Transcript Handling sharps – A framework for safe practice

A safer working environment –
sharps safety;
A training package to protect
healthcare staff from harm
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Safety devices/
engineering
controls
A quick tour
of the issues:
risk and safety
Overview of the
session
Reporting &
vaccination status
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Standard
Precautions &
waste
management
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Outline of the session
► The session will deliver knowledge for evidence based
safer practice and will cover the following areas:
►the most common procedures where needlestick
injuries occur.
►Types of devices and injuries that affect risk of
infection.
►methods for preventing exposure.
►critical review of the use of sharps and their necessity.
►how changes in work practice can prevent injuries
(includes the role of safer needle devices).
►current protocols and guidance, including standard
precautions.
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Objectives of the session
The session is designed to equip staff for safer
practice. By the end of the session staff should
be able to:
►Demonstrate knowledge of the risks of
exposure to potentially harmful viruses
►Explain the importance of safe practices
(demonstrating awareness of policies and
protocols).
►Identify the efficacy of preventative and
control measures.
►Describe the process of evaluation of
needlestick injury and post-exposure follow
up using real life examples
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Who is at risk:
►Who is at risk of needlestick injury?
►Any worker who may come in contact with
needles or other sharp instruments used
on patients, including nursing staff,
laboratory staff, doctors, porters and
housekeepers.
NIOSH 1998
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Definitions and scene setting
► Sharps injuries describe any incident in which a
healthcare worker is stuck by a needle or other sharp
instrument which penetrates the skin and which is
contaminated with potentially infected blood
► The National Audit Office (2003) stated that sharps
injuries are second only to back injuries as a cause of
harm to staff – 17% of all injuries
► Contaminated needles can transmit more than 20
dangerous blood-borne pathogens including HIV,
Hepatitis B and Hepatitis C
► At least 4 health care workers are known to have died
following occupationally acquired HIV
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Risk management
► An integrated risk management policy is a must
► Risk assessment:
►identify the risks
►Manage and minimise – eliminate unnecessary injections
► Safer technology
► Standard precautions
► Immunisation & vaccination
► Training
► A legal framework does exist (Health and Safety at Work
Act (HASAWA), 1974, and the Management of Health
and Safety at Work Regulations (1991)
► Control of Substances Hazardous to Health (COSHH
regulations (2002) reinforce risk assessment and
preventative strategies
Source: NHS Employers 2005
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The detail:
►Assessing the risks
►Risk assessment should be made of all situations
where HCW might be exposed to blood or other
potentially infectious material. The aim is to:
►Identify what technologies could be used to limit exposures
►Allow consideration of possible alternatives
►Eliminate the unnecessary use of sharps by implementing
changes in practice and providing, where practicable sharp
free devices or safer needle technologies which retract or
shield needles after use
Source: NSH Employers 2005www.daniels.co.uk
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Summary of key risk management
strategies for safer practice
Most effective
Least effective
Source: WHO 2005
►Hierarchy of Controls
►Elimination or substitution of sharp
(eliminate unnecessary injections)
►Engineering controls (auto disable
syringes, safer needle devices)
►Administrative and work practice
controls (standard precautions; no
recapping; provision and placement of
sharps containers)
►Personal protective equipment (eg
gloves)
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Reporting sharps injuries
►A core component of risk management:
►Underreporting is a serious threat to management of
such injuries
►Some studies suggest underreporting as high as 85%
►Prompt reporting is critical – following local policy
►This ensures quick management and reduces risk of BBV
transmission
►The incident is documented in case of future litigation
►Helps with accurate surveillance to inform =development of
effective risk reduction strategies
Source: NSH Employers 2005
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Reporting sharps injuries
►Managing exposures ►What is the local policy
►All cases of exposure from blood or body fluid
from patients infected with blood-borne
viruses (HIV, HCV, HBV) should be reported
to the HPA national surveillance scheme
►HCW anonymity is guaranteed
Source: NSH Employers 2005
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Identifying alternatives
►Independent studies show that a combination of
training, safer working practices and the use of
devices incorporating sharps protection
mechanisms can prevent more than 80% of
needlestick and sharps injuries.
►The NHS PASA website offers an array of such
devices.
►Provision of portable sharps containers for all
staff at all times is crucial to allow used sharps to
be disposed of at the point of use
Source: NSH Employers 2005
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Training
►Induction and ongoing training should cover
sharps safety for all staff and particularly:
►The risks associated with blood and body fluid
exposure
►Correct use and disposal of sharps
►The use of medical devices incorporating sharps
protection mechanisms
►Refresher training is important
Question – is on the job training evident in the workplace?
