Safety designs reduce phlebotomy injuries
Data underscore need for wider implementation
Three needle safety devices reduced percutaneous injuries by a range of 23% to 76% during phlebotomies, showing that such equipment could significantly reduce a type of injury that has been strongly linked to transmission of bloodborne pathogens to health care workers, according to the Centers for Disease Control and Prevention.1
"Looking at this data, we would hope that people would see that these devices can be effective and start using them more," says Louise Short, MD, medical epidemiologist in the HIV infections branch of the CDC hospital infections program, and principal investigator in the study.
The collaborative study with six hospitals was not designed to compare the three safety devices with each other, but to conventional devices used for blood-drawing. One of the most commonly performed medical procedures, phlebotomy has been frequently associated with occupational injuries reported in published studies, and with 20 (39%) of the 51 documented episodes of occupationally acquired HIV infection reported in the United States, the CDC reports.2,3 In general, the safety devices which blunt or shield the needle after use to protect the health care worker compared favorably to conventional devices without any clinically significant adverse patient outcomes, the CDC concluded.
"We need to have more studies like this. The results are generally quite supportive of the potential effectiveness that safety devices can have in preventing the most serious kinds of needlesticks," says Janine Jagger, PhD, director of the International Health Care Worker Safety Center at the University of Virginia in Charlottesville. Jagger and colleagues recently published a book on preventing occupational exposures to bloodborne pathogens, urging implementation of such devices and offering several suggestions to protect workers during phlebotomies.4 (See related story, p. 55.)
Vacuum-tube devices offer hope
In the CDC study, there was a dramatic reduction in injuries through use of two designs of vacuum-tube blood-collection devices, including a 76% reduction with a design that features a hinged recapping sheath. (See chart, p. 57.) A design featuring a bluntable vacuum-tube blood-collection needle activated while in the patient’s vein reduced injuries 66% when compared to conventional equipment. Use of a resheathable winged steel needle design reduced injuries by 23% from conventional devices. Each device requires the health care worker to activate the safety feature during or after phlebotomy. Accordingly, before introducing the devices, the participating hospitals conducted a comprehensive training program for workers. The collaborative study was conducted by the CDC and three hospitals in Minneapolis-St Paul, one in New York City, and two in San Francisco.
During phase one of the study, the hospitals used conventional phlebotomy devices and conducted enhanced surveillance for injuries by encouraging reporting, publishing notices in hospital newsletters, posting educational materials, and providing inservice training for staff. An anonymous survey was distributed to workers who routinely perform phlebotomies to estimate their rates of underreporting of needlesticks to hospital surveillance systems and to determine the average number of phlebotomies performed and days worked.
Investigators replaced conventional phlebotomy devices with safety devices hospitalwide during the second phase of the study and continued enhanced surveillance for injuries. They inventoried the autoclaved contents of a representative sample of disposal containers for sharp instruments to determine rates of use of safety devices and conventional devices, and rates of activation of safety features. A follow-up survey of workers who perform phlebotomies was conducted, and the estimated needlestick rates for safety and conventional devices were compared.
Of 41 needlesticks or sharps injuries associated with safety devices, 34 (83%) involved winged steel needles and seven (17%) involved vacuum-tube blood-collection needles. Twenty-five (61%) involved an injury before activation of the safety feature was appropriate or possible, for example, within seconds after the device was removed from the vein. Six injuries (15%) occurred during activation of the winged steel needle safety feature. For eight (20%), the safety feature had not been activated, and for two (5%), the mechanism of injury was unknown.
Passive’ needle presents possible solution
Eventual development of so-called "passive" needle designs that would provide protection without worker activation of the device are one solution to some of the injuries with safety designs, notes Rita Farner, RN, NP, coordinator of the occupational infectious disease program at San Francisco General Hospital, one of the participating facilities.
"Until we have passive devices we will continue to have these problems, both in issues around compliance with activation, and in accidents occurring during activation," she says. "We still need to continue to use the safety devices we have. This study finally has shown that there is a reduction in needlestick injuries when safety devices are used and activated appropriately."
Indeed, the bottom line is the injury rate with the safety device vs. the injury rate with a conventional device, Jagger adds.
"Even if injuries occur during activation of a safety device, that doesn’t necessarily mean the device isn’t working if the overall injury rate is lower," she says. "However, these data are very important for fine-tuning devices so they provide information on what are the most effective features and provide some future goals for product enhancement."
One-third preferred conventional needles
Though they demonstrated more protective power than traditional designs, the devices in the CDC study were not completely accepted by the health care workers. In the final survey, 33% of respondents said they still preferred to use conventional equipment.
"There is still a lot of resistance to change," Farner says. "Devices that require an action take more time and take more skill. When we are looking at health care workers in this era of speedup’ patients are sicker and there are less workers things that take more time or are more cumbersome are things that nobody wants to take on. What you generally find, however, is when somebody has an exposure, then they are willing to change their practice."
Acceptance of safety designs may vary by region and institution as well, as health care workers in urban institutions facing a greater prevalence of bloodborne pathogens in the patient population may be more active in getting their hospitals to purchase protective equipment, she notes.
"When you go to a community hospital in the Midwest that rarely sees patients with bloodborne pathogens, there is much less of a push among the staff and administration because these devices can cost anywhere from three to 10 times what the standard devices cost," she says. "In our institution, we have had health care workers become infected with bloodborne pathogens, so it is a very real issue."
Regardless of the device, it appears many health care workers still remain hesitant to report needlesticks. Overall, surveyed respondents in the study acknowledged reporting only 302 (54%) of 563 needlestick injuries they had sustained from all types of needles during the previous year. However, the reporting rates varied widely by occupation, as 91% of injuries among phlebotomists were reported. Nurses reported 68% of needlesticks, but the reporting rate was only 35% among medical students and 31% among residents, the CDC reported. Though underreporting has been well documented in other studies, the CDC reminded that it compromises follow-up, including possible post-exposure prophylaxis for HIV and hepatitis B virus. Factors such as lack of time, aversion to the paperwork required, or fear of reprisal from employers have been previously cited to explain the phenomenon.
"Health care institutions and health care workers must further assess reasons for underreporting and improve reporting of all occupational blood exposures," the CDC urged.
Reference
1. Centers for Disease Control and Prevention. Evaluation of safety devices for preventing percutaneous injuries among health-care workers during phlebotomy procedures Minneapolis-St. Paul, New York City, and San Francisco, 1993-1995. MMWR 1997; 46:21-25.
2. McCormick RD, Meisch MG, Ircink FG, et al. Epidemiology of hospital sharps injuries: A 14-year prospective study in the pre-AIDS and AIDS eras. Am J Med 1991; 91(suppl 3B): 301S-307S.
3. McGeer A, Simor AE, Low DE. Epidemiology of needlestick injuries in house officers. J Infect Dis 1990; 162:961-964.
4. Ippolito G, Puro V, Petrosillo N, et al. Prevention, Management & Chemoprophylaxis of Occupational Exposure to HIV. Charlottesville, VA: International Health Care Worker Safety Center; 1997.
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