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Needlestick injuries: How can we teach people better about risk assessment?
Journal
of Hospital
Infection
(1988)
12, 301-309
Papers from the Hospital Infection Society Meeting ‘Missing the Point’ held on 23 March 1988
Needlestick
injuries: How can we teach better about risk assessment? David
British
Medical
Association,
people
R. Morgan
Tavistock
Square,
London
WCjH
93p,
UK
Summary:
At work people run some small risk of death or injury which is directly attributable to their occupation. In biomedical sciences the accidental puncture of the skin by hypodermic needles, other instruments or broken glass has long been regarded as an occupational hazard and there is increasing concern that staff could become infected with a range of micro-organisms: including hepatitis B and the Human Immunodeficiency Virus (HIV). Needlestick injuries should be preventable if staff are trained effectively and take care about disposal of used syringes and needles. Staff at risk must be offered pre-exposure vaccination for hepatitis B and resources must be provided for special training. Fundamental changes may be required in methods and equipment and a number of new ways of targeting groups of health care staff with information are discussed.
Introduction
The next time someone reflects on some newly discovered risk to health and well-being at work or in the great outdoors, and reflects that the only truly safe place to be is at home, perhaps in bed, he should be reminded that it is almost certainly not true. Falls kill more people from unintentional injury than anything except traffic accidents and most falls occur at home. Most deaths from burning happen at home. Home is therefore not as safe as we think, (BMA, 1987a). We can express the risk of an individual dying in any 1 year from various causes as a ‘1 in so many’ risk. Smoking only 10 cigarettes a day is a major risk factor. Influenza carries a fairly high burden of risk particularly for the aged and those living in poor accommodation, but should we really be worried about living next door to Chernobyl? (Table I). A man or woman at work runs some risk of death or injury which is directly attributable to that occupation. Maybe the risk is lower than if the same individual had stayed at home and it probably is lower than the risk of driving to work. Nevertheless the risks that people face at work do fall into a special category. This is because to a large extent they are involuntarily imposed risks which the worker simply has to face in order to make a living and over the level of which he has limited but important control. The Royal Society summarized the average annual death rates at work in the UK per 0195-6701/88/080301+09
0 1988 The Hospital
$03 00,O
301
Infection
Society
D. R. Morgan
302 Table
I. Risk
of an individual
dying
Smoking 10 cigarettes a day: All natural causes, age 40: Any kind of violence or poisoning Influenza: Accident on the road: Leukaemia: Playing soccer: Accident at home: Accident at work: Radiation working in radiation industry: Homicide: Accident on railway: Hit by lightning: Release of radiation from nearby nuclear Source:
BMA,
Living
with
Risk,
in any
power
I year
from
various
causes
1 in 200 1 in 850 1 in 3300 1 in 5000 1 in 8000 1 in 12,500 1 in 25,000 1 in 26,000 1 in 43,500 1 in 57,000 1 in 100,000 1 in 500,000 1 in 10,000,000 1 in 10,000,000
station:
1987.
million at risk as shown in Table II. A relatively high death rate from injury and poisoning is found in the farming and fishing industries, the catering and other services groups, and mining and transport. Comparatively low rates from accidental death are to be found in the professional and scientific occupations. The health of laboratory workers has not often been studied but in some projects undertaken there were some interesting observations. Dewhurst writing in the mid-70s reviewed three such studies. He remarked that it had been found that there was “a lack of haemorrhoids in laboratory staff as they don’t sit around all day, and a low Table
II.
Average
annual
occidental
death
rates
at work stated)
in
UK
per
million
at risk
(1974-78
Ratios workers death
Deaths per million at work
Manufacture of clothing and footwear Manufacture of vehicles Manufacture of timber, furniture, etc. Manufacture of bricks, pottery, glass, cement, Chemical and allied industries Shipbuilding and marine engineering Agriculture (employees) Construction industries Railway staff Coal miners Quarries Non-coal miners Offshore oil and Deep sea fishing
gas (accidents
Showing miners
figures for the and construction
Sources:
Royal Society, and Surveys.
Censuses
at sea only, late 197Os, workers. Risk
this
Assessment,
before
1 1 1 1 1 1 1 1 1 1 1 1 1 1
5 15
40 65 85 105 110 150 180 210 295 750 1650 2800
etc.
