Prevention of sharp injuries

Introduction

Sharps and needlestick injuries are wounds caused by needles and other sharp medical instruments (e.g. scalpels, blades and scissors) that accidentally puncture or cut the skin. Sharps and needles may cause only small wounds in the skin, but the effects can be more serious. Such instruments come into contact with blood and other body fluids and may carry a risk of infections. More than 20 dangerous bloodborne pathogens including HIV and hepatitis may be transmitted through accidental injuries with contaminated needles and sharps^[1].

This article gives an overview about the risks associated with sharps and needlestick injuries, and about European legislation. It will focus on prevention measures, such as safe injection practices, safe medical devices, and training. In addition, it will provide information on what to do in case of an injury.

Who is at risk of sharps injuries?

Sharps and needlestick injuries remain a serious problem in the healthcare sector. Studies estimate that around 1.2 million injuries occur in Europe each year^[2]. Moreover, there is some evidence that this number increased even more during the COVID-19 pandemic. A survey of more than 300,000 healthcare workers in five European countries showed an average reported increase of 23% during the first year of the pandemic (2020 – 2021), especially due to increased work pressure, a lack of safety devices and PPE, and the vaccination rollout^[3]. Overall, studies estimate that 1 in 2 healthcare workers experience a sharps injury during their career^[4]. In addition, a large number of injuries go unreported (estimated at between 26% - 90%)^[5].

Not only healthcare workers are at risk but also other professional groups such as social workers, cleaning/laundry personnel, park-keepers, police officers, prison officers, and workers involved with waste disposal including street cleaning and refuse collection^[6].

In healthcare, it is not just medical professionals who are at risk from sharps injuries, but rather anyone who comes into contact with needles or medical sharps contaminated with blood or other body fluids. The majority of sharps injuries occur to nurses, because their daily routine involves using needles and sharps. While nurses who work in acute medical situations are identified as having the highest risk, many other healthcare workers are also at risk6, such as^[7]:

• Doctors
• Paramedics
• Dentists
• Operating department assistants
• Phlebotomists
• Laboratory workers
• Cleaners
• Laundry workers.

Workers outside the healthcare sector may also be at risk because they may come across material that is contaminated with blood and bodily fluid, such as needles used by intravenous drug users^[6].

Professions where workers may be at risk include:

• Prison and probation service
• Cleaners of public spaces
• Police and security services
• Customs services
• Social service workers and youth workers
• The funeral industry
• The body piercing/body art industry
• Waste disposal
• The construction/demolition industry.

What are the most common causes of sharps injuries?

Sharps or needlestick injuries are generic terms for injuries where infectious blood or other body fluids can come into contact with wounds or mucous membranes^[6]. The most common injuries are needlestick punctures or cuts with medical instruments, but also include^[8]:

• Contamination of broken skin with blood
• Swallowing a person’s blood e.g. after mouth-to-mouth resuscitation
• Contaminated through being soaked by blood where the injured person has an open wound / blood on clothes
• Bites (where the skin is broken).

Factors that can influence the risk of sharps injuries are equipment, design of instruments, working conditions and working practices. The causes of sharps injuries are multifactoria^l[9] and relate to aspects such as the type of instruments, the type of procedure, inexperience, lack of training and education, improper management of sharps, unsafe collection and disposal of sharp waste, poor organisational climate, high work pressure and fatigue^{[1] [10]}. According to the US Center of Disease Control and Prevention (CDC), sharps injuries often occur in a fast-paced, stressful and understaffed situation^[11]. Working under such a demanding situation may result in fatigue, poor concentration, and carelessness, thus increasing the risk of sharps injuries.

Table 1: Most common causes of sharps injuries

Source: adapted from^[12]

Many devices cause sharps injuries: needles, scalpels, blades, scissors, and test tubes. However, biological matter (such as bone fragments or patients’ teeth) can also cause sharp injuries^[7]. Data from Epinet show that most injuries are caused by a suture needle (26%) or a disposable syringe (23%)^[13]. Also according to Epinet, 43% of the injuries occur in the operating room and 30% in the patients room^[13]. In addition, findings from UK and US reporting systems suggest that sharps injuries mostly occur^[7]: 

• before the procedure
• during use
• after use, before disposal between steps in procedures
• during disposal
• while resheathing or recapping a needle.

