Art & science
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The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
A quality improvement initiative to reduce needlestick injuries Beynon A (2015) A quality improvement initiative to reduce needlestick injuries. Nursing Standard. 29, 22, 37-42. Date of submission: August 8 2014; date of acceptance: September 29 2014.
Abstract Peterborough and Stamford Hospitals NHS Foundation Trust introduced sharp-safe needles in January 2013; these became a part of general practice by April 2013. A service evaluation was undertaken to investigate whether the introduction of sharp-safe needles had reduced the incidence of needlestick injuries. Results showed that 608 percutaneous injuries were sustained during the use and disposal of sharps between April 2010 and March 2014. A total of 122 injuries occurred following the introduction of the new sharp-safe needles (2013-2014), which was a 26% reduction compared with the previous year (2012-2013, n = 165). These results could mean that the sharp-safe needles reduced the rate of injuries. A definitive evaluation of the effectiveness of the sharp-safe needles was not possible given the limited data available since their introduction.
Author Anthony Beynon At time of writing was staff nurse, emergency department, Peterborough City Hospital, Peterborough, Cambridgeshire, England. Correspondence to: [email protected]
Keywords Blood-borne infection, health service evaluation, HIV, incident reporting, needlestick injuries, nursing care, quality improvement, sharps injuries
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: rcnpublishing.com/r/author-guidelines
HYPODERMIC NEEDLES ARE part of essential patient care and treatment for healthcare professionals. Standards are in place to ensure that a new needle and syringe are used for each procedure, with the aim of reducing the risk of infection (Kotwal 2004). However, the prevalence of needlestick injuries is increasing (Jagger et al 2010). Needlestick injuries are usually a result of avoidable events, often occurring as a result of re-sheathing a needle, or during disposal, as the user attempts to remove the needle before putting it in a sharps bin (Jagger and Pearson 1991). The removal of a needle before disposal or its re-sheathing contravenes standard practice (Kozier et al 2008). A new method of reducing needlestick injuries is the introduction of devices deemed ‘sharp safe’. One such device is a hypodermic needle with guards that should be applied once the needles have been used. Cannulae for intravenous infusions have a different sharp-safe system in which the needle is automatically covered once it has been removed from the plastic access tube left in the patient’s vein. These new devices were first introduced into Peterborough and Stamford Hospitals NHS Foundation Trust in January 2013 and were being used by all departments within three months. Their introduction met with little resistance because the process was undertaken gradually and seamlessly – as the old stock was depleted it was replaced with new sharp-safe versions. Having been included in the initial trial and final implementation stages of sharp-safe hypodermic needles and cannulae, the author had significant experience of their use. Training for the new devices included a demonstration of the new equipment and their safety devices.
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Art & science service evaluation Practical sessions using manikins were also involved. The author’s own experience was that the sharp-safe cannulae originally appeared bulky to handle and seemed difficult to use, however they became more familiar and easier to use after only a few uses. The design of the new sharp-safe cannula should help reduce injuries. This is a passive safety device. Once the cannula is inserted into the patient, the needle section is then removed; during removal the sharp end is covered by a plastic shield and the main body of the needle is covered by a corrugated sheath. If used correctly, once the sharp end is covered it cannot be re-exposed, thereby eliminating the risk of injury from this device. The sharp-safe element on the hypodermic needles is an active mechanism, requiring the user to fold a plastic shield over the sharp end. This light plastic shield completely covers the needle. The design of the shield is quite cumbersome, but does not interfere with use of the needle during a procedure.
Needlestick injuries A needlestick injury is the result of a needle or other sharp implement penetrating the skin. It may also be termed a percutaneous injury (Health and Safety Executive 2013). Injuries from such incidents can have a serious psychological effect. Following such an injury, members of staff may be at risk of post-traumatic stress disorder as fear of the unknown consequences of a sharps injury becomes apparent (Naghavi et al 2013). Staff may be exposed to life-changing infections such as hepatitis B and human immunodeficiency virus (HIV) by a sharps injury. To combat anxiety, staff must quickly undergo tests and acquire test results, thus obtaining reassurance or at least a definitive care pathway. This, in combination with counselling, may help reduce the duration of any potential mental health issues that may arise as a result of a needlestick injury (Green and Griffiths 2013). Needlestick injuries should always be reported. This allows issues with sharps to be identified. It also enables staff members who are affected by injuries to have access to counselling services. The reporting of needlestick injuries permits accurate significant event statistics to be compiled, against which performance indicators can be measured. Mitigation strategies can also be monitored, and their efficiency evaluated. The main aim of this service evaluation was to assess whether the introduction of sharp-safe needles was a quality improvement measure which could mitigate against needlestick injuries.
