Safety devices do not eliminate all injuries

Comprehensive prevention approach needed

Nearly lost amid the surging legislative movement to mandate needle safety devices in the nation’s hospitals is the message that injuries and occupational bloodborne infections still can occur after the devices are implemented. Indeed, needle safety devices were involved in 9.2% of needlesticks and sharps injuries in 1998 surveillance data from the EPINet system at the International Health Care Workers Safety Center at the University of Virginia in Charlottesville.

"As we integrate more safety devices into the workplace, we are going to have more and more injuries associated with safety devices. This is a fact of life," Janine Jagger, PhD, director of the center, said recently in Washington, DC, at the Frontline Healthcare Workers Safety Conference. "Hopefully, there will be fewer injuries per number of devices used, but I think we need to keep that in perspective. The best safety devices prevent as many injuries as possible, but if they have a needle on them, there will be a fraction of injuries that continue to occur."

The EPINet surveillance system has collected some 1,500 reports of injuries with needle safety devices, but conventional needles, many of which could be replaced by existing safety designs, are still the source of the lion’s share of injuries. "We need to look at the information to make sure that the [safety] device is not causing a new type of risk," she said. "This information shouldn’t be used to condemn devices that actually have reduced the numbers [of injuries]."

Shedding further light on such findings, data collected by the Centers for Disease Control and Prevention reveal workers are being injured when they inappropriately add a needle to a "needleless" system; a safety device is withdrawn by sudden patient movement; or the worker fails to activate the protective feature after use, Linda Chiarello, MS, told Hospital Infection Control in an interview before the conference. "Sharps injury prevention is comprehensive," said Chiarello, an epidemiologist in the CDC’s hospital infections program. "An engineering control is a very important prevention strategy, but it is not the whole solution. We want to promote a culture of safety, where people are aware of the risks when they have an exposed sharp in the work environment."

Injuries happen despite needleless’ system

To determine the proportion of potentially preventable needlesticks, the CDC analyzed data from 33 hospitals in its National Surveillance System for Healthcare Workers. In data collected for 3,772 needlesticks that occurred in the hospitals from June 1995 to December 1999, the CDC found that 270 (7%) of the injuries involved an engineered sharps protection device. In 24 (9%) of those 270 injuries, use of a needle was considered unnecessary. For example, health care workers may have been injured while using needles to access tubing, draw blood, or give medication in a "needleless" intravenous system, she said.

"Needleless devices for the most part do not preclude the use of a needle with the system," Chiarello said. "They are designed to be used without needles, but they are not necessarily needle-free. This terminology has been promoted even in legislation [that states] use a needleless system.’ When you use the term, one assumes that no needle is going to be used, and the worker is going to be completely protected. That’s not true."

Of the remaining 246 needlesticks involving safety devices, 43% (106) occurred before activation was appropriate because, for example, the patient moved suddenly and the needle came out. Though some devices activate to cover or blunt the needle as it is withdrawn, sudden patient movement may leave the needle withdrawn and exposed, she notes.

In addition, another 25% (61) of the injuries occurred because the worker failed to activate the safety device. "After the needle has been used and the health care worker is applying pressure to the injection site, the device has to be activated," she said. "As long as the needle is exposed, there is opportunity for injury."

Truly passive’ devices are best

The more "truly passive" the device the better, she emphasized. "Some devices are advertised as being passive, but indeed, the worker still has to do something to activate it," she added. On the other hand, some workers may decide not to activate safety devices for reasons that are not completely understood. One possibility, for example, is if the procedure is done next to a sharps container, the worker might perceive the lowest-risk maneuver is simply to dispose of the needle immediately rather than handle it further to activate the safety measure. "But we also know that injuries occur because of overfilled sharps containers, and if devices with safety features are activated, they are protected in the container and it is less likely that another worker will be exposed," Chiarello said. "It is an area we need to better understand — why a worker who has a device with a safety feature doesn’t activate it."

Another five (2%) of the injuries were due to some failure of the safety device mechanism; such cases should be reported to the Food and Drug Administration, she stressed. Overall, the findings reinforce the need for ongoing collection of epidemiological data as needle safety devices continue to be implemented to protect health care workers. Injury data are critical to determine what devices are involved and when and how needlesticks are occurring. Target interventions and use engineering controls based on such surveillance, she emphasized.