College of American Pathologists
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  Needlestick patrol: breaking bad habits


CAP Today




January 2012
Feature Story

Anne Paxton

When Dennis J. Ernst, MT(ASCP), gives lectures to hospital staffs on accidental needlesticks, invariably a few audience members will seem to claim immunity from risk. “They’ll say, ‘I tear the fingertips off my gloves to find veins, I’m careful, I’ve never been stuck,’” says Ernst, executive director of the Center for Phlebotomy Education in Corydon, Ind. But these health care workers have a false sense of security, he says. “Legislation has taken us great lengths down the road to reducing needlesticks, but not all the way. You can only reduce accidental needlesticks so far by implementing safer devices.”

In his online webinars and other presentations, Ernst targets the behaviors that put people at risk even when they’re using safety devices. “It’s something we have to be on top of all the time. We have to be diligent, we have to educate, we have to put out reminders. We have to just be constantly on patrol to make people aware and get our accidental needlestick rates down as low as possible.”

A 2007 study by the Exposure Prevention Information Network (EPINet) found that roughly 78 percent of the sharps involved in injuries are hollow-bore needles, the kind used in drawing blood samples. In the study, which looked at 951 reported injuries from needlesticks and other sharps, 95 percent of the time the sharps were contaminated. Two-thirds of the injuries happened to doctors and nurses, most frequently in the operating room or recovery, followed by patient rooms, critical care units, and emergency departments.

The Occupational Safety and Health Administration adopted the bloodborne pathogens standard in 1991. Ten years later, the standard was revised in the Needlestick Safety and Prevention Act to specify that engineering controls such as blood collection devices with engineered sharps injury prevention features be used. By 2006, sharps injuries in nonsurgical settings had decreased 31.6 percent. But since that time, there has been no new safety legislation, and compliance with existing law is not perfect. “Right now it’s all up to OSHA to make sure employers are implementing the law,” Ernst points out. “And not everybody is compliant.”

What are the consequences of accidental needlesticks? Aside from the wound itself, workers can acquire one of some 200 bloodborne diseases. The infectivity rate from accidental needlesticks—the percentage of those exposed who become infected—is fairly low for HIV: 0.3 percent, says Ernst. “The bigger concern is with hepatitis B. Six to 30 percent of those who are not immunized will be infected with it if they have a needlestick.” Hepatitis C, for which no immunization yet exists, will infect people 0.5 percent to two percent of the time.

For a multitude of reasons, a high percentage of people who experience an accidental needlestick don’t report it, Ernst notes. In an online survey on his Web site,, 29.1 percent of those who had had an accidental needlestick in the past 20 years said they kept it to themselves. “It’s never justifiable, but human nature being what it is, people may not report because they are afraid of being ostracized, they’re afraid of the stigma, or they’re afraid of being considered inept. And I suppose some want to just ignore it and hope for the best.”

Despite OSHA requirements, the use of safety devices still is not universal. While it’s not a scientific survey, visitors to Ernst’s Web site were asked, “Do you ever use non-safety devices when you draw blood?” and 12.5 percent of those responding said yes. “About 40 percent of those were non-USA subscribers,” Ernst notes, “but that still means 7.5 percent of U.S. responders said yes.” Others have put the rate at 13 percent (“10th Anniversary of the Needlestick Safety and Prevention Act: Mapping Progress, Charting a Future Path.” International Health Care Worker Safety Center conference, Nov. 5–6, 2010, Charlottesville, Va.).

Similarly, although 91 percent of responders to his Web site survey say they always wear gloves, as required, “Five percent said they either seldom or never do. Why is that? Well, I think old habits die hard, and sometimes old habits never die until the person who’s harboring them does. People like that tactile sensitivity so they can feel that vein, and they’re willing to take risks to get it.” But the risks aren’t worth it, he says. “All it takes is one accidental movement, one jump or bump and that needle can impale you. Gloves aren’t going to prevent a needlestick—but gloves will wipe off up to 86 percent of the inoculum, and that reduces the amount of potentially contaminating blood that gets into your tissues pretty significantly.”

