AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 34:15–19 (1998)

Prevention of Needle-stick Injury

by the Scooping-Resheathing Method

Paul Froom, MD, MOccH,* Estela Kristal-Boneh, PhD, Samuel Melamed, PhD,
Avi Shalom, MD, and Joseph Ribak, MD, MPH

Background The objective of this study was to determine the effects of teaching the scooping-
resheathing method on the incidence of needle-stick injuries in medical students.
Methods Before starting their first clerkship, 81 medical students were given a 15-min lecture
on the high incidence and dangers of needle-stick injuries and a demonstration of the
scooping-resheathing method. The number of needle-stick injuries that occurred during the
3-month clerkship was compared with the number reported by 86 medical students who had
completed their first clerkship 1 year previously and had not been given such instruction.
Results Compared with controls, the study group had a 3.8-fold lower risk of needle-stick
injury (95% confidence interval, 2.0–7.4, P , 0.0001) and a 8.3-fold lower risk of multiple
needle-stick injuries (95% confidence interval, 2.0–35.0, P , 0.001). Those in the study
group, who consistently used the scooping method had a much lower risk of injury than those
who did not (1 of 36 [2.8%] vs. 8 of 45 [17.4%], P 5 0.039).
Conclusions We conclude that a lecture recommending the scooping-resheathing method is
effective in reducing the risk of needle-stick injuries in medical students during their first
rotation. Because this is the first time that an intervention not requiring change in equipment
has been successful, further studies are warranted to substantiate our findings and for
extrapolation to other medical personnel in other cultural settings. Am. J. Ind. Med.
34:15–19, 1998. r 1998 Wiley-Liss, Inc.

KEY WORDS: needle sticks; prevention; medical students; scooping

Needle-stick injuries are an important occupational
medical problem in medical care settings, among nurses
[Heald and Ransohoff, 1990], residents [Heald and Ranso-
hoff, 1990], physicians [Tandberg et al., 1991, Tokars et al.,
1992], blood bank technicians [McGuff and Popovsky,
1989], venipuncturists [Goldwater et al., 1989], and medical
students [Gompertz, 1990; Jones, 1990; Choudhury and
Occupational Health and Rehabilitation Institute, Israel, and the Department of
Epidemiology and Preventive Medicine, Sackler School of Medical, Tel Aviv
University, Ramat Aviv, Israel
Contract grant sponsor: the Committee for Preventive Action and Research in
Occupational Health, Israel Ministry of Labor and Social Welfare, Israel
*Correspondence to: P. Froom MD, Head of the Epidemiology Unit, Occupa-
tional Health and Rehabilitation Institute, P.O. Box 3, Raanana 43100, Israel.
Accepted 28 January 1998
Cleator, 1992; O’Neill et al., 1992; Chin et al., 1993;
Kirkpatrick et al., 1993; deVries and Cossart, 1994; Water-
man et al., 1994; Koenig and Chu, 1995; Resnic and
Noerdlinger, 1995; Shalom et al., 1995; Tereskerz, 1995;
Tereskerz et al., 1996]. They present a significant risk of
acquired infectious diseases, including HIV-1 [Link, 1988;
Gione et al., 1991], hepatitis B [Capilouto, 1992], and
hepatitis C [Kiyosawa et al., 1992].
Attempts to reduce the incidence of needle-stick inju-
ries have focused on eliminating recapping, because 22–
52% of needle-stick injuries [Ruben et al., 1983; Neuberger
et al., 1984; Advisory Committee on Dangerous Pathogens,
1986; Edmond et al., 1988; Jagger et al., 1988, 1990;
Kennedy, 1988; Gompertz, 1990; McGreer et al., 1990;
Morgan, 1991; Tandberg et al, 1991; Whitby et al., 1991] are
the result of such practices. However, recommendations
against recapping have been generally ignored because
doctors and nurses are afraid of sticking themselves and

r 1998 Wiley-Liss, Inc.

