1. from www.daniels.co.uk 1 A safer working environment – sharps safety; A training package to protect healthcare staff from harm © Daniels Healthcare 2007 All rights of copyright in connection with this work and all parts of it are reserved to Daniels Healthcare Ltd. This work may be reproduced by the customer only for the purpose of utilising the same for training purposes within the customer’s own organisation and no copies may be made for use by third parties without the specific written consent of Daniels Healthcare Ltd. No consent for such further reproduction of the material herein is deemed to have been given. Unauthorised use of the material may lead to legal proceedings including a civil claim for damages. Daniels Healthcare Ltd will not accept any responsibility for any amendments to or alterations to the material in this pack other than those produced and authorised by Daniels Healthcare Limited.

2. from www.daniels.co.uk Overview of the session Safety devices/ engineering controls Standard Precautions & waste management Reporting & vaccination status A quick tour of the issues: risk and safety

3. from www.daniels.co.uk Outline of the session ►The session will deliver knowledge for evidence based safer practice and will cover the following areas: ►the most common procedures where needlestick injuries occur. ►Types of devices and injuries that affect risk of infection. ►methods for preventing exposure. ►critical review of the use of sharps and their necessity. ►how changes in work practice can prevent injuries (includes the role of safer needle devices). ►current protocols and guidance, including standard precautions.

4. from www.daniels.co.uk Objectives of the session The session is designed to equip staff for safer practice. By the end of the session staff should be able to: ►Demonstrate knowledge of the risks of exposure to potentially harmful viruses ►Explain the importance of safe practices (demonstrating awareness of policies and protocols). ►Identify the efficacy of preventative and control measures. ►Describe the process of evaluation of needlestick injury and post-exposure follow up using real life examples

5. from www.daniels.co.uk Who is at risk: ►Who is at risk of needlestick injury? ►Any worker who may come in contact with needles or other sharp instruments used on patients, including nursing staff, laboratory staff, doctors, porters and housekeepers. NIOSH 1998

6. from www.daniels.co.uk Definitions and scene setting ►Sharps injuries describe any incident in which a healthcare worker is stuck by a needle or other sharp instrument which penetrates the skin and which is contaminated with potentially infected blood ►The National Audit Office (2003) stated that sharps injuries are second only to back injuries as a cause of harm to staff – 17% of all injuries ►Contaminated needles can transmit more than 20 dangerous blood-borne pathogens including HIV, Hepatitis B and Hepatitis C ►At least 4 health care workers are known to have died following occupationally acquired HIV

7. from www.daniels.co.uk Risk management ►An integrated risk management policy is a must ►Risk assessment: ►identify the risks ►Manage and minimise – eliminate unnecessary injections ►Safer technology ►Standard precautions ►Immunisation & vaccination ►Training ►A legal framework does exist (Health and Safety at Work Act (HASAWA), 1974, and the Management of Health and Safety at Work Regulations (1991) ►Control of Substances Hazardous to Health (COSHH regulations (2002) reinforce risk assessment and preventative strategies Source: NHS Employers 2005

8. from www.daniels.co.uk The detail: ►Assessing the risks ►Risk assessment should be made of all situations where HCW might be exposed to blood or other potentially infectious material. The aim is to: ►Identify what technologies could be used to limit exposures ►Allow consideration of possible alternatives ►Eliminate the unnecessary use of sharps by implementing changes in practice and providing, where practicable sharp free devices or safer needle technologies which retract or shield needles after use Source: NSH Employers 2005

9. from www.daniels.co.uk Summary of key risk management strategies for safer practice ►Hierarchy of Controls ►Elimination or substitution of sharp (eliminate unnecessary injections) ►Engineering controls (auto disable syringes, safer needle devices) ►Administrative and work practice controls (standard precautions; no recapping; provision and placement of sharps containers) ►Personal protective equipment (eg gloves) Source: WHO 2005 Least effective Most effective

10. from www.daniels.co.uk Reporting sharps injuries ►A core component of risk management: ►Underreporting is a serious threat to management of such injuries ►Some studies suggest underreporting as high as 85% ►Prompt reporting is critical – following local policy ►This ensures quick management and reduces risk of BBV transmission ►The incident is documented in case of future litigation ►Helps with accurate surveillance to inform =development of effective risk reduction strategies Source: NSH Employers 2005

11. from www.daniels.co.uk Reporting sharps injuries ►Managing exposures - ►What is the local policy ►All cases of exposure from blood or body fluid from patients infected with blood-borne viruses (HIV, HCV, HBV) should be reported to the HPA national surveillance scheme ►HCW anonymity is guaranteed Source: NSH Employers 2005

