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Workbook for Designing, Implementing and Evaluating a Sharps Injury Prevention Program

 

Part I: Background

Slide 1
Workbook for Designing, Implementing and Evaluating a Sharps Injury Prevention Program

HHS Logo and CDC Logo

A Program designed for: Infection Control & Occupational Health Personnel, Healthcare Administrators, Sharps Injury Prevention Committees

Speaker Notes: [During this presentation we will talk about needlesticks and injuries with other sharps.  We’ll first discuss why these injuries are a problem, how these injuries occur, and most importantly, how these injuries can be prevented.]

Slide 2

• Part I: Background
• Part II: Safer Sharps Devices
• Part III: Safe Work Practices

Speaker Notes: [Note to presenter– this presentation is divided into three parts.  Part I discusses background on the nature of sharps injuries, the risks of exposure to bloodborne pathogens, and how and where injuries tend to occur.  Part II describes the types of engineered sharps injury prevention devices that are available.  Part III presents safe work practices to prevent sharps injuries.]

[Feel free to discard slides or information to tailor this slide set to your particular organization’s needs.]

[Opportunities for discussion or to personalize the slide set will be indicated in bold.]

Slide 3
The Problem

• CDC estimates ~385,000 sharps injuries annually among hospital-based healthcare personnel (>1,000 injuries/day)
• Many more in other healthcare settings (e.g., emergency services, home care, nursing homes)
• Increased risk for bloodborne virus transmission
• Costly to personnel and healthcare system

Speaker Notes: CDC estimates that approximately 385,000 injuries with contaminated needles and other sharps devices occur annually among hospital-based healthcare personnel.  That’s over 1,000 injuries a day!  Many more occur in other healthcare settings, such as emergency services, home care, and nursing homes.  Injuries with contaminated needles and other sharp devices are an important concern because they pose the risk of transmission of bloodborne viruses, and they are costly to personnel and to the healthcare system.

Slide 4
Risks of Seroconversion due to Sharps Injury from a known positive source

Virus	Risk (Range)
HBV	6-30%*
HCV	~ 2%
HIV	0.3%
(*Risk for HBV applies if not HB vaccinated)

Speaker Notes: The three bloodborne viruses of primary concern for transmission from sharps injuries are hepatitis B (HBV) and C (HCV) viruses, and human immunodeficiency virus (or HIV), the virus that is associated with AIDS.  The average risk of transmission after an occupational percutaneous exposure varies by the type of bloodborne virus. As you can see, one is at a higher risk for being infected with HBV following a sharps injury than for HCV or HIV.  Fortunately, for hepatitis B virus, a vaccine and immune globulin are available that can protect healthcare personnel from becoming infected.  This is why this vaccine is heavily promoted for healthcare personnel.  The average risk for HCV transmission after a percutaneous exposure to HCV-infected blood is approximately 1 in 50 exposures.  The average risk for HIV infection after a percutaneous exposure to HIV-infected blood is about 1 in 300 exposures.

Slide 5
What is the Risk for HIV Alone?

• Percutaneous 0.3%
• Mucous membrane 0.1%
• Non-intact skin <0.1%

Speaker Notes: For all bloodborne viruses, the percutaneous route of exposure (for example, a needlestick injury) carries the greatest risk for transmission of infection. The average risk for HIV transmission after a mucous membrane exposure (for example, blood splashed in the eye) is estimated to be 0.09%, or about 1 in 1,000. Although episodes of HIV transmission after skin exposures have been documented, the average risk for transmission has not been precisely quantified but is estimated to be less than the risk for mucous membrane exposures.

Slide 6
Occupational HIV Transmission among U.S. Healthcare Personnel, 1985-2004

• 57 documented cases
• i.e., HIV negative at time of exposure and became HIV positive during follow-up period
• 137 other cases
• i.e., No documented exposure and no known risk factor for HIV infection

Speaker Notes: To date, there have been 57 documented cases of occupational HIV transmission to healthcare personnel and 137 possible cases in healthcare personnel where the source of infection and/or seroconversion could not be definitively determined. 

