Stick shift—new ideas in needle safety

June 2006
Feature Story

Karen Lusky

The Needlestick Safety and Prevention Act, which went into effect six years ago, may actually represent the long beginning of the end of needlestick injuries. The act requires employers to provide frontline staff with safety-engineered devices that the staff helps select. But just as important, it has instilled a growing awareness of sharps safety nationwide—a change in mindset from which there’s been no turning back.

Many believe that employers and providers, government agencies, and safety device manufacturers can work together to eventually drive down the rate of needlesticks to a Six Sigma level, which translates into 3.4 per every million opportunities for such injuries to occur.

The Centers for Disease Control and Prevention has set its sights for reducing needlestick injuries a bit higher. “The CDC has gone on the record to say the goal is to completely eliminate needlesticks,” says Elise Beltrami, MD, MPH, a medical epidemiologist with the CDC. “We don’t give a timeframe for doing that, and clearly it’s going to be a challenge. But with education, training, appropriate device development and implementation, and developing a culture of safety, it’s a potentially realistic goal.”

Prevention is, of course, the best medicine for needlesticks, given that injuries transmitting hepatitis C can be deadly. Post-exposure prophylaxis exists for HIV and hepatitis B, but neither prevents infection in all cases and needlestick injuries have been known to cause myriad other illnesses. Dr. Beltrami points to “cases reported in the literature of over 20 different diseases being transmitted by needlestick injuries, including syphilis, tuberculosis, herpes, malaria, and the West Nile virus.”

Safety-engineered sharps devices are the main line of defense in the battle against such exposures. The available products for phlebotomy are “numerous and some of them actually quite spectacular…,” says Sue Masoorli, RN, president of Perivascular Nurse Consultants, Philadelphia.

The trend has been to develop devices that can do what the CDC aims for: eliminate the possibility that a worker will come into contact with a bloody needle. For example, the second-generation BD Vacutainer Push Button Collection Set allows the user to push a button with the index finger of one hand to retract the needle while it’s still in the patient’s vein. That safety feature targets the 61 percent of needlesticks that a CDC study shows occur within seconds after the device is removed from the vein, says Ana Stankovic, MD, PhD, MSPH, vice president for BD Diagnostics–Preanalytical Systems and a member of the CAP Quality Practices Committee.

The third generation, or BD Vacutainer Passive Shielding Blood Collection Needle, takes the decision to activate a safety device out of the user’s hands—literally. As the needle is being pulled out, a shield covers it automatically, Dr. Stankovic says.

Then there’s Smiths Medical’s Saf-T-Wing Blood Collection Set. Nancy Erickson, PBT(ASCP), CPT(NHA), director of Phlebotomy Education LLC, Allen Park, Mich., says it retracts into the hub while still in the arm with no splash. “There is no uncontrollable spring and absolutely no chance of activating it prematurely. I’ve been teaching with this tool and find it to be one of the best on the market,” she says.

New safety device technology has also targeted arterial blood gas collection, a procedure known to pose a higher risk of needlesticks. Radiometer America’s SafePico self-filling arterial sampler, which has been on the market for about six months, offers features that prevent blood exposure that can typically occur while the sample is being collected and analyzed.

Paul Timko, product manager for Radiometer, says one thing that makes the arterial specimen collection so risky is that “when you stick the artery—typically the radial artery—you have to immediately apply pressure with gauze” to the site after removing the needle. Using the SafePico device, the person obtaining the sample can use the thumb of one hand to activate the safety feature. “The safety sheath slides up over the needle and locks in place,” he explains. “Then you discard the entire device with the needle attached.”

In addition, “people analyzing the sample don’t have to remove the vented tip cap” to access the sample, Timko adds. Instead, “the blood gas analyzer comes down through the tip of the cap to draw the sample out so there’s no exposure to blood.”

The Radiometer safety syringe can be used with any blood gas analyzer, Timko says. But other analyzers aren’t designed to “aspirate through the tip cap so you’d have to remove it,” he adds. For hospitals and other facilities that have bar-coded patient identification, the device comes with an information technology component that makes it possible to scan the patient’s bar-coded wristband and the bar-coded sampler.

