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A safer working environment – sharps safety;

A training package to protect healthcare staff from harm

© Daniels Healthcare 2007

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Overview of the session

A quick tour of the issues: risk and safety

Reporting & vaccination status

Standard Precautions &

waste management

Safety devices/engineering

controls


Outline of the session ► The session will deliver knowledge for evidence based

safer practice and will cover the following areas:►the most common procedures where needlestick

injuries occur.►Types of devices and injuries that affect risk of infection.►methods for preventing exposure.►critical review of the use of sharps and their necessity.►how changes in work practice can prevent injuries

(includes the role of safer needle devices).►current protocols and guidance, including standard

precautions.


Objectives of the sessionThe session is designed to equip staff for saferpractice. By the end of the session staff should be able to:

►Demonstrate knowledge of the risks of exposure to potentially harmful viruses

►Explain the importance of safe practices (demonstrating awareness of policies and protocols).

►Identify the efficacy of preventative and control measures.

►Describe the process of evaluation of needlestick injury and post-exposure follow up using real life examples


Who is at risk:

►Who is at risk of needlestick injury?

►Any worker who may come in contact with needles or other sharp instruments used on patients, including nursing staff, laboratory staff, doctors, porters and housekeepers.

NIOSH 1998


Definitions and scene setting

►Sharps injuries describe any incident in which a healthcare worker is stuck by a needle or other sharp instrument which penetrates the skin and which is contaminated with potentially infected blood

►The National Audit Office (2003) stated that sharps injuries are second only to back injuries as a cause of harm to staff – 17% of all injuries

►Contaminated needles can transmit more than 20 dangerous blood-borne pathogens including HIV, Hepatitis B and Hepatitis C

►At least 4 health care workers are known to have died following occupationally acquired HIV


Risk management►An integrated risk management policy is a must

►Risk assessment:►identify the risks►Manage and minimise – eliminate unnecessary injections

►Safer technology►Standard precautions►Immunisation & vaccination►Training

►A legal framework does exist (Health and Safety at Work Act (HASAWA), 1974, and the Management of Health and Safety at Work Regulations (1991)

►Control of Substances Hazardous to Health (COSHH regulations (2002) reinforce risk assessment and preventative strategies

Source: NHS Employers 2005


The detail:

►Assessing the risks►Risk assessment should be made of all situations

where HCW might be exposed to blood or other potentially infectious material. The aim is to:

►Identify what technologies could be used to limit exposures►Allow consideration of possible alternatives►Eliminate the unnecessary use of sharps by implementing

changes in practice and providing, where practicable sharp free devices or safer needle technologies which retract or shield needles after use

Source: NSH Employers 2005


Summary of key risk management strategies for safer practice

►Hierarchy of Controls►Elimination or substitution of sharp

(eliminate unnecessary injections)►Engineering controls (auto disable

syringes, safer needle devices)►Administrative and work practice

controls (standard precautions; no recapping; provision and placement of sharps containers)

►Personal protective equipment (eg gloves)

Source: WHO 2005

Least effective

Most effective


Reporting sharps injuries

►A core component of risk management:►Underreporting is a serious threat to management of

such injuries►Some studies suggest underreporting as high as 85%►Prompt reporting is critical – following local policy

►This ensures quick management and reduces risk of BBV transmission

►The incident is documented in case of future litigation►Helps with accurate surveillance to inform =development of

effective risk reduction strategies



Reporting sharps injuries

►Managing exposures - ►What is the local policy►All cases of exposure from blood or body fluid

from patients infected with blood-borne viruses (HIV, HCV, HBV) should be reported to the HPA national surveillance scheme

►HCW anonymity is guaranteed



Identifying alternatives

►Independent studies show that a combination of training, safer working practices and the use of devices incorporating sharps protection mechanisms can prevent more than 80% of needlestick and sharps injuries.

►The NHS PASA website offers an array of such devices.

►Provision of portable sharps containers for all staff at all times is crucial to allow used sharps to be disposed of at the point of use



Training

►Induction and ongoing training should cover sharps safety for all staff and particularly:

►The risks associated with blood and body fluid exposure

►Correct use and disposal of sharps►The use of medical devices incorporating sharps

protection mechanisms

►Refresher training is important


Question – is on the job training evident in the workplace?