What can be contracted from a needlestick?

Incidental punctures by contaminated sharps can inject hazardous fluids into the body through the skin. There is a risk of injection of hazardous medicinal products, but the greatest risk is contact with infectious fluids, especially blood^[10]. Contaminated needles and sharps can transmit more than 20 dangerous bloodborne pathogens, viruses, bacteria and protozoa, including HIV and hepatitis B (HBV) and C (HBC).

Diseases transmitted through infected blood include:

• Viral infections, e.g. hepatitis B, C, HIV
• Bacterial infections, e.g. tuberculosis and diphtheria
• Protozoal infection, e.g. malaria (plasmodium falciparum) and toxoplasmosis

Infections from bloodborne pathogens can result in serious illness and even death. After exposure to blood and body fluids due to needlestick injuries, the risk of being infected with Hepatitis B is 3-10%, for Hepatitis C it is 1-3%, and 0.3% for HIV^[12]. Hepatitis C represents the most serious health risk as it is ten times more transmissible than HIV and there is currently no vaccine^[14]. A systematic review (2022)^[15] found that hepatitis C virus infection was the most common disease transmitted by sharps injuries (21%), ahead of hepatitis B (18%) and HIV (17%).

The risk of infection depends on a range of factors, such as the depth of wound, the type of sharp instrument, whether or not the device was previously in a vein or artery, and how infectious the patient is^[7]. Fortunately, most sharp injuries do not lead to infections. However, infections such as hepatitis B, hepatitis C and HIV can take months to be diagnosed, leaving healthcare workers in anxiety for weeks or even months while undergoing blood tests and dealing with the side effects of antiviral drugs. Even if these injuries do not (always) lead to life-threatening infections, they cause a lot of stress and anxiety for both medical staff and their families^[7].

Legislation

All workers are protected by the framework Directive 89/391/EEC^[16]. This Directive’s basic principle is risk prevention, which requires employers to carry out risk assessments, and imposes a general duty on them to ensure the health and safety of employees. The Directive is supplemented by individual Directives.

Directive 2000/54/EC^[17] is aimed at protecting workers against risks to their health and safety, arising (or likely to arise) from exposure to biological agents at the workplace. This Directive sets out provisions to guarantee improved OSH where workers may be exposed to biological agents as a result of their work.

On 6 July 2006, the European Parliament adopted resolution 2006/2015 (INL)^[18] to protect European healthcare workers from bloodborne infections due to needle stick injuries.

A Europe-wide framework agreement on the prevention of sharps injuries was signed on 17 July 2009 by HOSPEEM (European Hospital and Healthcare Employers' Association) and EPSU (European Public Services Union) – the European social partners in the hospital and healthcare sector^[19]. The Agreement aims to protect workers at risk of injuries from all types of medical sharps by developing an integrated approach based on risk assessment, appropriate prevention measures, and training and information for workers.

Council Directive 2010/32/EU^[20] on prevention of sharp injuries in the hospital and healthcare sector brought into law the framework agreement negotiated by the sector’s European social partners. It applies to all workers (private and public) in the healthcare sector, as well as students, agency nurses, and healthcare staff in other workplaces, such as prisons. The key requirement of the Directive is risk assessment. The aims of the Directive are:

• Achieving the safest possible working environment;
• Preventing workers’ injuries caused by all medical sharps;
• Protecting workers at risk;
• Setting up an integrated approach, establishing policies in risk assessment, risk prevention, training, information, raising awareness and monitoring;
• Establishing response and follow up procedures.