Slide 7
Occupational HIV Transmission Documented Cases (n=57)

• 50 (88%) involved percutaneous exposures
• 45 caused by hollow-bore needles, half of which were used in a vein or artery
• 5 mucocutaneous exposures
• 2 exposure route unknown

Speaker Notes: Of the 57 documented cases of occupational HIV transmission, 88% involved a percutaneous exposure through a contaminated needle or other sharp device.  The majority of these injuries were associated with hollow-bore needles, the type typically used in a vein or artery.

An additional five cases were the result of mucocutaneous exposures.  The route of exposure is unknown for the remaining two cases.

Slide 8
Costs of Sharps Injuries

• Baseline and follow-up laboratory testing
• Treatment of exposed personnel
• $71-~$5,000 depending on treatment provided
• Lost productivity
• Time to complete paperwork
• Loss of income / loss of career
• Emotional costs
• Societal costs

O’Malley, et. al. Costs of Management of Occupational Exposure to Blood and Body Fluids. 
ICHE, July 2007, v 28, No. 7.

Speaker Notes: Although occupational transmission of HIV or hepatitis is relatively rare, the risks and costs associated with blood exposure are high. Some of the direct costs of sharps injuries are those associated with the initial and follow-up laboratory testing and treatment of exposed healthcare personnel.  These are estimated to range between $71 to approximately $5,000, per person depending on the treatment provided.
Costs that are harder to quantify include direct and indirect costs associated with potential side effects of antiretroviral therapies and lost time from work, time lost to completion of paperwork and follow-up (including obtaining informed consent for source patient testing), the emotional cost associated with fear and anxiety from worrying about the possible consequence of an exposure, and the societal cost associated with HIV or HCV seroconversion.  By societal cost, I’m referring to possible loss of a worker's services in patient care, the economic burden of medical care, any worker’s compensation claims due to injury and exposure, and the cost of any associated litigation.

[Note to presenter: Use local cost information if available.]

Slide 9
Preventing Sharps Injuries is Our Goal!

Speaker Notes: Because of the high burden of sharps injuries, our goal is to prevent – and ideally eliminate – sharps injuries.

Slide 10
How Do Sharps Injuries Happen?

• Who gets injured?
• Where do they happen?
• When do injuries occur?
• What devices are involved?
• How can they be prevented?

Speaker Notes: To prevent sharps injuries, we first need to understand how they occur.  Who gets injured?  Where do they happen?  What devices are involved?  When and how do injuries occur?  And, how can they be prevented?

[Note to Presenter:  The following slides may be augmented or replaced using local data.  Use the questions above as a guide.]

Slide 11
Data Sources

• National Surveillance System for Healthcare Workers (NaSH)
• Exposure Prevention Information Network (EPINet™)

Speaker Notes: The information I’m presenting about the epidemiology of sharps injuries comes from two voluntary surveillance systems. One is the National Surveillance System for Healthcare Workers (also known as NaSH), which was established by CDC in 1995 and has information on over 20,000 blood exposures from approximately 100 hospitals. The other is the Exposure Prevention Information Network (known as EPINet), which collects information on blood exposures from hospitals across the U.S.  EPINet  is a product of the International Health Care Worker Safety Center and the University of Virginia Health System.  This system was developed in 1991 and collects blood exposure information from approximately 70 hospitals.

Slide 12
Who Gets Injured?

Occupational Groups of Healthcare Personnel Exposed to Blood/Body Fluids,
NaSH June 1995—December 2003 (n=23,197)

Pie chart illustrating: Physician 28%, Technician 15%, Student 4%, Housekeeping/Maintenance 3%, Clerical/Admin 1%, Dental 1%, Other 5%, Nurse 43%.

Speaker Notes: Data from NaSH show that nurses sustain the highest percentage of percutaneous injuries. However other patient-care providers (such as physicians and specialized technicians), laboratory staff and support personnel (such as housekeeping and maintenance staff) are also at  risk. 
[ NOTE to presenter: Depending on audience, the collective data can be used to elicit discussion on issues that contribute to this  distribution: devices, training, staffing, disposal problems, etc. Ask audience members how they think injuries to housekeeping and maintenance staff occur. If the targeted group is primarily laboratory staff, you may want to include other bloodborne pathogens important to lab workers (See Workbook, Overview—Risks and Prevention of Sharps Injuries in Healthcare Personnel, Table 1).]      

