A critical review of the literature on sharps injuries: epidemiology, management of exposures and prevention

Effects of hospital staffing and organizational climate on needlestick injuries to nurses

OBJECTIVES

This study determined the effects of nurse staffing and nursing organization on the likelihood of needlestick injuries in hospital nurses.

METHODS

We analyzed retrospective data from 732 and prospective data from 960 nurses on needlestick exposures and near misses over different 1-month periods in 1990 and 1991. Staffing levels and survey data about working climate and risk factors for needlestick injuries were collected on 40 units in 20 hospitals.

RESULTS

Nurses from units with low staffing and poor organizational climates were generally twice as likely as nurses on well-staffed and better-organized units to report risk factors, needlestick injuries, and near misses.

CONCLUSIONS

Staffing and organizational climate influence hospital nurses' likelihood of sustaining needlestick injuries. Remedying problems with understaffing, inadequate administrative support, and poor morale could reduce needlestick injuries.

A produção científica sobre os acidentes de trabalho com material perfurocortante entre trabalhadores de enfermagem

A investigação ora apresentada teve por objetivos identificar as abordagens metodológicas das pesquisas publicadas em periódicos indexados nas bases de dados Lilacs e Medline, nos últimos 16 anos, referentes, ao estudo dos acidentes de trabalho com material perfurocortante e a identificação dos fatores predisponentes à ocorrência de tais acidentes entre trabalhadores da enfermagem. Foram analisados 55 artigos, sendo 39 internacionais, e 16 nacionais. As abordagens metodológicas mais utilizadas foram descritiva de campo, pesquisa-ação e bibliográfica. Dentre os fatores predisponentes a ocorrência dos acidentes em vários países, destaca-se a prática inadequada de re-encape de agulhas e o inadequado descarte do material.

Organizational climate, staffing, and safety equipment as predictors of needlestick injuries and near-misses in hospital nurses

BACKGROUND

Recently passed federal legislation requires institutions to adopt safety equipment to prevent needlesticks, but there is little empirical evidence of the effectiveness of specific types of safety devices or the contribution of safety devices to reducing needlesticks relative to the contributions of staffing, organizational climate, and clinicians' experience.

METHOD

In 1998, 2287 medical-surgical unit nurses in 22 US hospitals were surveyed in regard to staffing and organizational climate in their hospitals and about patient and nurse outcomes, including needlestick injuries. Hospitals provided information about available protective devices at the time of the survey. Relationships between nurse and hospital characteristics and protective equipment and the likelihood of needlestick injuries and near-miss incidents were examined.

RESULTS

Poor organizational climate and high workloads were associated with 50% to 2-fold increases in the likelihood of needlestick injuries and near-misses to hospital nurses. Capless-valve secondary intravenous set systems and use of any type of protective equipment for IV starts or blood draws were associated with 20% to 30% lowered risks of both event types.

CONCLUSIONS

Nurse staffing and organizational climate are key determinants of needlestick risk and must be considered with the adoption of safety equipment to effectively reduce sharps injuries.

Determinants of nurses' adherence to universal precautions for venipunctures

OBJECTIVES

The aim of this study was to predict and explain nurses' adherence to Universal Precautions (UPs) when performing venipunctures.

METHODS

Data were gathered from 156 registered nurses working at a regional hospital. A self-administered questionnaire assessing the psychosocial variables (intention, attitude, subjective norm, perceived control, etc) was completed at baseline, and behavior was self-reported 3 months later.

RESULTS

The regression of intention on the variables yielded an adjusted R(2) of 0.68, with perceived barriers (beta =.62, P <.001), social norm (beta =.17, P <.01), and personal normative belief (beta =.19, P <.01) being the significant variables. With respect to the 3-month follow-up, 28% of the variance associated with UPs adherence was explained by intention (beta =.37, P <.001) and perceived behavioral control (beta =.23, P <.05). Moreover, high (n = 116) and low intenders (n = 40) differed on several normative beliefs (P =.0003) and perceived barriers (P =.0001).

CONCLUSIONS

It is suggested that perception of control, assessed either globally or by means of a belief-based measure, is a key factor in adherence. Specifically, the perceived difficulties associated with adherence to UPs appear to be related to a nurse's training on UPs and to the existence of suboptimal working conditions.

Evaluation of interventions to prevent needlestick injuries in health care occupations

OBJECTIVE

The objective of this study was to evaluate interventions that reduce or prevent needlestick injuries in health care occupations.

METHODS

Cochrane Collaboration search strategies to locate studies that evaluated interventions to reduce needlestick injuries in health care occupations were used. Studies were selected if they met the following criteria: (1) interventions were evaluated in the defined population; (2) interventions were randomized, with a comparison group(s); (3) outcomes were objectively measured and had interpretable data. Eleven studies met inclusion criteria. The main outcomes of interest were changes in the number of glove or skin perforations and changes in amount of skin contamination.

