the commonest injury tical anonymous forms (Fig. 1) were distributed to
reported, over half of these injuries involving nursing anaesthesia and critical care physicians, nurses in the
staff. Injuries also occurred post procedure due to the operating theatres and critical care units and operating
unsafe disposal of instruments and were largely prevent- department practitioners at two hospitals, one in the
able, as were five of the 10 cases of sero-conversion. It is Midlands and the other on Merseyside. We did not
clear that the serious consequences of needle stick include short-term locum and agency staff in our survey.
injuries can be markedly reduced by increasing aware- The responses were collated and analysed using Microsoft
ness of safe needle practice. To assess the practice and EXCEL 2000 and the results from the two hospitals
attitudes of staff with regard to the use of universal were compared.

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Journal compilation  2006 The Association of Anaesthetists of Great Britain and Ireland 867
S. Raghavendran et al. Æ Needle stick injuries Anaesthesia, 2006, 61, pages 867–872
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Figure 1 Survey form used in the audit at the two hospitals.

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868 Journal compilation  2006 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2006, 61, pages 867–872 S. Raghavendran et al. Æ Needle stick injuries
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Table 1 Summary of standard precau-

tions for care of all patients [13].
A. Hand washing
Regardless of whether gloves are worn, between patient contacts, and when otherwise
indicated
Between procedures on the same patient to prevent cross contamination of different
body sites
Plain soap for routine hand washing and antimicrobial agent for specific circumstances
B. Gloves
Wear clean non-sterile gloves when touching blood, body fluids, secretions, excretions, and
contaminated items, before touching mucous membranes and non-intact skin
Change gloves between tasks and procedures on the same patient after contact with material
that may contain a high concentration of micro-organisms
Remove gloves promptly after use and wash hands immediately
C. Mask, eye protection, face shield, appropriate clean non-sterile gown
Use appropriate protective gear during procedures and patient-care activities that are likely
to generate splashes or sprays of blood, body fluids, secretions and excretions
Remove soiled protective gear as promptly as possible and wash hands
E. Patient-care equipment, linen
Handling soiled equipment and linen to prevent exposure, contamination or transfer of
micro-organisms
Ensure equipment and linen are cleaned, reprocessed or discarded as appropriate
F. Environmental control
Routine care, cleaning and disinfection of patient care environment
G. Occupational health and blood-borne pathogens
Prevention of injuries when using needles, scalpels and other sharp instruments or devices
Never recap used needles
Do not remove used needles from disposable syringes by hand or manipulate used needles by
hand
Use appropriate puncture-resistant containers located as close as practical to dispose ⁄ reprocess
sharp items
Use mouthpieces and other alternatives to mouth-to-mouth resuscitation methods
I. Patient placement
Appropriate placement of a patient who does not or cannot assist in maintaining hygiene or
environmental control

Table 2 Summary of comparative results of the two hospitals.

Results Midlands Merseyside

In all, 258 doctors, nurses and operating department Followed universal precautions sometimes or rarely
practitioners responded to our survey, with an overall Senior doctors 52% 35%
Trainee doctors 15% 19%
response rate of 68% (Midlands 60% compared with Nursing & operating department 5.7% 3.9%
Merseyside 75%). The responses were higher from medi- personnel
cal staff (90%) than from non-medical staff (61%). Leaving sharps behind
Senior doctors 52% 30%
• 64% of respondents almost always followed the Trainee doctors 35% 29%
universal precautions described in Table 1. Nursing & operating department 11% 14%
• only 31% of the doctors surveyed almost always personnel
Clearing sharps for others
followed universal precautions compared to 80% of Senior doctors 71% 70%
nursing staff surveyed. Trainee doctors 75% 76%
• 70% of respondents cleared sharps for others; Nursing & Operating Department 79% 63%
Personnel
• 21% of the respondents admitted leaving sharps for Recap needles
others to clear; Senior doctors 47% 52%
• 43% of the respondents recapped needles after use; Trainee doctors 50% 52%
Nursing & operating department 39% 39%
• 53% of the respondents had suffered a needle stick personnel
injury sometime in their practice; Awareness of safer needles 45% 60%
• only 66% of those respondents who suffered a needle Incident form after needle stick 64% 66%
Hepatitis B
stick injury had reported it; Immunised 99% 100%
• only 54% of those surveyed were aware of the use of Documentation of status 62% 39%
safer needle devices in their practice. HIV
Aware of PEP 69% 58%
The individual results from the two hospitals are shown in Source of PEP 37% 41%
Table 2 and in Figs 2 and 3.