National UK Guidelines

Standard Principles for the Safe Handling and

Disposal of Sharps:

►Part of a waste management strategy to protect staff, patients and visitors from exposure to blood borne pathogens.

►All sharps injuries are considered to be potentially preventable.

The UK Evidence BasedThe UK Evidence BasedGuidance (2001):Guidance (2001): EPIC

Prevention of HCAI in Primary and Prevention of HCAI in Primary and Community Care (2003)Community Care (2003)


National UK Guidelines

►National and international guidelines are consistent in their recommendations:►Assessment and management of risk►Safe systems of working►Safety devices (engineering controls)►Post exposure follow up and prophylaxis

The UK Evidence BasedThe UK Evidence BasedGuidance (2001):Guidance (2001): EPIC



Standard precautions1. Sharps must not be passed

directly from hand to hand and handling should be kept to minimum

2. Needles must not be bent or broken prior to use or disposal

3. Needles and syringes must not be disassembled by hand prior to disposal

Source: EPIC 2001

category 3/H&S

category 3/H&S

category 3/H&S



Standard precautions4. Needles should not be recapped.

5. Used sharps must be discarded into a sharps container (conforming to UN3291 and BS 7320 standards) at the point of use.

6. These must not be filled above the mark

indicating that they are full. Containers in public areas must not be placed on the floor and should be located in a safe position

7. They must be disposed of in community practices by the licensed route in accordance with local policy

Source: EPIC 2001

category 3/H&S

category 3/H&S

category 3/H&S

category 3/H&S



Standard precautions:Hands & gloves

8. Hands must be decontaminated immediately before each and every episode of direct patient contact/care and after any activity or contact that potentially results in hands becoming contaminated.

9. Use an alcohol based hand rub on hands not visibly soiled

10. Gloves must be worn for invasive procedures, contact with sterile sites, and non-intact skin, mucous membranes, and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions and excretions; and when handling sharp or contaminated instruments.

Source: EPIC 2001

category 3

category 3

category 3/H&S


Standard precautions:Hands & gloves

11 Gloves should be worn as single use items. Put gloves on immediately before an episode of patient contact or treatment and remove them as soon as the activity is completed.

12. Change gloves between caring for different patients, or between different care/treatment activities for the same patient.

13. Gloves must be disposed of as clinical waste and hands should be decontaminated following the removal of gloves.

Source: EPIC 2001

category 3/H&S

category 3/H&S

category 3


Standard precautions:Aprons & eye protection

14. Disposable plastic aprons should be worn when there is a risk that clothing or uniform may become exposed to blood, body fluids, secretions and excretions, with the exception of sweat.

15. Full body, fluid repellent gowns should be worn where there is a risk of extensive splashing of blood, body fluids, secretions and excretions, with the exception of sweat, onto the skin of health care practitioners.

category 3/H&S

category 3/H&S


Standard precautions:Aprons & eye protection

16. Plastic aprons should be worn as single use items for one procedure or episode of patient care and then discarded and disposed of as clinical waste.

17. Face masks and eye protection should be worn where there is a risk of blood, body fluids, secretions and excretions splashing into the face and eyes.

18. Respiratory protective equipmentshould be used when clinically indicated.

category 3/H&S

category 3/H&S

category 3/H&S


Safer needle devices►Needle safety devices must be

used where there are clear indications that they will provide safer systems of working for health care personnel.


Recent estimates suggest that safety devices exist in 11different product groups.Safety devices on the whole minimise risks in associationwith venepuncture, IV therapy, injections and "downstream"injuries following disposal (housekeeping and porteringstaff)

D/H&S


Sharps containers

►Should be at eye level and within arms reach►Should be emptied before they are full

►At ward or department level – whose responsibility is this?

►Are roles assigned and are checks made?►How would a situation be managed if there was a

failure to apply these simple measures?►Is a monthly, quarterly or annual audit enough?

