How

How can needle stick injuries be prevented? Legislation, education, and implementation of safety programs all contribute to the reduction and possible elimination of needle stick injuries.

Legislation

The Needle Stick and Prevention Act

• Places the requirement on the health care employer to document that they have implemented safety-engineered sharp devices and needless systems. This documentation must be provided in the employer’s exposure control plan, with the goal of reducing employees’ occupational exposure to HIV, hepatitis C and other blood borne diseases.
• The employer’s exposure control plans must be reviewed and updated annually. Any changes in sharps safety technology that has occurred must be included.
• There must be a sharps injury log maintained at every health care facility. Detailed information must be documented in the log, including:
  - The department where the injury occurred,
  - An explanation of how the injury occurred, and
  - The type and brand of the device involved in the injury.
• Employers must ask for input from non-managerial, frontline health care workers when identifying, evaluating and selecting safety-engineered sharp devices. These actions must be documented in the employer’s exposure control plan.
• The definition of “Engineering Controls” now includes devices with engineered sharps injury protection.

OSHA

The current Federal standard for addressing needle stick injuries among health care workers is the OSHA blood borne pathogens standard [29 CFR 1910.1030; 56 Fed. Reg.†† 64004 (1991)], which has been in effect since 1992. The standard applies to all occupational exposures to blood or other potentially infectious materials. Notable elements of this standard require the following:

• A written exposure control plan designed to eliminate or minimize worker exposure to blood borne pathogens.
• Compliance with universal precautions (an infection control principle that treats all human blood and other potentially infectious materials as infectious).
• Engineering controls and work practices to eliminate or minimize worker exposure.
• Personal protective equipment (if engineering controls and work practices do not eliminate occupational exposures).
• Prohibition of bending, recapping, or removing contaminated needles and other sharps unless such an act is required by a specific procedure or has no feasible alternative.
• Prohibition of shearing or breaking contaminated needles (OSHA defines contaminated as the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface).
• Free hepatitis B vaccinations offered to workers with occupational exposure to blood borne pathogens.
• Worker training in appropriate engineering controls and work practices.
• Post-exposure evaluation and follow-up, including post-exposure prophylaxis when appropriate.
• OSHA also intends to act to reduce the number of injuries that health care workers receive from needles and other sharp medical objects [OSHA 1999a].
  
  First, the agency has revised the compliance directive (guidance to be used in the field) accompanying its 1992 blood borne pathogens standard [29 CFR 1910.1030] to reflect newer and safer technologies now available and to increase the employer's responsibility to evaluate and use effective, safer technologies [OSHA 1999b].
  
  Second, the agency has proposed a requirement in the revised recordkeeping rule that all injuries resulting from contaminated needles and sharps be recorded on OSHA logs used by employers to record injuries and illnesses.
  
  Finally, OSHA will take steps to amend its blood borne pathogens standard by placing needle stick and sharps injuries on its regulatory agenda.

FDA

Under the regulations of the Food and Drug Administration (FDA) application clearance process [FDA 1995], the manufacturers of medical devices (including needles used in patient care) must meet requirements for appropriate registration and for listing, labeling, and good manufacturing practices for design and production.

The process for receiving clearance or approval to market a device requires device manufacturers to:

1. demonstrate that a new device is substantially equivalent to a legally marketed device or
2. document the safety and effectiveness of the new device for patient care through a more involved premarket approval process.

FDA has also released two advisories pertaining to sharps and the risk of blood borne pathogen transmission in the health care setting [FDA 1992; FDA et al. 1999].

State Regulations

As of the writing of the NIOSH Alert on Preventing Needle Stick Injuries in health Care Settings, three States have adopted and more than two dozen are considering legislation to require additional regulatory actions addressing blood borne pathogen exposures to health care workers.

The recent California standard [State of California 1998] has several requirements that go beyond those currently required by OSHA. These requirements include stronger language for the use of needle less systems for certain procedures or (where needle less systems are not available) the use of needles with engineered sharps injury protection for certain procedures.

Education

Know the facts. Know which devices and activities are associated with needle stick injuries. Understand the extent of the problem by learning the statistics on HIV, HCV, and HBV infections contracted via needle sticks. Learn the desirable characteristics of devices with safety features.

Devices Associated with Needle Stick Injuries:

Health care workers use many types of needles and other sharp devices to provide patient care. However, data from hospitals participating in the CDC National Surveillance System for Hospital Health Care Workers (NaSH) and from hospitals included in the EPINet research database show that only a few needles and other sharp devices are associated with the majority of injuries.

Of nearly 5,000 percutaneous injuries reported by hospitals participating in NaSH between June 1995 and July 1999, 62% were associated with hollow-bore needles—primarily hypodermic needles attached to disposable syringes (29%) and winged-steel (butterfly-type) needles (13%).

Activities Associated with Needle Stick Injuries:

Whenever a needle or other sharp device is exposed, injuries can occur. Data from NaSH show that approximately 38% of percutaneous injuries occur during use and 42% occur after use and before disposal.

The circumstances leading to a needle stick injury depend partly on the type and design of the device used. For example, needle devices that must be taken apart or manipulated after use (e.g., prefilled cartridge syringes and phlebotomy needle/vacuum tube assemblies) are an obvious hazard and have been associated with increased injury rates.

In addition, needles attached to a length of flexible tubing (e.g., winged-steel needles and needles attached to IV tubing) are sometimes difficult to place in sharps containers and thus present another injury hazard.

Injuries involving needles attached to IV tubing may occur when a health care worker inserts or withdraws a needle from an IV port or tries to temporarily remove the needle stick hazard by inserting the needle into a drip chamber, IV port or bag, or even bedding.

