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Understanding sharps use in an Australian Emergency Department: A mixed methods organisational case study
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Research paper
Understanding sharps use in an Australian Emergency Department: A mixed methods organisational case study Chantelle Judge a , Michael Sinnott a,b,c , Rob Eley a,b,∗ , Andy Wong a,c , Amy N.B. Johnston a,b a
Princess Alexandra Hospital, Ipswich Rd, Brisbane, Australia The University of Queensland, St Lucia, Brisbane, Australia c Queensland University of Technology, Brisbane, Australia b
a r t i c l e
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Article history: Received 5 May 2019 Received in revised form 11 November 2019 Accepted 6 December 2019 Keywords: Emergency department Sharps Percutaneous injuries Culture change
a b s t r a c t Background: Despite the introduction of a range of safety policies and sharps equipment designed to protect healthcare workers, rates of percutaneous injuries from occupational exposure to sharps remains high. This study examined the availability and use of various types of sharps devices in a tertiary hospital emergency department, to understand clinician choice between non-safety and safety devices; and to document their safe and unsafe use of sharps. Methods: This mixed methods study consisted of areview of stock levels, a survey of staff usage, and a content analysis of semi-structured interview data to explore factors which impact on staff preferences for different sharps devices. Results: Staff identified a range of sharps risks, as well as barriers and enablers to the use of safety devices. Availability of, and preference for, familiar devices influenced choice of devices used in clinical practice, despite awareness of associated risks. Conclusions: This understanding of equipment use and the factors that motivate such use have informed the first stage of the knowledge-to-action cycle. Knowledge translation, should include the development of policies to help reduce the risk of sharps injury. Culture change and ongoing skills development might help to overcome entrenched procedures and increase voluntary engagement with safer sharps. © 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Background Risks around sharps injuries for healthcare workers are significant [1], often underreported [2,3], and unacceptably high [4,5]. Processes, such as the Epic Project guidelines [6] in the UK which develop national evidence-based guidelines for preventing healthcare associated infections, have been introduced to mitigate risks from sharps injuries. Numerous studies have demonstrated that percutaneous injuries can decrease when safety devices are implemented in healthcare settings [7–12], particularly for procedures such as intravenous device insertion and phlebotomy [14]. However some of the evidence supporting this assertion is mixed [14]. Some countries enforce the use of safety engineered medical devices [8,15]. Despite this, rates of sharps injury internationally
∗ Corresponding author at: Department of Emergency Medicine, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, 4102, Queensland, Australia. E-mail address: [email protected] (R. Eley).
are still high [2,16,17] and they present one of the major occupational health risks to healthcare workers [18]. Sharps used in a healthcare setting are typically divided into three main categories based on their relative safety: conventional, active and passive safety devices [14]. Conventional sharp devices have no safety feature(s); active sharp devices (also known manually-activated) require users to manually activate a safety mechanism after use (e.g. by depressing a button); and passive sharps devices (fully-automatic) are those which do not require user activation. Passive devices are safer than Active devices which are safer than conventional devices in preventing injury [13,14,19–21]. Despite widespread education campaigns, the incidence of sharps injuries remains high in high-acuity, high-pressure and high-risk areas such as emergency departments (ED). At this Australian study hospital site, sharps injuries have remained relatively static over the last 12 years, with percutaneous injury rates ranging between 52–62% of reported occupational exposures. This was despite a previous surveillance study on such injuries at this site which generated attention and promoted action when it reported
https://doi.org/10.1016/j.auec.2019.12.006 2588-994X/© 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Judge C, et al. Understanding sharps use in an Australian Emergency Department: A mixed methods organisational case study. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.12.006
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Fig. 1. Knowledge translation framework underpinning this study [24,25].
one injury every two days [22]. The majority (55%) of percutaneous injuries to ED staff occurred through needle use (blood gas syringes, disposable needle with syringe and venous/arterial cannula) [23]. The study site’s ED rate of percutaneous injuries was surpassed by only the operating theatres and ICU [22]. More recent unpublished data indicate that one sharps injury is reported every four days thus reinforcing the need for more attention to this topic. There is little discussion in the literature around the impacts of the types of sharp devices available for venepuncture and cannulation on usage or choice of adoption by clinical staff. Aims The aims of this project were to: a) undertake a snapshot of the types sharps devices available to clinical staff in a metropolitan public ED, b) explore staff perceptions of processes around sharps usage, documenting the self-identified incidences of inappropriate or unintended uses of sharps devices and c) identify why clinicians might choose non-safety over safety devices or use a less safe over a safer process.