Source: NSH Employers 2005
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National UK Guidelines
Standard Principles for the Safe Handling
and
Disposal of Sharps:
►Part of a waste management strategy to
protect staff, patients and visitors from
exposure to blood borne pathogens.
►All sharps injuries are considered to be
potentially preventable.
The UK Evidence Based
Guidance (2001): EPIC
Prevention of HCAI in Primary and
Community Care (2003)
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National UK Guidelines
►National and international guidelines are
consistent in their recommendations:
►Assessment and management of risk
►Safe systems of working
►Safety devices (engineering controls)
►Post exposure follow up and prophylaxis
The UK Evidence Based
Guidance (2001): EPIC
Prevention of HCAI in Primary and
Community Care (2003)
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Standard precautions
1. Sharps must not be passed
directly from hand to hand and
handling should be kept to
minimum
2. Needles must not be bent or
broken prior to use or disposal
3. Needles and syringes must not
be disassembled by hand prior
to disposal
category 3/H&S
category 3/H&S
category 3/H&S
Source: EPIC 2001 Prevention of HCAI in Primary and
Community Care (2003)
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Standard precautions
4.
Needles should not be recapped.
5.
Used sharps must be discarded into a
sharps container (conforming to UN3291
and BS 7320 standards) at the point of use.
6.
These must not be filled above the mark
indicating that they are full. Containers in
public areas must not be placed on the
floor and should be located in a safe
position
7.
They must be disposed of in community
practices by the licensed route in
accordance with local policy
Source: EPIC 2001
category 3/H&S
category 3/H&S
category 3/H&S
category 3/H&S
Prevention of HCAI in Primary and
Community Care (2003)
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Standard precautions:
Hands & gloves
8.
Hands must be decontaminated
immediately before each and every
episode of direct patient contact/care and
after any activity or contact that potentially
results in hands becoming contaminated.
category 3
9.
Use an alcohol based hand rub on hands
not visibly soiled
category 3
10.
Gloves must be worn for invasive
procedures, contact with sterile sites, and
non-intact skin, mucous membranes, and
all activities that have been assessed as
carrying a risk of exposure to blood, body
fluids, secretions and excretions; and when
handling sharp or contaminated
instruments.
Source: EPIC 2001
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category 3/H&S
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Standard precautions:
Hands & gloves
11
12.
13.
Gloves should be worn as single use items.
Put gloves on immediately before an
episode of patient contact or treatment and
remove them as soon as the activity is
completed.
Change gloves between caring for different
patients, or between different
care/treatment activities for the same
patient.
Gloves must be disposed of as clinical
waste and hands should be
decontaminated following the removal of
gloves.
Source: EPIC 2001
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category 3/H&S
category 3/H&S
category 3
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Standard precautions:
Aprons & eye protection
14. Disposable plastic aprons should be
worn when there is a risk that clothing or
uniform may become exposed to blood,
body fluids, secretions and excretions,
with the exception of sweat.
15. Full body, fluid repellent gowns should
be worn where there is a risk of
extensive splashing of blood, body
fluids, secretions and excretions, with
the exception of sweat, onto the skin of
health care practitioners.
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category 3/H&S
category 3/H&S
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Standard precautions:
Aprons & eye protection
16. Plastic aprons should be worn as single
use items for one procedure or episode
of patient care and then discarded and
disposed of as clinical waste.
17. Face masks and eye protection should
be worn where there is a risk of blood,
body fluids, secretions and excretions
splashing into the face and eyes.
18. Respiratory protective equipment
should be used when clinically
indicated.
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category 3/H&S
category 3/H&S
category 3/H&S
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Safer needle devices
►Needle safety devices must be
used where there are clear
indications that they will provide
safer systems of working for
health care personnel.
D/H&S
Recent estimates suggest that safety devices exist in 11
different product groups.
Safety devices on the whole minimise risks in association
with venepuncture, IV therapy, injections and "downstream"
injuries following disposal (housekeeping and portering
staff)
Prevention of HCAI in Primary and
Community Care (2003)
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Sharps containers
►Should be at eye level and within arms reach
►Should be emptied before they are full
Questions for consideration:
►At ward or department level – whose responsibility is
this?
►Are roles assigned and are checks made?