1970)
demonstrates
1983;
the
Health
high
death
and Safety
rate
from
Executive;
injury
except
among
Office
: : : : : : : : : : : : : :
of per
200,000 70,000 250,000 150,000 12,000 9,500 9,000 7,000 6,000 5,000 3,000 1,500 600 360 fishermen,
of Population
as
N’eedlestick
injuries
303
ulcer level shows that they don’t worry much either.” He suggested that interestingly enough laboratory workers emerge from all three studies as remarkably accident free. This implies that a positive attitude to safety seems to be built into laboratory workers as a group. In biomedical sciences the accidental puncture of the skin by hypodermic needles, other instruments or broken glass has long been regarded as an occupational hazard, for doctors, nurses, laboratory staff and porters. The degree of hazard to lVHS personnel varies widely with the duties of staff and the prevalence of infection ,in different parts of the country. Collins & Kennedy (1987) showed that domestic and portering staff are very much at risk and the highest rate of hepatitis B infection (37 per 100,000) was reported in laboratory scientific staff, Gatley (1986). Until recently, there may have been little concern about such injuries due to the availability of antibiotics and infection control strategies in the population but needlestick and sharp injuries have assumed a far greater importance, with the prevalence of hepatitis B infection and the increasing spread of HIV. It is anticipated that the incidence of tuberculosis and syphilis in the community will also increase significantly over the next few years, as the AIDS virus becomes more widespread. Materials
and
methods
To investigate this matter flurther, a telephone questionnaire study of six hospital haematology departments chosen at random has been undertaken as a “benchmark study” to help in pinpointing how information can be targetted at high risk staff. Three hospitals from the Thames Regions were contacted and a further three were chosen from other regions in England. Telephone numbers were selected randomly from the “Hospitals and Health Services Year Book”. Respondents, who were Chief or Senior Medical Laboratory Scientific Officers were asked to comment on the various aspects of needlestick injury, disposal methods, training of staff and prophylactic measures currently used in their departments. Th ey were also asked for their personal recommendations on how to improve education about needlestick injury.
Results
General laboratory practice All workers must be provided with a safe working environment, w-here the risk of accident is minimized. Safety guidelines must be provided and staff may need reminding on an individual basis or as a group, of the simple, yet obvious principles of good working practices. Formal refresher training should be considered. Laboratory coats must always be worn and fastened properly. Gloves may be necessary and the work area must be kept clear. A disinfectant container and a sharps bin should be near at hand. Laboratory
304
D. FL Morgan
coats must be left behind during lunchbreaks and not worn in the staff canteen and the general principles of good hygiene must apply. Needle/syringe techniques The hypodermic syringe and needle certainly seems to be the most hazardous piece of equipment in common use, judged by surveys of equipment-related infections. Many of the early reports refer to inoculation injuries that occurred during experiments with animals. A difficult animal, or inexperienced handler or inoculator can result in any one of them receiving an injection. In the case of patient blood sampling, both the DHSS (1986) and the Advisory Committee on Dangerous Pathogens (1986) recommend that latex gloves should be worn when taking blood from people who are at risk from carrying infectious micro-organisms such as hepatitis B or HIV. Some disadvantages associated with glove use are that some materials may cause hypersensitivity, or loss of tactile sensation, the latex is quite likely to be pierced by sharps and may be uncomfortable for long periods of use. More importantly perhaps, safe phlebotomy technique is dependant upon sound instruction and considerable experience. The incorrect disposal of used needles and sharps is a potential major cause of injury. One laboratory in the pilot survey has an arrangement whereby all sharps are returned to the haematology division for correct disposal. This may shift the potential for injury from the point of use to the point of disposal, as indeed happened when a needle was hidden within some gauze and caused a thigh injury to a haematology technologist. Another hospital employs a whole time porter whose main function is to collect burnbins, seal them and arrange for proper disposal. This system would appear to have much to recommend it. Signs and posters None of the laboratory supervisors contacted had a policy of displaying posters or signs based, e.g. on the Hazchem model. Four respondents felt that signs would not be useful; two had not thought of using them but felt that they could have value. Four felt that cartoons may help reinforce the message and could be put at danger points, for example, they could be sited close to plastic bags used for departmental waste collection. One respondent considered that a cartoon or statement could be printed on the syringe pack to remind staff of correct disposal. Training All staff in the laboratories contacted have undergone some form of safety training. Four laboratories had specific written guidelines, one provided a general departmental safety document, one gave new staff a safety handbook which was obligatory to read. Four departments held formal courses of safety instruction and two used induction training and practical
Needlestick
injuries
CAUTION
DO NOT SHARPS
Cover grazes or cuts. TAKE CARE WITH NEEDLES AND SHARPS
PLACE HERE.