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Journal compilation  2006 The Association of Anaesthetists of Great Britain and Ireland 869
S. Raghavendran et al. Æ Needle stick injuries
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Universal Precautions – Midlands Hospital
Sometimes
11%
Rarely
5%
Figure 2 Adherence to universal precautions at the Midlands
Hospital.
Universal Precautions – Merseyside Hospital
Sometimes
7%
Rarely
4%
Figure 3 Adherence to universal precautions at the Merseyside
Hospital.
Discussion
The aim of this survey was to assess how well staff
followed precautions designed to protect them from
blood and body fluid-borne transmission of infection in
the operating theatre and critical care environments.
‘Universal Precautions’ were originally a CDC-defined
set of principles to protect against, and reduce the risk of,
blood-borne exposure. These were replaced by a different
set of principles called ‘Standard Precautions’ in 1996 [3].
This new set of Standard Precautions included principles
of body substance isolation and were aimed at reducing
not only the risk of blood-borne exposure but also
870
Anaesthesia, 2006, 61, pages 867–872
exposure to other body fluids. These standard precautions
are considered more relevant to the handling of con-
Usually
26% taminated instruments ⁄ equipment, and are described in
Table 1. In clinical practice, as in our survey, the terms
‘Universal Precautions’ and ‘Standard Precautions’ are
used interchangeably. These precautions apply to all
patients receiving care in hospitals, forming the corner-
stone for protection of HCWs from occupational expo-
sure. Omission of these precautions has been found to be
the commonest factor in occupational exposure [4].
In its surveillance report on occupational exposures in
England, Wales and Northern Ireland between July 1996
Always
58% and June 2004 entitled ‘The Eye of the Needle’, the Health
Protection Agency reported the following [4]:
• percutaneous injuries were the most common (78%);
• incidence was highest amongst nursing staff (45%)
followed by medical staff (37%);
• injuries occurring during the procedure were most
common (58%);
• injuries occurring postprocedure during disposal (37%)
were related to unsafe sharp practices and were mostly
preventable;
Usually • there were 10 documented sero-conversions, nine
18% hepatitis C virus (HCV) and one human immuno-
deficiency virus (HIV), all following percutaneous
exposure with hollow bore needles;
• of the nine HCV sero-conversions, six occurred
postprocedure, five of which were preventable;
• only 30% of HCV testing was done according to the
national guidelines.
Our survey has shown that only two-thirds of the
respondents followed universal precautions as described in
Always
Table 1. Doctors were more likely than nursing staff not
69% to observe universal precautions, following these guide-
lines less than a third of the time. Trainee doctors were
found to be better in their practice and this may reflect an
increased awareness and impact of changes in practice
during their training. Comparison of the responses
obtained from the two hospitals revealed a similar pattern,
with the exception of senior doctors performing better in
one hospital.
HCWs in the operating theatres and critical care areas
handle sharp instruments regularly and are at risk of
injury. These clinical locations accounted for 23% of
all reported occupational exposures, second only to the
wards [4]. We found that 53% of the respondents had
suffered a needle stick injury and the incidence was similar
in the two hospitals (Midlands 55%, Merseyside 51%).
The true incidence of sharp needle injuries remains
unknown due to under-reporting. The various study
methodologies and time scales used make incidence
comparison between different studies difficult. It is
estimated to be between 113 and 623 ⁄ 10 000 HCWs
 2006 The Authors
Journal compilation  2006 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2006, 61, pages 867–872 S. Raghavendran et al. Æ Needle stick injuries
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[5]. Since the first documented occupational exposure to viruses that are associated with a human carrier state with
a blood-borne virus (BBV) involving a HCW in the UK persistent viral replication and viraemia present the
in 1984, surveillance systems have been set up to examine greatest hazard. Immunisation is considered the most
exposures to blood-borne viruses [6, 7]. Incident reports important measure to protect the HCW against HBV and
are an important tool in these surveillance systems. Our provides immunity in up to 90% of the recipients [8].
survey found that only 65% of the HCWs who had With the exception of one person who was a non-
