Open Journal Systems

TEMAS DE ACTUALIDAD

Received: July 16^th 2014

Accepted: August 11^th 2014

Overview of sharps injuries among health-care workers

Rodrigo Gopar-Nieto,^a Cuauhtémoc Arturo Juárez-Pérez,^a Alejandro Cabello-López,^a Luis Cuauhtémoc Haro-García,^a Guadalupe Aguilar-Madrid^a

^aUnidad de Investigación de Salud en el Trabajo, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Distrito Federal, México

Communication with: Guadalupe Aguilar-Madrid

Telephone: (55) 5761 0725

Email: gpeaguilarm@gmail.com

Sharps injuries are one of the most frequent health-care related accidents. It is estimated globally that 35 million workers are at risk; in Mexico there is no data available for this type of injuries. They are associated with lack of training, instrument and procedure risk, fatigue and stress. The occupational distribution is nurses 45 %, technicians 20 %, doctors 20 % and maintenance workers 5 %. The most commonly associated procedures are injection, venipuncture, suture, and insertion and manipulation of IV catheters. Hepatitis B is the most commonly transmitted agent. Emotional distress is huge as well as the cost of prophylaxis and follow-up. More than half of the injuries are not notified. The most common reasons for not reporting are: the belief that the exposure has low risk of infection, the lack of knowledge of reporting systems and the assumption that it is difficult to notify. Many strategies have been created to reduce the incidence of sharps injuries, such as: identifying the risk of blood exposure, the creation of politics to minimize the risk, the education and training to create a safe workplace, the enhancing of the reporting system, the use of double-gloving and using safety-engineered sharps devices. In many countries these politics have reduced the incidence of sharps injuries as well as the economic burden.

Keywords: Occupational health; Health facility environment; Health personnel; Needlestick injuries

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Health workers are one of the occupational groups with the highest number of occupational risks. One of the most frequent accidents in this area is sharps injuries (SI). This category includes tools that can penetrate the skin or other body parts: needles, scalpel blades, vials, capillary tubes, catheters, and scissors, among others.¹

It is estimated that in the world every year 35 million health care workers are at risk of SI. In the United States 600,000 to 800,000 SI are estimated to occur each year, with an incidence of 14-839 SI per 1,000 health workers per year, while in the European Union nearly a million SI happen each year. Specifically, in Germany the existence of nearly 500,000 SI are calculated annually in health personnel with a number of injuries per person from 0.2 to 4.7 per year, and in the UK 100,000 SI happen per year.^2-6

In America, the health sector employs about 20 million workers. In Mexico, while 1.441 million people work in this field, our country does not have an up-to-date record of SI incidents, which represent 17% of all accidents for health care workers; the first place is occupied by injury from moving patients.^7,8

The highest-risk jobs in the hospital

Health workers perform various activities within the hospital environment; therefore, the risk and frequency of SI is different for everyone. Gillen et al. found the following distribution of SI: 45% nurses, 20% technicians, 20% doctors, 5% maintenance, and 3% students.⁹ Black et al. reported 3297 SI with safety devices and found 64.4% in nurses, 12.1% in technicians and 3.9% in doctors.¹⁰ Xu, in China, found 1680 health workers who suffered 2310 SI, with the highest incidence in nursing interns and students with 10.4%, nurses 8%, doctors 7%, management workers 4.2%, and laboratory technicians 3.9%.¹¹ In a trauma hospital in India, doctors had more SI (36.2%) than nurses (14.6%) and cleaning workers (7.6%).¹² As for sex, women suffer 73% of SI.⁹     

Of the labor categories mentioned, the studies agree that nurses have an increased frequency of SI.¹³ Honda et al. conducted a study on nurses in a hospital in Thailand where they found a prevalence of 55.5% of SI; nurses with bad attitudes about accident prevention had twice the SI of those with good attitudes.⁴ Ayranci et al. conducted surveys at a hospital in Turkey, where it was found that 52.5% of nurses had more than one SI and 47.5% reported having had at least one event in the last year.¹⁴ Outside the hospital setting but also involving nurses, Quinn et al. conducted a study in home health caregivers; it was found that 35% of nurses and 6.4% of the assistants have experienced at least one SI.¹⁵