Literature review There is substantial knowledge about the importance of reducing needlestick injuries within the healthcare setting. However, published studies have not included a real-time evaluation of the effectiveness of sharp-safe needles, compared with traditional needles, in reducing injury rates. This was the key focus for this service evaluation. Council Directive 2010/32/EU of 10 May 2010 Implementing the Framework Agreement on Prevention from Sharp Injuries in the Hospital and Healthcare Sector Concluded by HOSPEEM [European Hospital and Healthcare Employers’ Association] and EPSU [European Federation of Public Service Unions] directed member states of the European Union, including NHS trusts and manufacturers, to reduce the risk of sharps injuries by May 2013. The HOSPEEM-EPSU Joint Clarification of the Framework Agreement on Prevention from Sharp Injuries in the Hospital and Healthcare Sector recommended that all sharps should have a safety device where possible (HOSPEEM and EPSU 2010). The HOSPEEM-EPSU framework has been in force since May 2013 (EPSU 2013). The Peterborough and Stamford Hospitals NHS Foundation Trust introduced new sharp-safe needles to comply with the directive and in an effort to reduce the number of staff sharp injuries.
Method In the trust, data are collated using the Datix system. Permission was obtained from the non-clinical risk manager responsible for the data to access data relevant to the sharp-safe needles and undertake the service evaluation. Data for a four-year period from April 2010 to March 2014 were analysed. Sharps injuries were categorised as either ‘during use’ or ‘during disposal’ to determine when these injuries occurred. The information obtained was tabulated, using these categories, to enable comparison of sharps injuries over the four-year period.
Results The Datix data identified 608 reports of sharps injuries over the study period in the Peterborough and Stamford Hospitals NHS Foundation Trust. Comparative annual data of needlestick injuries during use and disposal, combining hypodermic needles and cannulae injuries, are shown in Table 1. Traditional needles were used until April 2013 with a handover period of one month between March 2013 and April 2013 when both
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traditional needles and sharp-safe needles were used. Full implementation of sharp-safe needles was achieved by May 2013. Following the introduction of the new sharp-safe needles in 2013-2014, 122 incidences of needlestick injuries occurred – a decrease of 43 (26%) reported incidents compared with 2012-2013 and a reduction in injuries compared with the previous three years (Figure 1). Needlestick injuries in 2013-2014 represented 20% of the total needlestick injuries occurring in the four-year study period. During 2013-2014, 78 injuries resulted from use of needles, a decrease of 30 reported incidences on the previous year. A total of 44 injuries occurred as a result of needle disposal in the same period, a reduced incidence in comparison with the previous three years. However, the fact that injuries were still occurring in 2013-2014 emphasises that the risks associated with needle use and disposal should not be underestimated, and that risks are still present, even with the sharp-safe needles.
Discussion In the four years under study, 608 percutaneous injuries were reported during the use or disposal of sharps. Of these incidents, 122 occurred following the introduction of the sharp-safe needles, a reduction of 43 injuries (26%) in comparison with the previous year. This result suggests that
the sharp-safe equipment is reducing injury rates, but it is not possible to state this definitively, or to determine the extent of the reduction. During the final three months of the service evaluation, no needlestick injuries were reported (Table 1). The absence of reported needlestick injuries during this three-month period is an anomaly. It seems probable that at least part of the reduction in sharps injuries observed is attributable to the introduction of sharp-safe needles, but it is also important to consider other factors that may have contributed to the reduced level of reports received. A change in reporting behaviour, perhaps because of perceived barriers to reporting, may have contributed to the decrease in sharps injuries reported. Alternatively, external factors, such as a decrease in the admission of patients requiring intravenous access, may have influenced needle use. Regardless of the factors responsible for the absence of needlestick injuries in these three months, this period had a significant effect on the results of the service evaluation. In the author’s experience, not all members of staff immediately understood how to use the new sharp-safe devices on hypodermic needles and have reported them to be a hindrance for certain techniques such as arterial stabs for blood gas sampling and ring block injections, when the physician’s accuracy is paramount. During these techniques the author witnessed physicians attempting to remove the safety cover during use.