.
.
.
Do not resheath. DISPOSE OF NEEDLES CAREFULLY. .
.
Figure 1. Pictogram signs to remind staff about the dangers from needles. demonstrations One laboratory years.
in their own department for new entrants to the laboratory. ensured that staff attended a refresher course at least every 5
Training material For professional staff, guidlelines incorporating text alone may be appropriate although pictograms are now being used more commonly to get a message across visually, in which case, the words can be kept to a minimum, and should have greater impact. This technique has been used in producing an illustrated guide to AIDS and HIV infection published by the British Medical Association (BMA, 19876). The information is presented in a novel format where nearly all facts are illustrated using pictograms or flow diagrams. Text is plain English and statements are kept short. A simple pictogram for a ‘sharp’ could be used with a straightforward warning such as “Caution do not place sharps here” and positioned near plastic bags or other hazardous disposal points. Simple signs could also be used to remind staff that the main danger is from
D. R. Morgan
306
micro-organisms entering through injury or open cuts and that needles should not be resheathed but disposed of in an appropriate container immediately after use, (see Figure 1). Discussion
Management of risk Taking the control of injury as a specific example of risk management, injury research pioneer, Dr William Haddon, defined 10 strategies some of which are probably relevant to needlestick injury. Firstly we could prevent the creation of the hazard. As sharps and needles have always been around hospitals and laboratories it is more feasible that we should reduce the amount of hazard and if possible separate the hazard from the human, by a barrier, or immediately counter the damage done. At the end of the day, in the case of needlestick or sharp injury we are essentially left with educational and barrier or separation techniques as a way of reducing the risk involved. It is clear that educational techniques need to be planned effectively for all those at risk and should involve induction training on the first day of commencing duties in the laboratory or hospital. Refresher training should be organized regularly, even for experienced staff. This would have the effect of reinforcing the message that injury should be avoided in the ways discussed, but should also reinforce a positive psychological attitude of workers to control behaviour, confirming that in the event that needlestick injuries do occur, then the level of risk is low. In-house video programmes provide an excellent source of education to reinforce reading material and can be adapted to the needs of the specific work groups. Indeed the workplace could serve as an important access point to convey the essentials of AIDS prevention in the community. (Morgan & Dawson, 1988). One respondent in our study who supervises a laboratory produced a letter which went to w-ards and other staff, following a needlestick injury caused by a needle being carelessly discarded. This was felt to be an effective way of reminding colleagues of the potential hazards. In another hospital, information about HIV and AIDS was circulated with payslips. Again, a useful and cost-effective way of delivering an important message. A further hospital has established a rigorous system of investigation for every needlestick injury notified. Early signs suggest that a subsequent reduction in such accidents has resulted. Risk
benejits
Risk management does not only mean reducing risks. To reduce any risk costs money, drains resources and sooner or later it costs too much to reduce a risk any further and the money would be better spent elsewhere. Most events, activities and technologies which carry a risk also offer a benefit if we reduce the risk too far we may find we have lost the benefit as well.
Meedlestick
injuries
307
These three elements are always interlinked, one cannot be changed without affecting the others. IHealth services for example have an insatiable hunger for money; it is needegd to pay for medical, paramedical and support staff, for buildings and facilities, for the provision of high technology equipment and for research. However, it is clear that the cost and benefit inter-relationship in terms of injury prevention can be effective in reducing the risk that staff will be exposed to a harmful agent, (see Figure 2). Training resources must be organized regularly and should include refresher training courses for all staff who are in contact with sharps and needles. Procedures must be adopted to suit particular hazards and circumstances, particularly if these are due to human error or mechanical fault. Guidelines or safety codes must be clearly written and