Historically the place in the hospital where the second most percutaneous injuries occur is the operation room; the first is the hospital patient's room.¹⁶ Percutaneous exposures to blood occur in 1.4-15% of surgical procedures.³ Of all doctors, surgeons are the ones who are most at risk, and subgroup analysis indicates that residents in this specialty have increased risk for such accidents, and that those lower in the hierarchy are the most affected.¹⁷ Makary et al. conducted a study that focused on surgeons in training in 17 medical centers in the United States; it was found that 83% had had an SI during their training and 53% of these accidents occurred when treating high-risk patients; by the fourth year of training, 99% had been injured; it is also important to mention that the greater the number of SI, the lower the chance of reporting.³   

O'Connor et al. conducted a study of non-surgical doctors in which they found that 38% had at least one SI in the previous twelve months.⁷ Dental workers, who are also at risk, have a reported SI incidence of 8.19%.²

Moreover medical students are another sector that, although not formally working in a hospital, has a high prevalence of SI. It is estimated that the incidence in this group ranges from 11 to 30%. In Germany, it has been reported that 24.5% of medical students had at least one SI.¹⁸ The United States reported that 59% of residents suffered at least one SI while they were students. A relationship is established between having had SI as a student and having another accident when one is a resident.¹⁹ Moreover, a prevalence of 8.8% was reported for nursing students.²⁰

According to the Exposure Information Network (EPINet), 34% of SI are experienced by people who were not the primary users of the material,13 such as the cleaning and maintenance staff of hospital facilities. In the United States it was found that 20% of SI occur in basic service staff9 and in India it was reported that 22% of those affected were cleaning staff, as a result of inadequate training in the management of waste.²¹

Risk factors for SI

SI have been seen more in those who have worked less than three months and less frequently in those who have been working more than five years. The age period in which they happen most is 35-44 years.⁹ In 2005 Perry and Jagger stated that the risk of accidents is not only related to lack of skill but to the risks of the instruments and procedures; this is coupled with the lack of training in handling of sharp materials, lack of proper supervision in clinical practice, fatigue, and anxiety, particularly when patients with a known infection are being treated, and the leaving of needles or sharps in inappropriate places. 

The procedures most commonly associated with SI are: injections (28%), venipuncture (25%), sutures (14%), manipulation of intravenous catheters (11%), insertion of intravenous catheters (11%) and other procedures (11% ).22 According to the Royal College of Nursing, SI frequencies are distributed as follows: intramuscular or subcutaneous injections (20%) during the process of throwing away (21%) and recapping (51%).⁸

The instruments most related SI are: insulin or intramuscular needles (26%), discarded needles (18%), lancets for glucose determination (14%), overcrowded containers of sharps material (10%) and taking blood (6%).²³ Insulin administration is considered a high-risk procedure for nurses because of the number of injections required and the lack of training and safety devices in this area.²⁴ 

It has been identified that the operating room is a place of risk. 59% of SI during surgery happen to surgeons and primary assistants.²⁵ Wounds by suture needles are the most common (43.4%), followed by scalpel blade injuries (17.1%) and disposable syringes (12.1%).^16,26

Meanwhile, labor fatigue is a factor contributing to increased SI; it has been observed that nurses whose shifts are longer than 13 hours have more risk of SI, as do those working on weekends or in the evenings.²⁷ Similarly, doctors who worked 18 hours on average more frequently had at least one SI because of the long working hours and lack of sleep.²¹ Fatigue increases the risk of SI three times and has been regarded as a preventable factor in 37.5% of accidents; in medical residents the risk increases exponentially after working more than 8-12 hours.^17,27,28 

Underreporting of SI: a hidden problem

Underreporting involves failure to report SI by affected individuals. According to the Centers for Disease Control and Prevention (CDC) there is underreporting of more than half of SI.⁸ Several studies in various parts of the world have attempted to detect this problem. In Mexico, where there are not up-to-date statistics, it is estimated that the undercount for SI might be 30 to 82.9% for mucous membrane contact.²⁹ In the United States it was found that 53% of exposures were not reported.^30,31 Thailand has estimated underreporting approaching 39.4 to 75%,⁴ in China more than 60%,²⁰ Ireland 50%,15 in Germany from 22 to 75%,¹⁸ and Saudi Arabia 27%.³² 