TABLE 1 Needlestick injuries (hypodermic needles and cannulae) reported April 2010 to March 2014 2010-2011 From use
During disposal
April
8
May
12
June July August
2011-2012 Total
From use
0
8
5
17
7
4
5
4
9
September October November December January
2012-2013
During disposal
Total
12
3
15
5
2
7
11
4
6
10
9
9
6
15
9
18
6
5
11
11
6
17
5
1
6
11
5
16
17
6
7
5
12
13
4
From use
2013-2014
During disposal
Total
From use
During disposal
Total
13
5
18
11
8
19
8
9
17
3
5
8
7
3
10
10
1
11
11
6
17
8
6
14
10
5
15
8
5
13
5
7
12
16
4
20
23
8
5
13
8
3
11
17
10
5
15
9
6
15
7
6
13
4
5
9
10
5
15
5
6
11
16
8
24
7
10
17
9
1
10
0
0
0
February
7
5
12
9
5
14
7
4
11
0
0
0
March
9
4
13
4
3
7
10
2
12
0
0
0
Total
109 (68%)
61 (38%)
170
95 (63%)
56 (37%)
151
57 (35%)
165
78 (64%)
44 (36%)
108 (65%)
122
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Art & science service evaluation A study by Coté et al (2003) compared use of new retractable and traditional cannulae in children in the United States (US). The authors discussed reports that use of the new sharp-safe devices meant that it took longer to obtain access in some cases and that, therefore, members of staff had increased risk of exposure to blood-borne pathogens. A protocol was subsequently developed to enable practitioners to make informed decisions as to which device to use (Coté et al 2003). Such a protocol could perhaps be introduced to aid practitioners’ decision making in the UK. Elder and Paterson (2006) suggested that, while sharp-safe needles may be called a ‘safe’ device, this does not necessarily translate to obliterating risk. Care is still required to use devices correctly. If the user is not fully trained, or is resistant to the implementation of the new device, such risks are elevated (Porta et al 1999). Analysis of the types of injuries reported in Peterborough and Stamford Hospitals NHS Foundation Trust revealed that most occurred for reasons other than design of the device, for example injuries resulting from patients in the community leaving used insulin needles lying around after use. Injuries resulting from scalpels were also observed. However, scalpels would be difficult to make sharp safe because of their specific function and comparatively limited use, being restricted mainly to operating theatres and emergency departments. The types of injury sustained during use and disposal of equipment were similar. They differed only in method of injury, be that a direct puncture or a graze by a passing implement. Analysis of sharps incidents also revealed that many injuries associated with the sharp-safe
FIGURE 1 Total number of needlestick injuries over the study period
Number of needlestick injuries
200 160
170
165 151
120 122
80 40
20 14 320 1
3 20 1 220 1
1-2 01 20 1
20 1
0-
20 1
1
2
0
needles occurred as a result of the previous user disposing of the needle inappropriately or the safety element of the needle not being used in the way for which it was designed. There were also incidences where sharps bins were allowed to overfill, which impairs quick and safe disposal. The results identified that injuries during disposal of sharps could be influenced and reduced, through a system of effective education on the correct use of sharps bins. It should be standard practice that, once a sharp is used, it is disposed of immediately in the correct way, using a suitable sharps bin (Wilburn and Eijkemans 2004). An important factor in the need for reduction of sharps injuries is the increased risk of exposure to harmful blood-borne pathogens that can occur. The risks of infection by blood-borne pathogens from an injury will vary in severity and type depending on their cause (Hamlyn and Easterbrook 2007, Royal College of Nursing 2013). The study by Coté et al (2003), which investigated the implementation of sharp-safe needles in a paediatric hospital, identified that the sharp-safe needles reduced the risk of percutaneous injuries. However, staff members may have had increased exposure to blood pathogens through other means. For example, clinicians’ exposure may have increased because the sharp-safe needles can increase blood flow times from cannulation to application of a non-return valve (Coté et al 2003). The sharp-safe covers on hypodermic needles can also increase the risk of splashing bodily fluid into a clinician’s eyes. This is as a result of the cover having to be applied by the clinician, which can cause the needle to jolt, thus flicking the remaining blood in the needle outwards and towards the clinician. The types of infection that a member of staff exposes themselves to as a result of a needlestick injury are predominantly blood-borne pathogens, the most severe of which is HIV (Beltrami et al 2000). The data from this service evaluation correlate with the overall national incidence of sharps injuries in the NHS (Elder and Paterson 2006). UK national sharps injury rates are similar to those experienced in the US; however, Yang and Mullan (2011) suggest that more than half of nurses do not report incidences of percutaneous injury. Incidence rates can be assessed only on available data, so staff must be encouraged to report when they have been exposed. There is a culture of under-reporting in the NHS and there are further barriers to reporting injury, including staff compliance, acceptance of the risks associated with using a sharps implement, the fear of a positive result, lack of knowledge and a lack of time (Jeanes 1999, Osborn et al 1999, May and
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Brewer 2001, Trim et al 2003, Azadi et al 2011, Yang and Mullan 2011). Under-reporting in the NHS is an issue that requires further exploration and education. Evidence obtained from incident reports can be used to identify potential practice issues or device failure (Elmiyeh et al 2004). From this, a system of education and continued quality improvement can be implemented, which can influence both reporting and injury rates. Two literature reviews, by Parantainen et al (2011) and by Yang and Mullan (2011), have observed that passive devices were the most successful type of sharp-safe device, requiring no input from the user following use. Implementation of such devices, in conjunction with a training programme, could reduce the incidence of sharps injuries (van der Molen et al 2012). The results of this service evaluation suggest that categorising sharps injuries by injury type only, rather than including the device involved, restricts comprehensive interpretation of the data. Additional data categories would enable a targeted approach to developing specific sharp-safe devices and education practices in the future, focusing on those most at risk. One study investigated injury rates among surgical staff, an area where staff are at high risk of sharps injuries because of the nature and number of implements in use (Parantainen et al 2011). Furthermore, hands and implements were not always visible, thereby increasing the risk to staff of sustaining an accidental percutaneous injury. Parantainen et al (2011) concluded that the use of blunt suture needles would be beneficial and would appreciably reduce the risk of exposure to injury. By focusing on one specific area, this service evaluation has been able to identify a quality improvement measure that has the potential to reduce sharps injuries. Subsequent research
could use a similar model to enable departments most at risk to improve their sharps practice. The lessons learnt from this process could then be used throughout the hospital to achieve similar results.
