Needlestick and sharps injuries in diabetes: R U FIT4Safety?

Needlestick injuries (NSIs) are common among healthcare workers (HCWs) within both the hospital and community environment. In a survey of over 600 nurses, it was identified that 32% had received an NSI whilst giving an injection to a patient with diabetes (Costigliola et al, 2012). Needlestick injuries may occur for a number of reasons including a lack of training on the safe use and disposal of needles and sharps, and a lack of knowledge of the consequences of such injuries, as well as the types of devices used and procedures undertaken.

NSIs can transmit disease and therefore are a significant occupational hazard for HCWs. Between 1997 and 2009, there were 17 recorded cases of HCWs sero-converting to hepatitis C in England following percutaneous exposure to a virus-infected patient (NHS Employers, 2011). Five cases of HIV sero-conversions resulting from percutaneous exposure were reported in HCWs in the UK up until 2007; however, there have been no new cases reported since 1999 (Health Protection Agency, 2008). In France, three occupationally acquired hepatitis C infections were transmitted from subcutaneous NSIs (Lot et al, 2001).

In October 2011, 57 leaders in the field of injection technique and sharp safety from 14 different countries gathered in Brussels to attend the Workshop on Injection Safety in Endocrinology (WISE). The delegates from the UK later formed “FIT4Safety in UK and Ireland” and, in May, published the “Safety of sharps in diabetes recommendations” (Forum for Injection Technique, 2012). These recommendations provide contemporaneous evidence-based best practice information to assist individuals and organisations in identifying the risks associated with sharps and accidental blood or body fluid exposure.

Safety of sharps in diabetes recommendations 2012
The recommendations are divided into seven categories: risk; European legislation; device implications; injection technique implications; education and training; value; and awareness and responsibility. The discussion below provides more insight into these recommendations.

Risk
Risk of transmission following an NSI
Cardo et al (1997) identified that the risk of transmission following NSIs or sharps injuries may be affected by:

• The depth of injury sustained.
• The type of needle or sharp used.
• The amount of blood or bodily fluid inoculated at the time of injury.
• Whether the device was previously in the patient’s vein or artery.
• How infectious the patient is at the time of the injury.

In cases where an injury results from a hollow-bore needle that has been used to access directly into a vein or artery, the risk of transmission is higher because it contains more blood and therefore carries a greater risk than that of a solid needle or blade.

Which healthcare workers are at risk?
The HCWs at increased risk of acquiring sharps injuries or NSIs include doctors, nurses, phlebotomists, and domestic service staff, such as cleaners, porters and waste removal teams. Data from the UK and US indicate that nurses account for 45–63% of reported NSIs and sharps injuries among HCWs, and that medical staff account for 9–17% of all such injuries (Mercier, 1994; Cone, 2000; NHS Scotland, 2001). In the UK, almost 40% of NSIs and sharps injuries were experienced by someone other than the original user of the device, known as downstream workers (May and Churchill, 2001).

Risk assessment
Foley and Leyden (2002) identified a hierarchy of controls to reduce the risk of exposure to blood-borne pathogens (see Box 1).

The priority is to eliminate and reduce the use of needles and other sharps where possible. Furthermore, Wittmann (2011) developed a standardised risk-assessment matrix for medical sharps which identifies the potential risks associated with devices or procedures, and the appropriate level of sharps safety required (see Figure 1).

European legislation

Many sharps injuries or NSIs are preventable and employers have a duty to ensure the safety of their employees. The key legislation in the UK, addressing the issues of protecting HCWs from obtaining a sharps injury or NSI, is identified in Box 2. Further to this legislation, member states of the European Union have until 11 May 2013 to implement the Council Directive 2010/32/EU framework agreement on the prevention from sharps injuries in the hospital and healthcare sector. The main aims of the directive include:

• To achieve the safest possible working environment for employees and patients.
• To prevent injuries to HCWs as a result of sharps or needlesticks.
• To set up an integrated approach, establishing policies in risk assessment, risk prevention, training, information, awareness raising and monitoring, including the provision of medical devices incorporating safety-engineered protection mechanisms.

The key requirements that need to be implemented include:

• Risk assessment – quantifying the risk of exposure to a blood-borne pathogen from NSIs and sharps.
• Risk elimination and prevention, and review practice. Where possible, eliminate the unnecessary use of sharps, use safety devices, improve education and awareness, review staffing levels, and ensure personal protective equipment and appropriate sharps disposal systems (SDSs) are available at the point of use. Ensure the organisation has developed an overall occupational exposure policy.
• Training on the use, safe handling and disposal of sharps procedures.
• Promoting occupational exposure awareness, such as that of the risks associated with exposure to blood and body fluid, hepatitis B virus immunisation and occupational exposure reporting.
• Information regarding sharps injuries or NSIs should be reported promptly and appropriately, and the risks identified following a root-cause analysis into each case.
• Awareness raising and monitoring. Employers are responsible for ensuring all staff are aware of the risks associated with occupational exposure from sharps/NSI. In addition, health monitoring and vaccination should be provided where available.

The directive requires that healthcare providers undertake all that is reasonably practical to prevent HCWs and other staff from harm. Failure to implement the directive will be seen as a criminal offence. Strauss (2012) identified the elements in the EU directive, which together create a “wall of safety” (see Figure 2).