By job category it has been found that underreporting by doctors can reach 51%;⁷ for surgeons and surgical residents it is estimated ranging from 50-95%,^16,17 in nurses and nursing students it ranges from 39.5 to 96.24%;²⁴ and cleaning staff 51.1%.¹² The most common reasons for not reporting are: assuming that the risk of disease transmission is low, the lack of knowledge of reporting systems, and the belief that the methods reporting are unclear and difficult to carry out.^5,33 In 15 of 28 studies where explanations for underreporting are given, the most prevalent reason for not reporting the event was perceiving it as low risk.³¹ Other reasons were that the needle was not used, that it was perceived as a minor injury, that it was thought that the needle was not infectious, that previous accidents had not had an impact, that users were ashamed and worried about getting into trouble, that there was no knowledge of the reporting procedure, that users were too busy, and did not want it to be thought that they were unskilled, that users were concerned that the accident would affect their evaluations, and lack of knowledge of the risks associated.²⁴

Consequences of SI

Biological and infectious

The diseases and infectious agents that can be transmitted through SI are hepatitis B, hepatitis C, HIV, tuberculosis, syphilis, malaria, herpes simplex, diphtheria, Ebola, cutaneous gonorrhea, Staphylococcus aureus, Streptococcus pyogenes, and Treponema pallidum, among others.^11,24 Within this context, from 20 to 38% of patients hospitalized in an urban environment are considered high risk by having at least one blood test positive for pathogens;19 about 38% of surgical procedures involve persons with at least one pathogen in their blood.^9,16 

The risk of transmission of infectious agents by SI is as follows: 6-30% for hepatitis B (without vaccination) 2-10% for hepatitis C, and 0.3% for HIV.^6,14,18 Because of the risk of seroconversion, hepatitis B is regarded as the major agent, with an estimated risk after a needle injury of 2% when the e-Antigen is negative and 30% when it is positive.³¹ In China, Romania, and India, it is estimated that about 80% of hepatitis B infections are caused by reusing needles.⁸

In the UK, between 1997 and 2009, 17 cases were reported of health care workers who developed Hepatitis C and 5 cases of HIV after having needlestick accidents.22 Moreover, in a retrospective study in Nuevo Leon, Mexico, 951 occupational exposures to blood-borne pathogens were reported either by SI or mucocutaneous exposure. Serological tests were done for 668 patients, of which 145 were positive: 62 for HIV, 55 for HCV, nine for HBV, three co-infected with HIV and HCV, and two co-infected with HIV and HBV.²⁹ 

The risk of disease transmission from patient to healthcare worker is commonly analyzed; however, it is worth mentioning that it also occurs in reverse, that is, from healthcare worker to patient. Since 1991 there have been 132 documented cases of infections by HIV, HBV, and HCV, of which 131 were transmitted during invasive surgeries.¹⁶  

The risk of infection after a needlestick injury is related to the depth of the wound, type of needle used (a hollow needle carries increased risk), the amount of blood or body fluid, if the needle was or was not in the vein or artery of the patient, and the degree of illness of the patient.²²

Emotional and psychological

Psychological and mental factors that cause SI have been little investigated; stress and fatigue have been described as the most common.³⁴ After an SI, 15.2% reported emotional disturbances such as anxiety, frustration and panic; 93.9% said the main factor that induced psychological disorders was fear of infection.³³ For nurses in Russia and Eastern Europe, depression, crying spells, family stress, panic attacks, anxiety attacks and loss of days of work were found.²² It has also been observed that nurses take a fatalistic view in which nothing can be done and decide not to deal with the problem if the object causing the SI is considered contaminated.²⁴

Economic consequences

The economic burden of SI to the health system or hospital is due to the completion of serological tests on the worker and, if possible, in the patient; to post-exposure prophylaxis, short- or long-term treatment, absenteeism, counseling and support to staff, and legal consequences, such as litigation and compensation. Cost estimates for health services in Germany were 4.6 to 30 million euros, in France 6.1 million, in Italy 7 million euros, in Spain 6 to 7 million euros, and between 4 and 300 million pounds in England and Wales.⁵ Spending per person due to post-exposure management, including laboratory tests for patients and workers, counseling and prophylaxis, is estimated at $2,003 in the US.¹

Preventive measures

Strategies to reduce the incidence of SI are: identifying risk of exposure to blood, creating processes and policies, education and appropriate training for health personnel in safe working environments, encouraging the reporting of accidents, the use of double gloving and use of safety devices such as blunt needles, safety scalpels, electrocautery, stapler, and cyanoacrylate adhesives.^8,17 