16 Froom et al.
others with the uncapped needle [Recommendations for
prevention of HIV transmission in heath-care settings, 1987;
Anderson et al., 1991]. Attempts to reduce recapping by
increasing the accessibility of disposal containers also failed
[Kransinski et al., 1987; Ribner et al., 1987; Edmond, 1988;
Linnemann et al., 1991], and in one study the reported
injuries actually increased [Linnemann et al., 1991]. The use
of a portable resheathing device has been shown to decrease
needle-stick injuries fourfold, from 1 in 4,000 to 1 in 16,000
injuries per blood drawing event [Goldwater et al., 1989],
but such equipment has not been widely adopted owing to
the added cost and administrative effort needed for implemen-
tation.
Other approaches have included a change in the recap-
ping method [Anderson et al., 1991] that does not require
any new equipment. One suggestion, the gravitational
resheathing method, calls for placing only the lower part of
the cap on the needle and then jiggling it with one hand so
that the cap falls into place [Anderson et al.,1991]. Another
one is the scooping-resheathing method [Green, 1986;
Anderson et al., 1991]: the cap is placed on any flat surface
available (including the patient’s bed), and the exposed
needle is inserted with one hand; the other hand does not
touch the cap. To date, neither of these methods has been
tested for efficacy in decreasing the incidence of needle-stick
injuries.
In Israeli medical students, the rate of needle-stick
injuries is high during the first rotation and then decreases
significantly on subsequent rotations [Shalom et al., 1995].
There are other limited data suggesting that in medical
students from other countries, percutaneous injuries are as
frequent or more frequent than the rate in health care
workers [Gompertz, 1990; Choudhury and Cleator, 1992;
O’Neill et al., 1992; Chin et al., 1993; Kirkpatrick et al.,
1993; deVries and Cossart, 1994; Waterman et al., 1994;
Koenig and Chu, 1995; Resnic and Noerdlinger, 1995;
Tereskerz, 1995; Tereskerz et al., 1996]. Jones [1990]
reported that 45% were stuck during a 10-month period,
with an average of 7.5 sticks over 2 years. Koenig and Chu
[1995] reported that 48% of all graduating medical students
recalled being exposed at least once to potentially infectious
body fluids during their last 2 years of medical school.
Another survey reported that 27% of medical students were
injured by sharp objects or had mucocutaneous exposure to
patients’ body fluids over a 6-month period [Resnic and
Noerdlinger, 1995]. Thus, this high-risk group is particularly
suited for interventional studies.
In the present study, we examined the effect of teaching
the scooping-resheathing method on the incidence of needle-
stick injuries among medical students during their first
clinical rotation.
METHODS
Study Group
The class of the Sackler School of Medicine, Tel Aviv
University, was asked to participate. This group was chosen
because their first experience on the wards is standardized,
and they are responsible for drawing the morning blood
samples. They have no special instruction on how to draw
blood. Before drawing their first blood, they accompany the
interns and are given instruction by the patient’s bedside. Of
the 86 students enrolled, 3 students did not respond despite
multiple attempts, and 2 students refused to participate. All
students were at the start of their first clinical rotation; the
study period covered the entire 3 months of the clerkship.
Historical controls were used for comparison and included
86 medical students of the previous year who did not receive
instruction on needle-stick risks and management and who
had no knowledge of the scooping method.
Intervention
Before starting the clerkship, the students were given a
15-min lecture on the dangers of needle-stick injuries and a
demonstration of the scooping-resheathing method.
Outcome Measures
A questionnaire, filled out at the end of the rotation to
avoid a possible interventional effect of monitoring, in-
cluded the following information: age, sex, marital status,
number of children, accident history, compliance with the
Center of Disease Control’s recommendations, experience
of drawing blood before starting the clerkship, number of
bloods drawn during the clerkship, number of needle-stick
injuries during the 12-week rotation, circumstance under
which each needle-stick injury occurred, knowledge of the
practice of recapping, and use of the scooping-resheathing
method taught to them previously. Accident proneness was
defined as a history of at least three injuries that resulted in
burns, broken bones, or cuts that required stitches. The
students were also asked about sleep time, amount of fatigue
they felt during the week, whether they were under stress
while drawing blood, whether they were under stress during
the rotation, and satisfaction with medical school. Re-
sponses to these questions ranged from 1 to 10 on a 10-cm
visual analogue scale, with 10 representing the highest score
for the various items. Previous experience was categorized
into four groups; none, 1–49, 50–99, and 100 or more blood
drawings.
Responses were compared with those of the controls
who had completed the same questionnaire a year previ-
ously. The results of this earlier study have been published
previously [Shalom et al., 1995]. Tests for statistical signifi-
 Prevention of Needle-stick Injury 17