This study was undertaken in the emergency department of a tertiary level metropolitan hospital in QLD, Australia. The ED manages in excess of 60,000 adult presentations annually. Part one first involved a review of cannulation and venepuncture equipment available to ED staff. This was followed by determination of how the equipment was used by those clinical staff. Cannulation and venepuncture equipment was selected as it is commonly associated with percutaneous injuries [14]. A review tool, was developed via reference to broader published literature [2,9,10,15,18], and used to collect data on device type, recommended usage (purpose), and common procedures for use. To ensure completeness, the review covered stock in the ED storerooms and the procedure trolleys in clinical areas, as well as asking staff a series of simple questions about sharps use and preferences. Identified devices were allocated to one of three categories; conventional, passive or active safety. In Part two, semi-structured interviews with a convenience sample of clinical staff representing a range of clinical entities, informed by the survey data, were undertaken to collect richer contextual information on the cannulation and venepuncture devices identified in Part one [26]. Interviews were undertaken by an independent research team, with experience of ED care processes. Staff were asked direct questions about which devices they use, why they use them, their knowledge/awareness of safety devices, their perceptions of barriers to using safety devices, and the reasons for their preferred choice. Staff were also asked to comment broadly on barriers to effective sharps safety, inappropriate or unintended use of sharps, circumstances when a non-safe device could be chosen, and the circumstances in which staff may breach existing sharps policies. The interview questions were developed to address the research questions and informed by outcomes of Phase 1 of the study. Interviews were recorded for review and analysis.
Data analysis Usage data was subject to a content analysis and simple tabulation [26] by three researchers independently. Discrepancies were resolved by consensus. Interview data analysis was informed by application of Haddon’s Matrix [28] which is a common framework in injury prevention to understand the aetiology (host, agent and environment) and influencing factors across the time frames (pre-event, event, post-event) involved in an injury event.
Methods
Ethics statement
This study used the knowledge-to-action (KTA) framework which has two components: Knowledge Creation and the seven component Action Cycle (see Fig. 1). The creation of knowledge includes literature review, synthesis and an understanding of the tools or products involved (i.e. tailoring the knowledge to a specific setting). These then inform the first stage of the action cycle, namely problem identification. The study completed the knowledge creation and then the first three phases of the action cycle by identifying the problem and applying relevant knowledge created to contextualise and understand the issues around staff use of safety sharps devices [24,25]. The knowledge creation will underpin future interventions and address a gap in current ED knowledge and published literature. A pragmatic two-part sequential mixed methods study [26], informed by case study design [27], was used. Data organization and presentation was informed by the National Institute for Health Research ‘Methodological Framework for Organizational Case Studies’ [27].
The research study adhered to the National Statement on the Conduct of Human Research by the Australian National Health and Medical Research Council and was approved by the Metro South Human Research Ethics Committee (HREC16/QPAH/198).
Results Part one The three cannulation devices were identified one which was passive, one active, and one which was conventional with no safety mechanism. There were six devices available for venepuncture. There were no passive devices, two active safety devices (both using a butterfly needle with a shield attachment) and four conventional devices (one a standard needle and syringe and three types of vacutainer).
Please cite this article in press as: Judge C, et al. Understanding sharps use in an Australian Emergency Department: A mixed methods organisational case study. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.12.006
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Table 1 Equipment identified by staff as associated with sharps risk.
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and ease of locating equipment were the mostly commonly cited reasons for use of traditional needle and syringe.