Employers that have safety devices in place must still monitor staff’s compliance in using them consistently and correctly. For example, Northwestern Memorial Hospital, Chicago, used the BD Safety-Lok Blood Collection Set for several years, but noticed that “nurses were still having needlestick exposures with butterflies,” says Ellen Wallace, MT (ASCP), manager of Northwestern’s Diagnostic Testing Center. “After an extensive audit, we discovered that many of the nurses were not covering the needle with the safety shield.”

So the hospital did a trial run of, and adopted, the BD Vacutainer Push Button Collection Set two years ago, which has reduced butterfly-related needlestick injuries. “The nurses love the device because they can easily activate the safety feature while the needle is still in the patient’s arm,” Wallace says. DSI Laboratories, Fort Myers, Fla., adopted the same BD push-button butterfly needle last fall and has not experienced any needlestick injuries from butterfly needles since the switch from the safety-lock needle to the push button, says Helen Ogden-Grable, MT (ASCP)PBT, clinical educator for DSI Laboratories. Staff must follow the manufacturer’s instructions when using the device, she stresses. Following the protocol, “you hold a 2x2 gauze sponge over the site, being careful not to touch the skin or to press on the needle while activating the button that retracts the needle,” she says. By pressing the button and retracting the needle while in the vein, staff is protected from exposure by spatter or splash. Staff must never, she adds, withdraw the needle before activating the device.

BD’s Dr. Stankovic agrees: “With any retractable, spring-activated device, micro droplets of blood may form from the force of retraction. So BD recommends putting the gauze over the site when activating” the device.

Hospitals also have to make sure that those who perform phlebotomy duties have enough training and practice to avoid getting stuck. And in that regard, some say, phlebotomists managed by the lab tend to suffer fewer needlesticks than nursing staff when drawing blood. Lab safety consultant Terry Jo Gile, MT(ASCP)MA Ed., president of Safety Lady LLC, Las Vegas, says she found that to be true in her decades of experience as a lab safety officer of a large hospital.

Sarah Bush Lincoln Health System, Mattoon, Ill., saw its needlestick injury rate drop by 73 percent shortly after the lab reclaimed responsibility for phlebotomy in 2004. Before that, the health system had a decentralized phlebotomy model where patient care partners did most of the collecting of inpatient lab specimens, reports Jodie Warner, MT (ASCP), director of laboratory services. In 2004, the lab also took over competency checks for nurses on select units and emergency department staff who continue to perform venipunctures.

Warner ties the dramatic reduction in needlestick injuries, in part, to the better skills that experienced phlebotomists bring to the job. She got involved in the recentralization effort, in fact, as part of a needlestick prevention team that was trying to reduce the number of needlestick injuries. But the team soon realized the problem with the decentralized phlebotomy ran much deeper, she says. “People doing the procedure didn’t have the training and weren’t familiar with the products they were using.”

Actually, the decentralized phlebotomy model worked well at first, Warner says, “because the care partners received phlebotomy training and the lab was involved.” But “over the years, with staff turnover...phlebotomy took a back seat to the care partners’ other duties” and the lab had difficulty training new employees.

DSI Laboratories’ Ogden-Grable says implementing Lean processes that “reduce chaos and make workflow more organized” lessen the odds of a needlestick. “I don’t have statistics on that but it’s logical,” she says. “We focus on that concept in the classroom where we tell our students to put themselves in slow motion and to not let anyone rush [them] in doing any phlebotomy procedure.” And they should “never, never try to do two things at one time. For example, don’t hold two pieces of equipment in your hand at once.”

Jamie Boone, MT (ASCP), assistant laboratory director, Jackson (Tenn.) Medical Center Lab, agrees. The laboratory, which implemented Lean in phlebotomy in 2004, didn’t look at needlestick injuries pre- and post-Lean. But “when you set things up in an efficient manner so the phlebotomists are organized and have everything they need on their tray, they are less likely to have a [needlestick] accident,” especially during sharps disposal, Boone says.

