Needle Stick Injuries - Concerns, Current Practices, Best Practices and Implementation of Change - Research Paper Example

? RUNNING HEAD: Needle stick injuries Needle Stick Injuries: Concerns, Current Practices, Best Practices and Implementation of Change of the student Under the guidance of University APA Format Word Count Date of submission Introduction During one of the ward procedures one of my colleague suffered a needle stick injury because of improper disposing of the used needle by another staff member. This incident made me think about needle stick injuries, their causes and strategies to prevent them. I chose this topic because of my personal interest in the topic and the need for me and other health professionals to be aware about this subject. Needle stick injuries are a common source of health hazards to health care workers like doctors, nurses, attendants and technicians and also to non-health workers like ancillary and support staff (NHS, 2008). These injuries pose a risk for development of various infectious diseases to the injured threatening their employment, health morbidity and mortality. More than 20 different pathogens have been identified to be transmitted through exposure to body fluids or sharps injury. Injuries by sharps and splashes of body fluids are the main routes of transmission for occupational acquisition of blood-borne pathogens among health care workers (Bi et al, 2008). Despite these injuries being common, they are often under reported and in many places, both health care and non-health care workers are unaware of safety methods to prevent these infections. Globally, needle stick injuries are the most common cause of blood-borne infections among health care workers (Wilburn and Eijekamans, 2004). More than 35 million people worldwide constitute health care work force and they represent 12 percent of the working population in the world (Wilburn and Eijekamans, 2004). It is estimated that people working with them as non-health workers are even more in numbers (NHS, 2008). While health care workers are exposed to several biological hazards including blood-borne pathogens and airborne pathogens directly, non-health workers too are at risk of exposure. In addition to pathogens, both health and non-health workers are also exposed hazardous chemicals like sterilizing agents and disinfectants which increase the risk of development of dermatitis, asthma, carcinogens, reproductive toxins, etc (Wilburn and Eijekamans, 2004). In this essay, various concerns pertaining to needle stick injuries will be discussed along with current and best practices and strategies to change. Needle stick injuries: causes, risks and concerns According to the Health Protection Agency report (2008), the most common type of exposure that has been reported among health care workers is the percutaneous injury which accounts for 45 percent of exposures. These exposures contributed to significant seroconversion for HCV, HIV and other diseases. The HIV seroconversion rates reported were high, 0.8 percent. In the NHS, needle stick injury continues to be the most commonly reported adverse incident among healthcare workers, which are a potential source for transmission of various diseases like Hepatitis B and C and human immunodeficiency virus. These injuries are also a potential source of transmission of prion-related diseases. The risk of transmission of hepatitis C with needle stick injuries is 3 percent, for hepatitis B is 30 percent and for HIV is 0.3 percent (Elmiyeh et al, 2004). The transmission from the patient to the healthcare worker through the injury depends on the viral load of the patient and also on the amount of blood that passes from the patient to the healthcare worker. Other infections which are transmissible through needle stick injuries are malaria, syphilis and herpes (Wilburn and Eijekamans, 2004). Needle stick injuries: current practices There is uncertain information about the prevalence of the diseases among hospital population and health care workers and non-health workers (Elmiyeh et al, 2004). According to a study by Elmiyeh et al (2004), 38 percent of health care workers had atleast one needle stick injury in the past one year and 74 percent has such injury atleast one time during their career. Of these, only 50 percent had notified needle stick injuries, despite the fact that more than 80 percent were aware of the fact that needle stick injuries need to be notified. According to Roy et al (cited in Elmiyeh et al, 2004), there is under estimation of institutional needle injuries by atleast 50 percent because of under reporting due to own risk assessment by doctors, time constraints and workload pressures. It is also yet unclear as to whether the advent of safer needle devices has decreased the risk of needle injury among health care workers. Mandatory post-exposure testing of health care professionals is very simple on theoretical grounds (NHS, 2000). However; it presents with ethical, legal and moral dilemmas and with risk of loss of gainful employment for those who have been diagnosed with infection. Globally, health care workers contribute to 2 million needle stick injuries per year that result in infections with HIV, hepatitis B and hepatitis C (Wilburn and Eijekamans, 2004). According to WHO, the global burden of infections subsequent to exposure through occupation is about 40 percent for hepatitis B and C infections and 2.5 percent for HIV infections. The WHO further informs that 90 percent