Equipment Syringe and needle Glass ampoules Blood gas syringe Non-retractable needles Incorrectly disposed sharps Sharps containers Suture needles Butterfly devices Scalpel Intraosseous device
Table 2 Staff-identified factors that influence the safety of sharps devices. Factor
Frequency of identification
Safety features The user/operator of the device Proper and timely disposal Ease of use Education Accessible/available sharps containers
18 10 6 2 3 2
Part two Participants A convenience sample of 23 nurses and 7 doctors, comparable to the current ED skill mix, participated in interviews. Female to male ratio was 3:2 and years of clinical experience ranged from 1.5 to 12. Staff identification of sharps risks, behaviours and processes All staff were aware of the risks and consequences of sharps injuries. They identified equipment commonly associated with sharps injury (Table 1), and a range of risk-ameliorating factors (Table 2). Staff recognised the hospital management’s expectation that the safety equipment provided would be used, and all were aware which devices were recommended for venepuncture and for cannulation. Despite this, a range of other devices were used and preferred (Table 3). Cannula preference While most of the staff preferred the active and passive safety devices, one third admitted to using the conventional device for routine cannulation. This was despite knowledge that its availability in the department was specifically for ultrasound guided IV access. While for three staff the conventional device was their preferred device, the other five said they used it if it was close to hand and other cannulas were not. Of the safety devices the passive one was preferred: a lack of familiarity and training with it was identified as a limitation to use by some staff who preferred the active device. With one exception, all staff reported that the devices available for cannulation had changed since they initially trained. All but one who had changed to a different device stated that they would not go back to the initial equipment. Venepuncture preference In the ED cannulation is standard practice and venepuncture less common as blood was often drawn through the cannula. This aligned with staff reporting less familiarity with newer equipment to undertake venepuncture. Despite awareness of the risks and the availability of safer devices, 10 staff indicated that they had not changed from needle and syringe since their initial training. Habit
Barriers to use of safety devices Participants identified a range of barriers to the use of safe devices. These included unavailability, time constraints, ingrained habits, access to unsafe devices, poor familiarisation and competency with newer devices, increased manual dexterity and steps required to use safety devices, increased costs of quality products, emergent/agitated patient scenarios and too many choices of device. Safe use of devices was compromised by full or inadequate access to sharps bins, poor (or absent) sharps disposal behaviour, and lack of training in the use of specific devices. Staff frequently stated that they deliberately selected non-safety devices in specific pressure situations requiring the need for speed and confidence. Non-safety devices were used for procedures such as ultrasound guided IV access where there was apparently no suitable alternative. There were also situations where staff felt that conventional devices were better and easier to use. They claimed this use was justified because of their previous training, pressure and time-constraints, and perceived availability. Other key themes that emerged during the interviews related to the risks of sharps injuries during clinical practice. Staff identified situational drivers that predisposed them to sharps injuries. These included inappropriate use of a sharp, typically driven by the need for speed, and the use of sharps for non-designed purposes (Table 4). Sharps disposal for others Despite awareness of the risks and the policy not to dispose of others’ sharps, 25 of the 30 staff interviewed reported this activity. Situations identified where this had occurred included while cleaning up after someone else, in resuscitation or emergent situations, and during assisting or teaching procedures. Haddon’s Matrix This framework [28] was used to inform categorisation of the factors identified by the interviewed staff as risk factors and the time (pre-, during- or post-use) when the factor poses a risk. For this study the ‘host’ is the clinician participant, ‘agent’ the equipment and environment is the surroundings within the study ED. As highlighted in Table 5 in the Host column, clinician risk of sharps injury may be reduced if appropriate pre-event knowledge and education is provided, the device is used correctly during the event, and then disposed of suitably post-event. Similar preventative strategies are identified for the agent (device) and environment in their respective columns. These data can be aligned with sharps availability and usage data to provide a comprehensive picture of staff risk during cannulation and venepuncture. Discussion Despite the real risks of disease transmission and the ready availability of safety devices, percutaneous injury remains an occupational hazard for healthcare workers, particularly in critical care areas such as emergency [29]. This local snapshot of sharps availability and usage reiterates national [29] and international data [2,7–13,16,30–32], that span decades. Completion of the first three phases of the knowledge-to-action framework to contextualise and understand staff (mis)use of safety sharps devices enabled the study to address a major gap in current ED knowledge and published literature that can underpin future interventions. Interviews with nurses and doctors revealed that knowledge of sharps risks and their access to safety devices did not strongly influence the devices they used. For some procedures many staff
Please cite this article in press as: Judge C, et al. Understanding sharps use in an Australian Emergency Department: A mixed methods organisational case study. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.12.006
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Table 3 Cannulation and venepuncture devices available, reported usage and comments on usage considerations. Device
Preferred by
Used by
Positive comments
Negative comments
Cannulation Device Conventional
3
8
Extra length; more manoeuvrability; easier to determine if in vein through flashback; easier feeding over stylet
Active Safety
7
17
Passive
20
23