12. from www.daniels.co.uk Identifying alternatives ►Independent studies show that a combination of training, safer working practices and the use of devices incorporating sharps protection mechanisms can prevent more than 80% of needlestick and sharps injuries. ►The NHS PASA website offers an array of such devices. ►Provision of portable sharps containers for all staff at all times is crucial to allow used sharps to be disposed of at the point of use Source: NSH Employers 2005

13. from www.daniels.co.uk Training ►Induction and ongoing training should cover sharps safety for all staff and particularly: ►The risks associated with blood and body fluid exposure ►Correct use and disposal of sharps ►The use of medical devices incorporating sharps protection mechanisms ►Refresher training is important Source: NSH Employers 2005 Question – is on the job training evident in the workplace?

14. from www.daniels.co.uk National UK Guidelines Standard Principles for the Safe Handling and Disposal of Sharps: ►Part of a waste management strategy to protect staff, patients and visitors from exposure to blood borne pathogens. ►All sharps injuries are considered to be potentially preventable. The UK Evidence Based Guidance (2001): The UK Evidence Based Guidance (2001): EPIC Prevention of HCAI in Primary and Community Care (2003)

15. from www.daniels.co.uk National UK Guidelines ►National and international guidelines are consistent in their recommendations: ►Assessment and management of risk ►Safe systems of working ►Safety devices (engineering controls) ►Post exposure follow up and prophylaxis The UK Evidence Based Guidance (2001): The UK Evidence Based Guidance (2001): EPIC Prevention of HCAI in Primary and Community Care (2003)

16. from www.daniels.co.uk Standard precautions 1.Sharps must not be passed directly from hand to hand and handling should be kept to minimum 2.Needles must not be bent or broken prior to use or disposal 3.Needles and syringes must not be disassembled by hand prior to disposal Source: EPIC 2001 category 3/H&S Prevention of HCAI in Primary and Community Care (2003)

17. from www.daniels.co.uk Standard precautions 4.Needles should not be recapped. 5.Used sharps must be discarded into a sharps container (conforming to UN3291 and BS 7320 standards) at the point of use. 6. These must not be filled above the mark indicating that they are full. Containers in public areas must not be placed on the floor and should be located in a safe position 7. They must be disposed of in community practices by the licensed route in accordance with local policy Source: EPIC 2001 category 3/H&S Prevention of HCAI in Primary and Community Care (2003)

18. from www.daniels.co.uk Standard precautions: Hands & gloves 8.Hands must be decontaminated immediately before each and every episode of direct patient contact/care and after any activity or contact that potentially results in hands becoming contaminated. 9.Use an alcohol based hand rub on hands not visibly soiled 10.Gloves must be worn for invasive procedures, contact with sterile sites, and non-intact skin, mucous membranes, and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions and excretions; and when handling sharp or contaminated instruments. Source: EPIC 2001 category 3 category 3/H&S

19. from www.daniels.co.uk Standard precautions: Hands & gloves 11Gloves should be worn as single use items. Put gloves on immediately before an episode of patient contact or treatment and remove them as soon as the activity is completed. 12.Change gloves between caring for different patients, or between different care/treatment activities for the same patient. 13.Gloves must be disposed of as clinical waste and hands should be decontaminated following the removal of gloves. Source: EPIC 2001 category 3/H&S category 3

20. from www.daniels.co.uk Standard precautions: Aprons & eye protection 14.Disposable plastic aprons should be worn when there is a risk that clothing or uniform may become exposed to blood, body fluids, secretions and excretions, with the exception of sweat. 15.Full body, fluid repellent gowns should be worn where there is a risk of extensive splashing of blood, body fluids, secretions and excretions, with the exception of sweat, onto the skin of health care practitioners. category 3/H&S

21. from www.daniels.co.uk Standard precautions: Aprons & eye protection 16.Plastic aprons should be worn as single use items for one procedure or episode of patient care and then discarded and disposed of as clinical waste. 17.Face masks and eye protection should be worn where there is a risk of blood, body fluids, secretions and excretions splashing into the face and eyes. 18.Respiratory protective equipment should be used when clinically indicated. category 3/H&S

22. from www.daniels.co.uk Safer needle devices ►Needle safety devices must be used where there are clear indications that they will provide safer systems of working for health care personnel. Prevention of HCAI in Primary and Community Care (2003) Recent estimates suggest that safety devices exist in 11 different product groups. Safety devices on the whole minimise risks in association with venepuncture, IV therapy, injections and "downstream" injuries following disposal (housekeeping and portering staff) D/H&S

