CORRESPONDENCE * All letters must be typed with double spacing and signed by all authors. * No letter should be more than 400 words.
* For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BMJ. * We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment.
* Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.
Preventing needlestick injuries SIR,-Professor D C Anderson and colleagues present some controversial views on needlestick injury.' The BMA recommends that operators who use syringes and needles should ensure personally the safe disposal of their needles but without resheathing them.2 Plastic sharps containers that conform to a British Standard are now available and ensure that, when discarded, a needle-syringe unit is safely contained and will not penetrate the outer layers of the container; this should prevent the "downstream" injuries suggested by Professor Anderson and colleagues. They present evidence from a local survey of doctors and nurses confirming that resheathing was practised by nearly half the nursing sisters questioned and by 87% of the doctors. Most nurses and doctors stated that despite an active policy not to resheathe they intended to continue this practice. I undertook two small surveys in April this year, which gave different results. In self assessment anonymous questionnaires 15 of 24 doctors who specialised in occupational health stated that they did not resheathe their needles after taking blood and 18 said that they discarded all used needlesyringe units directly into a sharps container. In a second survey of 64 health care workers (nurses, doctors, trainee nurses, radiographers, and other staff) from two Manchester hospitals similar results were obtained. Thirty three held positions where they would take blood; 22 would not resheathe needles. Twenty four of the 64 respondents reported having sustained one or more sharps injuries, five of which were due to resheathing needles. The scoop method of recapping and use of a device as described by Professsor Anderson and colleagues were found to be not popular or proved techniques in this study. There is evidence that trainee staff are at high risk of needlestick injury,4 and a recent survey of third year medical students showed that 45% suffered needlestick injury, with 51% of injuries occurring when the students were resheathing needles.5 Although efforts must be maintained to ensure a comprehensive programme of vaccination against hepatitis B for staff, a reduction in the accident rate is equally essential to reduce the risk of infection with HIV and hepatitis C virus.6 The World Health Organisation, United States Centers for Disease Control, Department of Health, and BMA agree that the risks from resheathing needles are too great for this practice to be recommended. DAVID R MORGAN
Professional and Scientific Division, BMA 1 Anderson DC, Blower AL, Packer JMV, Ganguli LA. Presenting needlestick injuries. BMJ 1991;302:769-70. (30 March.) 2 British Medical Association. A code of practice for the safe use and disposal ofsharps. London: BMA, 1990. 3 Morgan DR. Assessment of risks and control in occupational infection. Lancet 1991;337:679-80.
BMJ VOLUME 302
11 MAY 1991
4 Morgan DR. HIV and needlestick injury. Lancet 1990;335:1280. 5 Gompertz S. Needlestick injuries in medical students. J Soc Occup Med 1990;40:19-20. 6 Cariani E, Zonaro A, Primi D, et al. Detection of HCV RNA and antibodies to HCV after needlestick injury. Lancet 1991;337: 850.
SIR,-Having striven for years to re-educate ourselves and others not to resheathe needles, we were interested to read the article by Professor D C Anderson and colleagues advocating the use of "safe" techniques. We agree that, in theory, these might seem to be desirable practices and would help to eliminate the risks to third parties. In practice we have serious doubts. The methods suggested are not as foolproof as they seem. Scoop resheathing requires a steady hand, which might not be dependable in an emergency, when things are performed quickly. The same consideration applies to gravity resheathing. In the heat of the moment the hand may easily come into contact with the needle. The Saf-T-Cap is a better proposition, but is it going to be available when heeded? Our fear is that a return to sheathing will serve merely to undo all the efforts we have made and, in practice, unsafe methods of sheathing will reappear. Perhaps more serious is the fact that so many needles are loose and fall off. These will then require further resheathing, and when they fall on to the floor less safe methods may perhaps be used for this. We cannot understand the reference to Vacutainers as being safe. These have needles at both ends. The end for venepuncture is no safer than any other needle, and the one used to pierce the cap is covered by a piece of rubber, which is easily penetrated. These devices thus have a greater potential to cause injury. MALCOLM GATLEY MARGARET WORSLEY North Manchester Health Authority, Manchester M8 6RL 1 Anderson DC, BlowerAL,PackerJMV,Ganguli LA. Preventing needlestick injuries. BMJ7 1991,302:769-70. (30 March.)