Slide 13
Where Do Sharps Injuries Occur?

• Patient Room 39%

(Inpatient: Medical – ICUs )

• Operating Room 27%
• Outpatient 8%
• ER 8%
• Laboratory 5%
• Other 13%

Speaker Notes: Although sharps can cause injuries anywhere within the healthcare environment, NaSH data show that a large share (39%) of injuries occur on inpatient units (particularly medical floors and ICUs) and in operating rooms (27%).

[NOTE to presenter: Focus discussion according to targeted audience. Ask why they think there are differences and what may be involved (e.g., devices, work practices, or both).]

Slide 14
When Do Sharps Injuries Occur?

• During use 41%
• After use/before disposal 40%
• During and after disposal 15%
• Other 4%

Speaker Notes: Injuries with needles and other sharp devices can happen at any time during use.   NaSH data show that the majority of injuries occur during or immediately after use; 15% occur during or after disposal.

• During use injuries often occur when the device is being inserted or withdrawn and/or the patient moves.
• After use injuries occur during cleanup or in transit to another location.
• Injuries during disposal often involve
  • Placing used sharps into the container or
  • Disposing of a sharps devise inappropriately; that is, when a device is placed in the trash or left at the bedside or other location.

In the next few moments, we will look in greater detail at how these injuries occur.

Slide 15
What Devices are Involved in Sharps Injuries?

   Six Devices Account for 78% of All Injuries

• Disposable Syringes 30%
• Suture Needles 20%
• Winged-Steel Needles 12%
• Intravenous Catheter Stylets 5%
• Phlebotomy Needles 3%
• Scalpels 8%

Speaker Notes: Think about all the needles and other sharp devices that are used to provide healthcare.  While many different devices that can cause sharps injuries, six types account for nearly 80% of injuries in NaSH hospitals. Hollow-bore needles alone account for 56% of all sharps injuries.

Hollow-bore needle injuries, especially from devices used for blood collection or for IV catheter insertion, are of particular concern, since they are likely to contain residual blood and are associated with an increased risk for bloodborne virus transmission. Of the 57 documented cases of occupational HIV transmission to healthcare personnel reported to CDC from June 1995 to December 2002, 50 (88%) involve percutaneous exposure. Of these, 45 (90%) were caused by hollow-bore needles and half of these needles were used in a vein or an artery.

Although two scalpel injuries (both in an autopsy setting) caused HIV seroconversions, solid sharps such as suture needles or scalpels, generally deliver a smaller blood inoculum, especially if they first penetrate gloves or another barrier. Therefore these devices theoretically pose a lower risk for HIV transmission. Similar descriptive data are not available for type of devices or exposures involved in transmission of HBV or HCV.

Slide 16
Devices that Require Manipulation after Use  are Associated with an Increased Rate of Injury

Bar chart illustrating:

	Disposable Syringe	Cartridge Syringe	Butterfly	IV Stylet	Phlebotomy Needle	IV Tubing Needle
Percentage of injuries	35	12	7	2	5	26
Rate/100K devices purchased	6.9	8.3	18.2	18.4	25.4	36.7

Speaker Notes: One of the important factors that can contribute to a sharps injury is any manipulation of a sharps device. In a 1988 study, Dr. Janine Jagger and colleagues reported that devices requiring manipulation or disassembly after use (such as needles attached to IV tubing, winged steel needles, and IV catheter stylets) were associated with higher rate of injury than hypodermic needles or syringes, which typically do not need to be disassembled.

Slide 17
How Do Injuries Occur With Hollow-Bore Needles?

Circumstances Associated with Hollow-Bore Needle Injuries NaSH June 1995—December 2003 (n=10,239)

Pie Chart illustrating:
During Sharps Disposal 13%, Improper Disposal 9%, During Clean Up 9%, In Transit to Disposal 4%, Manipulate Needle in Patient 28%, Collision W/Worker or Sharp 10%, Recap Needle 6%, Handle/Pass Equipment 6%, Access IV Line 5%, Transfer/Process Specimens 5%, Other 5%.