Other relevant individual Directives for protecting healthcare workers from the risk of sharps injuries are Council Directive 89/655/EEC^[21], which lays down the essential health and safety requirements for work equipment, and Directive 92/85/EEC^[22], which provides specific protection for pregnant workers or nursing mothers. This Directive states that employers must take all appropriate steps to ensure that neither the worker nor the unborn child is exposed to a health risk in the workplace. In addition, hazardous medicinal products which contain one or several carcinogens, mutagens or reprotoxic substances at work (CMR) fall under the scope of Directive 2004/37/EC on CMR ^[23]. Hazardous medicinal products were added to the scope of the Directive in 2022 (amending Directive 2022/431/EU).

Risk assessment

Risk assessment means identifying hazards and controlling the risks in the workplace. The EU framework Directive 89/391/EEC^[16] obligates employers to ensure every aspect of workers’ health and safety, and to carry out a risk assessment. Clause 5 of Directive 2010/32/EU20 stipulates that "risk assessment shall include an exposure determination, understanding the importance of a well resourced and organised working environment and shall cover all situations where there is injury, blood or other potentially infectious material." And, further, that "risk assessments shall take into account technology, organisation of work, working conditions, level of qualifications, work related psycho-social factors and the influence of factors related to the working environment."

Risk assessment - the basis for successful OSH management - is the key requirement of Directive 2010/32/EU^[20]. The guiding principles that should be considered throughout the risk assessment process can be broken down into five steps^[6]:

Step 1 – Identifying hazards and those at risk

All sharps injuries are a hazard that can lead to a risk of infection: What might cause harm? What can go wrong?

Finding the answer is possible, by:

• Determining how many and which workers are exposed. Taking into account that there are many types of workers that might be exposed to sharps injuries (clinical staff, ancillary staff, laboratory staff).
• Identifying the types of procedures where sharps injuries occur.
• Identifying practices with a higher injury risk.
• Using existing data on sharps injuries to identify high-risk areas.

Step 2 – Evaluating risks and prioritising

What is the likelihood of the risk? How serious are the potential consequences?

Risks are assessed and prioritised according to the hierarchy of control measures:

1. Elimination of risk
2. Isolation of the hazard: engineering control, protective devices
3. Collective control measures – (work practice control, and administrative controls)
4. Individual control measures – (personal control, PPE)

Step 3 - Deciding on the preventive action

How can the risk of sharps injuries be eliminated or reduced?

Identifying the appropriate measures to eliminate or control the risk, e.g.:

1. Elimination of risk: removing sharps and needles when possible; considering whether the task is necessary, e.g. by eliminating unnecessary injections
2. Isolation of the hazard through engineering controls: use of sharps protection devices
3. Collective control measures: a) administrative control (policies and procedures to limit hazard exposure), and b) work practice control (safe disposal of needles, no re-capping, safe sharps containers)
4. Individual control measures: double gloving (PPE)

Step 4 – Taking action

Putting in place the preventive and protective measures and specifying who does what and when.

Step 5 – Monitoring and reviewing

Recording findings: The findings of the risk assessment should be recorded and be part of an action plan to reduce the risk of sharps injuries. The outcomes should be shared with all workers.

Reviewing the assessment and updating if necessary: checking the effectiveness of control measures.

Prevention measures – elimination, prevention, and protection

Prevention measures to eliminate or reduce sharps injuries can be done in different ways. The Directive 2010/32/EU^[20] lists a variety of preventive and protective measures, which must be considered when aiming to eliminate the risk of sharps injuries. These measures include:

• Eliminating the unnecessary use of sharps
• Providing medical devices
• Incorporating safety-engineered protection mechanisms
• Implementing safe systems of work
• Implementing safe procedures for using and disposing medical sharps
• Banning recapping
• Using personal protective equipment
• Vaccination
• Information and training

Directive 2010/32/EU^[20] states that employers must comply with the hierarchy of controls as set out in EU OSH framework Directive 89/391^[16] as well as in the Biological agents Directive (2000/54/EC)^[17]. The hierarchy of controls, reflecting the efficacy of preventive measures, indicates that the first priority and most effective level is the elimination or substitution of needles and other sharps, where possible, i.e. eliminate unnecessary injections, introduce needleless intravenous (IV) systems.

