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NEEDLESTICK INJURIES: SHARPEN YOUR AWARENESS

3 NEEDLESTICK INJURIES IN THE NHSSCOTLAND

EVIDENCE

3.1 One of the main barriers to the work of the group has been the lack of adequate information. Data pertaining to needlestick injuries are not collected consistently across the NHSScotland. In September 1999, all NHSScotland Trusts and Health Boards were asked by the Scottish Executive Health Department to provide information relating to the incidence of needlestick injuries in their area, 23 out of 28 Trusts and 15 out of 21 Health Boards (including Special Health Boards and the CSA) responded. The data, in general, covered the time period 1996-99 and have been extrapolated to represent all 28 Trusts in Scotland. The total number of reported injuries over the three years was 6811. Table 1 shows the annual breakdown. It has been estimated that 11 million needles are used in Scotland per annum but it is not known how many are involved in contact with patients or microbiological hazards. It can clearly be seen that there has been an increase in the reported number of needlestick injuries over the specified time period of almost 12.5 %. Whether this is a true increase in the number of needlestick injuries or a reflection of greater awareness and hence increased reporting is not known. However, if the number of needlestick injuries is considered as a factor of occupied beds, the percentage increase from 1997-1998 to 1998-99 is only 1.1 %. It should be noted that GP Medical and Dental Practices have not been included in this evaluation as only a small number of returns were received from these areas.

Table 1 Needlestick Injuries in NHSScotland Trusts 1996-1999

*Occupied beds have been used as a measure of activity but it is recognised that this does not reflect all activity.

3.2 The data provided by the Trusts were further analysed with respect to the occupational groups reporting needlestick injuries. As shown in Table 2, the majority of reported needlestick injuries involve nursing staff. The percentage of reported incidents involving medical and dental staff was somewhat lower but anecdotal evidence suggests that this group are inclined to self-assess and not report such injuries, contributing to the apparent lower incidence. Of reported incidents, 20% involved ancillary staff and others, including porters, domestic and grounds/estates staff. When the data are considered in terms of the percentage of total staff in the NHSScotland, needlestick injuries are shown to be more pronounced amongst the medical and dental category. This statistic, combined with the anecdotal evidence suggesting medical and dental staff are most likely to under report, provides a strong argument for greater training in awareness and safe practice particularly for medical and dental staff.

3.3 While a great deal of information is available from the United States, we do not know whether the US data are relevant to the situation in Scotland. For example we have little information on the type of needle which caused the accident or indication of the kind of safer device that might have been used as a replacement.

Table 2 Needlestick Injuries in the NHSScotland by Occupational Group

* The figures shown are taken from the Manpower Summary, ISD at 30/9/97

WHERE DO NEEDLESTICK INJURIES OCCUR?

3.4 A number of Trusts (corresponding to 25% of the total number of needlestick incidents) provided information as to where the needlestick injury occurred. These data are shown in Table 3. The Trusts used in this breakdown included large acute Trusts and some of the smaller primary care Trusts but are not necessarily indicative of the picture across the country.

Table 3 Needlestick Injuries in Trust in the NHSScotland by Location

WHAT ARE THE MAIN CAUSES OF NEEDLESTICK INJURIES IN THE NHSSCOTLAND?

3.5 Only a minority of Trusts provided information pertaining to the procedures being undertaken when a needlestick injury occurred. A comprehensive breakdown was however supplied by one Trust, South Glasgow University Hospitals NHS Trust, which detailed the procedure and type of device involved in reported needlestick injuries in the Trust over a one-year period. It should be noted that only a small number of incidents are involved and so minor variations may have a large impact on the figures quoted. The breakdown did, however, give an insight into how and why needlestick injuries were occurring. It can be seen from Figure 1, that only 15% of the injuries were directly attributable to clinical practice. The vast majority of incidents, 85%, may have been as a result of incorrect use or disposal of the equipment. The injuries can be further broken down into three main categories:

• Injuries which occur during a clinical procedure (IV-Line Related, Splash of Fluid, Restless Patient and handling/Passing Device) 24 %
• Injuries which occur after a clinical procedure but before disposal (Collision with HCW/Sharp, Disposal Related, Clean Up and Recapping) 48 %
• Injuries which occur after disposal (Concealed Sharps) 28 %

If correct procedure is followed, no injuries should result from collision of staff, cleaning-up after procedures or concealed sharps.

Figure 1. Breakdown of Needlestick Injuries by Procedure

The data shown are taken from a study in South Glasgow University Hospitals NHS Trust carried out between April 1999 and March 2000.

3.6 These data are similar to those of a larger American study (CDC, 1999) where only one quarter of the procedures undertaken when a needlestick injury occurred was during the clinical procedure. Again, the majority of needlestick injuries were as a result of improper use and disposal of needles. Safer disposal of needles is an important area where practice and procedure needs to be carefully reviewed with staff.

STANDARDISATION OF REPORTING

3.7 The lack of consistent, reliable data relating to the incidence and cause of needlestick injuries in the NHSScotland shows a requirement for minimum datasets for the collection of needlestick injury information to be established at local and national level. The resultant data would enable employers to monitor compliance with existing policies, to assist to evaluate new safer devices or procedures and to identify problem areas. A suggested local dataset is shown at Annex 1 along with a sample template for the collection of the data by the occupational health service. The local and national minimum dataset is set out in the Report of the Minimum Dataset Short Life Working Group published in March 2001. This asks all NHSScotland organisations to ensure they record the number, rate and occupational group of needlestick and sharps injuries.