Conclusion This service evaluation investigated whether the introduction of sharp-safe needles to the Peterborough and Stamford Hospitals NHS Foundation Trust was effective in reducing the number of needlestick injuries. A definitive evaluation of this intervention has not been possible because of the limited data available. However, initial findings suggest a reduction in reported sharps injury rates. An extended data collection period would enable a more definitive evaluation to be made. Further research into sharps injuries and/or a new education programme might also help reduce injury rates. This service evaluation suggests that sharps practice appears to be changing for the better, but this may result from changes in reporting sharps injuries or improved familiarity with the sharp-safe devices. The lack of comprehensive data is compounded by under-reporting of sharps injuries, which masks the true scale of the problem. Potential barriers to reporting sharps injuries should be further explored. Following this service evaluation, a clinical audit will be undertaken, extending the analysis to include additional data categories. This will enable a more definitive evaluation of the true extent of sharps injuries throughout the trust. The use of statistical analysis in future audits will assist the identification of significant changes in sharps injury rates NS
References Azadi A, Anoosheh M, Delpisheh A (2011) Frequency and barriers of underreported needlestick injuries amongst Iranian nurses, a questionnaire survey. Journal of Clinical Nursing. 20, 3-4, 488-493. Beltrami EM, Williams IT, Shapiro CN, Chamberland ME (2000) Risk and management of blood-borne infections in health care workers. Clinical Microbiology Reviews. 13, 3, 385-407. Coté CJ, Roth AG, Wheeler M et al (2003) Traditional versus new needle retractable i.v. catheters in children: are they really safer,
and whom are they protecting? Anesthesia & Analgesia. 96, 2, 387-391. Elder A, Paterson C (2006) Sharps injuries in UK healthcare: a review of injury rates, viral transmissions and potential efficacy of safety devices. Occupational Medicine. 56, 8, 566-574. Elmiyeh B, Whitaker IS, James MJ, Chahal CA, Galea A, Alshafi K (2004) Needle-stick injuries in the National Health Service: a culture of silence. Journal of the Royal Society of Medicine. 97, 7, 326-327.
European Federation of Public Service Unions (2013) Prevention of Sharps Injuries and Promoting the Implementation of Directive 2010/32/EU (2012/2013). www.epsu.org/r/629 (Last accessed: December 5 2014.) European Hospital and Healthcare Employers’ Association, European Federation of Public Service Unions (2010) HOSPEEM – EPSU Joint Clarification of the Framework Agreement on Prevention from Sharp Injuries in the Hospital and Healthcare Sector. tinyurl. com/mnwujxs (Last accessed: December 5 2014.)
Green B, Griffiths EC (2013) Psychiatric consequences of needlestick injury. Occupational Medicine. 63, 3, 183-188. Hamlyn E, Easterbrook P (2007) Occupational exposure to HIV and the use of post-exposure prophylaxis. Occupational Medicine. 57, 5, 329-336. Health and Safety Executive (2013) Sharps Injuries. www.hse.gov.uk/ healthservices/needlesticks/ (Last accessed: December 4 2014.) Jagger J, Pearson RD (1991) Universal precautions: still missing
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Art & science service evaluation the point on needlesticks. Infection Control and Hospital Epidemiology. 12, 4, 211-213. Jagger J, Berguer R, Philips EK, Parker G, Gomaa AE (2010) Increase in sharps injuries in surgical settings versus nonsurgical settings after passage of national needlestick legislation. Journal of American College of Surgeons. 210, 4, 496-502. Jeanes A (1999) Zero-Stik-Safety Syringe: an automatic safety syringe. British Journal of Nursing. 8, 8, 530-535. Kotwal A (2004) Innovation, diffusion and safety of a medical technology: a review of the literature on injection practices. Social Science & Medicine. 60, 5, 1133-1147.