of such infections occur in the developing countries and 90 percent of reports come from developed countries. While 70 percent of the world's health care workers live in sub-saharan Africa, only 4 percent of the reported cases in the world come from this region. Most researchers opine that the estimates by the WHO are actually low (Wilburn and Eijekamans, 2004). Injection safety surveys in different parts of the world have provided different estimates with regard to needle stick injuries, but mainly among health care workers and not among ancillary or support staff. In the Asian, African and Eastern Mediterranean regions, the estimates have been four needle stick injuries per healthcare worker per year. In Vietnam, 66 percent of nursing staff and 38 percent of physicians report needle stick injury in the past 9 months. In South Africa, 91 percent of doctors reported needle stick injuries in the previous one year, 55 percent of which from HIV positive patients (Wilburn and Eijekamans, 2004). Ng and Hassim (2006) conducted a cross sectional study among Emergency department healthcare workers at 2 teaching hospitals in Malaysia. From this study, it was evident that the prevalence of needle stick injuries in emergency departments is 31.6 to 52.9 percent, the greatest risk was faced by medical assistants. According to the NHS (2009; cited in Knott, 2010), injuries related to needle stick and sharps account for more than 400,000 injuries to NHS staff every year. The NHS (2009, cited in Knott, 2009) summaries that "the average risk following percutaneous exposure to HIV-infected blood in healthcare settings is about 3 per 1,000 injuries, less than 1:1000 following mucocutaneous exposure and has never been recorded following contact of HIV blood with intact skin." In a study by Thompson and Murray (2009) in which surgeons from district general hospital were evaluated, 44 percent of surgeons admitted to having needle stick injury. According to a study by Mehta et al (2009), 45 percent of those who reported needle stick injuries were nurses, 33 percent were attendants, 11 percent were doctors and 11 percent technicians. Of the 380 health workers who reported needle stick injuries, 23, 15 and 12 were positive for HBsAg, HIV and HCV. Analysis of sources of needle stick injuries revealed that of the 380 reported cases, 254 injuries were from known sources of injury and the rest were from unknown sources like garbage bags. The most common immediate action following injury was washing hands with soap and water, encouraging bleeding and reporting the incident to emergency. Those who suffered needle stick injuries from patients with hepatitis B positive patients took hepatitis B booster immunisation. Those who were Anti-HBs negative took a full course of hepatitis b vaccination. All the staff who sustained injury from HIV positive patients received immediate antiretroviral therapy in the form of AZT 600mg per day for six weeks. The most common causes of needle stick injuries include two handed needle recapping and unsafe disposal and collection of waste of sharps (Wilburn and Eijekamans, 2004). In the study by Mehta et al (2005), most of the needle stick injuries occurred during intravenous line insertion, followed by drawing samples for blood collection, then surgical blade injury and lastly recapping of needles. Determinants of needle stick injuries include lack of proper awareness with regard to the possible hazards, lack of appropriate training of the health care workers, overuse of needles, injections and unnecessary sharp instruments, lack of adequate supplies of sharp instruments like disposable syringes, sharps disposable containers and safer needle devices, lack of access to sharps containers after administering injections, failure to use sharps containers immediately after injection, inadequate staffing, recapping of needles after use and passing of used sharp instrument from one hand to another (Wilburn and Eijekamans, 2004). Factors which increase the risk of transmission of HIV infection from the patient to the health care worker include presence of deep wound, presence of visible blood over the needle, presence of blood in the needle that was hollow bore, use of device that has accessed vein or artery and high-viral-load status of the patient. When taken together, these factors increase the risk of transmission of HIV infection from the contaminated sharp by atleast 5 percent (Wilburn and Eijekamans, 2004). One major contributing factor in the developing countries is increased handling of syringes which are contaminated (Wilburn and Eijekamans, 2004). According to HPA (2008), in addition to these, terminal HIV-related illness is also an important high risk factor for developing infection subsequent to injury. There is very little evidence among non-health workers. According to a retrospective study by O'Leary and Green (2003), males, cleaners and police officers are at particular risk of needle stick injuries and the most common mechanism of injury was exposure to syringes that were discarded. While 36 percent were work-related, 20 percent were non-accidental. Blenkharn and Odd (2008) opined that the main cause for sharp injuries among ancillary and support workers is deficiencies in glove selection and use and also in hand hygiene. The researchers reported that due to discomfort associated with ballistic-puncture-resistant gloves, these workers preferred thin-walled nitrile gloves which provide no resistance to penetrating