RESULTS

Three studies found a decrease in glove or skin perforations when double gloves or combinations of gloves were used by surgeons and their assistants. One study found an increase in glove perforations but a decrease in hand contamination. Three studies evaluated the effectiveness of specialized needles in reducing needlestick injuries during surgical wound closure with decreases in glove or skin perforations reported. Protective devices were evaluated in three studies and significant reductions in glove perforations were found with the use of a needleless intravenous system and surgical assist device. One study evaluated a "no-touch" technique used by surgeons during wound closure and found a significant decrease in the number of glove perforations compared to the traditional "hand-in" method of closure.

CONCLUSIONS

Few randomized controlled trials have been employed to evaluate the effectiveness of interventions to reduce needlestick injuries in health care occupations. The majority of the studies evaluated interventions during surgical procedures, rather than during patient care on nursing units, probably because the latter is more difficult to observe.

Painless intravenous catheterization by intradermal jet injection of lidocaine: a randomized trial

STUDY OBJECTIVE

To compare efficacy and cost of lidocaine cutaneous anesthesia by two jet injectors to routine needle infiltration for pain relief of intravenous (i.v.) catheterization, hypothesizing that jet injection of lidocaine is less painful than its needle infiltration.

DESIGN

Randomized, prospective, controlled trial.

SETTING

University hospital outpatient surgical unit.

PARTICIPANTS

75 surgical patients ASA I and II.

INTERVENTIONS

Three groups of 25 patients each were given intradermal lidocaine anesthesia via conventional 25-gauge needle/syringe; by MedEJet or Biojector jet injector prior to IV catheterization with an 18-gauge Jelco catheter.

MEASUREMENTS AND MAIN RESULTS

Visual analogue pain scores (VAS) (0 = no pain, 10 = intolerable pain) and subjective pain intensity scores (PIS) (0 = not painful, 4 = intolerable pain) at lidocaine application and at i.v. catheterization, were recorded. Cost assessment of each method was made. At local anesthetic application, no pain by proportion of VAS = 0 with MedEJet: 25/25 (confidence interval [CI]: 0.868, 0.999) and Biojector: 24/25 (CI 0.804, 0.991) was noted, but-22 of 25 patients experienced pain with needle administration: (with VAS = 0; 3/25 [CI: 0.044, 0.302]) (posterior probability [PP] > 0.999). The corresponding VAS scores (means +/- SD) were 0.00 +/- 0.00, 0.04 +/- 0.20, and 2.4 +/- 2.23 (p < 0.001). No pain by proportion of PIS = 0 with MedEJet: 25/25 (CI: 0.868, 0.999 and Biojector: 23/25 (0.749, 0.976) was noted, but pain in 20/25 was felt with the needle: 5/25 (CI: 0.090, 0.394) (PP > 0.999). The corresponding PIS scores were 0.00 +/- 0.00, 0.16 +/- 0.55, and 1.24 +/- 1.00 (p < 0.001). At i.v. catheterization, no pain by proportion of VAS = 0 with MedEJet: 22/25 (CI: 0.698, 0.956) or Biojector: 21/25 (CI: 0.651, 0.934) was noted; but pain in 19/25 with needle administration was experienced: 6/25 (CI: 0.116, 0.436) (PP > 0.999). The corresponding scores were 0.12 +/- 0.33, 0.44 +/- 0.20, and 1.64 +/- 1.50 (p < 0.001). No pain by proportion of PIS = 0 with MedEJet: 24/25 (CI: 0.804, 0.991) or Biojector: 24/25 (CI: 0.804, 0.991) was noted, but pain was apparent in 12/25 with needle administration: 13/25 (CI: 0.334, 0.701) (PP > 0.999). The corresponding scores were 0.00 +/- 0.00, 0.00 +/- 0.00, and 0.76 +/- 0.88 (p < 0.001). Cost per application: MedEJet = $0.13; needle/syringe = $0.50; Biojector = $0.94.

CONCLUSIONS

Almost completely painless i.v. catheterization was carried out by jet injection of lidocaine, but needle infiltration produced discomfort or pain and did not significantly reduce discomfort or pain at the i.v. needle insertion.

Occupational exposure to human immunodeficiency virus: what healthcare providers should know

PURPOSE

The author reviews the risks of occupational exposure to HIV and provides a rationale for new postexposure guidelines for healthcare workers.

OVERVIEW

Approximately 50,000 percutaneous exposures occur yearly among healthcare workers in the United States. Of these, approximately 5000 involve exposures to blood that is known to be infected with HIV. The risk of transmission after percutaneous exposure to HIV-tainted blood has been estimated to be 0.3%, but the risk may be considerably higher to the healthcare worker if any of the following is present: a deep injury; visible blood on the sharp device; a procedure that involves a needle placed in the patient's artery or vein; and a patient with advanced AIDS. The increasing resistance of HIV strains to antiretroviral therapy continues to make treatment more difficult.

CLINICAL IMPLICATIONS

Postexposure prophylaxis with zidovudine may reduce the risk of occupational infection by 80%. Advances in the ability to ameliorate HIV transmission rates and to treat individuals with resistant disease through innovations in drug therapy, engineering of controls for injury prevention, and more focused postexposure evaluation offer the hope of reducing this infrequent, but dangerous, occupational threat.