// / / / /’ / v A/’ >
Troinlng
Worker
<
Safety
code
r---Humon
error
and
mechanical
Sterlllzatlon and decontamlnatlon
Figure practice training
2. The health care worker can be protected and appropriate equipment. Human error and education. (Source: H. M. Darlow).
foul%
SolId round
barrier worker
SolId round
barrier agent
from harmful agents by good working must be reduced to a minimum by
308
D. R. Morgan
comprehensible to all staff and the pocket handbook format would be ideal to ensure that they are readily available. Posters, possibly incorporating cartoons, should be produced by the employing authority and displayed at places of risk. Individuals must understand their personal responsibility for disposal whether broken glass or needles are being sent to someone else for final disposal or if undertaken personally. Needles left in lab coat pockets are a regular cause of injury, particularly for ancillary and laundry staff. One large multinational pharmaceutical company considers the problem so important, that it is now removing all pockets from laboratory coats. The pre-exposure provision of vaccination against hepatitis B infection should be routinely offered and staff should be encouraged to take it up. Ironically it is clear that the serum-derived vaccine which was the only type available until recently, was not always acceptable to staff as evidenced from our survey, because there was a perceived high risk of possible contamination, for example by HIV. However, staff are now actively accepting the new genetically engineered variety. Post-exposure treatment, apart from simple first aid procedures and reporting of the accident does not yet appear to be a matter of general interest to the scientific staff co-operating with this study. None of our sample had read the recent Lancet paper (Meylan et al., 1988) which discussed the potential but controversial treatment with zidovudine (AZT), following needlestick injury involving samples from HIV patients. The general perception of risk of infection from blood or other body fluids in the UK is not yet at a level recognised in the USA. A study published in the Journal of the American Medical Association showed that the use of biohazard labels for blood samples may actually raise the risk that health care workers will be exposed to HIV or HBV or other micro-organisms, by fostering complacency in handling unlabelled specimens. One third of HIV positive blood samples examined did not have biohazard tags. The same was true for more than 70% of the samples from patients affected with hepatitis B virus. There is little conclusive evidence regarding the transmission rate of HIV by needlestick injury although the risk appears to be in the range of 1:lOO to 1:lOOO per injury, from current observations worldwide. In comparison, hepatitis B appears to be much more infectious with an estimated seroconversion rate following such injury of 1:3 to 1:16. Accordingly, the American researchers suggest that all clinical and laboratory personnel should handle all blood specimens as if they were infected, regardless of biohazard labelling. Most of the health care workers responding to our survey would consider this impracticable in the UK at present and would not consider the risk high enough to warrant the resources and work involved. The World Health Organisation reported that epidemiological studies of needlestick injuries in hospital personnel indicates that 40% of accidents are
Needlestick
injuries
309
potentially preventable if recommended precautions are followed when handling used needles or other sharp objects, WHO (1985). Educational programmes to familiarize health care workers with the basic practices in infection control are essential for the prevention of AIDS and other infections and it will be important for health authorities, safety managers and supervisors to ensure a continuing reinforcement of the often simple but key ways in which needlestick injury can be avoided. I am indebted to Mr Walter Thanks are also due to Miss Figure 1 and the laboratory
Gunthorpe for helpful discussion and Deboralh Morton for typing, Mrs Hilary scientists who took part in the telephone
for providing Figure 2. Glanville who prepared questionnaire study.
References Advisory Committee on Dangerous Pathogens (1986). LAV/HTLV III - The Causative Agent of AIDS and Related Conditions ~ Revised Guidelines. On behalf of the Health and Safety Executive and the Department of Health and Social Security HC(85)2. British Medical Association (1987a). The Measurement of risk, In Living with Risk. First Edition. Chichester: John Wiley and Sons. British Medical Association (19876) -AIDS and You-An Illustrated Guide. Board of Science and Education, BMA, London. Collins, C. H. & Kennedy, D. .A. (1987). M’ icro-biological hazards of occupational needlestick and ‘sharps’ injuries. rournal of Applied Bacteriology 62, 385402. Department of Health and Social Security Booklet 3, (1986). AIDS: Guidance for Surgeons, Anaesthetists, Dentists and their Teams Dealing with Patients Infected with HTLV III. Gatley, M. S. (1986). Hepatitis B Vaccine of Medical Staff. Lancet ii, 697. Meylan, P. R., Francioli, P., Decrey, H., Chave, J. Ph. & Glauser, M. P. (1988). Post-exposure prophylaxis against HIV infection in health care workers. Lancet, i 481. Morgan, D. R. & Dawson; J. (1988). 0 ccupational health aspects of the human immunodeficiency virus and AIDS. Ann Occup Hyg 32, 69-82. World Health Organisation (1985). Acquired Immunodeficiency Syndrome (AIDS) Update: Evaluation of LAV/HTLV III Infection in Health Care Personnel - Editorial Note. Weekly Epidemiological Record 42, 321-328.