In addition to risks related to device characteristics, needle stick injuries have been related to certain work practices such as recapping, transferring a body fluid between containers, and failing to properly dispose of used needles in puncture-resistant sharps containers.

Past studies of needle stick injuries have shown that 10% to 25% occurred when recapping a used. Although recapping by hand has been discouraged for some time and is prohibited under the OSHA blood borne pathogens standard, unless no alternative exists, 5% of needle stick injuries in NaSH hospitals are still related to this practice.

Injury may occur when a health care worker attempts to transfer blood or other body fluids from a syringe to a specimen container (such as a vacuum tube) and misses the target.

If used needles or other sharps are left in the work area or are discarded in a sharps container that is not puncture resistant, a needle stick injury may result.

Statistics on HIV, HBV, and HCV Infections Contracted via Needle Sticks:

HIV

Between 1985 and June 1999, cumulative totals of 55 documented cases and 136 possible cases of occupational HIV transmission to U.S. health care workers were reported to the Centers for Disease Control and Prevention (CDC).

Most involved nurses and laboratory technicians. Percutaneous injury (e.g., needle stick) was associated with 49 (89%) of the documented transmissions. Of these, 44 involved hollow-bore needles, most of which were used for blood collection or insertion of an IV catheter. HIV infection is a complex disease that can be associated with many symptoms. The virus attacks part of the body’s immune system, eventually leading to severe infections and other complications—a condition known as AIDS. Despite current therapies that delay the progression of HIV disease, most health care workers who become infected with HIV are likely to eventually develop AIDS and die.

HBV

Information from national hepatitis surveillance is used to estimate the number of HBV infections in health care workers.

In 1995, an estimated 800 health care workers became infected with HBV [CDC unpublished data]. This figure represented a 95% decline from the 17,000 new infections estimated in 1983. The decline was largely due to the widespread immunization of health care workers with the hepatitis B vaccine and the use of universal precautions and other measures required by the Occupational Safety and Health Administration (OSHA) blood borne pathogens standard.

About one-third to one-half of persons with acute HBV infection develop symptoms of hepatitis such as jaundice, fever, nausea, and abdominal pain. Most acute infections resolve, but 5% to 10% of patients develop chronic infection with HBV that carries an estimated 20% lifetime risk of dying from cirrhosis and 6% risk of dying from liver cancer.

HCV

Hepatitis C virus infection is the most common chronic blood borne infection in the United States, affecting approximately 4 million people [CDC 1998b]. Although the prevalence of HCV infection among health care workers is similar to that in the general population (1% to 2%) [CDC 1998b], health care workers clearly have an increased occupational risk for HCV infection.

In a study that evaluated risk factors for infection, a history of unintentional needle stick injury was independently associated with HCV infection. The number of health care workers who have acquired HCV occupationally is not known. However, of the total acute HCV infections that have occurred annually (ranging from 100,000 in 1991 to 36,000 in 1996), 2% to 4% have been in health care workers exposed to blood in the workplace.

HCV infection often occurs with no symptoms or only mild symptoms. But unlike HBV, chronic infection develops in 75% to 85% of patients, with active liver disease developing in 70%. Of the patients with active liver disease, 10% to 20% develop cirrhosis, and 1% to 5% develop liver cancer [CDC 1998b].

Desirable Characteristics of Devices with Safety Features:

• The safety feature is an integral part of the device.
• The user can easily tell whether the safety feature is activated.
• The safety feature cannot be deactivated and remains protective through disposal.
• The device performs reliably.
• The device is easy to use and practical.
• The device is safe and effective for patient care.

Although each of these characteristics is desirable, some are not feasible, applicable or available for certain health care situations. For example, needles will always be necessary where alternatives for skin penetration are not available. Also, a safety feature that requires activation by the user might be preferable to one that is passive in some cases. Each device must be considered on its own merit and ultimately on its ability to reduce workplace injuries. The desirable characteristics listed here should thus serve only as a guideline for device design and selection.

Safety Programs

Needle stick injuries can be avoided by eliminating the unnecessary use of needles, using devices with safety features, and promoting education and safe work practices for handling needles and related systems. These measures should be part of a comprehensive program to prevent the transmission of blood borne pathogens. Specifically:

Employers: Needle stick injuries can best be reduced when the use of improved engineering controls is incorporated into a comprehensive program involving workers. Employers should implement the following program elements:

• Eliminate the use of needles where safe and effective alternatives are available.
• Implement the use of devices with safety features and evaluate their use to determine which are most effective and acceptable.
• Analyze needle stick and other sharps-related injuries in your workplace to identify hazards and injury trends.
• Set priorities and strategies for prevention by examining local and national information about risk factors for needle stick injuries and successful intervention efforts.
• Ensure that health care workers are properly trained in the safe use and disposal of needles.
• Modify work practices that pose a needle stick injury hazard to make them safer.
• Promote safety awareness in the work environment.
• Establish procedures for and encourage the reporting and timely follow-up of all needle stick and other sharps-related injuries.
• Evaluate the effectiveness of prevention efforts and provide feedback on performance.

Health care workers: The number of needle stick injuries can be reduced by health care workers taking the following steps to protect themselves and their fellow workers:

• Avoid the use of needles where safe and effective alternatives are available.
• Help your employer select and evaluate devices with safety features.
• Use devices with safety features provided by your employer.
• Avoid recapping needles.
• Plan for safe handling and disposal before beginning any procedure using needles.
• Dispose of used needles promptly in appropriate sharps disposal containers.
• Report all needle stick and other sharps-related injuries promptly to ensure that you receive appropriate follow-up care.
• Tell your employer about hazards from needles that you observe in your work environment.
• Participate in blood borne pathogen training and follow recommended infection prevention practice, including hepatitis B vaccination.