Immediate flashback; easier for difficult veins as can get good angles; good success rate; familiar; easy to use; safe; comfortable Wings help to articulate angle and control; ease of use; wings for stability; flashback straight away then blood delay; easy to secure; valve stops the blood flow; manoeuvrability; pressure distribution
Difficult to hold; uncomfortable; not ideal for securing; doesn’t have wings; sharps risk; bleed out; no safety mechanism Hub is too long; unwieldy; not ideal for securing; doesn’t have wings; bleed out; speed of needle retraction; fiddly; harder to use Can’t re-feed stylet; feels blunt; blow veins; difficult to retract; not as good for difficult veins; bulkier
16
22
0
2
3
4
0
3
7
18
0
7
4
n/a
Venepuncture Device Conventional: Standard needle and syringe Conventional: Standard needle with luer lock vacutainer Conventional: Vacutainer shield/needle Conventional: Vacutainer needles and vanish point shield Active Safety: Butterfly with vacutainer shield Active Safety: Butterfly with syringe Undecided or no preference stated
Easier especially with a difficult access; familiarity; high success rate; easy to find equipment
Risks of needlestick injury
Simple and easy to use; easy to handle; good for large samples (many vials); blood contained
Easier to manipulate and more accessible
Table 4 Examples of injury predisposing situational drivers. Inappropriate use of safety devices Using a needle to open a nicotine patch when scissors not available Recapping needles
Suturing clothes Not activating safety device on retractable needles Suturing shoes
Filling gas syringe with needle/syringe instead of direct from patient
High risk of needle stick injury
Devices used for unintended purposes Needle to remove eye foreign body Removal of cannula stylet and using device to flush, paracentesis (difficult airway) Arterial lines done with cannulas Transferring blood with needle/syringe instead of transfer device Using a blood gas syringe by bending needle and making a burr hole in a finger nail 18 G needle used for IMI
preferred to use the equipment they were most or first familiar with. In fact, habit, or initial training was the most common reason cited for why a clinician might choose a non-safety over a safety device, or an unsafe over a safer process. A common secondary reason, particularly for venepuncture, was that the standard needle and syringe were most fit-for-purpose, providing the greatest “feel” and accuracy. Thus, data reported here suggest that sharps usage maybe typically related to long-standing (entrained) behaviour patterns. Habits, often triggering behaviours because of situational or contextual cues, rather than clinical reasoning or focused intentions are cited as a barrier to clinical behaviour change [33,34]. The corollary of this is that behaviour change may require some sort of contextual change (e.g. removing equipment from easy access)
No flashback; can lose vein especially while attaching vials; can’t control blood flow Lack of pressure increases risk of losing vein; bulky; can’t see flashback; unfamiliar; fiddly Fiddly
Table 5 Haddon’s Matrix.
Preevent
Event
Post -event
Host = Clinician
Agent = Device
Environment
Safe sharp techniques knowledge Education Safe operation of device
Safety mechanism for sharps
Sharp container accessibility
Appropriate disposal
Needleless devices Availability of sharps with safety mechanism
Easy retraction or trigger of safety feature – non-complicated mechanism
Agitated patient Emergency/ Resuscitation situation Sharps bin placement and non-frequent emptying
or incentive to undertake vigilant monitoring of behaviours [34]. Researchers exploring implementation science suggest “There is a need to explore intervention strategies that account for the habitual nature of clinical practice by investigating various means of contextual changes or disturbances to break unwanted habits and/or achieving behavioural repetition in consistent contexts to promote formation of desired habits.” [33, pg 5]. Involving frontline healthcare staff in the selection of safety devices and thus self-initiating contextual change is one of the consensus recommendations from the International Safety Center (formerly, the International Healthcare Worker Safety Center) [35]. This is echoed by the Australian Alliance for Sharps Safety and Needlestick Prevention in Healthcare [36] and others [37]. The data presented herein, coupled with recent review evidence, sug-
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gests that even allowing for positive publication bias, safety devices are only one important part of a multifactor solution [2,5,33,38]. Our data suggests that there is unlikely to be further change until conventional sharps are either available only with limited access or removed from clinical spaces. This would require prioritising staff safety over equipment costs, as safer devices are usually more expensive than conventional devices. In the USA, Occupational Health and Safety Administration (OSHA) regulations dictate use of sharps injury prevention devices. Data pre- and post the Needlestick Safety and Prevention Act (2000) shows that safety devices positively impact on injury rates [32,38,39], although these effects are slow to emerge. Our results echo a Canadian study where despite a regulatory framework, needlestick injuries continued to occur and injuries were associated with the (lack of) ease of use of safer devices, unpredictable patient interactions and non-compliance with intended device use [10]. Emergency staff maybe at greater risk of exposure to percutaneous injuries than many of their professional colleagues [17,22], or they may just be more likely to report such injuries [16,34]. High staff workload is often cited as a factor in the incidence of percutaneous injury rates [38,39]. Such risks may relate to the number of clinical activities undertaken in EDs that require use of a range of sharps (devices) and so a greater opportunity for nonspecified (non-safe) use of conventional and safety devices; such as some of those reported herein. This is unlikely to change without a positive intervention. The clinical literature is replete with examples of evidence-based innovations or care pathways that are not adopted, or only partially adopted because of poor evidencetranslation [19,24,25]. It is clear that while education is an effective adjunct [2,39], it is not a complete solution. This small study would suggest that adoption of systematic implementation of behaviour change strategies, using a validated implementation science framework such as the theoretical domains framework, is required to enhance staff safety with sharps in busy EDs. Specifically recommended is exploring what staff use, why they use what they do and ensuring staff practice with newly introduced equipment until they are comfortable with using them in their regular practice.
