Needle Stick Injury–Consequences & Prevention

Purnima Gupta

A hospitalised patient with AIDS became agitated and tried to remove the intravenous (IV) catheters in his arm. Several hospital staff members struggled to restrain the patient. During the struggle, an IV infusion line was pulled, exposing the connector needle that was inserted into the access port of the IV catheter. A nurse at the scene recovered the connector needle at the end of the IV line and was attempting to reinsert it when the patient kicked her arm, pushing the needle into the hand of a second nurse. The nurse who sustained the needle stick injury tested negative for HIV that day, but she tested HIV positive several months later (American Health Consultants 1992a).

This is not the only case. Everyday healthcare workers are exposed to dangerous and deadly blood-borne pathogens and are at risk of occupational acquisitions of blood-borne illnesses. Occupational exposure to blood-borne pathogens among healthcare workers include percutaneous exposure ie exposure to needles and other sharp objects, and mucocutaneous exposure ie contact with intact or nonintact skin, the contact with mucous membranes. In the healthcare settings, percutaneous injuries are the most common form of occupational exposures and most likely to result in infection. Needle stick injuries account for upto 80 per cent of accidental exposure to blood-borne pathogens. It is one of the greatest risk faced by the front line healthcare workers in the light of HIV/ AIDS pandemic and Hepatitis B and C. Yet, these exposures have often been considered as part of the job and neglected.

Risk Involved With Exposure To Blood-Borne Pathogens

Although national statistics underestimate the severity of the problem, statistics from the US provide some insight into these occupational risks. Every year, healthcare workers experience between 6,00,000 and 8,00,000 exposures to blood-borne pathogens. The most serious and commonly transmitted pathogens are Hepatitis B and C virus (HBV, HCV) and the human immunodeficiency virus (HIV), the virus that causes AIDS. Each of these viruses poses a different risk if a healthcare worker is exposed. More than 20 other infections can be transmitted through needle sticks, including syphilis, malaria, and herpes. At least 1,000 healthcare workers are estimated to contract serious infections annually from needle stick and sharp injuries. As of June 2001, there were at least 57 CDC documented cases of healthcare workers with occupationally acquired HIV and at least 137 cases of possible transmissions. According to world health report 2002 published by WHO, needle stick injury is accountable for 40 per cent of Hepatitis B, 40 per cent of Hepatitis C, and 2 per cent of HIV infections. The Centers for Disease Control and Prevention (CDC) estimates that each year 3,85,000 needle sticks and other sharps related injuries are sustained by hospital based healthcare personnel.

How Do Needle Stick Injuries Occur?

A needle stick injury is the result of an accident with a needle. These injuries can occur at any time when people use, disassemble, or dispose of needles. When not disposed of properly, needles can conceal in linen or garbage and injure other workers who encounter them unexpectedly. It is found that 30 to 50 per cent of all injuries occur during clinical procedures. However, there are other factors like equipment design, nature of the procedure, condition of work, staff experience, recapping, and improper disposal which influence these occurrences.

• Equipment design: The CDC highlights that blood-filled hollow-bore needles present the highest risk for pathogen transmission. For instance, blood-filled needles such as IV catheter stylets, butterfly needles and phlebotomy needles are associated with the greatest incidence of high risk exposure. Safer innovative devices would alleviate many of these injuries. Evidence suggests that syringes with safety features reduce needle stick injuries.
• Nature of procedure: The risk of accidental needle stick injuries is most common during invasive procedures such as collection of blood and giving injections. If the device is given a jolt by a patient then injury may happen. Injuries commonly occur when workers try to do several things at the same time, especially while disassembling or disposing of needles.
• Conditions at work: Staff reduction (where nurses, laboratory personnel and students have to perform some additional duties), difficult patient care situations, and working at night with reduced lighting are some of the work conditions which might contribute to an increase in the number of needle stick injuries.
• Staff Experience: It is found that inexperienced or new staff and students tend to have more such exposures than experienced staff.
• Recapping: Recapping can account for 25 to 30 per cent of all needle stick injuries. It is often considered as the single most common cause.
• Improper disposal: These injuries occur when needles are disposed of improperly in regular garbage or lost in the workplace. Janitors and garbage handlers can also experience needle stick injuries or cuts from sharps when handling trash or dirty linens where needles have been inappropriately discarded.