Kozier B, Erb G, Berman A, Snyder S, Lake R, Harvey S (2008) Fundamentals of Nursing: Concepts, Process and Practice. First edition. Pearson Education, Harlow. May D, Brewer S (2001) Sharps injury: prevention and management. Nursing Standard. 15, 32, 45-52. Naghavi SH, Shabestari O, Alcolado J (2013) Post-traumatic stress disorder in trainee doctors with previous needlestick injuries. Occupational Medicine. 63, 4, 260-265.
Blunt versus sharp suture needle for preventing percutaneous exposure incidents in surgical staff. Cochrane Database of Systematic Reviews. Issue 11, CD009170. Porta C, Handelman E, McGovern P (1999) Needlestick injuries among health care workers. A literature review. American Association of Occupational Health Nurses. 47, 6, 237-244.
Osborn EH, Papadakis MA, Gerberding JL (1999) Occupational exposures to body fluids among medical students. A seven-year longitudinal study. Annals of Internal Medicine. 130, 1, 45-51.
Royal College of Nursing (2013) Sharps Safety. RCN Guidance to Support the Implementation of The Health and Safety (Sharp Instruments in Healthcare Regulations) 2013. tinyurl. com/cdznrpq (Last accessed: December 4 2014.)
Parantainen A, Verbeek JH, Lavoie M-C, Pahwa M (2011)
Trim JC, Adams D, Elliot TS (2003) Healthcare workers’ knowledge
of inoculation injuries and glove use. British Journal of Nursing. 12, 4, 215-221. van der Molen HF, Zwinderman KA, Sluiter JK, Frings-Dresen MH (2012) Interventions to prevent needle stick injuries among healthcare workers. Work. 41, Suppl 1, 1969-1971. Wilburn SQ, Eijkemans G (2004) Preventing needlestick injuries among healthcare workers: a WHO-ICN collaboration. International Journal of Occupational Environmental Health. 10, 4, 451-456. Yang L, Mullan B (2011) Reducing needle stick injuries in healthcare occupations: an integrative review of the literature. International Scholarly Research Network Nursing. doi: 10.5402/2011/315432
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If you would like to contribute to the Art & science section, email [email protected] or @NSclinicalEd
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
A quality improvement initiative to reduce needlestick injuries Beynon A (2015) A quality improvement initiative to reduce needlestick injuries. Nursing Standard. 29, 22, 37-42. Date of submission: August 8 2014; date of acceptance: September 29 2014.
Abstract Peterborough and Stamford Hospitals NHS Foundation Trust introduced sharp-safe needles in January 2013; these became a part of general practice by April 2013. A service evaluation was undertaken to investigate whether the introduction of sharp-safe needles had reduced the incidence of needlestick injuries. Results showed that 608 percutaneous injuries were sustained during the use and disposal of sharps between April 2010 and March 2014. A total of 122 injuries occurred following the introduction of the new sharp-safe needles (2013-2014), which was a 26% reduction compared with the previous year (2012-2013, n = 165). These results could mean that the sharp-safe needles reduced the rate of injuries. A definitive evaluation of the effectiveness of the sharp-safe needles was not possible given the limited data available since their introduction.
Author Anthony Beynon At time of writing was staff nurse, emergency department, Peterborough City Hospital, Peterborough, Cambridgeshire, England. Correspondence to: [email protected]
Keywords Blood-borne infection, health service evaluation, HIV, incident reporting, needlestick injuries, nursing care, quality improvement, sharps injuries
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: rcnpublishing.com/r/author-guidelines
HYPODERMIC NEEDLES ARE part of essential patient care and treatment for healthcare professionals. Standards are in place to ensure that a new needle and syringe are used for each procedure, with the aim of reducing the risk of infection (Kotwal 2004). However, the prevalence of needlestick injuries is increasing (Jagger et al 2010). Needlestick injuries are usually a result of avoidable events, often occurring as a result of re-sheathing a needle, or during disposal, as the user attempts to remove the needle before putting it in a sharps bin (Jagger and Pearson 1991). The removal of a needle before disposal or its re-sheathing contravenes standard practice (Kozier et al 2008). A new method of reducing needlestick injuries is the introduction of devices deemed ‘sharp safe’. One such device is a hypodermic needle with guards that should be applied once the needles have been used. Cannulae for intravenous infusions have a different sharp-safe system in which the needle is automatically covered once it has been removed from the plastic access tube left in the patient’s vein. These new devices were first introduced into Peterborough and Stamford Hospitals NHS Foundation Trust in January 2013 and were being used by all departments within three months. Their introduction met with little resistance because the process was undertaken gradually and seamlessly – as the old stock was depleted it was replaced with new sharp-safe versions. Having been included in the initial trial and final implementation stages of sharp-safe hypodermic needles and cannulae, the author had significant experience of their use. Training for the new devices included a demonstration of the new equipment and their safety devices.
