Gwen Beiningen, RN, MS, CIC
*Posted with permission from Infection Control Resource. The publication Infection Control Resource is funded by an educational grant from Kendall, a business unit of Tyco Healthcare, LP.
View the full issue in Acrobat .pdf format: Infection Control Resource Vol. 2. No. 3
*Requires Adobe Acrobat Reader (download here)
Is the ICU different from other healthcare settings when it comes to sharps safety? All settings where needles and sharps are used for patient care have potential for percutaneous injury. Some settings might promote worker injury simply because of the nature of patient care?for example, in operating rooms, many different types of sharps unique to surgery are used. Another example is the emergency department, which manages the initial care of critically injured or ill individuals; the pace of this department and the tests, procedures, and other characteristics unique to it can present distinct risks for sharps injuries.
Similar to the emergency department, intensive care units (ICUs) continue the management of critically injured and ill patients. Although many invasive devices utilized in the ICU are similar to those in other general patient care areas, this setting is unique and has its related, unique risks.
ICU needlestick injury data
The National Surveillance System for Health Care Workers (NaSH) Summary Report, covering June 1995 through July 1999, reported the following data from 23 hospitals:1
- 5,520 body fluid exposures
- 83% (4,569) percutaneous exposures
- 13% (range 0%?28%) events in ICU settings
The Exposure Prevention Information Network (EPINet) tracks voluntarily reported exposure incidents in hospitals. Figure A shows the aggregate rates of injury from reporting hospitals between 1997 and 2001.:2,6
According to the average daily census, rates of injuries are decreasing. This decline in injury rates might be explained by various reasons. Most obviously, engineered sharps-safety devices have become the norm and the expected in healthcare. Workers depend on needles and other sharp objects having safety features; when this is not the case, workers question why, and they have now begun to demand safety devices.:7
Another factor could be more focused education. Workers are informed about risks associated with sharps and the benefits of safety devices. When a new safety device is introduced, workers must be trained in its safe use and disposal. Ongoing education reinforces awareness of job safety.
Perils in the ICU environment
Even though hospital data show injury rates declining, the proportion of percutaneous injuries specific to ICUs has remained between 5 and 8 percent (figure B). What makes percutaneous injuries in the ICU different from those in general patient care departments?
ICU practices and the patients themselves might account for some of the differences. Staff might view their risks differently or might not practice sharps safety to its fullest potential. Procedures and treatments in the ICU can be distinct to the setting, and some sharp devices are specific to the ICU.
Patient behavior
Although many ICU diagnoses and treatments are similar to those in other parts of the hospital, differences do exist in the ICU patient that place workers at risk for percutaneous injury. Patients with certain medical conditions such as head injuries or drug and alcohol detoxification can be intensely aggressive and combative. Working with sharp instruments around such patients is difficult, but restraining them, either physically or chemically, might be medically contraindicated or prohibited.
More workers might be needed to steady patients during procedures or treatments. These additional workers are key in controlling some patient behavior, but will also add more hands to the injury prevention equation. More workers involved in an uncontrolled situation (although needed to restrain the patient) can become injured in the commotion of the moment.
Blood, blood everywhere!
Patients with diagnoses such as gastrointestinal bleeding or bleeding disorders can present with or develop massive exsanguination. Containing blood and body fluids can be challenging. These patients will have multiple tubes and devices to be maneuvered around. This added equipment increases the challenges of maneuvering safely. Care and caution must be exercised to assure both that tubes and devices are not dislodged and that worker injuries are avoided.
Daily distractions
Staff attention to patient care is critical to successful patient outcomes. Many patient-care activities that the worker must be fully cognizant of are happening simultaneously. Along with attention to routine care and monitoring, workers are distracted from duties regularly and frequently: beepers beep; phones ring; pagers sound; alarms go off; medical staff, family members, and other workers make requests; and the list goes on. When interruptions are constant and focus is lost, accidents are more likely.
The pace
The most obvious difference in ICU departments is the fast pace required to provide intensive care. Although nearly every department in healthcare works at a fast pace, the ICU is faster.
Throughout healthcare, patients require immediate intervention for stabilization. In the ICU, this need for immediate intervention happens not only daily but multiple times each day. After all, it is called intensive care for a reason. Workers must remember multiple patient-care tasks at the same time as providing a safe environment for other workers and themselves. Be alert. Be careful. And anticipate!
Multiple personnel in tight places
Another obvious difference in the intensive-care setting is that a nurse is assigned to one or two patients only, as opposed to several patients as is done in other hospital departments. Numerous workers provide direct care and interventions for an individual patient; this includes medical staff, respiratory technologists, radiology technicians, physical therapists, surgery personnel, etc. More hands involved means that activities multiply, thus amplifying the danger.
Handling sharps safely when others are nearby is critical. Be certain to account for all used sharps and dispose of them immediately. Sharps that are not discarded into proper containers immediately pose a risk to others. Think of the person who will next handle the sharp: needles thrown in the trash, or scalpels left on a counter, will be encountered by housekeeping or maintenance staff. Sharps safety is essential for you and your co-workers.