Needlestick injuries can occur when staff gets distracted or engages in OSHA-verboten behaviors. And recapping a needle is one of the riskiest things a worker can do, says Dennis Ernst, MT (ASCP), director of the Center for Phlebotomy Education, Ramsey, Ind. Staff from the “old school” who continue to do so may eventually end up with a serious injury. Phlebotomy educator Erickson recalls one nurse who had uncapped and recapped needles using her mouth for 12 years without an incident. Then one day she stuck herself in the lip with a contaminated needle.

Also on the list of risky behaviors, Ernst says: Failure to use a safety transfer device when drawing blood into a syringe. (Syringes, of course, should not be used for blood drawing unless the health care worker has no other option, because it requires transferring the sample to a blood tube holder, creating additional needlestick risk.)

Emergent care situations can also be a needlestick waiting to happen. “For example, if a patient passes out, the collector might drop the exposed needle, set it down… or keep it in his hand. The next thing you know the person has stuck him/herself,” Ernst says. To prevent this, “safety in-services should emphasize the importance of keeping a presence of mind in an emergent situation, and following procedures for preventing needlesticks so people will be less vulnerable at that vulnerable time.”

Needlesticks also occur when a patient jolts or becomes combative during the collection procedure. HealthPartners Laboratories at Bon Secours Richmond has had only two needlesticks among its 40 lab phlebotomists in the past 18 months. One of those was a sterile needlestick; the other occurred when the patient jumped during venipuncture “and the needle landed in the phlebotomist’s leg,” says Ann Lecarpentier, supervisor of phlebotomy services for the Richmond, Va.-based health system.

Kathy Clark, respiratory therapy department manager for Intermountain Health Care, Salt Lake City, says the riskiest time for a needlestick to occur during an arterial blood gas specimen collection is “when you’ve punctured the artery and the patient becomes combative. So the needle jerks out of the artery and into you.”

To avert such injuries, Intermountain Healthcare trains the blood gas technicians collecting the specimen to assess whether a person may become combative. “The nurses may know that information, especially if the patient has been in the unit before,” Clark says. “We also teach the blood gas techs to explain the procedure to the patient before doing it and to talk the person through each step—even if the patient appears to be comatose.”

Another strategy: “Having additional personnel there to assist or using soft restraints during the procedure,” suggests the CDC’s Dr. Beltrami.

Trying to push a safety device—especially a needle with a blood tube holder attached—into a sharps container poses a serious threat. In such cases, phlebotomists or nurses who get stuck can’t even readily identify the source patient to determine if they need post-exposure prophylaxis.

A needlestick can also occur if someone tries to seal an overly filled sharps container. OSHA requires staff to close and replace sharps containers before they overfill, Ernst says. Now that OSHA is requiring disposal of needles and tube holders as a complete assembly, Ernst notes, facilities should use larger sharps containers that require replacement less frequently.

Since 2002, OSHA has stood firm in its position that health care personnel cannot reuse a blood tube holder because it requires removing contaminated needles from the device. “Even though the health care worker uses an automatic device to dislodge the needle without touching it, the needlestick hazard still remains with the back end of the used needle,” says OSHA senior industrial hygienist Dionne Williams. OSHA has an administrative law judge ruling saying it’s appropriate for the agency to cite a lab or other health care setting that reuses blood tube holders—although it’s not the reuse we are citing— [it’s the] removal of the contaminated needle,” Williams says.

If hospitals have undergone a sea change in implementing safety devices, outpatient settings remain islands of relative noncompliance, at least for now. “Currently only about 45 percent of primary care doctors’ offices use safety needles and syringes,” says lab safety consultant Sheila Dunn, DA, MT (ASCP), president of Quality America Inc., Asheville, NC.

Dr. Dunn suspects physician offices haven’t complied yet because they perceive that needlesticks in their settings are few. “Or they think their patient population isn’t likely to be infected with a bloodborne disease,” she says. “They might not realize that a shockingly high proportion of healthy looking people are infected with hepatitis C.”