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Art & science service evaluation Practical sessions using manikins were also involved. The author’s own experience was that the sharp-safe cannulae originally appeared bulky to handle and seemed difficult to use, however they became more familiar and easier to use after only a few uses. The design of the new sharp-safe cannula should help reduce injuries. This is a passive safety device. Once the cannula is inserted into the patient, the needle section is then removed; during removal the sharp end is covered by a plastic shield and the main body of the needle is covered by a corrugated sheath. If used correctly, once the sharp end is covered it cannot be re-exposed, thereby eliminating the risk of injury from this device. The sharp-safe element on the hypodermic needles is an active mechanism, requiring the user to fold a plastic shield over the sharp end. This light plastic shield completely covers the needle. The design of the shield is quite cumbersome, but does not interfere with use of the needle during a procedure.
Needlestick injuries A needlestick injury is the result of a needle or other sharp implement penetrating the skin. It may also be termed a percutaneous injury (Health and Safety Executive 2013). Injuries from such incidents can have a serious psychological effect. Following such an injury, members of staff may be at risk of post-traumatic stress disorder as fear of the unknown consequences of a sharps injury becomes apparent (Naghavi et al 2013). Staff may be exposed to life-changing infections such as hepatitis B and human immunodeficiency virus (HIV) by a sharps injury. To combat anxiety, staff must quickly undergo tests and acquire test results, thus obtaining reassurance or at least a definitive care pathway. This, in combination with counselling, may help reduce the duration of any potential mental health issues that may arise as a result of a needlestick injury (Green and Griffiths 2013). Needlestick injuries should always be reported. This allows issues with sharps to be identified. It also enables staff members who are affected by injuries to have access to counselling services. The reporting of needlestick injuries permits accurate significant event statistics to be compiled, against which performance indicators can be measured. Mitigation strategies can also be monitored, and their efficiency evaluated. The main aim of this service evaluation was to assess whether the introduction of sharp-safe needles was a quality improvement measure which could mitigate against needlestick injuries.
Literature review There is substantial knowledge about the importance of reducing needlestick injuries within the healthcare setting. However, published studies have not included a real-time evaluation of the effectiveness of sharp-safe needles, compared with traditional needles, in reducing injury rates. This was the key focus for this service evaluation. Council Directive 2010/32/EU of 10 May 2010 Implementing the Framework Agreement on Prevention from Sharp Injuries in the Hospital and Healthcare Sector Concluded by HOSPEEM [European Hospital and Healthcare Employers’ Association] and EPSU [European Federation of Public Service Unions] directed member states of the European Union, including NHS trusts and manufacturers, to reduce the risk of sharps injuries by May 2013. The HOSPEEM-EPSU Joint Clarification of the Framework Agreement on Prevention from Sharp Injuries in the Hospital and Healthcare Sector recommended that all sharps should have a safety device where possible (HOSPEEM and EPSU 2010). The HOSPEEM-EPSU framework has been in force since May 2013 (EPSU 2013). The Peterborough and Stamford Hospitals NHS Foundation Trust introduced new sharp-safe needles to comply with the directive and in an effort to reduce the number of staff sharp injuries.
Method In the trust, data are collated using the Datix system. Permission was obtained from the non-clinical risk manager responsible for the data to access data relevant to the sharp-safe needles and undertake the service evaluation. Data for a four-year period from April 2010 to March 2014 were analysed. Sharps injuries were categorised as either ‘during use’ or ‘during disposal’ to determine when these injuries occurred. The information obtained was tabulated, using these categories, to enable comparison of sharps injuries over the four-year period.
Results The Datix data identified 608 reports of sharps injuries over the study period in the Peterborough and Stamford Hospitals NHS Foundation Trust. Comparative annual data of needlestick injuries during use and disposal, combining hypodermic needles and cannulae injuries, are shown in Table 1. Traditional needles were used until April 2013 with a handover period of one month between March 2013 and April 2013 when both
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traditional needles and sharp-safe needles were used. Full implementation of sharp-safe needles was achieved by May 2013. Following the introduction of the new sharp-safe needles in 2013-2014, 122 incidences of needlestick injuries occurred – a decrease of 43 (26%) reported incidents compared with 2012-2013 and a reduction in injuries compared with the previous three years (Figure 1). Needlestick injuries in 2013-2014 represented 20% of the total needlestick injuries occurring in the four-year study period. During 2013-2014, 78 injuries resulted from use of needles, a decrease of 30 reported incidences on the previous year. A total of 44 injuries occurred as a result of needle disposal in the same period, a reduced incidence in comparison with the previous three years. However, the fact that injuries were still occurring in 2013-2014 emphasises that the risks associated with needle use and disposal should not be underestimated, and that risks are still present, even with the sharp-safe needles.