Device implications types of devices
Passive versus active
There are two main types of features used in the design of safety-engineered needle devices (SENDs). These include the passive SEND, in which no additional actions are required by the user to activate the safety feature, and the active SEND, in which the user is required to activate the safety feature (Centers for Disease Control and Prevention, 2008). Strauss and WISE Consensus Group (2012) identified the main features of a SEND (see Box 3).

Evaluating safety-engineered needle devices
When evaluating a SEND, four key factors should be examined, including safety, usability, compatibility with need and ensuring the device does not cause other concerns, such as splashing on activation (Adams and Elliott 2003; 2006a; Roff, 2011). To assess product safety, a systematic evaluation should be undertaken by the users of the device in the clinical setting (Adams and Elliott, 2003). Examples of safety device evaluation tools have been devised by the Training for Development of Innovative Control Technologies (2012; see Figure 3).

Adams and Elliott (2006a) reported that, following the introduction of three SENDs, including safety insulin syringes, safety needles and safety blunt needles, a significant reduction in the number of reported NSIs (70%) was achieved.

Injection pens are auto-delivery devices designed for the self-administration of medicine via the subcutaneous route. Pellissier et al (2006) identified in a study undertaken in France that the NSI rate associated with injection pens (IPs), of which 60% was related to disassembly and re-capping, was six times that of the NSI rate associated with disposable syringes. It is recognised that IPs have been shown to improve the patient experience and should be offered to patients routinely (Da Costa et al, 2002). Furthermore, nurses agreed that IPs were more convenient, simple and easy to use, and noted an overall improvement compared with conventional vials and syringes (Davis et al, 2009). Therefore, there is a need to improve the HCW safety associated with these devices. There are a variety of IP-SENDs available, which have been designed to minimise the risk of NSIs (see Box 4).

Costs and benefits
Financial considerations are of paramount importance when initiating any change of clinical practice. Glenngård and Persson (2009) completed a study to evaluate the costs associated with the implementation of SENDs to reduce the risk of NSIs in 18 hospitals in Sweden. The study demonstrated that the increased cost of SENDs was offset by the reduction of costs associated with the investigation and treatment of potential NSIs.

Injection technique implications
Correct injection technique is important to ensure the optimum benefit is gained from the injected drug, such as insulin. Needle length is also important to ensure the insulin is delivered into the subcutaneous layer. Unfortunately, there are only 8 mm and 12.7 mm needles available on disposable insulin syringes; 12.7 mm needles should not be used as there is a real danger of administering the insulin intramuscularly, which can cause major hypoglycaemia (Karges et al, 2005), and 8 mm needles may not be suitable for all patients, especially thin adults or children. Where only an 8 mm needle is available, then a lifted skin-fold will be necessary to ensure that the insulin is still delivered into the subcutaneous layer. This could cause a potential problem as the hand holding the lifted skin-fold is at risk from an NSI. Thus, IP-SENDs and insulin syringes should always be used when insulin is being administered by an HCW.

Education and training
Safe handling and disposal of sharps
All HCWs should be trained and assessed in the correct use and disposal of sharps and SENDs. The principles concerning the safe use and disposal of sharps and IPs have been identified by the Royal College of Nursing (2012), Centers for Disease Control and Prevention (2012) and NICE (2012); see Box 5 for an overview of these principles.

Vaccination
Pre-exposure vaccinations to hepatitis B should be considered for all HCWs who are at risk of exposure to the virus from contact with blood, blood-stained body fluid or tissue (Department of Health, 2006).

First-aid action
The Department of Health (2008) advises that the initial action in the event of either an NSI or sharps injury should be to encourage the wound to bleed. Sucking of the wound by mouth is not recommended. Healthcare workers should then immediately follow local policy and protocol regarding receiving further expert advice in order to reduce their risks associated with potential viral transmission following the sharps injury or NSI.

Value and costs related to needlestick and sharps injuries
Treatment costs and loss of productivity as a result of NSIs and sharps injuries may place additional financial strain on the NHS. Financial costs associated with the initial treatment of a staff nurse following exposure to a patient with hepatitis B, hepatitis C or HIV have been calculated (Adams and Elliott, 2006b).

The costs were estimated to be £1540, £235 and £938 for exposure to patients with hepatitis B, hepatitis C and HIV respectively. In addition to the financial costs, there are the psychological traumas that the injured HCW may experience whilst waiting for the results of blood tests confirming whether there has been transmission of a life-threatening infection following a sharps injury or NSI. Costigliola et al (2012) identified the following emotional responses: depression; crying spells; tension in the family; relationship issues; panic attacks; excessive worry; and the inability to work.

Awareness and responsibility
Waste disposal varies amongst councils throughout the UK. The “gold standard” option is a system providing the sharps user with an SDS to dispose of sharps after every use. When the SDS is two-thirds full, it would be collected free of charge by the waste department of the local council and replaced with an empty SDS for future use.

If people with diabetes do not have access to an SDS, then this may result in the syringe or IP being discharged into the household refuse, leading to an increase the risk of NSIs by downstream workers, exemplified by an incident in West Sussex where two waste disposal men accidently incurred NSIs from waste (BBC News, 2012).

Conclusion
All HCWs are at risk from NSIs and sharps injuries. Continuing implementation of safe working practices is vital, as is risk assessment, risk elimination, training in the use of devices and awareness of the consequences such injuries. HCWs have a pivotal role in assessing risks and evaluating any new SEND introduced in their clinical areas.

It is anticipated that the “Safety of sharps in diabetes recommendations” (Forum for Injection Technique, 2012) will support individuals and organisations to apply the new EU directive to clinical practice in their field of care.