23. from www.daniels.co.uk Sharps containers ►Should be at eye level and within arms reach ►Should be emptied before they are full ►At ward or department level – whose responsibility is this? ►Are roles assigned and are checks made? ►How would a situation be managed if there was a failure to apply these simple measures? ►Is a monthly, quarterly or annual audit enough? Source: EPIC 2001 Prevention of HCAI in Primary and Community Care (2003) Questions for consideration:

24. from www.daniels.co.uk National strategies to promote infection control: Saving Lives ►A tool for evaluation of current practices. ►Identifies areas for improvement. ►All about getting the infrastructure right: ►Poses a series of questions for hospitals and clinical teams: ► are the EPIC guidelines for hand hygiene, personal protection, and sharps disposal being followed? ► is an audit tool (e.g. ICNA audit tool in use and results acted upon?). Source: DH 1 2005 Q1. Q2.

25. from www.daniels.co.uk Saving Lives ►High Impact Intervention number 1 (elements of care, based on national evidence based, EPIC guidance (Pratt et al 2001): ►Safe disposal of sharps ►Sharps container available at the point of use ►No disassembling of needle and syringe ►Not passed from hand to hand ►Container should not be overfilled Source: DH 1 2005

26. from www.daniels.co.uk After an injury or exposure 1.Local policy. 2.Key points: ►First aid ►Place under running water ►Flush splashes to nose, mouth with water ►Irrigate eyes with clean water or saline ►Report to occupational health ►Know your Hepatitis B vaccination status. ►Prompt reporting is important in all cases to determine whether post exposure prophylaxis is required (this needs to be started as soon as possible)

27. from www.daniels.co.uk Root Cause Analysis (RCA) ►The key to RCA is asking the question "why?" as many times as it takes to get down to the root cause of an event: ►What happened? ►How did it happen? ►Why did it happen? ►What can be done to prevent it happening in the future? Source: CDC 2004

28. from www.daniels.co.uk Average risk of transmission ►Hepatitis B Virus (HBV): ►Hepatitis C Virus (HCV): ►Human Immunodeficiency Virus (HIV): Source: EPIC 2001 33.3% or 1 in 3 3.3% or 1 in 30 0.31% or 1 in 319

29. from www.daniels.co.uk Risk Factors that increase the likelihood of HIV transmission following a needlestick injury 1.Deep injury 2.High viral titre in the patient on whom the device had been used 3.Visible blood on the device 4.Device in artery/vein Source: CDC, MMWR 6/98

30. from www.daniels.co.uk The Health Protection Agency (HPA) study 2005: Occupational Exposure to Blood-borne viruses (BBV) ►Over 2000 exposures to BBV reviewed ►Percutaneous injury: 78% of all reviewed injury's from the Health Protection Agency (HPA) ►Nursing related professions – most commonly reported (45%) Source: HPA 2005

31. from www.daniels.co.uk The Health Protection Agency (HPA) study 2005: Occupational Exposure to Blood-borne viruses (BBV) ►2% of exposures were to porters, security and housekeeping staff ►Largely from sharps in rubbish bins ►Medical professions: 37% ►Injuries sustained during the procedure were dependent on the procedure – many not generally amenable to prevention. ►Injuries sustained after the procedure and during disposal – much more preventable – usually related to failure to comply with procedures relating to the safe handling and disposal Source: HPA 2005

32. from www.daniels.co.uk Outcome of exposure to BBVs ►Nine seroconversions following significant occupational exposure over a 7 year period ►Six involved male injection drug user source patients ►All seroconversions followed percutatous exposure mostly to fresh blood and involved hollow bore needles ►Six occurred after the procedure and five were preventable ►Many were preventable with adherence to standard precautions (38%) Source: HPA 2005

33. from www.daniels.co.uk The importance of surveillance of Occupational Exposure to Blood Borne Viruses in Health Care Workers 1.Data collection 2.To identify risk factors necessary for seroconversion to occur 3.To examine type of exposure, staff involved and circumstances surrounding the exposure 4.To use the data to inform national prevention policies 5.To monitor implementation of national HIV post exposure prophylaxis (HIV PEP) guideline and influence future policy 6.To raise awareness of reports of occupational exposure and encourage all trusts and other health care providers to take part 7.To use data collected on HBV immunisation to monitor adherence to policy Source: HPA 2005

34. from www.daniels.co.uk Case study examples ►Review the scenarios on the handout. ►Address the following questions in groups: Based on WHO needlestick case studies 2005 ►Was the use of a needle essential? ►Could the use of a needle safety device have prevented the injury, if so what type? ►Are these devices available on your unit? ►Are staff knowledgeable about their use? ►Would a change in work practice have prevented the injury? Q3. Q2. Q4. Q5. Q1.