Discussion In the four years under study, 608 percutaneous injuries were reported during the use or disposal of sharps. Of these incidents, 122 occurred following the introduction of the sharp-safe needles, a reduction of 43 injuries (26%) in comparison with the previous year. This result suggests that
the sharp-safe equipment is reducing injury rates, but it is not possible to state this definitively, or to determine the extent of the reduction. During the final three months of the service evaluation, no needlestick injuries were reported (Table 1). The absence of reported needlestick injuries during this three-month period is an anomaly. It seems probable that at least part of the reduction in sharps injuries observed is attributable to the introduction of sharp-safe needles, but it is also important to consider other factors that may have contributed to the reduced level of reports received. A change in reporting behaviour, perhaps because of perceived barriers to reporting, may have contributed to the decrease in sharps injuries reported. Alternatively, external factors, such as a decrease in the admission of patients requiring intravenous access, may have influenced needle use. Regardless of the factors responsible for the absence of needlestick injuries in these three months, this period had a significant effect on the results of the service evaluation. In the author’s experience, not all members of staff immediately understood how to use the new sharp-safe devices on hypodermic needles and have reported them to be a hindrance for certain techniques such as arterial stabs for blood gas sampling and ring block injections, when the physician’s accuracy is paramount. During these techniques the author witnessed physicians attempting to remove the safety cover during use.
TABLE 1 Needlestick injuries (hypodermic needles and cannulae) reported April 2010 to March 2014 2010-2011 From use
During disposal
April
8
May
12
June July August
2011-2012 Total
From use
0
8
5
17
7
4
5
4
9
September October November December January
2012-2013
During disposal
Total
12
3
15
5
2
7
11
4
6
10
9
9
6
15
9
18
6
5
11
11
6
17
5
1
6
11
5
16
17
6
7
5
12
13
4
From use
2013-2014
During disposal
Total
From use
During disposal
Total
13
5
18
11
8
19
8
9
17
3
5
8
7
3
10
10
1
11
11
6
17
8
6
14
10
5
15
8
5
13
5
7
12
16
4
20
23
8
5
13
8
3
11
17
10
5
15
9
6
15
7
6
13
4
5
9
10
5
15
5
6
11
16
8
24
7
10
17
9
1
10
0
0
0
February
7
5
12
9
5
14
7
4
11
0
0
0
March
9
4
13
4
3
7
10
2
12
0
0
0
Total
109 (68%)
61 (38%)
170
95 (63%)
56 (37%)
151
57 (35%)
165
78 (64%)
44 (36%)
108 (65%)
122
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Art & science service evaluation A study by Coté et al (2003) compared use of new retractable and traditional cannulae in children in the United States (US). The authors discussed reports that use of the new sharp-safe devices meant that it took longer to obtain access in some cases and that, therefore, members of staff had increased risk of exposure to blood-borne pathogens. A protocol was subsequently developed to enable practitioners to make informed decisions as to which device to use (Coté et al 2003). Such a protocol could perhaps be introduced to aid practitioners’ decision making in the UK. Elder and Paterson (2006) suggested that, while sharp-safe needles may be called a ‘safe’ device, this does not necessarily translate to obliterating risk. Care is still required to use devices correctly. If the user is not fully trained, or is resistant to the implementation of the new device, such risks are elevated (Porta et al 1999). Analysis of the types of injuries reported in Peterborough and Stamford Hospitals NHS Foundation Trust revealed that most occurred for reasons other than design of the device, for example injuries resulting from patients in the community leaving used insulin needles lying around after use. Injuries resulting from scalpels were also observed. However, scalpels would be difficult to make sharp safe because of their specific function and comparatively limited use, being restricted mainly to operating theatres and emergency departments. The types of injury sustained during use and disposal of equipment were similar. They differed only in method of injury, be that a direct puncture or a graze by a passing implement. Analysis of sharps incidents also revealed that many injuries associated with the sharp-safe
FIGURE 1 Total number of needlestick injuries over the study period
Number of needlestick injuries
200 160
170
165 151
120 122
80 40
20 14 320 1
3 20 1 220 1
1-2 01 20 1
20 1
0-
20 1
1
2
0
needles occurred as a result of the previous user disposing of the needle inappropriately or the safety element of the needle not being used in the way for which it was designed. There were also incidences where sharps bins were allowed to overfill, which impairs quick and safe disposal. The results identified that injuries during disposal of sharps could be influenced and reduced, through a system of effective education on the correct use of sharps bins. It should be standard practice that, once a sharp is used, it is disposed of immediately in the correct way, using a suitable sharps bin (Wilburn and Eijkemans 2004). An important factor in the need for reduction of sharps injuries is the increased risk of exposure to harmful blood-borne pathogens that can occur. The risks of infection by blood-borne pathogens from