Wearing gloves with missing fingertips is not a solution, he cautions. “Everybody in the industry has seen the tips cut off gloves, or has done it themselves. People say they can just tear the tips off and technically abide by the policy to wear gloves and be able to feel the vein and not have to stick the patient twice. But gloves by definition have fingers, and if you tear the fingers off, you’re no longer wearing a glove. So you’re fooling yourself that you’re complying. You’re not.”

Under OSHA regulations, “if there is a safer device, it must be used.” Glass has been shown to compound risk because lacerations from broken glass can introduce a larger inoculum of patient blood into a wound than needlestick injuries. So glass tubes should be replaced by plastic whenever possible, Ernst says. But a high number of respondents on his Web site said they didn’t use plastic. That’s dangerous and may put the facility in line for a citation, he says.

Re-use of tubeholders is also considered unacceptable, but 7.5 percent of online survey respondents in the U.S. said this was a common practice at their facility. “Whether single-use tubeholders are mandated or not, you should not be separating the needle from the tubeholder because that act increases risk dramatically. When you separate the needle from the tubeholder, then that back end of the needle is a risk, not only for the individual but also for multiple downstream waste handlers who handle sharps that are suddenly sharp on both ends.”

Most respondents said they use a safety transfer device. “That is the recommended way to evacuate blood from a syringe into a tube,” Ernst says. But about eight percent of U.S. respondents use another way. “They might say they take the needle off, pop the top off the tube, and squirt the blood inside. Or people pierce the stopper with the same needle used to draw the blood. But neither of those is acceptable. OSHA prefers that the needle with a safety device is activated, discarded, and the safety transfer device is put on. This allows the tubes to fill without risk to the individual.”

About 95 percent of needlestick/sharps injuries are to the hand—most often the left hand, according to EPINet. And recapping with two hands is historically the most common practice or behavior that has resulted in accidental needlesticks, Ernst says. “Any time you’re bringing two hands together, one of which is holding a contaminated needle, you’re increasing the risk substantially for accidental needlesticks, and OSHA has said since 1991, when the bloodborne pathogen standard was introduced, that you should not do that.”

In fact, Ernst recommends that people not only halt recapping of contaminated needles, “they shouldn’t even recap a clean needle.” It frequently happens that health care workers may be getting ready to draw blood and, for example, the patient passes out, or maybe they find they don’t have all the tubes they need, and they’ll recap. “But I don’t recommend that, because if you permit yourself to recap a clean needle, someday you’re going to recap a dirty one.”

There are circumstances in which a syringe is going to mean the difference between successful and unsuccessful draws, Ernst says, such as with a difficult draw when one needs to have more control over the pressure when pulling blood out of the vein. But syringes should be used only on patients who have delicate veins, such as oncology or geriatric patients. “Syringes are the device most commonly in use when health care workers get accidental needlesticks. So if we reduce our syringe use, we reduce our accidental needlesticks.”

He has been surprised at the number of health care workers who say they always use butterfly needles or winged infusion sets. “It’s a very polarizing topic,” he notes. “Because there are people who just love them and use them exclusively. They probably don’t realize that they are the devices used more frequently when phlebotomists get accidental needlesticks. If they restricted their use to only those patients whose veins require them, their risk of an accidental needlestick would plummet.”

Some patients complicate things by demanding that butterfly needles be used on them. “There is a conception among some patients that butterflies are the best device and the least painful. And it doesn’t hurt that the device has a friendly name. But the question is, Should I compromise my own safety for the patient’s preference? The answer should be a resounding no. A patient should no more be allowed to pick the blood collection device than a dental patient should be allowed to select the dentist’s drill bit. Some choices are best left to the professional.”