Education
Education is critical. Why then is education in the fight against sharps injuries not as effective as hoped? Behavior can be very difficult to change. We are creatures of habit, and habits die hard. Unless we consciously and repeatedly try to change unsafe practices, we fall back on our habitual behaviors. Safe work practices are an expectation. Workers must handle sharps cautiously. They must trigger the safety feature on all sharps. They must dispose of sharps immediately and properly.
Evaluation of work practices helps one recognize unsafe practice that should be changed. Evaluating specific safe work practices can involve direct or covert observation and monitoring of practices by other workers, holding peer or annual performance reviews, and self- evaluation with questionnaires and focused education.
Inability or unwillingness to modify unsafe practices presents ongoing risk to the worker and others. Personnel with unsafe work habits might have to be reassigned or even asked to leave. When conversing with ICU staff, I hear, “We’re different here in ICU. Some of these practices just don’t work here! I won’t be involved in an accident.” In other words, “I’m invincible!” Each department is different; but when it comes to sharps safety, every department is the same. Safety cannot be an afterthought; it must be a forethought.
As is true of all healthcare areas, the average worker is older than in years past. Workers might not see as well as they used to and wear corrective lenses; these lenses can pose a challenge in peripheral vision or judging distances. Concentration is even more important to see where sharps are going.
ICU procedures and treatments
Point-of-care testing
Modern technology allows diagnostic laboratory testing to be performed at or near the bedside. This point-of-care testing provides faster turnaround times and thus faster therapeutic decision-making, improving patient outcomes. This technology, beneficial for the patient, could conceivably adversely affect workers.
In years past, laboratory staff came to the ICU, drew the specimen, and returned to the laboratory to complete testing. Now, ICU staff are often designated to collect specimens, moving the risk of exposure from laboratory personnel to ICU workers. As current healthcare practices require more testing, more ICU workers collect and handle patients’ body fluids. More needles for specimen collection mean more opportunity for injury.
Many safer devices are now available for drawing blood via various routes: finger-stick devices automatically retract the lancet after the puncture, unbreakable plastic micro blood-collection tubes eliminate contaminated-glass injuries. Other products allow blood to be drawn from intravenous ports without using needles; for example, Kendall manufactures the , and the Angel Wing Luer lock set for IV-line blood collection.
Intensive invasive procedures
Some invasive procedures not provided in other wards can be done in the ICU: thoracentesis, bronchoscopy, open-chest procedures, acute dialysis, etc. These are often urgent procedures, forcing workers to move quickly with sharp instruments.
Kits are available for many of these procedures. When sharps safety devices are included in these kits, the movement toward a safer ICU work environment is realized. When engineered safety devices are not included, the hospital is left to determine how to provide safe products to be used with the kits. Manufacturers are becoming more aware of this need, and are working toward user safety.
ICU sharps
Some needles or sharps are unique to critical-care settings. Pulmonary artery catheters, arterial lines, femoral lines, etc. are generally used with the more critically ill patients. Given the intensity and urgency of patient care and the unpredictable nature of the ICU setting, it is clear that devices engineered to protect needle tips play a crucial role in needlestick prevention.
Although some treatments and therapies involving needles are not exclusive to the ICU, they are used more frequently, with more devices per patient?for example, drawing blood specimens. In the ICU, most medications are administered intravenously; thus, needle devices such as peripheral IV lines, central IV lines, and sutures to secure these lines are utilized with greater frequency per patient.
A practice that deserves candid discussion is carrying syringes of medications in clothing pockets. Having emergency or frequently used medications in the pocket reduces critical time for administration; however, for both infection prevention and sharps safety, this is a dangerous practice. It is especially dangerous when medications are titrated and when portions of IV medication are dispensed from one syringe. These syringes should not be placed in pockets, especially once a dose has been administered.
Primary prevention
Given the fast pace, urgency of care, and unpredictability of ICU patients’ health, sharps safety is essential. NAPPSI places greater emphasis and demand on primary prevention over secondary prevention. Primary sharps-injury prevention is defined as needleless products: no needle, no injury.8
Although not all devices are needleless, manufacturers are moving in this direction. For example, recent trends include more use of non-invasive hemodynamic monitoring. New advancements include transcutaneous testing for pO2, blood glucose, and . Breath tests, such as those for detecting Helicobacter pylori, are available. These advances remove the need for blood sampling or for some intravascular lines.
Some central intravascular devices, drains, and tubing are usually anchored with sutures, but sutureless products are becoming more available. Eliminating the suture needle from stabilizing lines and tubing eliminates a source of injury.:9
Transdermal patches, inhalants, and needleless injectors also allow medication to penetrate the skin. Nearly every manufacturer of IV administration systems has products that minimize the need for needle entry. Better yet, some have made needle entry an impossibility!
>Secondary prevention
Secondary prevention devices have a safety feature triggered either passively or actively after use. Syringes with needles that automatically retract after medication administration are considered passive devices. The safety feature activation is a normal part of product use and is triggered by simple use of the product.