Source: EPIC 2001 Prevention of HCAI in Primary and Prevention of HCAI in Primary and Community Care (2003)Community Care (2003)

Questions for consideration:


National strategies to promote infection control: Saving Lives

►A tool for evaluation of current practices.►Identifies areas for improvement.►All about getting the infrastructure right:►Poses a series of questions for hospitals and

clinical teams: ► are the EPIC guidelines for hand hygiene,

personal protection, and sharps disposal being followed?

► is an audit tool (e.g. ICNA audit tool in use and results acted upon?).

Source: DH1 2005

Q1.

Q2.


Saving Lives

►High Impact Intervention number 1 (elements of care, based on national evidence based, EPIC guidance (Pratt et al 2001):►Safe disposal of sharps

►Sharps container available at the point of use►No disassembling of needle and syringe►Not passed from hand to hand►Container should not be overfilled

Source: DH1 2005


After an injury or exposure

1. Local policy.2. Key points:

► First aid► Place under running water► Flush splashes to nose, mouth with water► Irrigate eyes with clean water or saline► Report to occupational health► Know your Hepatitis B vaccination status.► Prompt reporting is important in all cases to determine whether

post exposure prophylaxis is required (this needs to be started as soon as possible)


Root Cause Analysis (RCA)

►The key to RCA is asking the question "why?" as many times as it takes to get down to the root cause of an event:►What happened?►How did it happen?►Why did it happen?►What can be done to prevent it happening in

the future?

Source: CDC 2004


Average risk of transmission

►Hepatitis B Virus (HBV):

►Hepatitis C Virus (HCV):

►Human Immunodeficiency Virus (HIV):

Source: EPIC 2001

33.3% or 1 in 3

3.3% or 1 in 30

0.31% or 1 in 319


Risk Factors that increase the likelihood of HIV transmission following a needlestick injury

1. Deep injury

2. High viral titre in the patient on whom the device had been used

3. Visible blood on the device

4. Device in artery/vein

Source: CDC, MMWR 6/98


The Health Protection Agency (HPA) study 2005: Occupational Exposure to Blood-borne viruses

(BBV)

►Over 2000 exposures to BBV reviewed

►Percutaneous injury: 78% of all reviewed injury's from the Health Protection Agency (HPA)

►Nursing related professions – most commonly reported (45%)

Source: HPA 2005


The Health Protection Agency (HPA) study 2005: Occupational Exposure to Blood-borne viruses

(BBV)►2% of exposures were to porters, security

and housekeeping staff►Largely from sharps in rubbish bins

►Medical professions: 37%►Injuries sustained during the procedure were

dependent on the procedure – many not generally amenable to prevention.

►Injuries sustained after the procedure and during disposal – much more preventable – usually related to failure to comply with procedures relating to the safe handling and disposal

Source: HPA 2005


Outcome of exposure to BBVs

►Nine seroconversions following significant occupational exposure over a 7 year period

►Six involved male injection drug user source patients

►All seroconversions followed percutatous exposure mostly to fresh blood and involved hollow bore needles

►Six occurred after the procedure and five were preventable

►Many were preventable with adherence to standard precautions (38%)

Source: HPA 2005


The importance of surveillance of Occupational Exposure to Blood Borne Viruses in Health Care

Workers1. Data collection2. To identify risk factors necessary for seroconversion to

occur3. To examine type of exposure, staff involved and

circumstances surrounding the exposure4. To use the data to inform national prevention policies5. To monitor implementation of national HIV post exposure

prophylaxis (HIV PEP) guideline and influence future policy6. To raise awareness of reports of occupational exposure

and encourage all trusts and other health care providers to take part

7. To use data collected on HBV immunisation to monitor adherence to policy

Source: HPA 2005


Case study examples►Review the scenarios on the handout.

►Address the following questions in groups:

Based on WHO needlestick case studies 2005

►Was the use of a needle essential?

►Could the use of a needle safety device have prevented the injury, if so what type?

►Are these devices available on your unit?

►Are staff knowledgeable about their use?

►Would a change in work practice have prevented the injury?

Q3.

Q2.

Q4.

Q5.

Q1.


Critical questions for safer practice:

►Where is the needlestick policy kept and how is it publicised?

►What is the plan following an exposure and how are staff made aware of this?