Who Is At Risk Of Injury?

Evidences show that nurses sustain the highest number of percutaneous injuries as they are the largest segment of the workforce at most hospitals. However, other patient care providers like physicians, technicians, laboratory staff, and support personnel (like housekeeping staff), are also at a greater risk.

Steps For Prevention

Preventing needle stick injuries is the most effective way to protect the healthcare workers from the infectious diseases caused by it. To prevent the accidents, we need to have a comprehensive programme in place which includes:

• Education (Employee training): An important element of a needle stick injury prevention programme is the education and training of healthcare personnel in sharps injury prevention as a part of continuing medical education. Healthcare workers need to know how to use, assemble, disassemble, and dispose of needles properly. An effective programme should address all the aspects of needle stick injuries including risk of injury, potential hazards, recommended precautions etc. Apart from it, there should be a system in place for reporting these injuries and post-exposure management.
• Implementation of work practice control including effective disposal system: Work practice controls are meant to alter the way in which a task is performed so that it is done in a safer manner. The following points provide some general work practice controls that should be observed when working with sharp devices.
• Employees must consider all the sharps items as potentially infectious and handle them with care to prevent accidental exposure.
• Needles should never be recapped and reused.
• No attempt should be made to remove the needles from the body of the syringe(eg. bending, breaking or shearing).
• An appropriate sharp container must be used (they should be closable, leak proof, and puncture resistant).
• The container should be placed in easily accessible locations where the sharps are being used.
• Sharp containers should never be over filled. Make sure they are sealed, collected, and disposed of in accordance with recommended guidelines for biomedical waste.
• Implement engineering controls: Before implementing engineering controls, hospital should identify the types and designs of needle instruments that are potentially capable of causing needle stick injuries, and to understand better how needles devices are normally handled in the workplace and how they cause injuries. A number of sources have identified the desirable characteristics of safety engineered sharps. These characteristics include the following:
  • The device is needle less.
  • Have safety features integral to the device itself rather than as accessories.
  • The device preferably works passively (ie requires no activation by the users). If user activation is necessary, the safety features can be engaged with a single-handed technique and allows the workers hands to remain behind the exposed sharp.
  • The device is simple and easy to operate.
  • The device is safe and effective for patient care.
• Surveillance: Experience has shown that most institutions do not have robust data that allows for good analysis of which procedure and devices create the highest risk. Institutions should have a surveillance programme which can provide in depth analysis of needle stick injuries. Goal of these programmes should include:
  • Determining the rate of needle stick injuries.
  • Investigate the factors that cause the injuries.
  • Ensuring that injured workers receive proper treatment.
  • Providing practical strategies for dealing with the problem.

Conclusion

Needle stick injuries cause a high burden of death and disability among healthcare workers. Available statistics probably underestimate the severity of the problem because many cases go unreported as workers do not report their injuries. This makes it difficult to know exactly how serious the problem is or how well prevention programme works.

This may also have the indirect consequences on healthcare delivery, particularly in regions where the qualified workforce is small compared to the disease burdens in the population. These injuries have not only the potential health consequences but also have emotional distress on healthcare workers which result in missed work days and directly affecting the health care services and resources. Institutionalisation of a culture of safety in the work environment is very much required to prevent such incidents.

Clearly, there is much room for improvement in protecting the healthcare workers from needle stick injury, which can be accomplished through a comprehensive programme that addresses institutional, behavioural, and device-related factors that contribute to the occurrence of these injuries. Apart from this, greater collaborative effort by all stakeholders are needed to prevent such injuries and the tragic consequences that can result.

No one should be made ill by their work!

The writer Assistant Manager, Mata Chanan Devi Hospital, New Delhi.
Email: purnima_gupta@rediffmail.com