Active devices require the safety feature to be specifically activated by the user, for example by pushing a button or sliding a cap or sheath to cover the needle tip. You can visit the NAPPSI Web site at to find a list of primary and secondary prevention injection equipment.
Sharps disposal
Disposal of sharps is the final step in eliminating sharps from the work environment. Sharps-disposal boxes should be close to the point of care to avoid transport of used needles. Placement of the sharps box is decided by the unit and is based on preference, user friendliness, and history of sharps injuries related to disposal. Sharps-disposal containers should have the following characteristics:10
- Containers should remain functional during their entire use: durable, closable, leak-resistant on their sides and bottoms, and puncture-resistant until final disposal. Individual containers should have adequate volume and safe access to the disposal opening (inlet).
- Containers should be accessible to workers who use, maintain, or dispose of sharp devices. A sufficient number should be provided. Containers should be conveniently placed and (if necessary) portable within the workplace.
- Containers should be plainly visible to the workers who use them. Workers should be able to see proper warning labels, color coding, and the degree to which the container is full.
- Containers should be accommodating or convenient for the user and the facility, and they should be environmentally sound (e.g., free of heavy metals and composed of recycled materials). Accommodation also includes ease of storage and assembly, and simplicity of operation.
In the ICU, high volumes of sharps are necessary in delivering patient care. Given the increased waste that accompanies sharps safety devices, manufacturers are producing containers that are larger and more portable (e.g., with wheels for transport), have larger inlets to accommodate larger devices, and are ergonomically friendly. Kendall’s Sharpscart is one example of this new-generation container.
New-generation sharps boxes can help engineer out injuries related to sharps disposal. Some boxes are designed so that simply the weight of the needle and syringe activates the “mailbox drop” opening, and the device falls into the box, isolated from the work environment. When the box fills to a designated level, its design prevents further use; more sharps cannot be stuffed into the box because it will not open.
Larger sharps containers have become popular. With the advancement of safety needles, sharps used in patient care have become larger and more bulky, resulting in additional waste volume. Standard boxes fill up more quickly. Larger boxes allow workers to empty boxes less often and thus to handle boxes less frequently. Of course, larger boxes are also appropriate where high numbers of sharps are used.
It is also important to emphasize that the mattress is not a pin cushion. The needle opens the integrity of the mattress, and patient safety, worker safety, and mattress integrity are compromised. More than once, mattresses have been destroyed from this practice. Sharps boxes placed near the point of use can discourage workers from putting needles into mattresses.
Summary
The ICU is called an intensive care unit for a reason. Some ICU factors can not be changed. Certain actions or procedures are simply a part of the “perils of the ICU.” Safer sharps practices must be followed wherever possible. Purchase of needles and sharps with safety features that cannot be bypassed is fundamental. All workers are accountable for keeping the ICU environment as safe as possible.
1. National Surveillance System for Health Care Workers (NaSH). Summary report for data collected from June 1995 through July 1999. CDC Hospital Infections Program.
2. EPINet Exposure Prevention Information Network. Uniform Needlestick and Sharp Object Injury Report 55 Hospitals, 1997. Available from http://www.med.Virginia.EDU/medcntr/centers/epinet/soi97.html Accessed 28 October 2003.
3. EPINet Exposure Prevention Information Network. Uniform Needlestick and Sharp Object Injury Report 52 Hospitals, 1998. Available from http://www.med.Virginia.EDU/medcntr/centers/epinet/soi98.html Accessed 28 October 2003.
4. EPINet Exposure Prevention Information Network. Uniform Needlestick and Sharp Object Injury Report 21 Hospitals, 1999. Available from http://www.med.Virginia.EDU/medcntr/centers/epinet/soi99.html Accessed 28 October 2003.
5. EPINet Exposure Prevention Information Network. Uniform Needlestick and Sharp Object Injury Report 26 Hospitals, 2000. Available from http://www.med.Virginia.EDU/medcntr/centers/epinet/soi00.html Accessed 28 October 2003.
6. EPINet Exposure Prevention Information Network. Uniform Needlestick and Sharp Object Injury Report 58 Hospitals, 2001. Available from http://www.med.Virginia.EDU/medcntr/centers/epinet/soi01.html Accessed 28 October 2003.
7. Perry J, Parker G, Jagger J. EPINet Report: 2001 Percutaneous Injury Rates. Advances in Exposure Prevention. 2003;6(3):32-36.
8. National Alliance for the Primary Prevention of Sharps Injuries (NAPPSI). Available from http://www.nappsi.org/safety.shtml Accessed 28 October 2003.
9. Schears G, Yamamoto A. Eliminating suture needlesticks through primary prevention. Associations Digest for NARI. Winter 02/03. Available from http://www.nappsi.org/nari.shtml. Accessed 23 October 2003.
10. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Selecting, evaluating, and using sharps disposal containers. Atlanta, Georgia; 1998 (January). DHHS (NIOSH) publication No. 97-111. Available from http://www.cdc.gov/niosh/pdfs/97-111.pdf Accessed 23 October, 2003.