Limitations The study was limited to one site which may not be representative of other hospital EDs. The doctor nurse staff (ratio 3:2) available for interview was lower than that of review participants (1:3). Staff may have misrepresented their actions, particularly when discussing actions that contravened policy, however data was collected in a deidentified manner by research staff – not involved in direct patient care or staff management. Risks and risk interpretation by staff may be impacted by workload and departmental stress which vary widely across time, day of the week and seasonally.
Conclusions This study used a review and survey methodology to produce a greater understanding of the types of sharps devices available to ED staff, the use and misuse (intentional and unintentional) of sharps within the ED, and the rationales for sharps usage which, when added to the knowledge to act action cycle, will assist in the development of policies and processes to help reduce the risk and incidence of sharps injury. Culture change, ongoing skills development and repeated practice (habit building) with preferred safety equipment is required. This might help to overcome entrenched procedures and increase voluntary engagement with safer sharps devices and clinical processes using these devices.
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Funding The study was funded in part by Queensland Health, Health Improvement Unit. Provenance and conflicts of interest The authors declare no conflict of interest and that this manuscript is not under consideration for any other journal. Acknowledgements The researchers thank the nurses and doctors in the ED who gave up their time to participate in this study. References [1] Rapiti E, Prüss-Üstün A, Hutin YJ (WHO Environmental Burden of Disease Series, No. 11). Available at Sharps injuries: assessing the burden of disease from sharps injuries to health-care workers at national and local levels. Geneva: World Health Organization; 2005 https://www.who.int/quantifying ehimpacts/publications/ebd11/en/. [2] Hasak JM, Novak CB, Patterson JMM, Mackinnon SE. Prevalence of needlestick injuries, attitude changes, and prevention practices over 12 years in an urban academic hospital surgery department. Ann Surg 2018;267:291–6. [3] Centre for Disease Control and Prevention, Available at Sharps injury prevention workbook. Atlanta: CDC; 2004 https://www.cdc.gov/sharpssafety/ . [4] Mannocci A, De Carli G, Di Bari V, Saulle R, Unim B, Nicolotti N, et al. How much do needlestick injuries cost? A systematic review of the economic evaluations of needlestick and sharps injuries among healthcare personnel. Infect Control Hosp Epidemiol 2016;37:635–46. [5] Cooke CE, Stephens JM. Clinical, economic, and humanistic burden of needlestick injuries in healthcare workers. Med Devices (Auckl) 2017;10:225. [6] Loveday H, Wilson J, Pratt R, Golsorkhi M, Tingle A, Bak A, et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 2014;86:S1–70. [7] Laramie AK, Pun VC, Fang SC, Kriebel D, Davis L. Sharps injuries among employees of acute care hospitals in Massachusetts, 2002–2007. Infect Control Hosp Epidemiol 2011;32:538–44. [8] Jagger J, Perry J, Gomaa A, Phillips EK. The impact of US policies to protect healthcare workers from bloodborne pathogens: the critical role of safety-engineered devices. J Infect Public Health 2008;1:62–71. [9] Adams D, Elliott T. Impact of safety needle devices on occupationally acquired needlestick injuries: a four-year prospective study. Can J Infect Control 2006;64:50–5. [10] Stringer B, Astrakianakis G, Haines T, Kamsteeg K, Danyluk Q, Tang T, et al. Conventional and sharp safety devices in 6 hospitals in British Columbia, Canada. Am J Infect Control 2011;39:738–45. [11] Azar-Cavanagh M, Burdt P, Green-McKenzie J. Effect of the introduction of an engineered sharps injury prevention device on the percutaneous injury rate in healthcare workers. Infect Control Hosp Epidemiol 2007;28:165–70. [12] Lamontagne F, Abiteboul D, Lolom I, Pellissier G, Tarantola A, Descamps J, et al. Role of safety-engineered devices in preventing needlestick injuries in 32 French hospitals. Infect Control Hosp Epidemiol 2007;28:18–23. [13] Ballout RA, Diab B, Harb AC, Tarabay R, Khamassi S, Akl EA. Use of safety-engineered devices by healthcare workers for intravenous and/or phlebotomy procedures in healthcare settings: a systematic review and meta-analysis. BMC Health Serv Res 2016;16:458. [14] Lavoie MC, Verbeek JH, Pahwa M. Devices for