35. from www.daniels.co.uk Critical questions for safer practice: ►Where is the needlestick policy kept and how is it publicised? ►What is the plan following an exposure and how are staff made aware of this? ►Are sharps injuries discussed at a regular team meeting? ►Are safer needle devices used and if so do you play a part in selection and evaluation of these devices ►Are there any informational materials eg leaflets on sharps injuries and are they readily accessible? Are these visible/pocket sized for example ►From the session – draw up a list of ways you could protect yourself

36. from www.daniels.co.uk Learning checks: ►Avoid the use of needles wherever possible ►Avoid recapping needles – instead immediately place the uncapped needle into a sharps box ►Think ahead and plan the safe handling and disposal of sharps before using them – is there a sharps container in the vicinity ►Never fill a sharps container more than three quarters full ►Carry used sharps containers carefully ►Don’t open or empty sharps containers ►Store sharps containers in a secure place until ready for removal for incineration ►Make sure your immunisations are up to date Source: WHO 2005

37. from www.daniels.co.uk National Hospital Ward/ department Individual National guidance, Policies and tools Saving Lives EPIC guidelines National e training ICNA audit NHS Employers Trust policies Procedures and committees Infection Control H & S committee Risk Management Occ Health NHS Employers Policies and promotion of same. Is the ward climate conductive to safety? What about training/refreshment? And audit programmes? Personal experiences in terms of availability of training/sharps boxes/policy/safer needle devices Summary: a map of prevention – from national strategies to individual staff

38. from www.daniels.co.uk Recap – hierarchy of controls ►Remove the Hazard ►Isolate the hazard – protective devices/engineering controls ►Use needles that retract, sheath or blunt immediately after use ►Work practice controls and personal protective equipment (Hep B vaccination) Source: CDC Workbook. Sharps Injury Prevention

39. from www.daniels.co.uk Summary: ►While studies show that reductions of needlestick injuries are achievable, it is difficult to identify the efficacy of individual control measures in studies with numerous interventions. ►Reducing sharps injuries by the greatest amount possible will entail a combination of ►Elimination of procedures using sharps ►Education ►Safer devices ►Positive work conditions ►Standard precautions Source: WHO 2005

40. from www.daniels.co.uk Conclusion ►The risk of a sharps injury begins at the moment a sharp is first exposed and ends once the sharp is permanently removed from exposure in the work environment. ►Staff need to have an awareness of the risk of injury throughout the time a sharp is exposed and use a combination of strategies to protect themselves and their co-workers. Source: CDC 2004

41. from www.daniels.co.uk Sources of material and references ►Publications: ►Health Protection Agency (2005) Eye of the Needle: Surveillance of Significant Occupational Exposure to Bloodborne Viruses in Healthcare Workers. Centre for Infections; England, Wales and Northern Ireland Seven-year report ►Department of Health (2005) Saving Lives khcdja ►Pratt RJ, Pellowe C, Loveday HP, Robinson N, Smith GW, et al (2001) The EPIC Project : developing national evidence baesed guidelines for preventing healthcare associated infections. Phase 1 guideliens for preventing hospital-acquired infections J Hosp Infect 2001; 47: S3-S82 ►NHS Employers (2005) The management of health, safety and welfare issues for NHS staff, chapter 19: Needlestick Management ►NAO (2003) A safer place to work – improving the management of health and safety risks of staff in NHS Trusts ►NIOSH (1998) How to Protect Yourself From Needlestick Injuries Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Instutute for Occupational Safety and Health ►Wilburn S, Eijkemans G (2004) Preventing needlestick injuries among HCWs: A WHO – ICN collaboration. Int J Occup Environ Health vol 10 no 4 www.ijoeh.com www.ijoeh.com ►Websites : ►EPIC Guidelines: http://www.epic.tvu.ac.uk/epicphase/1.htmlhttp://www.epic.tvu.ac.uk/epicphase/1.html ►ICNA Audit Tools: Infection Control Nurses Association (2004) available from: www.icna.co.ukwww.icna.co.uk ►The European Forum for protection of Healthcare Professionals in a safer working environment http://www.needlestickforum.nethttp://www.needlestickforum.net ►NHS Purchasing and Supplies Agency product related information relating to sharps safety: www.pasa.nhs.uk/medicalconsumables/sharps/www.pasa.nhs.uk/medicalconsumables/sharps/ ►WHO (2005) Protecting Healthcare Workers, Preventing Needlestick Injuries Toolkit. Occupational and Environmental Health Unit http://www.who.int/occupational_health http://www.who.int/occupational_health ►CDC Workbook for designing, implementing and evaluating a sharps injury prevention programme (2004): http://www.cdc.gov/sharpssafety/http://www.cdc.gov/sharpssafety/