an injury will vary in severity and type depending on their cause (Hamlyn and Easterbrook 2007, Royal College of Nursing 2013). The study by Coté et al (2003), which investigated the implementation of sharp-safe needles in a paediatric hospital, identified that the sharp-safe needles reduced the risk of percutaneous injuries. However, staff members may have had increased exposure to blood pathogens through other means. For example, clinicians’ exposure may have increased because the sharp-safe needles can increase blood flow times from cannulation to application of a non-return valve (Coté et al 2003). The sharp-safe covers on hypodermic needles can also increase the risk of splashing bodily fluid into a clinician’s eyes. This is as a result of the cover having to be applied by the clinician, which can cause the needle to jolt, thus flicking the remaining blood in the needle outwards and towards the clinician. The types of infection that a member of staff exposes themselves to as a result of a needlestick injury are predominantly blood-borne pathogens, the most severe of which is HIV (Beltrami et al 2000). The data from this service evaluation correlate with the overall national incidence of sharps injuries in the NHS (Elder and Paterson 2006). UK national sharps injury rates are similar to those experienced in the US; however, Yang and Mullan (2011) suggest that more than half of nurses do not report incidences of percutaneous injury. Incidence rates can be assessed only on available data, so staff must be encouraged to report when they have been exposed. There is a culture of under-reporting in the NHS and there are further barriers to reporting injury, including staff compliance, acceptance of the risks associated with using a sharps implement, the fear of a positive result, lack of knowledge and a lack of time (Jeanes 1999, Osborn et al 1999, May and
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Brewer 2001, Trim et al 2003, Azadi et al 2011, Yang and Mullan 2011). Under-reporting in the NHS is an issue that requires further exploration and education. Evidence obtained from incident reports can be used to identify potential practice issues or device failure (Elmiyeh et al 2004). From this, a system of education and continued quality improvement can be implemented, which can influence both reporting and injury rates. Two literature reviews, by Parantainen et al (2011) and by Yang and Mullan (2011), have observed that passive devices were the most successful type of sharp-safe device, requiring no input from the user following use. Implementation of such devices, in conjunction with a training programme, could reduce the incidence of sharps injuries (van der Molen et al 2012). The results of this service evaluation suggest that categorising sharps injuries by injury type only, rather than including the device involved, restricts comprehensive interpretation of the data. Additional data categories would enable a targeted approach to developing specific sharp-safe devices and education practices in the future, focusing on those most at risk. One study investigated injury rates among surgical staff, an area where staff are at high risk of sharps injuries because of the nature and number of implements in use (Parantainen et al 2011). Furthermore, hands and implements were not always visible, thereby increasing the risk to staff of sustaining an accidental percutaneous injury. Parantainen et al (2011) concluded that the use of blunt suture needles would be beneficial and would appreciably reduce the risk of exposure to injury. By focusing on one specific area, this service evaluation has been able to identify a quality improvement measure that has the potential to reduce sharps injuries. Subsequent research
could use a similar model to enable departments most at risk to improve their sharps practice. The lessons learnt from this process could then be used throughout the hospital to achieve similar results.
Conclusion This service evaluation investigated whether the introduction of sharp-safe needles to the Peterborough and Stamford Hospitals NHS Foundation Trust was effective in reducing the number of needlestick injuries. A definitive evaluation of this intervention has not been possible because of the limited data available. However, initial findings suggest a reduction in reported sharps injury rates. An extended data collection period would enable a more definitive evaluation to be made. Further research into sharps injuries and/or a new education programme might also help reduce injury rates. This service evaluation suggests that sharps practice appears to be changing for the better, but this may result from changes in reporting sharps injuries or improved familiarity with the sharp-safe devices. The lack of comprehensive data is compounded by under-reporting of sharps injuries, which masks the true scale of the problem. Potential barriers to reporting sharps injuries should be further explored. Following this service evaluation, a clinical audit will be undertaken, extending the analysis to include additional data categories. This will enable a more definitive evaluation of the true extent of sharps injuries throughout the trust. The use of statistical analysis in future audits will assist the identification of significant changes in sharps injury rates NS
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