preventing percutaneous exposure injuries caused by needles in healthcare personnel. Cochrane Database Syst Rev 2014;3. [15] Mitchell A, Parker G, Kanamori H, Rutala W, Weber D. Comparing non-safety with safety device sharps injury incidence data from two different occupational surveillance systems. J Hosp Infect 2017;96:195–8. [16] Dulon M, Lisiak B, Wendeler D, Nienhaus A. Causes of needlestick injuries in three healthcare settings: analysis of accident notifications registered six months after the implementation of EU Directive 2010/32/EU in Germany. J Hosp Infect 2017;95:306–11. [17] Nagi MLF, Kazmi STH, Saleem AA, Khan D, Afsar HH, Akhtar HS. Needlestick and sharps injuries; frequency and the factors contributing among healthcare workers of a tertiary care private hospital. Lahore Prof Med J 2017;24:11–5. [18] Elseviers MM, Arias-Guillén M, Gorke A, Arens HJ. Sharps injuries amongst healthcare workers: review of incidence, transmissions and costs. J Renal Care 2014;40:150–6. [19] Tosini W, Ciotti C, Goyer F, Lolom I, L’Hériteau F, Abiteboul D, et al. Needlestick injury rates according to different types of safety-engineered devices: results of a French multicenter study. Infect Control Hosp Epidemiol 2010;31:402–7. [20] Mendelson MH, Lin-Chen BY, Solomon R, Bailey E, Kogan G, Goldbold J. Evaluation of a safety resheathable winged steel needle for prevention of
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Australasian Emergency Care journal homepage: www.elsevier.com/locate/auec
Research paper
Understanding sharps use in an Australian Emergency Department: A mixed methods organisational case study Chantelle Judge a , Michael Sinnott a,b,c , Rob Eley a,b,∗ , Andy Wong a,c , Amy N.B. Johnston a,b a
Princess Alexandra Hospital, Ipswich Rd, Brisbane, Australia The University of Queensland, St Lucia, Brisbane, Australia c Queensland University of Technology, Brisbane, Australia b
a r t i c l e
i n f o
Article history: Received 5 May 2019 Received in revised form 11 November 2019 Accepted 6 December 2019 Keywords: Emergency department Sharps Percutaneous injuries Culture change
a b s t r a c t Background: Despite the introduction of a range of safety policies and sharps equipment designed to protect healthcare workers, rates of percutaneous injuries from occupational exposure to sharps remains high. This study examined the availability and use of various types of sharps devices in a tertiary hospital emergency department, to understand clinician choice between non-safety and safety devices; and to document their safe and unsafe use of sharps. Methods: This mixed methods study consisted of areview of stock levels, a survey of staff usage, and a content analysis of semi-structured interview data to explore factors which impact on staff preferences for different sharps devices. Results: Staff identified a range of sharps risks, as well as barriers and enablers to the use of safety devices. Availability of, and preference for, familiar devices influenced choice of devices used in clinical practice, despite awareness of associated risks. Conclusions: This understanding of equipment use and the factors that motivate such use have informed the first stage of the knowledge-to-action cycle. Knowledge translation, should include the development of policies to help reduce the risk of sharps injury. Culture change and ongoing skills development might help to overcome entrenched procedures and increase voluntary engagement with safer sharps. © 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Background Risks around sharps injuries for healthcare workers are significant [1], often underreported [2,3], and unacceptably high [4,5]. Processes, such as the Epic Project guidelines [6] in the UK which develop national evidence-based guidelines for preventing healthcare associated infections, have been introduced to mitigate risks from sharps injuries. Numerous studies have demonstrated that percutaneous injuries can decrease when safety devices are implemented in healthcare settings [7–12], particularly for procedures such as intravenous device insertion and phlebotomy [14]. However some of the evidence supporting this assertion is mixed [14]. Some countries enforce the use of safety engineered medical devices [8,15]. Despite this, rates of sharps injury internationally
∗ Corresponding author at: Department of Emergency Medicine, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, 4102, Queensland, Australia. E-mail address: [email protected] (R. Eley).