Also, some reference and outreach labs provide nonsafety devices to the physicians’ offices because it’s cheaper, Dr. Dunn adds. But “physicians in some areas have caught on that they should have safety needles…so they tell the lab that if you want me to send specimens, send safety needles.”

Some physician offices may believe they are in compliance with OSHA requirements if they accept any safety device provided by their reference or outreach laboratory. But, says OSHA’s Williams, “If a physician office staff uses a safety device provided by a reference or outreach lab, and that staff isn’t involved in selecting the device, then the physician office would not be in compliance.” On the other hand, she says, if the lab’s employees are collecting the specimen using the device and the lab has documented employee input in selecting the device being used, “that’s a different situation.”

Amber Hogan, a former OSHA industrial hygienist and now health affairs and public policy manager at BD, sees the compliance in “alternate sites increasing over time, just as it did in acute-care settings.”

“Doctors’ offices will realize that the market has converted to safety devices for a reason, and that reason is to keep their employees safe,” she says.

You can’t solve a problem if you don’t know you have one. Thus, encouraging employees to report needlesticks is paramount in vanquishing them. Without surveillance, says the CDC’s Dr. Beltrami, there’s no way to develop an “accurate picture of what’s truly happening in terms of the number and type of needlestick injuries.” And “unreported injuries offer no opportunity to analyze them and figure out how to prevent similar injuries,” she adds.

Jane Perry, associate director of the International Health Care Worker Safety Center, University of Virginia, says an employee needs to report needlestick injuries and blood exposures so he or she can obtain “baseline tests to establish their seropositivity status for HIV, HBV, and HCV.” That way, “if the worst happens and an infection occurs, [the health care worker] can clearly show, for workers’ compensation purposes, that they were not infected prior to the exposure.”

By reporting injuries, workers can also take advantage of post-exposure prophylaxis for HIV and HBV (if they haven’t been vaccinated for hepatitis B or their antibody titers are too low). As far as PEP for HIV, “the gold standard,” says Dr. Beltrami, is to receive it within “hours after the exposure rather than days. But people have received PEP up to a week after a sharps-related blood exposure.”

Even for HCV, for which no PEP is available now, “it’s important that the health care worker’s infection status be monitored closely,” Perry says. “Some studies have shown that early treatment of HCV in the acute phase of infection can prevent chronic infection.”

Despite the importance of reporting needlesticks and blood exposures, a CDC study found an average underreporting rate of 57 percent among health care workers, with rates as high as 73 percent for surgeons, Perry says. “So we need to continue to stress the importance of reporting and make it as easy as possible for health care workers to do so.”

Dr. Beltrami believes that as health care organizations “foster a culture of safety” that encourages reporting needlestick injuries, “one would initially or perhaps forever see an increase” in the rate of reported injuries. Pathologist Paul Valenstein, MD, of St. Joseph Mercy Hospital, Ann Arbor, Mich., and chair of the CAP Quality Practices Committee, compares that phenomenon to what’s happened in the commercial airline industry where “the threshold for reporting” safety issues has gone down over the years. “People are more likely to report a slip walking to the bathroom down the aircraft aisle than they were 30 years ago,” he says. “The proportion of flights that involve safety incidents is increasing, while the proportion that involve fatalities has been declining over the same period,” he says.

By the same token, more reporting of sharps injuries would improve safety over time by making it possible to analyze the injuries and thus prevent them. “So you would hopefully see a decrease not necessarily in the number of reports but in the severity of outcomes or in bad outcomes,” Dr. Beltrami says.

“Maybe more people would be reporting exposures but they would be treated,” she says. And that would “decrease disease transmission and lower work absenteeism related to anxiety after an exposure.”

Health care employers are, in fact, finding it pays to keep their workforce safe and happy. For one, Sarah Bush Lincoln’s Jodie Warner says, “Better employee retention seems to correlate with [lower rates of] needlesticks.”

And as Dr. Beltrami sums up: When an organization has a “culture of safety and workers are confident that their institution is committed to their safety, they are going to be better workers.”