Forcing blood by applying pressure to the plunger of the syringe is, unfortunately, not a rare practice, Ernst says. “When the vacuum in the tube doesn’t pull the blood automatically, then one of two things is happening: Either the tube is flat—in which case another tube should solve the problem—or there’s a clot in the luer of the syringe. If there’s a clot, we probably can’t salvage the sample. Forcing the blood into the syringe risks hemolyzing the sample, and we’re compromising our own safety because we’re more than likely going to get splattered.”

A number of health care workers still say they employ the “two finger stretch” to anchor veins for a draw, Ernst notes. “It frequently goes back to the way they were taught. Sometimes bad technique gets perpetuated even when the risk of acquiring bloodborne pathogens increases, as it has since the 1980s when AIDS emerged. But people need to realize, when they put a finger in front of the needle as it’s going into the vein, that the finger is in harm’s way. All the patient has to do is jump about and the needle comes out of their skin into the finger.” His Center for Phlebotomy Education, and the CLSI standards, advocate anchoring from below the intended site only, not compromising safety by anchoring from above.

Another surprise is the number of people who say they “never” have a sharps disposal unit available for use. “My guess is that these are people who go into unconventional draw sites like people’s homes and they don’t think to bring in a sharps disposal unit and are just going to carry that sharp out to the car. But it’s easy to fix, because sharps containers are small and can be carried anywhere. It’s what OSHA refers to as a work practice control, and not having it can subject them to a fine.”

Even more common, however, is the habit of letting a sharps disposal unit fill beyond 75 percent capacity. This, Ernst knows from personal experience, is a significant risk. In the 1980s when there was a lower level of awareness about the dangers, “my sharps container was overfilled. I came in and pulled out the tray. I tried to seal it and I had to push so hard on the lid that a needle penetrated through the bottom of the container, right into my thumb.”

Nobody should observe an overfilled container and not bring it to the attention of somebody who can correct the problem with disciplinary measures, he says. As he sums it up: “Treating an accidental needle-stick: $4,000. Liver transplant: $150,000. Treating HIV: Over $500,000. Sharps containers: five bucks. Some things money can’t buy; for accidental needlesticks, there’s prevention.”

Ernst’s informal surveys also show that the average time people take to activate a needle’s safety device is far from optimal. “Sixty-two percent of all accidental needlesticks occur within moments of when the needle is removed from the patient,” he says. “So the longer we leave the needle exposed, the longer our window of vulnerability is left open for needlesticks.” He recommends that health care workers focus on eliminating pauses in their technique. “Permanent concealment should take place immediately and in one fluid motion after the needle is removed from the patient’s vein.”

Manufacturers have done a pretty good job of adding safety features that work—as long as health care workers put them to use, Ernst points out. “I hear so many times of people coming on their shift and immediately ripping off the safety guards and shields so they can use the device the way they used to, without interference. That’s not the manufacturer’s fault; that is behavior that needs to be addressed.” However, he predicts more aggressive development of passive safety devices that do not require an activation step. “Passive safety devices require expensive engineering, so it’s difficult to price them within reach of a lot of facilities, but over time prices are coming down.”

Health care facilities call Ernst in to discuss the many situations that create risk of an accidental needlestick and how workers can avoid them. “The thing is, sometimes managers can say something to staff until they’re blue in the face, but only when they hear it from an outside party is it validated. So that’s what I do.” Even so, he emphasizes, the best weapon against accidental needlesticks is constant, diligent, vigilant education. “Education has been estimated to reduce accidental needlesticks by 50 percent,” he says.

“You cannot just simply have an in-service and think that will fix the problem for good. The message has to be repeated, and people have to hear the same message in a variety of ways and from a variety of sources. We’re talking about getting people to change their behavior permanently, and the way we do that is to constantly educate, constantly discipline, and constantly monitor infractions and react accordingly.”

Anne Paxton is a writer in Seattle.

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