The next level is to isolate the hazard through the use of an engineering control, e.g. safer needlestick devices, sharps containers. This is followed by work-practice controls (universal precautions, no recapping) and administrative controls (policies and training programmes). Work practice controls should not be a substitute for engineering controls and should only be considered if the technology to eliminate or reduce the hazard is not yet available. Training measures, however, should complement all types of controls.

The last priority (and least effective) are individual control measures: personal protective equipment, such as gloves, masks, gowns, etc. 

Elimination: alternatives to using needles

Different systems are available to eliminate unnecessary use of needles. Needle-free systems provide an alternative to needles for some procedures, reducing the risk of injury from contaminated sharps, e.g.:

• Needle-free liquid jet injections: a high-speed jet is used to puncture the skin and deliver drugs without the use of a needle. They have been used to deliver vaccines and insulin, as well as anaesthetics and antibiotics^[24]. Occasional pain and bruises have limited the acceptance of jet-injectors.
• Needle-free intravenous medication systems: The system uses interlocking parts instead of needles connections. It delivers medication or fluids through a catheter by using non-needle connections. The connections can be plugged together without using a needle, and without opening the line and exposing the bloodstream.
• Needle-free urine sampling.

Other measures to eliminate the use of needles:

• Alternative routes for delivering medication and vaccination, e.g. oral medications (if available and safe for the patient).
• Eliminating unnecessary punctures - a strategy that is good for both patients and healthcare personnel.

Isolation: Safety devices

Safety devices are designed to prevent workers being injured by contaminated needles or other sharps. They are equipped with safety features which prevent needlestick injuries (Table 2).

There are many different types of safer devices. They can be divided in two categories^[9]:

• Active devices that require worker activation of the safety mechanism (e.g. activation of an integrated protection shield such as a hinged cap or by pressing an activation button).
• Passive devices that work automatically (not requiring workers activation as the safety element will activate during normal use, e.g. retractable syringe)^[9].

Directive 2010/32/EU^[20] stipulates that safety devices must be used were technically useful and safe for patients. Evidence suggests that safety devices, combined with training and safe working practices, significantly reduce needlestick injuries. A Polish study^[25] showed that the use of safety devices significantly reduced the risk of injury compared with non-safety devices. Active devices, such as retractable needles, require manual activation and depend on user compliance, making them less reliable than passive devices that activate automatically. Studies in France^[26], Germany^[27] and Italy^[28] have confirmed that passive devices are more effective in reducing injuries. A study in a German hospital^[27] showed that the majority of safety-engineered device-related injuries could have been prevented by a correct activation of the safety feature. Dulon et al.^[9] showed similar results and identified lack of practical experience as the main cause of failure in the use of safety devices. Being stressed and/or overworked seems to further increase the incorrect use of safety devices.

Healthcare staff must be involved in the implementation of new safety devices in hospitals, and the following criteria must be considered (adapted from^[29]):

• The device must not compromise patient care
• The device must perform reliably
• The safety mechanism must be an integral part of the safety device, not a separate accessory
• The device must be easy to activate and use
• The activation of the safety mechanism must be convenient and allow the care-giver to maintain appropriate control of the procedure
• The device must not create other safety hazards or sources of blood exposure
• A single-handed or automatic activation is preferable

Table 2: Priorities for safety-engineered sharps

Source: adapted from^[14]

Administrative and work practice control – safe work

Effective measures to prevent sharps injuries also include administrative and work practice controls^{[7] [30]}. These reduce the likelihood of exposure by changing the way work is done.

Administrative control measures include policies and programmes to limit the exposure to sharps injuries, e.g.:

• Preparing a written statement of the health and safety policy.
• Providing adequate staffing and adjusting work schedules.
• Defining local health and safety policies to detail how safe working will be achieved on a day-to-day basis.
• Defining/detailing clear health and safety responsibilities.
• Implementing an incident reporting system.
• Providing regular information and training.
• Implementing vaccination programmes.