injury. They estimated that sharp injuries occurred in 1 per 29 000 man hours and these injuries were mainly related to hypodermic needles from improperly closed or overfilled sharps boxes or from sharps incorrectly discarded into thin-walled plastic sacks intended only for soft wastes. Strategies to prevent needle stick injuries: best practices Bi et al (2008) conducted an epidemiological study over 3 years in a tertiary teaching hospital in Adelaide, Australia. According to the safety regulations of the hospital, every health care worker is required to report any sharp injury or body fluid exposure to the emergency department or the Occupational Health Safety and Injury Management. The hospital has a standard reporting form which included information pertaining to exposure like work activity, causal factors, type of procedure, device used, source of fluid, etc. The guidelines of the hospital are that the information stated is confidential and at the discretion of the person who has been exposed. The Infectious Diseases Department and the Occupational Health Safety and Injury Management work together to manage the follow-up procedures and also the serological testing and post-exposure prophylaxis that needs to be administered to the exposed candidate. In the study by Bi et al (2008), it was evident that most of the sharp injuries were acquired by medical and nursing staff members and they were at significant risk of acquiring blood borne pathogens because they were providing direct medical care services to the patients. Of the two, nurses are at increased risk for sharp and body fluid exposures, suggesting that occupational health and safety education for nursing staff is critical to prevent infections related to sharp injuries and body fluid exposure. 45 percent of sharp injuries occurred in the departments of Oncology, gastroenterology, orthopedics and general surgery suggesting that these departments must be a priority in educating the staff towards prevention of sharp injuries. The past decade has seen advances in the technology that allows use of safer sharp devices. Several nursing organizations, including the American Nursing Association have launches a marched against sharp injuries. One such campaign is the Safe Needles Save Lives campaign in the 1990s (Trossman, 2012). Such and other campaigns have advocated acts and policies to control needle stick and other sharps injuries. The Needle Stick Safety and Prevention Act demands that "it requires employers in all health care settings to identify, evaluate and implement safer medical devices, as well as include front-line workers in those key processes, among other factors" (Trossman, 2012). Such recent advances have dramatically decreased the incidence of sharps injuries (Trossman, 2012). According to Jane Perry, who is an associate director at the Worker Safety Center, "when evaluating devices, nurses should consider which safety device mechanisms cause the least interference while still providing adequate protection. Passive devices that automatically activate after use, requiring no additional action on the part of the user, may help reduce injury risk. But they may not be appropriate for all procedures" (cited in Trossman, 2012). According to Workshop on Injection Safety in Endocrinology guidelines (cited in Strauss, 2013), "as deep injuries incur three times the transmission risk of blood borne pathogen than superficial ones, the need for widespread adoption of sharps-prevention devices in diabetes healthcare settings, together with other preventive measures, must be implemented." Management of needle stick injuries should follow state, national and international protocols. From various studies, especially the study by Thomson and Murray (2009), it is evident that only 3 percent of those who suffered from needle stick injuries followed any policy, be it either reporting or prevention of disease. The first aid for contaminated sharps injury must be encourage bleeding and washing with soap and water. The type of injury and the status of the patient must be discussed with local public health consultant immediately who will conduct an urgent preliminary risk assessment. In case there is risk of HIV infection, post exposure prophylaxis must be initiated as soon as possible, ideally within one hour. This is estimated to reduce the risk of transmission by 80 percent. Post exposure prophylaxis must initiated much before the reports of the donor are available. Post exposure prophylaxis is a 28-day treatment with triple combination of antiretroviral drugs. it is associated with significant complications and needs follow up (Knott, 2010). In case, the source is known to have HBsAg positive, hepatits B immunoglobulin must be given within 72 hours (Knott, 2010). Exposed persons must be advised to practice safe sex for 3 months and not to donate any blood or blood products during that period (Knott, 2010). Suitable investigations must be performed for the injured worker after 3 months. Liver function tests must be done after 3-6 months. Female workers must do tests to rule out pregnancy (Knott, 2010). Needle stick injuries can be prevented by washing hands before and after contact patients with soap and water, by changing gloves between patients, by wearing water proof dressing as and when required: especially when wounds and skin lesions exist, by avoiding sharps as much as possible, by avoiding wearing open foot wear, by cleaning up blood spillage promptly, by performing