discussion to mutual benefit. This enabled us to draw up a common contract with provider units; gave us a stronger negotiating edge; and helped us to identify grey areas, which we reported back to the regional health authority. By having a combination of vested interest and clinical experience we have been able not only to identify problems but also to explore means of solving them. The district representatives with their more unwieldy machinery admit that they have not had the time or knowledge for such an approach and have had to contend with simpler broad principles and block contracts for this year. Already many good qualities have emerged from the six district general hospitals of Birmingham. The most impressive and progressive of these has been the desire of administrators and consultants throughout all units to achieve a higher standard of care for patients. There has been a concerted effort to involve the fundholding general practitioners in their planning, and if the standard of care for all patients ultimately rises then it is to their credit. After local discussions between the consortium and our laboratory services an improved service to collect specimens and deliver results (for all practices in the neighbourhood) has occurred on a daily basis. Many other initiatives are currently being explored. Wards closed as a result of cutbacks may soon be reopened as we negotiate "out of hours" surgical lists funded from our practice purses. The possibility of practice based clinics for glaucoma, endoscopy, colposcopy, and vasectomy is being talked through, as also is the possibility of funding a research post in rheumatology. Finally, we are not naive about the long term cash limiting effect of this programme, but if, as many sceptics suggest, we are short changed we will at least have known figures and not merely inspired estimates with which to argue with whichever political party forms the government of the day. It is our opinion that fundholding should be given a chance. TED HISCOCK
Streetly Road Surgery, Erdington, Birmingham B23 7BD
Budget holding: a step into the unknown SIR,-It is a pleasure to read an unrhetorical account of the steps taken so far by the practice in Calverton, Nottinghamshire, whose partners seem to have adopted a similar attitude to our own.' Our practice profile differs from theirs-our catchment area is 100% inner city, and we have a list of just over 10000 patients, which is shared among four and a half partners. During the preparation period seven fundholding practices, each with similar problems, formed a consortium in which we could hold open
1 Bain J. Budget holding: a step into the unknown. BM 1991;302: 771-3. (30 March.)
The GP contract SIR, -The first anniversary of the enforced general practitioners' contract has passed without as much as a two minute silence in all general practice surgeries. It is said that 18% of the 30 000 principals approve of the contract, rather than that about 24 600 disapprove. So much for the anachronistic independent contractor status of general prac-
1147
* For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BMJ. * We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment.
* Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.
Preventing needlestick injuries SIR,-Professor D C Anderson and colleagues present some controversial views on needlestick injury.' The BMA recommends that operators who use syringes and needles should ensure personally the safe disposal of their needles but without resheathing them.2 Plastic sharps containers that conform to a British Standard are now available and ensure that, when discarded, a needle-syringe unit is safely contained and will not penetrate the outer layers of the container; this should prevent the "downstream" injuries suggested by Professor Anderson and colleagues. They present evidence from a local survey of doctors and nurses confirming that resheathing was practised by nearly half the nursing sisters questioned and by 87% of the doctors. Most nurses and doctors stated that despite an active policy not to resheathe they intended to continue this practice. I undertook two small surveys in April this year, which gave different results. In self assessment anonymous questionnaires 15 of 24 doctors who specialised in occupational health stated that they did not resheathe their needles after taking blood and 18 said that they discarded all used needlesyringe units directly into a sharps container. In a second survey of 64 health care workers (nurses, doctors, trainee nurses, radiographers, and other staff) from two Manchester hospitals similar results were obtained. Thirty three held positions where they would take blood; 22 would not resheathe needles. Twenty four of the 64 respondents reported having sustained one or more sharps injuries, five of which were due to resheathing needles. The scoop method of recapping and use of a device as described by Professsor Anderson and colleagues were found to be not popular or proved techniques in this study. There is evidence that trainee staff are at high risk of needlestick injury,4 and a recent survey of third year medical students showed that 45% suffered needlestick injury, with 51% of injuries occurring when the students were resheathing needles.5 Although efforts must be maintained to ensure a comprehensive programme of vaccination against hepatitis B for staff, a reduction in the accident rate is equally essential to reduce the risk of infection with HIV and hepatitis C virus.6 The World Health Organisation, United States Centers for Disease Control, Department of Health, and BMA agree that the risks from resheathing needles are too great for this practice to be recommended. DAVID R MORGAN
Professional and Scientific Division, BMA 1 Anderson DC, Blower AL, Packer JMV, Ganguli LA. Presenting needlestick injuries. BMJ 1991;302:769-70. (30 March.) 2 British Medical Association. A code of practice for the safe use and disposal ofsharps. London: BMA, 1990. 3 Morgan DR. Assessment of risks and control in occupational infection. Lancet 1991;337:679-80.