►Are sharps injuries discussed at a regular team meeting?►Are safer needle devices used and if so do you play a

part in selection and evaluation of these devices►Are there any informational materials eg leaflets on

sharps injuries and are they readily accessible? Are these visible/pocket sized for example

►From the session – draw up a list of ways you could protect yourself


Learning checks:

►Avoid the use of needles wherever possible►Avoid recapping needles – instead immediately place the

uncapped needle into a sharps box►Think ahead and plan the safe handling and disposal of

sharps before using them – is there a sharps container in the vicinity

►Never fill a sharps container more than three quarters full►Carry used sharps containers carefully►Don’t open or empty sharps containers►Store sharps containers in a secure place until ready for

removal for incineration►Make sure your immunisations are up to date

Source: WHO 2005


National

Hospital

Ward/ department

Individual

National guidance,Policies and

tools

SavingLives

EPICguidelines

National e training

ICNA audit

NHS Employers

Trust policiesProcedures and

committees

Infection Control

H & Scommittee

Risk Management

Occ Health

NHS Employers

Policies and promotion of same.Is the ward climate conductiveto safety?What about training/refreshment?And audit programmes?

Personal experiences in terms of availability of training/sharps boxes/policy/safer needle devices

Summary: a map of prevention – from national strategies to individual staff


Recap – hierarchy of controls

►Remove the Hazard

►Isolate the hazard – protective devices/engineering controls

►Use needles that retract, sheath or blunt immediately after use

►Work practice controls and personal protective equipment (Hep B vaccination)

Source: CDC Workbook. Sharps Injury Prevention


Summary:

►While studies show that reductions of needlestick injuries are achievable, it is difficult to identify the efficacy of individual control measures in studies with numerous interventions.

►Reducing sharps injuries by the greatest amount possible will entail a combination of►Elimination of procedures using sharps►Education►Safer devices►Positive work conditions►Standard precautions

Source: WHO 2005


Conclusion

►The risk of a sharps injury begins at the moment a sharp is first exposed and ends once the sharp is permanently removed from exposure in the work environment.

►Staff need to have an awareness of the risk of injury throughout the time a sharp is exposed and use a combination of strategies to protect themselves and their co-workers.

Source: CDC 2004


Sources of material and references► Publications: ► Health Protection Agency (2005) Eye of the Needle: Surveillance of Significant Occupational Exposure to Bloodborne Viruses in Healthcare Workers.

Centre for Infections; England, Wales and Northern Ireland Seven-year report► Department of Health (2005) Saving Lives khcdja ► Pratt RJ, Pellowe C, Loveday HP, Robinson N, Smith GW, et al (2001) The EPIC Project : developing national evidence baesed guidelines for

preventing healthcare associated infections. Phase 1 guideliens for preventing hospital-acquired infections J Hosp Infect 2001; 47: S3-S82 ► NHS Employers (2005) The management of health, safety and welfare issues for NHS staff, chapter 19: Needlestick Management ► NAO (2003) A safer place to work – improving the management of health and safety risks of staff in NHS Trusts► NIOSH (1998) How to Protect Yourself From Needlestick Injuries Department of Health and Human Services Public Health Service Centers for Disease Control and

Prevention National Instutute for Occupational Safety and Health

► Wilburn S, Eijkemans G (2004) Preventing needlestick injuries among HCWs: A WHO – ICN collaboration. Int J Occup Environ Health vol 10 no 4 www.ijoeh.com

► Websites:

► EPIC Guidelines: http://www.epic.tvu.ac.uk/epicphase/1.html ► ICNA Audit Tools: Infection Control Nurses Association (2004) available from: www.icna.co.uk ► The European Forum for protection of Healthcare Professionals in a safer working environment http://www.needlestickforum.net ► NHS Purchasing and Supplies Agency product related information relating to sharps safety: www.pasa.nhs.uk/medicalconsumables/sharps/► WHO (2005) Protecting Healthcare Workers, Preventing Needlestick Injuries Toolkit. Occupational and Environmental Health Unit

http://www.who.int/occupational_health ► CDC Workbook for designing, implementing and evaluating a sharps injury prevention programme (2004): http://www.cdc.gov/sharpssafety/

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