of Hospital
Infection
(1988)
12, 301-309
Papers from the Hospital Infection Society Meeting ‘Missing the Point’ held on 23 March 1988
Needlestick
injuries: How can we teach better about risk assessment? David
British
Medical
Association,
people
R. Morgan
Tavistock
Square,
London
WCjH
93p,
UK
Summary:
At work people run some small risk of death or injury which is directly attributable to their occupation. In biomedical sciences the accidental puncture of the skin by hypodermic needles, other instruments or broken glass has long been regarded as an occupational hazard and there is increasing concern that staff could become infected with a range of micro-organisms: including hepatitis B and the Human Immunodeficiency Virus (HIV). Needlestick injuries should be preventable if staff are trained effectively and take care about disposal of used syringes and needles. Staff at risk must be offered pre-exposure vaccination for hepatitis B and resources must be provided for special training. Fundamental changes may be required in methods and equipment and a number of new ways of targeting groups of health care staff with information are discussed.
Introduction
The next time someone reflects on some newly discovered risk to health and well-being at work or in the great outdoors, and reflects that the only truly safe place to be is at home, perhaps in bed, he should be reminded that it is almost certainly not true. Falls kill more people from unintentional injury than anything except traffic accidents and most falls occur at home. Most deaths from burning happen at home. Home is therefore not as safe as we think, (BMA, 1987a). We can express the risk of an individual dying in any 1 year from various causes as a ‘1 in so many’ risk. Smoking only 10 cigarettes a day is a major risk factor. Influenza carries a fairly high burden of risk particularly for the aged and those living in poor accommodation, but should we really be worried about living next door to Chernobyl? (Table I). A man or woman at work runs some risk of death or injury which is directly attributable to that occupation. Maybe the risk is lower than if the same individual had stayed at home and it probably is lower than the risk of driving to work. Nevertheless the risks that people face at work do fall into a special category. This is because to a large extent they are involuntarily imposed risks which the worker simply has to face in order to make a living and over the level of which he has limited but important control. The Royal Society summarized the average annual death rates at work in the UK per 0195-6701/88/080301+09
0 1988 The Hospital
$03 00,O
301
Infection
Society
D. R. Morgan
302 Table
I. Risk
of an individual
dying
Smoking 10 cigarettes a day: All natural causes, age 40: Any kind of violence or poisoning Influenza: Accident on the road: Leukaemia: Playing soccer: Accident at home: Accident at work: Radiation working in radiation industry: Homicide: Accident on railway: Hit by lightning: Release of radiation from nearby nuclear Source:
BMA,
Living
with
Risk,
in any
power
I year
from
various
causes
1 in 200 1 in 850 1 in 3300 1 in 5000 1 in 8000 1 in 12,500 1 in 25,000 1 in 26,000 1 in 43,500 1 in 57,000 1 in 100,000 1 in 500,000 1 in 10,000,000 1 in 10,000,000
station:
1987.
million at risk as shown in Table II. A relatively high death rate from injury and poisoning is found in the farming and fishing industries, the catering and other services groups, and mining and transport. Comparatively low rates from accidental death are to be found in the professional and scientific occupations. The health of laboratory workers has not often been studied but in some projects undertaken there were some interesting observations. Dewhurst writing in the mid-70s reviewed three such studies. He remarked that it had been found that there was “a lack of haemorrhoids in laboratory staff as they don’t sit around all day, and a low Table
II.
Average
annual
occidental
death
rates
at work stated)
in
UK
per
million
at risk
(1974-78
Ratios workers death
Deaths per million at work
Manufacture of clothing and footwear Manufacture of vehicles Manufacture of timber, furniture, etc. Manufacture of bricks, pottery, glass, cement, Chemical and allied industries Shipbuilding and marine engineering Agriculture (employees) Construction industries Railway staff Coal miners Quarries Non-coal miners Offshore oil and Deep sea fishing
gas (accidents
Showing miners
figures for the and construction
Sources:
Royal Society, and Surveys.
Censuses
at sea only, late 197Os, workers. Risk
this
Assessment,
before
1 1 1 1 1 1 1 1 1 1 1 1 1 1
5 15
40 65 85 105 110 150 180 210 295 750 1650 2800
etc.