BMJ VOLUME 302
11 MAY 1991
4 Morgan DR. HIV and needlestick injury. Lancet 1990;335:1280. 5 Gompertz S. Needlestick injuries in medical students. J Soc Occup Med 1990;40:19-20. 6 Cariani E, Zonaro A, Primi D, et al. Detection of HCV RNA and antibodies to HCV after needlestick injury. Lancet 1991;337: 850.
SIR,-Having striven for years to re-educate ourselves and others not to resheathe needles, we were interested to read the article by Professor D C Anderson and colleagues advocating the use of "safe" techniques. We agree that, in theory, these might seem to be desirable practices and would help to eliminate the risks to third parties. In practice we have serious doubts. The methods suggested are not as foolproof as they seem. Scoop resheathing requires a steady hand, which might not be dependable in an emergency, when things are performed quickly. The same consideration applies to gravity resheathing. In the heat of the moment the hand may easily come into contact with the needle. The Saf-T-Cap is a better proposition, but is it going to be available when heeded? Our fear is that a return to sheathing will serve merely to undo all the efforts we have made and, in practice, unsafe methods of sheathing will reappear. Perhaps more serious is the fact that so many needles are loose and fall off. These will then require further resheathing, and when they fall on to the floor less safe methods may perhaps be used for this. We cannot understand the reference to Vacutainers as being safe. These have needles at both ends. The end for venepuncture is no safer than any other needle, and the one used to pierce the cap is covered by a piece of rubber, which is easily penetrated. These devices thus have a greater potential to cause injury. MALCOLM GATLEY MARGARET WORSLEY North Manchester Health Authority, Manchester M8 6RL 1 Anderson DC, BlowerAL,PackerJMV,Ganguli LA. Preventing needlestick injuries. BMJ7 1991,302:769-70. (30 March.)
discussion to mutual benefit. This enabled us to draw up a common contract with provider units; gave us a stronger negotiating edge; and helped us to identify grey areas, which we reported back to the regional health authority. By having a combination of vested interest and clinical experience we have been able not only to identify problems but also to explore means of solving them. The district representatives with their more unwieldy machinery admit that they have not had the time or knowledge for such an approach and have had to contend with simpler broad principles and block contracts for this year. Already many good qualities have emerged from the six district general hospitals of Birmingham. The most impressive and progressive of these has been the desire of administrators and consultants throughout all units to achieve a higher standard of care for patients. There has been a concerted effort to involve the fundholding general practitioners in their planning, and if the standard of care for all patients ultimately rises then it is to their credit. After local discussions between the consortium and our laboratory services an improved service to collect specimens and deliver results (for all practices in the neighbourhood) has occurred on a daily basis. Many other initiatives are currently being explored. Wards closed as a result of cutbacks may soon be reopened as we negotiate "out of hours" surgical lists funded from our practice purses. The possibility of practice based clinics for glaucoma, endoscopy, colposcopy, and vasectomy is being talked through, as also is the possibility of funding a research post in rheumatology. Finally, we are not naive about the long term cash limiting effect of this programme, but if, as many sceptics suggest, we are short changed we will at least have known figures and not merely inspired estimates with which to argue with whichever political party forms the government of the day. It is our opinion that fundholding should be given a chance. TED HISCOCK
Streetly Road Surgery, Erdington, Birmingham B23 7BD
Budget holding: a step into the unknown SIR,-It is a pleasure to read an unrhetorical account of the steps taken so far by the practice in Calverton, Nottinghamshire, whose partners seem to have adopted a similar attitude to our own.' Our practice profile differs from theirs-our catchment area is 100% inner city, and we have a list of just over 10000 patients, which is shared among four and a half partners. During the preparation period seven fundholding practices, each with similar problems, formed a consortium in which we could hold open
1 Bain J. Budget holding: a step into the unknown. BM 1991;302: 771-3. (30 March.)
The GP contract SIR, -The first anniversary of the enforced general practitioners' contract has passed without as much as a two minute silence in all general practice surgeries. It is said that 18% of the 30 000 principals approve of the contract, rather than that about 24 600 disapprove. So much for the anachronistic independent contractor status of general prac-
1147
