True Protection from Syringe-Related Needlestick Injuries Can Become a Reality
Evaluating cost efficient, safe options
by Julie Shomo, BS, BSN, RN, CRNI
Sharps safety has been hammered into my brain since 1985 when I began nursing school. I do not recap needles and I always dispose of them correctly in the sharps container. Did that help me to feel better when a patient jerked as I pulled the needle out of her skin and accidentally jabbed it into my own skin? Absolutely not!
The reaction stages I experienced were:
—at the pain of the prick;
—at the realization that I had been injected with someone else’s blood;
—of the possibility of contracting a potentially fatal disease;
—at the fact that I was exposed to this danger;
—when I was told after testing that the patient had no transmissible diseases.
This incident has prompted me to do an in-depth safety search. Am I being protected adequately from needle-stick injury?
The Centers for Disease Control and Prevention (CDC) estimates that each year 385,000 needlesticks and other sharps-related injuries are sustained by hospitalbased healthcare personnel; an average of 1,000 sharps injuries per day. Surveillance data from the National Surveillance System for Health Care Workers (NaSH) shows that hollow-bore needles are responsible for 59 percent of all sharps injuries with 32 percent of all sharps injuries coming from disposable syringes. The percutaneous injury rate for healthcare workers was at its highest in 1995 at 30 incidents per 100 beds. Safety initiatives reduced the sharps injury rate to 23.87 incidents per 100 beds in 2003.3 The decrease is promising but the statistics are still daunting in light of the fact that enhanced safety syringe technology has been available for years. From 1984 to 1996 alone, more than 1,000 patents were issued for safety devices designed to prevent needlesticks. Why, then, are syringe-related needlestick injuries continuing? Examining the history of syringe development seems a good place to start.
Injections have been recorded as far back as the 1650s with the injection of animals. Technology progressed to produce glass syringe barrels with hollow pointed needles that were sharpened between uses if the patient was fortunate enough to have a conscientious clinician. In 1954, Becton, Dickinson and Company created the first mass-produced disposable glass syringe and needle in order to facilitate the delivery of Dr. Jonas Salk’s new Salk polio vaccine to 1 million American children. Over the next few years, plastic syringe barrel technology was used to further the widespread use of the disposable syringe for injection.
With the 1980s’ surging spread of hepatitis B and HIV came an increased public demand for more measures to prevent the accidental spread of bloodborne pathogens. Protection of healthcare professionals from accidental needlestick injuries became paramount and sent inventors and technology development companies into a scramble to create protective devices.
In 2001 the Occupational Safety and Health Administration (OSHA) developed a mandate for using safer devices and creating prevention strategies, complete with monitoring and evaluation.
The federal guidelines specify that facilities must:
- Reduce sharps use if alternatives are available;
- Review and update exposure plans annually;
- Evaluate safety devices’ effectiveness;
- Obtain worker input on selecting and reviewing safety devices;
- Maintain a sharps injury log in facilities with 20 or more staff.
The guidelines specify yearly reviews of exposure plans and worker input on selecting and reviewing safety devices. Depending on the size and type of facility, decisions on safety equipment may be influenced by infection control staff, nurses, physicians, product management personnel or others. Too often the decisions are driven by cost or contract issues
and may not actually represent the best balance of safety and cost-effectiveness. This may happen simply because the people making the decisions do not take the time to fully understand the options and their positive and negative impacts.
Safety Syringe Categories
The best way to understand syringe safety products is to group them into categories according to the needle protection feature. Although a myriad of syringe safety products exist, there are several general categories. Please realize that the following categorization is very general. Because specific products in the sliding sheath and hinged cap/guard categories vary in their characteristics, not all safety syringes fit nicely into a single category, so each product should be evaluated individually for its strengths and weaknesses.
Non-locking Sliding Sheath/Sleeve
This safety feature is activated by sliding a round plastic sheath around the barrel down until it covers the needle. The clinician activates this after injection and removal of the needle from the patient’s skin. The method described here is the least safe of the technologies for several reasons:
- Even though the sheath is covering the needle horizontally, a person could place a finger accidentally into the sheath when handling the syringe and be stuck by the needle.