3.8 It is generally recognised that needlestick injuries are under reported. To address this deficiency, the importance of reporting all needlestick injuries should be emphasised to staff. It is recognised however that some staff may be in possession of information which they feel enables them to make their own risk assessment and decide on whether or not they are at risk and therefore whether to report an incident to the occupational health service or their equivalent. Such staff must be persuaded to report incidents or there will continue to be under-reporting and difficulty in determining the full extent of the problem. To capture as much reporting as possible, all staff should be encouraged to report all incidents and to complete an accident form or as a very minimum to make an entry in the accident book. Employers and employees are referred to the Clinical Negligence and Other Risks Indemnity Scheme (CNORIS), MEL (2000)18 and the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR).

NEEDLESTICK POLICY

3.9 The statistics, reported in Table 3 show that although the majority of needlestick injury incidents take place in clinical settings, 8.5 % occurred in "downstream" areas. While all incidents must be regarded as avoidable, those occurring in the "downstream" areas must be due to inappropriate disposal of used needles by clinical staff and wholly avoidable by using good practice and procedures for needle disposal. These are also the types of incident that may cause most stress and anxiety to the sufferer as it is often impossible to ascertain the source of the needle and hence the possible risk from infection. All Trusts must have robust needlestick policies in place that reflect current legislation, guidance and good practice. They must cover the use and disposal of needles and sharps; reporting and monitoring of any injuries; and the procedure to be used in the event of an injury occurring. Trust policies should also cover training and development of staff in the safe use of needles and need to raise awareness. Policies must have commitment from the top and be developed in partnership with staff and be readily accessible.

NEEDLESTICK AND SHARPS RISK ASSESSMENT AND AUDIT

3.10 A key element in the OHSS Strategy for improving the OHSS is the setting up of a system of audit, peer review and benchmarking and to promote the use of good practice where it is seen to succeed. It is not enough simply to have procedures and monitoring in place. NHSScotland employers must first know where needles and sharps are used in their organisation, what risk might be involved in using those needles and consider whether there might be safer alternatives based on potential risk and harm to staff. They must also be aware of the type of needle or sharp being used and for what procedure. In determining what might be a safer alternative the employer must also consider the clinical risk to the patient. Improved data collection will allow organisations to identify areas and activities of highest risk. This is illustrated by the data provided by the South Glasgow University Hospitals NHS Trust (paragraph 3.5).

RAISING AWARENESS

3.11 A main part of the Education, Training and Lifelong Learning Strategy is about continuing these key issues throughout working life to enable staff to provide the best service possible for patients. Occupational health and safety issues are an integral part of this process. A key factor leading to needlestick injuries that has been identified in studies is staff behaviour. NHS employers, with staff representatives, should raise staff awareness of health and safety and its importance to staffs own health and well being. Staff who are fully aware of and practise good health and safety procedures are less likely to put at risk their own health or that of the health of patients or fellow colleagues. Good occupational health and safety practices must be promoted to all staff throughout their career and form an integral part of pre-employment NHS training courses. The importance of occupational health and safety in the NHSScotland should be emphasised by employers including it in their local induction programmes. That emphasis can be maintained through continuing training programmes for staff which can be a practical method of ensuring staff are kept up to date and made aware of new needlestick policies, practices or procedures.

3.12 Occupational health and safety research into employee related illness is important in helping to determine new and improved practices. Research can also raise staff awareness and sends the message to staff that their health and well being is a priority. The Chief Scientist Office of the Health Department should therefore encourage research into employment related staff health.

OCCUPATIONAL HEALTH AND SAFETY (OHSS)

3.13 A key element in the OHSS Strategy for improving the OHSS is the setting up of a system of audit, peer review and benchmarking and to promote the use of good practice where it is seen to succeed. Occupational health and safety also has the key role in delivering a safer workplace through risk assessment, advice, treatment and counselling services. It is recognised that it is not always Occupational Health departments in all Health Board areas who cover such functions. These recommendations should be applied to the relevant department, be that occupational health, infection control teams or other similar units.

3.14 All staff need to be aware of the procedure to be undertaken in the event of a needlestick injury. This can be done for example through posters, leaflets and induction training. Lothian NHS Occupational Health Service provide a 24-hour service and this is highlighted to all staff by means of an advice card in the style of a credit card which details the procedure and contact details in the event of an injury. This is an on-call service out of normal working hours. It is recognised that it is not practical for all Trusts to provide a 24-hour service via occupational health departments. However, guidance issued by the Scottish Office Department of Health in 1997 recommended that Post Exposure Prophylaxis should be available in A & E Departments, and other key sites. Collaboration between occupational health departments and A & E departments is to be encouraged so all NHSScotland staff have access to appropriate care. This concept was reinforced by the recent Guidance from the UK Chief Medical Officers Expert Advisory Group on AIDS (July 2000) which covers all UK Health Departments.

3.15 To reduce the risk to staff from Hepatitis B infection the occupational health and safety service must ensure an appropriate immunisation and surveillance programme for staff is in place. Where a needlestick injury occurs it is necessary to undertake a risk assessment, to offer counselling and Post Exposure Prophylaxis and treatment where necessary.

3.16 Much of the OHSS information concerning an individual member of staff is paper based and not readily transferable between OHSS. To assist the OHSS it is proposed to investigate the use of a smart card and/or electronic employment record which will be held by individual members of staff and which they can take with them when they move jobs and present to their new employer. The card would for example show vaccination status.

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