are still high [2,16,17] and they present one of the major occupational health risks to healthcare workers [18]. Sharps used in a healthcare setting are typically divided into three main categories based on their relative safety: conventional, active and passive safety devices [14]. Conventional sharp devices have no safety feature(s); active sharp devices (also known manually-activated) require users to manually activate a safety mechanism after use (e.g. by depressing a button); and passive sharps devices (fully-automatic) are those which do not require user activation. Passive devices are safer than Active devices which are safer than conventional devices in preventing injury [13,14,19–21]. Despite widespread education campaigns, the incidence of sharps injuries remains high in high-acuity, high-pressure and high-risk areas such as emergency departments (ED). At this Australian study hospital site, sharps injuries have remained relatively static over the last 12 years, with percutaneous injury rates ranging between 52–62% of reported occupational exposures. This was despite a previous surveillance study on such injuries at this site which generated attention and promoted action when it reported
https://doi.org/10.1016/j.auec.2019.12.006 2588-994X/© 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Judge C, et al. Understanding sharps use in an Australian Emergency Department: A mixed methods organisational case study. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.12.006
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Fig. 1. Knowledge translation framework underpinning this study [24,25].
one injury every two days [22]. The majority (55%) of percutaneous injuries to ED staff occurred through needle use (blood gas syringes, disposable needle with syringe and venous/arterial cannula) [23]. The study site’s ED rate of percutaneous injuries was surpassed by only the operating theatres and ICU [22]. More recent unpublished data indicate that one sharps injury is reported every four days thus reinforcing the need for more attention to this topic. There is little discussion in the literature around the impacts of the types of sharp devices available for venepuncture and cannulation on usage or choice of adoption by clinical staff. Aims The aims of this project were to: a) undertake a snapshot of the types sharps devices available to clinical staff in a metropolitan public ED, b) explore staff perceptions of processes around sharps usage, documenting the self-identified incidences of inappropriate or unintended uses of sharps devices and c) identify why clinicians might choose non-safety over safety devices or use a less safe over a safer process.
This study was undertaken in the emergency department of a tertiary level metropolitan hospital in QLD, Australia. The ED manages in excess of 60,000 adult presentations annually. Part one first involved a review of cannulation and venepuncture equipment available to ED staff. This was followed by determination of how the equipment was used by those clinical staff. Cannulation and venepuncture equipment was selected as it is commonly associated with percutaneous injuries [14]. A review tool, was developed via reference to broader published literature [2,9,10,15,18], and used to collect data on device type, recommended usage (purpose), and common procedures for use. To ensure completeness, the review covered stock in the ED storerooms and the procedure trolleys in clinical areas, as well as asking staff a series of simple questions about sharps use and preferences. Identified devices were allocated to one of three categories; conventional, passive or active safety. In Part two, semi-structured interviews with a convenience sample of clinical staff representing a range of clinical entities, informed by the survey data, were undertaken to collect richer contextual information on the cannulation and venepuncture devices identified in Part one [26]. Interviews were undertaken by an independent research team, with experience of ED care processes. Staff were asked direct questions about which devices they use, why they use them, their knowledge/awareness of safety devices, their perceptions of barriers to using safety devices, and the reasons for their preferred choice. Staff were also asked to comment broadly on barriers to effective sharps safety, inappropriate or unintended use of sharps, circumstances when a non-safe device could be chosen, and the circumstances in which staff may breach existing sharps policies. The interview questions were developed to address the research questions and informed by outcomes of Phase 1 of the study. Interviews were recorded for review and analysis.
