Resource Packages: Safe Handling, Usage and Disposal of Sharp Objects

Historical Overview

The accidental puncture of the skin by hypodermic needles and other instruments has long been regarded as an occupational hazard of health care workers.

Reports more than ninety years old illustrate the hazards of such injuries. Evans reported an early case of blastomycosis in 1903 following a sharp injury by a physician during an autopsy on a patient with a systemic blastomycosis. In 1933 Sigerist reported on a professor and his colleague who both sustained cuts during the course of their work and probably died of septicaemia. Over 25 cases of laboratory acquired leptospirosis were reported by Blumenberg in 1937. Most were associated with needlestick injury or cuts with contaminated glass.

Collins and Kennedy, in the Journal of Applied Bacteriology (1987), reported on 22 different infections that have been acquired from needlestick and sharps injuries. These included diphtheria, herpes, malaria, scrub typhus, syphilis, toxoplasmosis, hepatitis B virus (HBV), human immunodeficiency virus (HIV) and Ebola fever. Historically, however, there had been little concern about what are now known as “needlestick” injuries.

Recent Developments

In recent years needlestick injuries have assumed far greater importance. The reasons for a change in attitude have been due to the fears regarding the transmission of HIV, HBV and hepatitis C (HCV). Because of the potentially lethal nature of the disease process of these viruses, these are the primary blood-borne pathogens that currently present an occupational hazard to health care workers in Australia.

In 1985, largely because of HIV, a new strategy was developed in the United States to minimise the risk of transmitting blood-borne pathogens in the healthcare setting. The strategy developed by the Centers for Disease Control and Prevention (CDC), placed emphasis for the first time on applying blood and body fluid precautions universally to all persons regardless of their infectious status. This strategy, which was termed Universal Precautions and revised throughout the late 1980’s, emphasised infection control efforts for preventing transmission of blood-borne pathogens in the workplace. Preventing needlestick injuries and providing hepatitis B immunisation were two of the most important strategies addressed.

With a few modifications, Australia adopted the Universal Precautions outlined by the CDC. Special care was recommended to prevent injuries caused by needles, scalpels and other sharp instruments or devices, during procedures and during handling, cleaning or disposal following procedures. To prevent needlestick injuries health care workers were now instructed not to recap needles. Purposely bending or breaking needles, removing them from disposable syringes, or otherwise manipulating by hand was discouraged. After use, disposable needles and syringes, scalpel blades and other sharp items had to be placed in puncture resistant containers for disposal. These containers had to be located as close as practicable to the area of use. Equipment manufacturers started to produce safety devices and needle-less systems.

However, safer needle devices for performing venipuncture and other procedures have not completely eliminated the risk of needlestick injuries, or the subsequent exposure of health care workers to blood-borne pathogens. Numerous studies still show that the main reasons for needlestick injuries are preventable. Saghafi (1992) found 69% of needlestick injuries are preventable, an alarming consistent percentage found in other studies. In Saghafi’s study the main reasons for the preventable needlestick were recapping needles, manipulation of needles and incorrect disposal of needles.

This study also concluded that incorrect disposal of sharps was the main reason housekeeping staff reported needlestick injuries.

The New South Wales Health Department Infection Control Policy Circular 99/87 states that health care facilities have a responsibility to ensure adequate and accessible resources for the disposal of sharps. Each health care worker who uses sharps is responsible for their management and disposal.

Preventing Sharps Injuries

The following recommendations are simple, but should help reduce the incident of needlestick injuries.

A hypodermic needle can be a potentially lethal instrument. Venipuncture for example, is one of the most dangerous procedures a health care worker can perform if it results in a needlestick injury.

Preparation

Assemble all equipment required for the procedure. Needlestick injuries often occur when a health care worker is distracted because they have to stop halfway through a procedure to get additional equipment
Minimise distractions. For example, ask relatives or visitors to leave the bedside while you perform the procedure; wait until doctors have completed their rounds; give the drug keys to another colleague. If possible perform the procedure in an area otherwise free from distraction
Ensure patient compliance. If a patient is confused get assistance from colleagues to enable the procedure to be performed safely

Equipment

Equipment should be used strictly according to protocols and only for the purpose for which it was designed
Choose the safest equipment. There are a variety of safety products available that meet most budgets. Remember health care workers need to be educated how to use the safety features. Studies have shown hospitals are buying safety equipment only to have it wasted, because staff lack the knowledge to correctly activate the safety features. This fact is reflected in the consistent number of needlestick injuries that occur in hospitals that extensively use safety equipment