suffered a needle stick injury had filled in an incident responder, all HCWs surveyed were immunised against
form, with a similar pattern in the two hospitals (i.e. over HBV. However, many were unaware of their titres or
one third of all needle stick injuries were unreported). had no documentation of their immune status. Inadequate
Failure to report results in underestimation of the true immunity may expose the HCW to a sero-conversion
incidence and contributes to a lack of understanding of risk of up to 1 in 3 when the source is HBe antigen
the risk factors, hampering the objective evaluation of positive. The risk of HIV sero-conversion is believed to
remedial measures. Several respondents attributed their be 1 in 300 but could be higher depending on the viral
failure to complete an incident form to either a lack of load and volume of infected blood injected [9]. It has
time or felt it did not serve any purpose. Another been suggested that to achieve effective viral suppression,
reason quoted often was injury with a ‘clean needle’. therapy should target multiple sites on the virus [10].
However, where several professionals work together, a There is little published data addressing the efficacy of
sharp or a needle that is apparently ‘clean’ may not multidrug postexposure prophylaxis (PEP), but zidovu-
always be so. dine alone is reported to reduce the odds of HIV sero-
The National Audit Office quoting the EPINet conversion by 81% [9]. For optimal efficacy the Expert
results reported that 40% of HCWs who were injured Advisory Group on AIDS recommends that PEP should
were not the original users [1]. This is not surprising, be started as soon as possible following the incident,
considering that over two-thirds of those surveyed ideally within 1 h [11]. It is therefore essential that HCWs
admitted to clearing sharps for others and a fifth had are aware of the availability of PEP and where they can
left sharps for others to clear. These practices are a obtain it, especially out of hours. Only 39% of the
breach of universal precautions and increase the circle respondents in our survey knew where they could obtain
of exposure and the risk of injury. In our survey, 37% PEP.
of doctors left sharps for others to clear away, whilst We did not specifically ask questions regarding aware-
only 13% of nurses and operating department personnel ness of HCV but interviews with the respondents in both
reported doing so. With regard to clearing sharps for the hospitals led us to believe that they considered HIV
others, all three groups in both the hospitals were to be the greatest risk from needle stick injuries. We
equally guilty of non-compliance. Taken in conjunc- consider that the risk of HCV sero-conversion (up to 7%)
tion with the fact that doctors were three times more combined with the lack of an effective vaccine or any
likely to leave sharps behind, it is likely that nurses and proven prophylaxis after exposure needs to be stressed to
operating department personnel are left to clear away the HCWs [12].
these sharps. In our survey nearly half admitted to In conclusion, our survey illustrates the presence of
recapping needles, with little variation between the several deficiencies in safe needle practice that expose
different groups of HCWs. It is a common perception HCWs to blood-borne viruses. Strict adherence to
that this is a benign practice but it is in fact another universal precautions is fundamental and needs to be
independent factor in occupational exposure. All these emphasised. Although trainee doctors and nurses were
factors need to be addressed to reduce postprocedural better at safe sharp practices, there is room for further
risk of exposure that has contributed to six out of nine improvement. With a few exceptions, the trends in fol-
HCV sero-conversions in the HPA report [4]. The lowing various aspects of safe practice were similar in the
postprocedure phase is a vulnerable period, with oper- two hospitals and may represent a wider pattern. Not only
ators possibly lowering their guard. Failure to follow departments and trusts but also, more importantly, every
safe needle practice further escalates the risk. HCW must reflect on their individual practice and
The occupational health departments, the government address these deficiencies.
and the unions have highlighted the need for awareness of
safer devices and their use in clinical practice. Only half
Acknowledgements
the respondents in our survey were aware of the use of
such safer devices in their practice. The authors wish to express sincere thanks to the nursing
The risk of viral transmission is greater from the pati- staff, operating department practitioners and physicians
ent to the HCW [8]. HIV and the various hepatitis for their help and participation in our survey.

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