- Because sheath moves easily back and forth and does not lock into place, moving the syringe could easily expose the needle and cause injury.
After injection, a clinician using this technology would activate a cover for the needle that locks into place. Various companies have developed different designs and slightly different activation mechanisms, but all share the same general characteristics.
- The clinician’s finger remains behind the needle tip.
- Once activated, the safety feature remains locked into place.
- Most can be activated with one hand. The negative aspects of this category include:
- The needle is removed completely from the skin before safety device activation, leaving opportunity for clinician injury in that period of time.
- Most of the needle covers are irregularly shaped. When placed in sharps containers, the jagged edges hang up on each other and keep the containers from filling smoothly. Retractable Needle
The retractable needle is the newest technology available today. The clinician fills and injects the vaccine or medication using standard technique. Once the vaccine or medication is delivered the clinician continues to apply pressure between the thumb, index, and middle fingers as the needle is removed from the patient. This small amount of pressure during the removal step causes the safety activation feature to retract the needle safely and painlessly from the patient.
General characteristics include:
- The clinician’s fingers are behind and completely away from the needle during safety feature activation.
- Once the needle is retracted, it is locked into place and cannot be used again.
- The syringe with needle after retraction is smooth in shape and allows sharps containers to be filled more fully.
- The needle is retracted into the syringe as the needle leaves the body, eliminating the potential for post-injection needle stick when used as directed.
As a practicing RN, I have used each of these categories of syringes repeatedly. The retractable syringe is, in my opinion, the safest syringe of these categories because the needle is retracted in less than one second as the syringe is pulled from the body. The other needles all have a period of
risk to the patient and clinician following the removal of the needle and prior to activation of the safety feature. CDC survey data estimates that 50 percent of injuries occur between the time the procedure is completed and disposal of the device. When used correctly, the retractable syringe technique
dramatically reduces needle stick injury during the crucial time when the needle has been exposed to potentially contaminated blood.
Overcoming the Cost Barrier to Greater Safety
The barrier of cost can be a large one for all of us whose goal is to keep patients and clinicians safe. Not only must we show research supporting the need for new technology, but we must also show that it is cost effective. Anyone working with medical product selection and implementation, especially in larger facilities, realizes the complexities of navigating contract issues and evaluating financial impact of any new product.
Retractable syringe technology has been historically higher in cost than the other safety syringes. Although available for years, the price difference between retractable and nonretractable options has been so great that few facilities have been able to convert. Competition has driven costs down somewhat, and new products are emerging.
Although bringing safer products into a system can be a difficult task, it is up to us as safety facilitators to do our best to overcome the barriers. Hopefully the following information will assist in making the case for investing in more advanced safer syringe technology.
Costs of Needle stick Injuries
When evaluating the cost of safety technology like the auto-retractable syringe, it’s important to consider not just the cost of the product itself; but the “saved costs” of avoidable needlestick injuries. Testing and treatment of each person receiving a contaminated needle stick injury is estimated at $1,500 to $3,000. At the current published average rate of 23.87 injuries per 100 beds, these costs add up quickly. When considering the fact that each year healthcare professionals contract bloodborne diseases through contaminated needlesticks, the costs have the potential to skyrocket. In examining HIV, for example, one notes that the annual costs of treatment drugs alone is $25,000 to $60,000 each year. Hospitalization and treatment of the associated medical conditions drive the cost of care much higher.
The 2001 CDC mandate that facilities continue to look for ways to increase safety for patients and employees is to the benefit of both patients and clinicians. Understanding current safety syringe technology helps us present options to the committees responsible for choosing products that can improve safety within the healthcare environment. In direct comparison to syringes with safety features activated after leaving the body, the retractable syringe is consistently safer if used as directed. Although this product technology has been available for years, new lower cost options are now available— making their safety features more cost efficient than ever before. Savings from avoidable injury costs and reduced medication and sharps container costs may even make the use of this product less expensive overall than the syringes currently being used. By looking to products that reduce costs while also improving patient and clinician safety, we can all take a step closer to the goal of making the broader healthcare system safer and more cost efficient.