The consequences of a needlestick incident can be farreaching and unpleasant, for victims and for their organisations. The possibility of infection may mean the injured healthcare worker needs medication or post-exposure prophylactics immediately. Then they might take legal action, which drains time and money, whichever way the case turns out. Even if neither of those things eventuates, there’s still a fair amount of stress imposed on the victim: the emotional shock of the initial injury, reporting the incident up the management chain, and perhaps taking time away from work as they wait to find out whether they have become an unwilling incubator for hepatitis or HIV. The NHS recently estimated that sharps injuries cost it almost £4.1 million between 2012 and 2017, and that 80% of those injuries were preventable.
To prevent sharps injuries requires upfront investment in training programmes and injuryprevention gadgets, but the right balance of those two things can be hard to find. Adequate training does not preclude the need for equipment such as needle guards and retractable syringes, but neither are those solutions completely effective against needle sticks if staff aren’t properly informed on safety procedures.
Philip Tanner is assistant director of health, safety and well-being for NHS Blood and Transplant, a specialist body that manages organ and blood donation, and performs more than 1.3 million venipunctures a year. In 2015, as part of a partnership group of management and union representatives, Tanner was asked to look over updated guidance for NHS employers on managing the risks of sharps injuries. The guidance, which is still in use, had to cover the risks of sharps injuries; how to prevent exposure; risk assessment; managing blood exposure incidents; and informing employers of their responsibilities. Tanner says convincing NHS employers to spend money on equipment is the relatively simple part.
“The cost per unit is very small, and there is a really good argument to say that the cost, in terms of emotional wellbeing and also a claim for an individual case, would far outweigh the small amount per unit that it would be for any trust,” Tanner explains.
He adds, “If there is a specific procedure where there is no safer needle, then you have to use that one, and it's only as good as the suppliers.”
Guarded response
One piece of equipment in particular has made a significant impact.
“Putting needle guards on most different applications has been great for us as an organisation,” Tanner says. “[But] it does mean that you have to go hand in hand with the knowledge and education of why we're doing it and how it works.”
Even with such a simple piece of equipment, staff members need to be trained on how to guide the needle into the guard until they hear the click that means it has properly engaged – otherwise, the needle could be left poking out of the guard and they risk getting scratched when they dispose of it. Additionally, to place a syringe guard, the user’s fingers must be close to the needle, potentially raising the risk of injury. The NHS sharps guidance found that 27% of injuries occurred after the injection, but before disposal, and 10% happened during disposal.
Aside from guards and sheaths, retractable safety syringes are quickly gaining popularity and market share, which is expected to grow from $1.3 billion globally in 2016 to $2.3 billion by 2025. The boom is being driven in large part by an ageing European population and an accompanying spike in chronic diseases, which has led to rising demand for self-injection equipment. Patient compliance tends to be very low when it comes to injectable medications, so safety needles for self-injection need to minimise discomfort as much as possible while also keeping needle exposure and reuse to a minimum.
Retractable syringes use an internal – sometimes irreversible – mechanism to pull the needle back into the body of the syringe after the injection has been given. Some models achieve this with spring-loading, but the sudden retraction can have the counter-productive effect of flicking blood and fluids off the needle. They also require more effort to depress the plunger, which can mean a less comfortable patient experience.
Other recent innovations have focused on disposal, such as UK manufacturer NeedleSmart’s heat-driven technology, which was announced in July last year. Instead of storing sharps for later destruction, the device melts needles down and compresses them into a ball so that they’re no longer either sharp or infectious. The manufacturers claim it could “generate a reduction in sharp disposal costs in the order of 30%”.
Much of this, however, could be swept away in the next few years with the advent of needle-free technology. While the concept itself has been around for more than a century, it has only recently reached the point of being able to compete with the hypodermic needle as a safe and comfortable way to administer parenteral drugs.
“It could be a real boon for this area. If you can eliminate using a needle or a healthcare sharp, then you should,” Tanner says.