Since between 22 and 37% of accidents occur during sharps disposal, mainly from overfilling of containers and putting the needles into these,²⁴ the Occupational Safety and Health Administration (OSHA) has recommended, among other measures, eliminating the use of sharps wherever possible. Since December 1991, OSHA has established designs that sharps disposal containers must comply with, besides indicating that they should be available as close as possible to where the material is used. This measure has reduced SI related to the disposal of such materials by 53% since 1993.³⁵ 

Education and training are essential for the safe handling of sharps. Double gloving reduces the risk of contamination from blood 7-8 times.³ One study found that only 26% of workers used gloves when taking blood samples in patients considered low risk; this figure rose to 96% when the patient was considered high risk. A reduction has also been observed from 4.65 events to 0.16 events per nurse after safety training and education for handling sharp objects.²⁸

In 2005 the American College of Surgeons was in favor of universally adopting dull needles as the first choice for to suturing fascias.¹⁶ Alternatives to scalpel, sutures, and laparoscopic ports are electrocautery, tissue stapler, cyanoacrylate, and laparoscopic ports without points. Makary et al. have shown that 25% of operations can be carried out without sharp objects.³ Comparing the healing of midline incisions made with a scalpel and electrocautery has not found differences in the short or long term.   

As evidence of the effectiveness of preventive measures, in non-surgical scenarios before the Needlestick Safety and Prevention Act of 2000, which includes most of the aforementioned strategies, 24.1 injuries occurred per 100 occupied beds; after its implementation, the frequency of SI decreased 31% (16.5 injuries per 100 occupied beds). However, the rate in operating rooms increased from 6.3 to 6.8 per 100 occupied beds, reflecting the low adoption of safety devices and measures in this area.¹⁶

As for safety devices, since 2000, traditional devices have been replaced by safety devices; in the US, 95% of the devices in acute care situations include security mechanisms. In Germany, Technical Standard 250 states that the sharp or breakable objects are replaced by devices or methods in which there is little or no risk of SI.⁶ As for usage trends, 95% of nurses though it essential or preferable to use needle safety devices.²⁴

In 2012, the Health and Safety Executive carried out a systematic review of the effectiveness of the safety devices and their effect on SI; it found sufficient evidence to recommend the use of safety devices in healthcare workers in the UK. The CDC, like several multicenter studies, found a reduction in SI ranging between 23 and 76% upon evaluating safety devices, and it sets the limit that about 34 to 50% of SI can be avoided with these and 13% can be prevented by organizational measures.^6,10,30

Most safety devices require manual activation to cover the needle before being discarded: if a safety device is not activated or is incompletely activated, the desired SI risk reduction will not be obtained. The risk of injury is still high despite the introduction of new devices because they are not activated; it has been shown that the activation frequency was 64.5% at six months and 87.5% at 12 months of implementation, so training programs are still needed.²⁴ 

The World Health Organization estimated that about 535 million dollars a year are spent worldwide to treat infections caused by SI, triple what it costs to implement safety sharps devices.⁸ A hospital in Belgium implemented the use of safety devices for collecting blood samples, infusions, injections, and insulin administration; it was estimated that at five years SI had been reduced from 310 per year to 75; this projection implies a savings of 12% of hospital costs due to SI reduction, although the cost of security devices is greater than the traditional ones.⁵

Conclusions

SI include those caused by instruments that can injure or penetrate the skin barrier. The consequences of these accidents are various; they include biological, economic, social, psychological and labor issues.

In Mexico, it is a main objective to prevent these accidents. It is also relevant that the exposed population (doctors, nurses and other members of the health system) does not go to the appropriate entities when they are victims of this occupational hazard, either through ignorance, convenience, or fear of reprisals at work.

It is essential based on that reality, since taking preventive measures and the implementation of safer instruments for hospital tasks will not have the expected impact on populations at risk if you do not work in raising awareness among health workers, to emphasize that every job involves risks by nature of the labor process, and that the occurrence of accidents does not imply a lack of competence to carry out one’s work activities; these are random events whose occurrence can be mitigated with prevention measures. In addition, it has been found that if the safety of the work environment is improved there is no economic burden on medical service providers, so cost-effective investment in preventive measures such as training programs, acquisition of safety devices, and SI system log to know the real incidence, is considered plausible, which would be reflected as a benefit to workers and users of the services that they provide.

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