1970)
demonstrates
1983;
the
Health
high
death
and Safety
rate
from
Executive;
injury
except
among
Office
: : : : : : : : : : : : : :
of per
200,000 70,000 250,000 150,000 12,000 9,500 9,000 7,000 6,000 5,000 3,000 1,500 600 360 fishermen,
of Population
as
N’eedlestick
injuries
303
ulcer level shows that they don’t worry much either.” He suggested that interestingly enough laboratory workers emerge from all three studies as remarkably accident free. This implies that a positive attitude to safety seems to be built into laboratory workers as a group. In biomedical sciences the accidental puncture of the skin by hypodermic needles, other instruments or broken glass has long been regarded as an occupational hazard, for doctors, nurses, laboratory staff and porters. The degree of hazard to lVHS personnel varies widely with the duties of staff and the prevalence of infection ,in different parts of the country. Collins & Kennedy (1987) showed that domestic and portering staff are very much at risk and the highest rate of hepatitis B infection (37 per 100,000) was reported in laboratory scientific staff, Gatley (1986). Until recently, there may have been little concern about such injuries due to the availability of antibiotics and infection control strategies in the population but needlestick and sharp injuries have assumed a far greater importance, with the prevalence of hepatitis B infection and the increasing spread of HIV. It is anticipated that the incidence of tuberculosis and syphilis in the community will also increase significantly over the next few years, as the AIDS virus becomes more widespread. Materials
and
methods
To investigate this matter flurther, a telephone questionnaire study of six hospital haematology departments chosen at random has been undertaken as a “benchmark study” to help in pinpointing how information can be targetted at high risk staff. Three hospitals from the Thames Regions were contacted and a further three were chosen from other regions in England. Telephone numbers were selected randomly from the “Hospitals and Health Services Year Book”. Respondents, who were Chief or Senior Medical Laboratory Scientific Officers were asked to comment on the various aspects of needlestick injury, disposal methods, training of staff and prophylactic measures currently used in their departments. Th ey were also asked for their personal recommendations on how to improve education about needlestick injury.
Results
General laboratory practice All workers must be provided with a safe working environment, w-here the risk of accident is minimized. Safety guidelines must be provided and staff may need reminding on an individual basis or as a group, of the simple, yet obvious principles of good working practices. Formal refresher training should be considered. Laboratory coats must always be worn and fastened properly. Gloves may be necessary and the work area must be kept clear. A disinfectant container and a sharps bin should be near at hand. Laboratory
304
D. FL Morgan
coats must be left behind during lunchbreaks and not worn in the staff canteen and the general principles of good hygiene must apply. Needle/syringe techniques The hypodermic syringe and needle certainly seems to be the most hazardous piece of equipment in common use, judged by surveys of equipment-related infections. Many of the early reports refer to inoculation injuries that occurred during experiments with animals. A difficult animal, or inexperienced handler or inoculator can result in any one of them receiving an injection. In the case of patient blood sampling, both the DHSS (1986) and the Advisory Committee on Dangerous Pathogens (1986) recommend that latex gloves should be worn when taking blood from people who are at risk from carrying infectious micro-organisms such as hepatitis B or HIV. Some disadvantages associated with glove use are that some materials may cause hypersensitivity, or loss of tactile sensation, the latex is quite likely to be pierced by sharps and may be uncomfortable for long periods of use. More importantly perhaps, safe phlebotomy technique is dependant upon sound instruction and considerable experience. The incorrect disposal of used needles and sharps is a potential major cause of injury. One laboratory in the pilot survey has an arrangement whereby all sharps are returned to the haematology division for correct disposal. This may shift the potential for injury from the point of use to the point of disposal, as indeed happened when a needle was hidden within some gauze and caused a thigh injury to a haematology technologist. Another hospital employs a whole time porter whose main function is to collect burnbins, seal them and arrange for proper disposal. This system would appear to have much to recommend it. Signs and posters None of the laboratory supervisors contacted had a policy of displaying posters or signs based, e.g. on the Hazchem model. Four respondents felt that signs would not be useful; two had not thought of using them but felt that they could have value. Four felt that cartoons may help reinforce the message and could be put at danger points, for example, they could be sited close to plastic bags used for departmental waste collection. One respondent considered that a cartoon or statement could be printed on the syringe pack to remind staff of correct disposal. Training All staff in the laboratories contacted have undergone some form of safety training. Four laboratories had specific written guidelines, one provided a general departmental safety document, one gave new staff a safety handbook which was obligatory to read. Four departments held formal courses of safety instruction and two used induction training and practical
Needlestick
injuries
CAUTION
DO NOT SHARPS
Cover grazes or cuts. TAKE CARE WITH NEEDLES AND SHARPS
PLACE HERE.