Jet power
The oldest form of needle-free delivery is the jet, which is often used in automobile fuel injection. Instead of a metal needle, the fluid itself punctures the skin in a narrow, forceful jet. The technique was first used on humans in the 1960s, but the inability to control the flow of liquid meant it was imprecise and somewhat painful. But, in 2012, a team of researchers at the Massachusetts Institute of Technology (MIT) used magnets controlled by computers to modulate the stream for a quick, forceful burst followed by a more moderate delivery, and jet injectors by manufacturers like PharmaJet are now beginning to hit the market.
WHO is especially interested in the technology for immunisation programmes in developing countries; the lack of a needle means the potential for injury or infection is drastically lowered. It’s especially useful in environments that lack the healthcare resources to deal properly with a needle stick, and as an added benefit, it’s much easier to convince patients to get vaccinated if they don’t first have to conquer their fear of needles.
Another method currently on the rise is a 3D-printed skin patch, the underside of which is covered in dozens of microneedles, either coated or imbued with the medication. The microneedles are long enough to break the skin, but no bigger, and the drug is absorbed passively. The potential for accidental application or a scratch is still there, but much reduced. Patients also find it less challenging: in a study last year by Georgia Institute of Technology and Emory University School of Medicine, more than 70% of participants who received a flu vaccine via the patch preferred it over a nasal spray or a traditional shot.
It’s worth noting that microneedles and jet injection have been developed to introduce drugs into a patient, but blood draws require a different approach. A 2017 study in the Journal of Infusion Nursing looked at whether a short peripheral catheter, known as Pivo and manufactured by VelanoVascular, measured up to a traditional syringe in terms of patient comfort and usability of the samples it collected. While the flexible plastic catheter still has to be inserted into a patient’s vein, it doesn’t present the injury risk of metal sharps. Additionally, the researchers said, the device “was comparable with venipuncture in terms of providing high-integrity samples (no hemolysis or clotting), equivalent laboratory values, and better patient experience as assessed by pain scores.”
But, in Tanner’s words, “they can’t just ban normal needles”. A large-scale change in how the healthcare industry administers parenteral drugs will need to be a gradual process, assessing the risk for every single procedure.
“You can't do anything other than wait until people have got used to the new needles and how they work, and then eventually they will migrate over to them,” he explains.
For the moment, training will continue to be at the forefront of the NHS’ approach. Tanner says the key is to make safety techniques easy to follow and ensure they stay at the top of healthcare workers’ minds.
“It's a bit like mowing the grass,” he says. “You need to keep on refreshing it and it never goes away, and as soon as you take your eye off it, that's when you eventually have problems.”
But a 2015WW16 inspection of NHS organisations across the UK found that 83% of them weren’t following sharps regulations. One area where procedures often fall short is in incident reporting: an in-house survey of surgeons found that 73% had sustained a sharps injury in the past year, but only 26% of them had reported every incident.
Individual responsibility
Reporting sharps incidents used to be a legal requirement for employers, but the liability has now shifted to the injured individual. NHS healthcare workers are encouraged to report not just needle sticks, but near misses, so that health and safety advisers can spot operational hazards before they result in an injury. There’s also a 24-hour sharps hotline for employees, staffed by occupational health nurses. In practice, busy medical staff can find it tempting to ignore the incident and go about their day. But the NHS health, safety and wellness team can’t respond to problems it doesn’t know about. Ideally, Tanner says, the procedure should be simple, staff should understand exactly why reporting is important and, above all, those who do report should receive plenty of feedback.
“The incident needs to be followed up and analysed for root cause, and the individual needs to be contacted with what's happened with it,” he explains. “That way, they'll know that it's treated importantly by management and unions, and something will be done about it. If things are going into nothingness, people will think there was no point bothering.”
Ultimately, the only way to completely eliminate needle-stick injuries is to eliminate the needles themselves. But needle-free technology isn’t in a position just yet to save the industry from that risk, if indeed it will ever be able to completely replace healthcare’s enormous reliance on the hypodermic syringe. Safety innovations alone can’t remove the hazard of the needle entirely, either; for the moment, there’s no substitute for intelligent training procedures, rigorously enforced and created with the needs of healthcare workers in mind.