Training and accessible guidelines must be available for all workers (including new recruits, agency staff, self-employed and ancillary workers). Workers should be involved in decisions about safe working practices.

Working practices controls aim to change the behaviour of the workers. Appropriate training is needed to ensure that all workers are aware of the risks of exposure to biological agents, and know about safe work procedures and the use of safe medical device, as well as standard operating procedures.

Safer working practices include:

• Use of safe medical devices.
• Ban on recapping: Manual recapping leads to a high risk of being punctured by a needle. Re-capping is the practice of re-sheathing used needles. According to Directive 2010/31/EU “the practice of recapping shall be banned with immediate effect."
• Safe disposal of used sharps and needles in appropriate containers (puncture resistant, leak proof and closable). Used needles and sharps must be disposed immediately after use.
• Easy accessibility of appropriate sharps containers in the immediate vicinity where sharps and needles are used.
• Regularly checking sharps containers (and exchanging if full).
• No passing on of contaminated sharps and needles from one person to another.
• Sharing information among all workers about risk situations (e.g. uncooperative or confused patients).
• Immobilisation of sharps and needles before they are disposed of, e.g. by gypsum moulding.

Personal protective equipment (PPE) and vaccination

Personal protective equipment is the least effective control measure. PPE provides a barrier between the worker and the hazard. It can only prevent exposure to blood or other body fluids, but it cannot protect workers from sharps and needlestick injuries. It should only be used when workers’ exposure to sharps injuries cannot be eliminated by safe work practices and engineering controls.

Examples of PPE are:

• Gloves (cutting resistant gloves, double gloving)
• Masks
• Face shields
• Protective glasses

To prevent occupational infections of healthcare workers from bloodborne pathogens, Directive 2010/32/EU^[20] stipulates in clause 6 paragraph 4 that ‘Vaccination and, if necessary, revaccination shall be carried out in accordance with national law and/or practice, including the determination of the type of vaccines: — Workers shall be informed of the benefits and drawbacks of both vaccination and non-vaccination, — Vaccination must be offered free of charge to all workers and students delivering healthcare and related activities at the workplace.’

Hepatitis B vaccination is mandatory for medical, nursing and paramedical staff in ten EU member states (Belgium, Croatia, Czech Republic, France, Hungary, Latvia, Netherlands, Poland, Portugal and Slovenia). It is recommended in the others^[31].

Incident reporting

Sharps and needlestick injuries are highly underreported. According to a Swiss study, the highest level of non-reporting needlestick injuries is among doctors^[32]. The main reasons identified were desensitisation (seeing injuries as "business as normal") and underestimating the real risk. According to a survey conducted by Diprose et al, only 34% of anaesthetists questioned were aware of the real risk of transmission of HIV from a needlestick injury^[33]. The second reason given for not reporting was a lack of time^[32].

It is, however, important to report injuries, so that appropriate treatment can follow without delay. Reporting injuries is also important for identifying the causes of an injury, and for taking the necessary measures to prevent further injuries.

What to do in case of an injury

If workers are contaminated with blood or other body fluids, they should take the following actions without delay:

• Wash splashes off their skin with soap and running water.
• Wash out splashes in their eyes using tap water or an eye wash bottle. Wash nose or mouth with plenty of tap water. Do not swallow the water.
• Wash cuts thoroughly under running water with soap, without scrubbing the wound.
• Do not suck the wound.
• If soap and water are not available, use alcohol-based hand rubs or solutions.
• Encourage bleeding from the wound.
• Cover the wound with a dressing.
• Ensure the sharp instrument is disposed of safely.
• Record the source of contamination.
• Report the incident to the supervisor, line manager or health and safety advisor, and to the occupational health department or occupational physician.
• Go straight to a doctor, or to the nearest hospital emergency department.
• Check vaccination status.

Immediate action is required in cases of accidental exposure to bloodborne pathogens through sharp injuries. This involves an assessment of the risk of infection, individual medical consultation, and the prescription of post exposure prophylaxis (PEP), if advised^[7].