This Might Hurt

28 February 2007 (Last Updated February 28th, 2007 18:30)

Levels of needlestick injury among healthcare workers have risen sharply in the UK, despite technologies for prevention. So what can be done? Nic Paton asks Dr Paul Grime, chairman of the Safer Needles Network.

It is hard to believe that, in 2007, we are still talking about needlestick injuries and the dangers to healthcare workers from hypodermic needles, eye-splash injuries and blood-borne infections. Retractable needles, needle-free devices and devices incorporating a range of safety features have been available since the 1990s, yet, according to the UK National Health Service (NHS) Purchasing and Supply Agency, while sales of such devices now total more than £8m (2004–05), this still pales in comparison to the £20m spent in England on needles and syringes.

What’s more, the most up-to-date figures from the Health Protection Agency (HPA), published in November 2006, showed that 11 healthcare workers had been infected with hepatitis C via needlestick injuries in the previous eight years. Two incidents had been reported in the previous 12 months.

The HPA’s report, Eye of the Needle, found that the number of reported occupational exposures to infection increased by 49% between 2002 and 2005. Between July 1996 and June 2004, 2,140 significant occupational exposure incidents were reported, 78% of which broke the skin. The vast majority of injuries were caused by a failure to comply with procedures for the safe handling and disposal of sharps and clinical waste and, tragically, "were mostly preventable".

Other studies have painted a similar picture. The National Audit Office’s A Safer Place to Work report in 2003 estimated that needlestick injuries accounted for 17% of staff accidents and were second only to bad backs as a cause of occupational injury among NHS staff. In 2005 health workers union Unison calculated that there were some 100,000 needlestick injuries in the NHS each year.

"The number of reported occupational exposures to infection increased by 49% between 2002 and 2005."

The problem is compounded by what some might call the rather relaxed attitude of the UK Government to the whole issue. There does not seem to be any sense of urgency on the matter.

Dr Paul Grime, chairman of the Safer Needles Network, and a consultant and honorary senior lecturer in occupational medicine at the Royal Free Hospital in London, suggests that there is a cultural barrier in both the NHS and the private healthcare sectors that sees needlestick injuries as almost a rite of passage and, certainly, nothing to make a fuss about.

He says: "What is reported is still only a small proportion of what happens. The majority of cases go unreported. I would say that only about a quarter of cases are being reported."

SOME PROGRESS

Nevertheless, some progress is being made. One reason for the rising number of needlestick injuries is increasing reporting levels. More and more trusts now have protocols in place that staff must rigidly follow in the event of a needlestick or similar accident.

Investment in safer devices is at least rising. Walk around most hospitals and there will be many more sharps buckets or portable bins with guards on them, and educational messages about disposing of sharps are more prominent.

Small things, such as the marking of bins with a black line to show when they are full and ensuring that people do not stick their hands in overflowing bins, have helped, says Grime. "It is so easy just to keep filling the bin. But people must be encouraged to seal them and take them away before they get too full. There is still scope for more education and training. In the majority of [injury] cases that get reported, injury could have been prevented by better adherence to best practice."

THREE-PRONGED STRATEGY

A three-pronged strategy is the best approach when it comes to prevention, argues Grime. This should consist of a programme to reduce exposure and transmission, increase education and training, and improve the accuracy of surveillance.

The Safer Needles Network has, to this end, put together guidance on some of the steps employers and workers should be taking to help ensure workplaces become as risk free as possible. It highlights four key areas:

  • Formal risk assessments
  • Risk management to improve workplace design and put in place safer working practices
  • Effective and regular training
  • The provision of medical devices that incorporate safety engineered protection mechanisms

All exposure incidents, it recommends, should be reported promptly, following local reporting arrangements to ensure the incident is appropriately managed and documented.

All cases of occupational exposure to blood or body fluid from patients infected with HIV, HCV or HBV and all incidents where post-exposure prophylaxis for HIV has been started (whatever the HIV status of the source) should then be reported to the HPA’s national surveillance scheme, it advises.

On top of this, employees need to be given adequate time for training at staff induction, while ongoing refresher training should be provided. This should cover:

  • The risks associated with blood and body fluid exposures
  • Preventive measures, including standard precautions
  • Safe systems of work
  • The importance of hepatitis B immunisation
  • The correct use and disposal of sharps
  • The correct use of medical devices incorporating sharps protection mechanisms

THE COST CASE

There is also a need for healthcare practitioners at all levels to make the business case for preventing needlestick and eye splash injuries.

"We need to show organisations that it is worth the investment," says Grime. "What often puts managers off is the upfront cost. We need to show them how investment in prevention adds up against the cost of a needlestick injury – the health bill that goes with it, not to mention the legal costs – and that it is not just about protecting workers, but patients, too."

"In the majority of [injury] cases that get reported, injury could have been prevented by better adherence to best practice."

Grime believes that, when NHS trust bureaucrats and managers question the cost of investing in education or equipment to reduce needlestick injuries, the clinician needs to stress that such investment may result in savings on clinical negligence payments.

Grime estimates that a trust with 5,000 staff can spend around £100,000 a year on managing exposure incidents, through blood tests, lost staff time and post-exposure prophylaxis – but excluding litigation costs. A study by the Scottish Executive showed that 41% of sharps injuries could probably be prevented by using safety devices, while 14% could definitely be prevented. Grime calculates that, in a trust with 5,000 staff, annual savings of between £14,000 and £42,000 could be achieved by eliminating sharps injuries.

Trusts, he says, sometimes reject the business cases on cost grounds, only to subsequently be forced to make the rejected changes in response to adverse incidents – such as expensive court cases – when with a little investment upfront in safer systems, such incidents could be prevented.

Grime says: "Often needlestick injury prevention is not seen as a priority by the infection control specialist, particularly when they are working on things such as MRSA or Clostridium difficile. But you have to have the same zero tolerance approach to needlestick injuries. It is about changing the culture."

The message for UK healthcare professionals is that best practice, education and, crucially, challenging accepted norms is the best way forward for tackling needlestick injuries. Changing working practices has to be at the heart of any effective needlestick and eye splash strategy. The development of safer devices is just one part of the task ahead.