Disposal Related: 35%

Speaker Notes: You may also know that there are many possible mechanisms for injuries.  In NaSH hospitals, 26% of hollow-bore needle injuries occur while the needle is being inserted, manipulated or withdrawn from the patient, and the patient moves or jars the device.
Some needle injuries occur when accessing intravenous lines, such as giving an IV flush.  With needle-free IV systems now available, these injuries should not be occurring.
The same applies to recapping injuries.  Why do you think people recap needles when it is so dangerous? [NOTE to presenter: Encourage discussion of this subject if time permits]
You can see that many injuries in NaSH hospitals occur after use on the patient, such as during clean up, in transit to disposal, and during disposal.  An additional 9% of injuries are due to improper disposal or result from leaving a sharp device on a table, stuck in a mattress, on the floor, or some other location.
Another 10% of injuries occur when healthcare personnel collide with each other during a procedure.

[NOTE to presenter: Encourage discussion of the different injury mechanisms, including some not mentioned here.]

Slide 18
Sharps Injuries Are Preventable

Preventability of Needlesticks in 78 NaSH Hospitals,  June 1995--December 2004 (n=11,625)

Pie Chart illustrating: [non preventable 18%, Undetermined 18%, Preventable 64%]

Speaker Notes: Data from the NaSH system show that most sharps injuries from hollow-bore needles are preventable. A majority (64%) of all hollow-bore needle-related injuries can be prevented by using needles only when necessary, using devices with engineered safety features, properly using the safety features on these devices, following proper work practices (such as not recapping used needles), and properly disposing of needles after use.

Slide 19
Preventing Sharps Injuries is a National Priority!

• Federal and state laws increase enforcement of sharps injury prevention
• Needlestick Safety and Prevention Act, 2000
• OSHA enforcement of needlestick prevention increasing
• 21 states with laws/regulations
• CDC: targets needlesticks for elimination

Speaker Notes: The prevention of sharps injuries among healthcare personnel is a national priority.  In November 2000, Congress passed and President Clinton signed into law the Needlestick Safety and Prevention Act that mandated OSHA to increase its enforcement of sharps injury prevention and the implementation of engineered sharps injury prevention devices in particular.
To date, 21 states have passed legislation that increases surveillance and prevention of needlestick injuries.
The Centers for Disease Control and Prevention has also targeted the elimination of needlesticks an agency priority.

Slide 20
Sharps Injuries at ______Hospital (period of time)

• Last year _____ sharps injuries were reported by our employees/staff
• The occupations most affected were _____
• The devices most commonly involved were _____
• The most common ways sharps injuries occurred were _____

Speaker Notes:  [NOTE to presenter: Develop one or two slides to present your local data.]

Slide 21
What are Strategies to Eliminate Sharps Injuries?

• Eliminate or reduce the use of needles and other sharps
• Use devices with safety features to isolate sharps
• Use safer practices to minimize risk for remaining hazards

 

Speaker Notes: The prevention of sharps injuries is a priority at __________ [your facility name].  In the hierarchy of priorities to prevent sharps injuries, the first priority is to eliminate and reduce the use of needles and other sharps wherever possible.  For example, use alternate routes for medication delivery and vaccination when available and safe for patient care. 

The next priority is to isolate the hazards and thereby protect otherwise exposed sharps, through the use of engineering controls. The emphasis on engineering controls has led to the development of many types of devices with engineered sharps injury prevention features.

When these strategies are not available or do not provide total protection, the focus shifts to work-practice controls and the use of personal protective equipment.  In the operating room, for example, instruments, rather than fingers, can be used to grasp needles, retract tissues, and load and unload scalpels; verbal announcements should be given when passing sharps; and hand-to-hand passage of sharps instruments can be avoided by using a basin or neutral zone.

Slide 22

• Part II: Safer Sharps Devices
• Part III: Safe Work Practices

 

Speaker Notes: [NOTE to presenter: Part II discusses engineered sharps injury prevention devices in a 15-slide presentation.  This presentation should be 10-20 minutes in length.  Part III discusses safe work practices for the prevention of sharps injuries in a 24-slide presentation.  This presentation should be 15-25 minutes in length.]