►How would a situation be managed if there was a
failure to apply these simple measures?
►Is a monthly, quarterly or annual audit enough?
Source: EPIC 2001 Prevention of HCAI in Primary and
Community Care (2003)
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National strategies to promote infection
control: Saving Lives
►A tool for evaluation of current practices.
►Identifies areas for improvement.
►All about getting the infrastructure right:
►Poses a series of questions for hospitals and
clinical teams:
► Q1. are the EPIC guidelines for hand hygiene,
personal protection, and sharps disposal being
followed?
► Q2. is an audit tool (e.g. ICNA audit tool in use and
results acted upon?).
Source: DH1 2005
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Saving Lives
►High Impact Intervention number 1
(elements of care, based on national
evidence based, EPIC guidance (Pratt et
al 2001):
►Safe disposal of sharps
►Sharps container available at the point of use
►No disassembling of needle and syringe
►Not passed from hand to hand
►Container should not be overfilled
Source: DH1 2005
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After an injury or exposure
1.
2.
Local policy.
Key points:
►
►
►
►
►
►
►
First aid
Place under running water
Flush splashes to nose, mouth with water
Irrigate eyes with clean water or saline
Report to occupational health
Know your Hepatitis B vaccination status.
Prompt reporting is important in all cases to
determine whether post exposure prophylaxis is
required (this needs to be started as soon as
possible)
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Root Cause Analysis (RCA)
►The key to RCA is asking the question
"why?" as many times as it takes to get
down to the root cause of an event:
►What happened?
►How did it happen?
►Why did it happen?
►What can be done to prevent it happening in
the future?
Source: CDC 2004
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Average risk of transmission
►Hepatitis B Virus (HBV):
33.3% or 1 in 3
►Hepatitis C Virus (HCV):
3.3% or 1 in 30
►Human Immunodeficiency
Virus (HIV):
Source: EPIC 2001
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0.31% or 1 in 319
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Risk Factors that increase the likelihood of HIV
transmission following a needlestick injury
1. Deep injury
2. High viral titre in the patient on whom the
device had been used
3. Visible blood on the device
4. Device in artery/vein
Source: CDC, MMWR 6/98
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The Health Protection Agency (HPA) study 2005:
Occupational Exposure to Blood-borne viruses
(BBV)
►Over 2000 exposures to BBV reviewed
►Percutaneous injury: 78% of all reviewed
injury's from the Health Protection Agency
(HPA)
►Nursing related professions – most
commonly reported (45%)
Source: HPA 2005
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The Health Protection Agency (HPA) study 2005:
Occupational Exposure to Blood-borne viruses
(BBV)
►2% of exposures were to porters, security
and housekeeping staff
►Largely from sharps in rubbish bins
►Medical professions: 37%
►Injuries sustained during the procedure were
dependent on the procedure – many not generally
amenable to prevention.
►Injuries sustained after the procedure and during
disposal – much more preventable – usually related
to failure to comply with procedures relating to the
safe handling and disposal
Source: HPA 2005
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Outcome of exposure to BBVs
►Nine seroconversions following significant
occupational exposure over a 7 year period
►Six involved male injection drug user source
patients
►All seroconversions followed percutatous
exposure mostly to fresh blood and involved
hollow bore needles
►Six occurred after the procedure and five were
preventable
►Many were preventable with adherence to
standard precautions (38%)
Source: HPA 2005
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The importance of surveillance of Occupational
Exposure to Blood Borne Viruses in Health Care
Workers
1. Data collection
2.
3.
4.
5.
6.
7.
To identify risk factors necessary for seroconversion to
occur
To examine type of exposure, staff involved and
circumstances surrounding the exposure
To use the data to inform national prevention policies
To monitor implementation of national HIV post
exposure prophylaxis (HIV PEP) guideline and
influence future policy
To raise awareness of reports of occupational
exposure and encourage all trusts and other health
care providers to take part
To use data collected on HBV immunisation to monitor
adherence to policy
Source: HPA 2005
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Case study examples
►Review the scenarios on the handout.
►Address the following questions in groups:
Q1.
► Was the use of a needle essential?
Q2.
► Could the use of a needle safety device have prevented
the injury, if so what type?
Q3.
► Are these devices available on your unit?
Q4.
► Are staff knowledgeable about their use?
Q5.
► Would a change in work practice have prevented the
injury?
Based on WHO needlestick case studies 2005
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Critical questions for safer practice:
► Where is the needlestick policy kept and how is it
publicised?