TABLE I. Characteristics of the Medical Students Who Were Taught the compared with 69 6 38% in the controls. In the study group,
Scooping Method Compared With the Control Group Who Did Receive 36 students used the scooping method consistently (90% or
Such Instruction more of the time) and 45 students used it occasionally. In the
controls, none used the scooping method or the gravitational
Study Control method but recapped using both hands. The study group had
Characteristics group (n 5 81) group (n 5 86) P a nearly fourfold lower overall risk of needle-stick injury
and an eightfold lower risk of repeated injury than the control
Males 45 (56%) 51 (59%) N.S. group (Table III). The lower risk was for all types of injuries and
Married 17 (21%) 26 (30%) N.S. included those related to and unrelated to recapping.
Children 1 (1%) 7 (8%) N.S. Subgroup analysis of the study group showed that only
Mean age (years) 26 6 3 25 6 3 N.S. one student was injured by a needle-stick in two separate
Sleep (hours) 6.5 6 1.0 6.4 6 1.0 N.S. incidents of the 36 students in the study group who used the
Smoking 5 (6%) 5 (6%) N.S. scooping method 90% or more of the time. He was,
Accident proneness 12 (15%) 17 (20%) N.S. however, very accident prone, with a history of six signifi-
Previous experiencea 10 (12%) 14 (16%) N.S. cant accidents. The other 45 students who used the scooping
Vaccinated—hepatitis B virus 81 (100%) 85 (99%) N.S. method only occasionally had eight needle-stick injuries.
Close examination revealed that four of these injuries could
aDrew at least 50 blood samples before entering the clinical rotation. have been prevented by use of the scooping method: one
injury occurred during recapping, one injury occurred when
TABLE II. Comparison of Psychological Parameters in Medical the cap fell off, and two students were stuck with an
Students Who Were Taught the Scooping Method Compared uncapped needle. The other four injuries were unrelated to
With Controls the method used and occurred (one each) during filling of a
tube, while drawing blood, while withdrawing the needle,
Study Control and during intravenous manipulation. Thus, the risk of
Parameters group (n 5 81) group (n 5 86) P injury was sixfold higher among the students who did not
consistently use the scooping method compared with those
Ability to draw blood 7.7 6 1.6 7.9 6 1.5 N.S. who did (1 of 36 [2.8%] vs. 8 of 45 [17.4%], P 5 0.039, by
Tension while drawing blood 3.6 6 2.3 2.9 6 2.0 N.S. two-tailed Fisher’s exact test).
Desire to draw blood 6.4 6 2.5 6.1 6 2.7 N.S.
Tension on the wards 4.6 6 2.3 4.4 6 2.2 N.S.
DISCUSSION
Satisfied with medical school 7.5 6 1.7 7.1 6 2.0 N.S.
Fatigue 5.7 6 2.2 6.3 6 2.2 N.S.
The major finding of our study is that instructing
medical students about the dangers of needle-stick injury
and demonstrating the scooping-resheathing method can
cance included the student’s t test for continuous variables, substantially decrease the risk of needle-stick injury during
and the chi-squared test for nonparametric data. Fisher’s the first rotation. It is possible that most if not all of the effect
exact test was substituted if there were small numbers. was due to the lecture itself, because the instruction also
Relative risks with 95% confidence intervals (95% CI) were decreased the rate of injuries unrelated to recapping. Still,
calculated. the risk was much less in the students who used the scooping
method 90% or more of the time (44% of the cohort);
RESULTS previous interventional attempts that included information
on the dangers of needle-stick injuries were not successful
No significant differences were noted between the study [Ribner et al., 1987; Kransinski et al., 1987; Edmond et
and control groups in demographic parameters as well as al.,1988; Linnemann et al., 1991].
sleep time, accidents, previous experience in drawing blood, We were unable to achieve complete compliance, and
and vaccination against hepatitis B (Table I). Self-evaluated perhaps a more intensive educational process could have
fatigue, tension, and ability to draw blood as well as yielded better results, because in the high compliers, only
satisfaction with medical school were nearly identical in the one student was stuck, and he was accident prone, a trait we
two groups (Table II). have shown previously to be associated with needle-stick
On the average, between 8 and 12 venous blood injuries in medical students [Shalom et al., 1995].
samples were drawn per week by the study group over the The present study has several limitations. First, histori-
3-month period, which was also true for the control group. In cal controls were used, and it is possible that they were not
the study group, 70 6 41% of the time recapping was used equivalent to the study group in all relevant respects.
18 Froom et al.
TABLE III. Needle Sticks in Medical Students Taught the Scooping Method Compared With Controls
Injuries Study group (n 5 81)
Total number 9 (11%)
Unrelated to recapping 5 (6.2%)
Related to recappingb 4 (5%)
.1 injury 2 (2.5%)
aConfidence interval.
bIncludes injuries caused by the cap falling off and by leaving needles uncapped after sampling.
Personal characteristics, and self-evaluations of sleep, fa-
tigue, and tension were not significantly different in the two
groups, but we cannot rule out the possibility that increasing
publicity and concern about needle-stick injuries influenced
the study group more than the controls. This possibility does,
however, seem to be unlikely given the stable climate over
the 2 years of the study. Second, the questionnaires were
filled out after the end of the rotation, so that recall bias was
possible. This bias, however, would have been the same for
both groups, and we have already shown that questionnaires
repeated after a 3-month gap yielded identical answers
regarding the number of needle-stick injuries [Shalom et
al.,1995]. Finally it is possible that our results cannot be
extrapolated to other settings, because experience greatly
reduces the incidence of needle sticks in medical students
[Shalom et al., 1995], and it is uncertain if this intervention
would have any effect in those with more experience or if its
effect persists over time. There also may be cultural differ-
ences that could decrease the effectiveness of such interven-
tions.
We conclude that a lecture stressing the dangers of
needle sticks and recommending the use of the scooping
method resulted in a decreased incidence of needle-stick
injuries in medical students. Because this is the first time an
intervention not requiring a change in equipment has been
shown to be effective, further studies in medical students and
other medical personnel are warranted to substantiate our
findings and to determine whether increased compliance will
lead to an additional decrease in the incidence of needle-
stick injuries.
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