.
.
.
Do not resheath. DISPOSE OF NEEDLES CAREFULLY. .
.
Figure 1. Pictogram signs to remind staff about the dangers from needles. demonstrations One laboratory years.
in their own department for new entrants to the laboratory. ensured that staff attended a refresher course at least every 5
Training material For professional staff, guidlelines incorporating text alone may be appropriate although pictograms are now being used more commonly to get a message across visually, in which case, the words can be kept to a minimum, and should have greater impact. This technique has been used in producing an illustrated guide to AIDS and HIV infection published by the British Medical Association (BMA, 19876). The information is presented in a novel format where nearly all facts are illustrated using pictograms or flow diagrams. Text is plain English and statements are kept short. A simple pictogram for a ‘sharp’ could be used with a straightforward warning such as “Caution do not place sharps here” and positioned near plastic bags or other hazardous disposal points. Simple signs could also be used to remind staff that the main danger is from
D. R. Morgan
306
micro-organisms entering through injury or open cuts and that needles should not be resheathed but disposed of in an appropriate container immediately after use, (see Figure 1). Discussion
Management of risk Taking the control of injury as a specific example of risk management, injury research pioneer, Dr William Haddon, defined 10 strategies some of which are probably relevant to needlestick injury. Firstly we could prevent the creation of the hazard. As sharps and needles have always been around hospitals and laboratories it is more feasible that we should reduce the amount of hazard and if possible separate the hazard from the human, by a barrier, or immediately counter the damage done. At the end of the day, in the case of needlestick or sharp injury we are essentially left with educational and barrier or separation techniques as a way of reducing the risk involved. It is clear that educational techniques need to be planned effectively for all those at risk and should involve induction training on the first day of commencing duties in the laboratory or hospital. Refresher training should be organized regularly, even for experienced staff. This would have the effect of reinforcing the message that injury should be avoided in the ways discussed, but should also reinforce a positive psychological attitude of workers to control behaviour, confirming that in the event that needlestick injuries do occur, then the level of risk is low. In-house video programmes provide an excellent source of education to reinforce reading material and can be adapted to the needs of the specific work groups. Indeed the workplace could serve as an important access point to convey the essentials of AIDS prevention in the community. (Morgan & Dawson, 1988). One respondent in our study who supervises a laboratory produced a letter which went to w-ards and other staff, following a needlestick injury caused by a needle being carelessly discarded. This was felt to be an effective way of reminding colleagues of the potential hazards. In another hospital, information about HIV and AIDS was circulated with payslips. Again, a useful and cost-effective way of delivering an important message. A further hospital has established a rigorous system of investigation for every needlestick injury notified. Early signs suggest that a subsequent reduction in such accidents has resulted. Risk
benejits
Risk management does not only mean reducing risks. To reduce any risk costs money, drains resources and sooner or later it costs too much to reduce a risk any further and the money would be better spent elsewhere. Most events, activities and technologies which carry a risk also offer a benefit if we reduce the risk too far we may find we have lost the benefit as well.
Meedlestick
injuries
307
These three elements are always interlinked, one cannot be changed without affecting the others. IHealth services for example have an insatiable hunger for money; it is needegd to pay for medical, paramedical and support staff, for buildings and facilities, for the provision of high technology equipment and for research. However, it is clear that the cost and benefit inter-relationship in terms of injury prevention can be effective in reducing the risk that staff will be exposed to a harmful agent, (see Figure 2). Training resources must be organized regularly and should include refresher training courses for all staff who are in contact with sharps and needles. Procedures must be adopted to suit particular hazards and circumstances, particularly if these are due to human error or mechanical fault. Guidelines or safety codes must be clearly written and