► What is the plan following an exposure and how are staff
made aware of this?
► Are sharps injuries discussed at a regular team meeting?
► Are safer needle devices used and if so do you play a
part in selection and evaluation of these devices
► Are there any informational materials eg leaflets on
sharps injuries and are they readily accessible? Are
these visible/pocket sized for example
► From the session – draw up a list of ways you could
protect yourself
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Learning checks:
► Avoid the use of needles wherever possible
► Avoid recapping needles – instead immediately place the
uncapped needle into a sharps box
► Think ahead and plan the safe handling and disposal of
sharps before using them – is there a sharps container in
the vicinity
► Never fill a sharps container more than three quarters full
► Carry used sharps containers carefully
► Don’t open or empty sharps containers
► Store sharps containers in a secure place until ready for
removal for incineration
► Make sure your immunisations are up to date
Source: WHO 2005
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Summary: a map of prevention – from national
strategies to individual staff
National
Hospital
National guidance,
Policies and
tools
Trust policies
Procedures and
committees
National e
training
ICNA
audit
H & S Infection
NHS
committee Control Employers
Risk
Management
Occ
Health
Policies and promotion of same.
Is the ward climate conductive
to safety?
What about training/refreshment?
And audit programmes?
Ward/
department
Individual
EPIC
Saving
NHS
guidelines Lives Employers
Personal experiences in terms of availability
of training/sharps boxes/policy/safer needle
devices
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Recap – hierarchy of controls
►Remove the Hazard
►Isolate the hazard – protective
devices/engineering controls
►Use needles that retract, sheath or blunt
immediately after use
►Work practice controls and personal
protective equipment (Hep B vaccination)
Source: CDC Workbook. Sharps Injury Prevention
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Summary:
►While studies show that reductions of
needlestick injuries are achievable, it is difficult
to identify the efficacy of individual control
measures in studies with numerous
interventions.
►Reducing sharps injuries by the greatest amount
possible will entail a combination of
►Elimination of procedures using sharps
►Education
►Safer devices
►Positive work conditions
►Standard precautions
Source: WHO 2005
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Conclusion
►The risk of a sharps injury begins at the moment
a sharp is first exposed and ends once the sharp
is permanently removed from exposure in the
work environment.
►Staff need to have an awareness of the risk of
injury throughout the time a sharp is exposed
and use a combination of strategies to protect
themselves and their co-workers.
Source: CDC 2004
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Sources of material and references
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Publications:
►
Health Protection Agency (2005) Eye of the Needle: Surveillance of Significant Occupational Exposure to Bloodborne Viruses in Healthcare Workers.
Centre for Infections; England, Wales and Northern Ireland Seven-year report
Department of Health (2005) Saving Lives khcdja
Pratt RJ, Pellowe C, Loveday HP, Robinson N, Smith GW, et al (2001) The EPIC Project : developing national evidence baesed guidelines for
preventing healthcare associated infections. Phase 1 guideliens for preventing hospital-acquired infections J Hosp Infect 2001; 47: S3-S82
NHS Employers (2005) The management of health, safety and welfare issues for NHS staff, chapter 19: Needlestick Management
NAO (2003) A safer place to work – improving the management of health and safety risks of staff in NHS Trusts
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NIOSH (1998) How to Protect Yourself From Needlestick Injuries Department of Health and Human Services Public Health Service Centers for Disease Control and
Prevention National Instutute for Occupational Safety and Health
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Wilburn S, Eijkemans G (2004) Preventing needlestick injuries among HCWs: A WHO – ICN collaboration. Int J Occup Environ Health vol 10 no 4
www.ijoeh.com
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Websites:
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EPIC Guidelines: http://www.epic.tvu.ac.uk/epicphase/1.html
ICNA Audit Tools: Infection Control Nurses Association (2004) available from: www.icna.co.uk
The European Forum for protection of Healthcare Professionals in a safer working environment http://www.needlestickforum.net
NHS Purchasing and Supplies Agency product related information relating to sharps safety: www.pasa.nhs.uk/medicalconsumables/sharps/
WHO (2005) Protecting Healthcare Workers, Preventing Needlestick Injuries Toolkit. Occupational and Environmental Health Unit
http://www.who.int/occupational_health
CDC Workbook for designing, implementing and evaluating a sharps injury prevention programme (2004): http://www.cdc.gov/sharpssafety/
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