Technique

Perform the procedure slowly and carefully
Minimise the handling of sharp instruments. The less they are handled the less chances of needlestick injuries occurring
Supervise all unskilled or new staff. This is especially important at the start of each New Year when university graduates, such as registered nurses and interns flood the health care setting
Sharp instruments must not be passed from the hand of a health care worker to another person. A puncture resistant tray must be used to transfer sharp instruments from one health care worker to another, or from the procedure site to the sharps container, if there is any distance to be covered
Needles must not be resheathed, except in special circumstances. Where resheathing is required, the needle must be properly recapped; the sheath must not be held in the fingers; either a single-handed technique, forceps or a suitable protective guard designed for the purpose, must be used
Needles must not be removed from disposable syringes for disposal. They must not be purposefully broken; or otherwise manipulated by hand, except when it is necessary to remove the needle for technical reasons, or when performing procedures where needles must be bent. Those needles must not be bent after contamination with blood or body substances
Each health care worker who uses sharp instruments is responsible for their management and disposal
Dispose of all the sharp instruments used during the procedure immediately, carefully and appropriately
The sharps container must never be overfilled and must be securely sealed with a lid before disposal

Sharps Containers

Sharps containers should be placed as close as practicable to the patient, or the procedure, to ensure sharp instruments are not carried unprotected through the facility
Sharps containers should be placed so that visitors, particularly children, do not easily access them
Non-reusable sharp instruments must, immediately after use, be disposed of in a puncture resistant container
Sharps containers must be puncture resistant, waterproof, leakproof and meet Australian standards. They must be designed to have an opening that is wide enough to allow sharp instruments to be dropped into the container by a single hand operation, but small enough to prevent insertion of a persons hand
The sharps container must be clearly labelled with black lettering on yellow background with the biohazard symbol printed on the container
The sharps container must never be overfilled and must be securely sealed with a lid before disposal
Sharp instruments should never be forcibly placed into a sharps container
Re-useable sharps containers must be cleaned before reuse
Re-useable sharp instruments must, immediately after use, be placed in a puncture resistant container, especially kept and labelled for that purpose

Gloves

Gloves need not be worn for subcutaneous, intramuscular or intradermal injection unless exposure to blood is anticipated. Gloves do not prevent needlestick injuries. However, studies have shown that transmission of blood-borne pathogens can be significantly reduced due to the ‘cleaning’ effect the latex or vinyl has on the instrument as it passes through the glove. Gloves appear to be protective against the extent of exposure to blood.

Needlestick Injuries

All occupational exposures must be fully documented to meet legal requirements and to ensure that health care workers are able to obtain the support to worker’s compensation, if appropriate.

A Needlestick Injury Hotline has been established to assist area health services and health care facilities in the management of occupational exposures to blood and body substances. The Hotline provides information, support and a referral service. The Hotline is not a substitute for local area services. The hotline provides a 24 hour service and can be contacted on free call 1800 804 823 within NSW.

Reporting

Every health care facility, including, general practices and dental surgeries, must have an Occupational Exposure Policy so that staff members know the reporting mechanism of their workplace, and the steps to follow in the event of a needlestick injury.

All needlestick injuries must be reported

Health care workers must never be made to feel guilty or careless when reporting a needlestick injury. The response given to a person reporting a needlestick injury may impact upon future reporting amongst peers. Some staff members are concerned that by reporting a needlestick injury they will immediately be assumed to have been careless and will incur a degree of blame from the authorities of the health care establishment. A punitive approach is not recommended, as it may result in a reluctance to report the injury. Under-reporting by as much as 70% is already well documented. It is preferable that staff are encouraged to report needlestick injuries and that they are well supported and cared for during their subsequent management.

The New South Wales Health Department has issued very clear and concise circulars that provide guidelines for the management of health care workers who sustain needlestick injuries.

References

Collins C. H., and Kennedy D.A.(1987) Microbiological hazards of occupational needlestick and ‘sharps’ injuries. Journal of Applied Bacteriology, vol.62, pp385-402.

Jagger J. and Balon M.(1994) Blood and body exposures to skin and mucous membranes Advances in Exposure Prevention, vol.1 no. 2. Jan-Feb 1995, pp1-2, 4-8.

NSW Health Department Report July 1994, Health Care Workers Exposure to Blood and Body Fluids; Results of a survey of NSW Health Facilities 1993. AIDS/Infectious Diseases Branch, Sydney.

NSW Health Department. (1999) Infection Control Policy 99/87. AIDS /Infectious Diseases Branch, Sydney.

NSW Health Department. (1998) Management of healthcare workers potentially exposed to HIV hepatitis B and hepatitis C, Circular 98/11. AIDS /Infectious Diseases Branch, Sydney.

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