pre-employment occupational health assessment for identification of damaged skin like for eczema and by following safe procedures for disposal of waste (Knott, 2010). Staff members must be appropriately trained for safe use and also disposal of sharps. There is evidence that targeted education for prevention and control of infections decreases needle stick injuries. The training must be imparted during induction itself and mandatory updates must be provided about safe use and disposal of sharps and also in dealing with body fluid exposures in a safe manner. The staff must be trained for correct usage of personal protective equipment and the organization also must provide with appropriate protective equipment in terms of quality and quantity. According to WHO (cited in Beckett and Birght, 2013), "gloves should be worn for direct contact with patients’ mucous membranes, blood, body fluids, moist body substances and non-intact skin." In case there is a risk for splash of body fluids, visors, masks and eye protection should be worn as these provide a physical barrier between contaminated body fluids and eyes and mouth of the staff (Beckett and Birght, 2013). According to Molen et al (2012), "the use of relatively simple protective needle safety devices and interactive communication are effective measures for reducing needle stick injuries. These interactive communications, additional safety measures, such as good housekeeping, training and the use of personal protective equipment should be discussed and implemented." It has been recommended that staff must be trained to dispose sharps immediately and also at the point of use itself into the sharps container. The needles must neither be re-sheathed not be removed from the syringes. The sharp bins must be filled only up to three quarters full and they must be locked and replaced appropriately when full. The size and type of sharp bins must be appropriate for the disposed items and must be placed in such a manner that they are away from visitor and resident areas. In case a sharp injury occurs or splashing of body fluids has occurred, the area must be washed immediately and covered with waterproof dressing. The injury must be reported to appropriate officials (Aziz, 2012). Recapping increases the risk of needle stick injury and staff must be trained about that. According to Kable et al (2011), "recapping remains a high-risk activity, and reported compliance and attendance at sharps safety training is low." Conclusion Injury by sharp needles and instruments that are contaminated is a major occupational hazard to health care workers and non-health care workers. Needle stick injuries continue to be the most commonly reported adverse incident among healthcare workers, which are a potential source for transmission of various diseases like Hepatitis B and C and human immunodeficiency virus. There is under estimation of institutional needle injuries by atleast 50 percent because of under-reporting. The risk of transmission of hepatitis C with needle stick injuries is 3 percent, for hepatitis B is 30 percent and for HIV is 0.3 percent. However, there is not much data available about the incidence of needle stick injuries among ancillary and support staff. The main responsibility for protection against contraction of legal viral pathogens vests with workers who must handle sharp objects carefully and adhere to the hospital guidelines in their disposal. In this regard, the employer of the hospital also has a role to provide and environment that is safe and also educate all employees about the risk of viral transmission through sharp instrument injuries and about protocols which help in the prevention of needle injuries and safe disposal of needles. References Aziz, A. (2012). Preventing needle stick injuries. British Journal of Nursing, 21(21), S4-5. Bi, P., Tully, P.J., Boss, K., and Hiller, J.E. (2008). Sharps Injury and Body Fluid Exposure Among Health Care Workers in an Australian Tertiary Hospital. Asia Pac J Public Health, 20, 139-142. Beckett, G., and Bright, J. (2013). Preventing exposure to blood and body fluids. Nursing & Residential Care, 15(1), 35- 37. Blenkharn, J.I., Odd, C. (2008). Sharps injuries in healthcare waste handlers. Ann Occup Hyg., 52(4), 281-6. Elmiyeh, B., Whitaker, S., James, M.J., et al. (2004). Needle-stick injuries in the National Health Service: a culture of silence. J R Soc Med., 97(7), 326–327. Health Protection Agency. (2008). Eye of the Needle. Surveillance of significant Occupational Exposure to bloodborne Viruses in Healthcare Workers. Kable, A.K., Guest, M., and McLeod, M. (2011). Organizational risk management and nurses’ perceptions of workplace risk associated with sharps including needlestick injuries in nurses in New South Wales, Australia. Nursing and Health Sciences,13, 246–254. Knott, L. (2010). Needle stick injury. Retrieved on 16th May, 2013 from http://www.patient.co.uk/doctor/Needle-Stick-Injury.htm. Molen, H.F., Zwinderman, K.A.H., Sluiter, J.K., and Frings-Dresen, M.H.W. (2012). Interventions to prevent needle stick injuries among health care workers. Work, 41, 1969-1971. Mehta, A., Rodrigues, C., Ghag, S., et al. (2009). 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The incidence and reporting rates of needle-stick injury amongst UK surgeons. Ann R Coll Surg Engl., 91(1), 12-7. Wilburn, S.Q., Eljkemans, G. (2004). Preventing needle stick injuries among health care owrkers: A WHO-ICN collaboration. IJOEH, 10(4), 451- 456. Read More