// / / / /’ / v A/’ >
Troinlng
Worker
<
Safety
code
r---Humon
error
and
mechanical
Sterlllzatlon and decontamlnatlon
Figure practice training
2. The health care worker can be protected and appropriate equipment. Human error and education. (Source: H. M. Darlow).
foul%
SolId round
barrier worker
SolId round
barrier agent
from harmful agents by good working must be reduced to a minimum by
308
D. R. Morgan
comprehensible to all staff and the pocket handbook format would be ideal to ensure that they are readily available. Posters, possibly incorporating cartoons, should be produced by the employing authority and displayed at places of risk. Individuals must understand their personal responsibility for disposal whether broken glass or needles are being sent to someone else for final disposal or if undertaken personally. Needles left in lab coat pockets are a regular cause of injury, particularly for ancillary and laundry staff. One large multinational pharmaceutical company considers the problem so important, that it is now removing all pockets from laboratory coats. The pre-exposure provision of vaccination against hepatitis B infection should be routinely offered and staff should be encouraged to take it up. Ironically it is clear that the serum-derived vaccine which was the only type available until recently, was not always acceptable to staff as evidenced from our survey, because there was a perceived high risk of possible contamination, for example by HIV. However, staff are now actively accepting the new genetically engineered variety. Post-exposure treatment, apart from simple first aid procedures and reporting of the accident does not yet appear to be a matter of general interest to the scientific staff co-operating with this study. None of our sample had read the recent Lancet paper (Meylan et al., 1988) which discussed the potential but controversial treatment with zidovudine (AZT), following needlestick injury involving samples from HIV patients. The general perception of risk of infection from blood or other body fluids in the UK is not yet at a level recognised in the USA. A study published in the Journal of the American Medical Association showed that the use of biohazard labels for blood samples may actually raise the risk that health care workers will be exposed to HIV or HBV or other micro-organisms, by fostering complacency in handling unlabelled specimens. One third of HIV positive blood samples examined did not have biohazard tags. The same was true for more than 70% of the samples from patients affected with hepatitis B virus. There is little conclusive evidence regarding the transmission rate of HIV by needlestick injury although the risk appears to be in the range of 1:lOO to 1:lOOO per injury, from current observations worldwide. In comparison, hepatitis B appears to be much more infectious with an estimated seroconversion rate following such injury of 1:3 to 1:16. Accordingly, the American researchers suggest that all clinical and laboratory personnel should handle all blood specimens as if they were infected, regardless of biohazard labelling. Most of the health care workers responding to our survey would consider this impracticable in the UK at present and would not consider the risk high enough to warrant the resources and work involved. The World Health Organisation reported that epidemiological studies of needlestick injuries in hospital personnel indicates that 40% of accidents are
Needlestick
injuries
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potentially preventable if recommended precautions are followed when handling used needles or other sharp objects, WHO (1985). Educational programmes to familiarize health care workers with the basic practices in infection control are essential for the prevention of AIDS and other infections and it will be important for health authorities, safety managers and supervisors to ensure a continuing reinforcement of the often simple but key ways in which needlestick injury can be avoided. I am indebted to Mr Walter Thanks are also due to Miss Figure 1 and the laboratory
Gunthorpe for helpful discussion and Deboralh Morton for typing, Mrs Hilary scientists who took part in the telephone
for providing Figure 2. Glanville who prepared questionnaire study.
References Advisory Committee on Dangerous Pathogens (1986). LAV/HTLV III - The Causative Agent of AIDS and Related Conditions ~ Revised Guidelines. On behalf of the Health and Safety Executive and the Department of Health and Social Security HC(85)2. British Medical Association (1987a). The Measurement of risk, In Living with Risk. First Edition. Chichester: John Wiley and Sons. British Medical Association (19876) -AIDS and You-An Illustrated Guide. Board of Science and Education, BMA, London. Collins, C. H. & Kennedy, D. .A. (1987). M’ icro-biological hazards of occupational needlestick and ‘sharps’ injuries. rournal of Applied Bacteriology 62, 385402. Department of Health and Social Security Booklet 3, (1986). AIDS: Guidance for Surgeons, Anaesthetists, Dentists and their Teams Dealing with Patients Infected with HTLV III. Gatley, M. S. (1986). Hepatitis B Vaccine of Medical Staff. Lancet ii, 697. Meylan, P. R., Francioli, P., Decrey, H., Chave, J. Ph. & Glauser, M. P. (1988). Post-exposure prophylaxis against HIV infection in health care workers. Lancet, i 481. Morgan, D. R. & Dawson; J. (1988). 0 ccupational health aspects of the human immunodeficiency virus and AIDS. Ann Occup Hyg 32, 69-82. World Health Organisation (1985). Acquired Immunodeficiency Syndrome (AIDS) Update: Evaluation of LAV/HTLV III Infection in Health Care Personnel - Editorial Note. Weekly Epidemiological Record 42, 321-328.