Data analysis Usage data was subject to a content analysis and simple tabulation [26] by three researchers independently. Discrepancies were resolved by consensus. Interview data analysis was informed by application of Haddon’s Matrix [28] which is a common framework in injury prevention to understand the aetiology (host, agent and environment) and influencing factors across the time frames (pre-event, event, post-event) involved in an injury event.
Methods
Ethics statement
This study used the knowledge-to-action (KTA) framework which has two components: Knowledge Creation and the seven component Action Cycle (see Fig. 1). The creation of knowledge includes literature review, synthesis and an understanding of the tools or products involved (i.e. tailoring the knowledge to a specific setting). These then inform the first stage of the action cycle, namely problem identification. The study completed the knowledge creation and then the first three phases of the action cycle by identifying the problem and applying relevant knowledge created to contextualise and understand the issues around staff use of safety sharps devices [24,25]. The knowledge creation will underpin future interventions and address a gap in current ED knowledge and published literature. A pragmatic two-part sequential mixed methods study [26], informed by case study design [27], was used. Data organization and presentation was informed by the National Institute for Health Research ‘Methodological Framework for Organizational Case Studies’ [27].
The research study adhered to the National Statement on the Conduct of Human Research by the Australian National Health and Medical Research Council and was approved by the Metro South Human Research Ethics Committee (HREC16/QPAH/198).
Results Part one The three cannulation devices were identified one which was passive, one active, and one which was conventional with no safety mechanism. There were six devices available for venepuncture. There were no passive devices, two active safety devices (both using a butterfly needle with a shield attachment) and four conventional devices (one a standard needle and syringe and three types of vacutainer).
Please cite this article in press as: Judge C, et al. Understanding sharps use in an Australian Emergency Department: A mixed methods organisational case study. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.12.006
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Table 1 Equipment identified by staff as associated with sharps risk.
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and ease of locating equipment were the mostly commonly cited reasons for use of traditional needle and syringe.
Equipment Syringe and needle Glass ampoules Blood gas syringe Non-retractable needles Incorrectly disposed sharps Sharps containers Suture needles Butterfly devices Scalpel Intraosseous device
Table 2 Staff-identified factors that influence the safety of sharps devices. Factor
Frequency of identification
Safety features The user/operator of the device Proper and timely disposal Ease of use Education Accessible/available sharps containers
18 10 6 2 3 2
Part two Participants A convenience sample of 23 nurses and 7 doctors, comparable to the current ED skill mix, participated in interviews. Female to male ratio was 3:2 and years of clinical experience ranged from 1.5 to 12. Staff identification of sharps risks, behaviours and processes All staff were aware of the risks and consequences of sharps injuries. They identified equipment commonly associated with sharps injury (Table 1), and a range of risk-ameliorating factors (Table 2). Staff recognised the hospital management’s expectation that the safety equipment provided would be used, and all were aware which devices were recommended for venepuncture and for cannulation. Despite this, a range of other devices were used and preferred (Table 3). Cannula preference While most of the staff preferred the active and passive safety devices, one third admitted to using the conventional device for routine cannulation. This was despite knowledge that its availability in the department was specifically for ultrasound guided IV access. While for three staff the conventional device was their preferred device, the other five said they used it if it was close to hand and other cannulas were not. Of the safety devices the passive one was preferred: a lack of familiarity and training with it was identified as a limitation to use by some staff who preferred the active device. With one exception, all staff reported that the devices available for cannulation had changed since they initially trained. All but one who had changed to a different device stated that they would not go back to the initial equipment. Venepuncture preference In the ED cannulation is standard practice and venepuncture less common as blood was often drawn through the cannula. This aligned with staff reporting less familiarity with newer equipment to undertake venepuncture. Despite awareness of the risks and the availability of safer devices, 10 staff indicated that they had not changed from needle and syringe since their initial training. Habit
Barriers to use of safety devices Participants identified a range of barriers to the use of safe devices. These included unavailability, time constraints, ingrained habits, access to unsafe devices, poor familiarisation and competency with newer devices, increased manual dexterity and steps required to use safety devices, increased costs of quality products, emergent/agitated patient scenarios and too many choices of device. Safe use of devices was compromised by full or inadequate access to sharps bins, poor (or absent) sharps disposal behaviour, and lack of training in the use of specific devices. Staff frequently stated that they deliberately selected non-safety devices in specific pressure situations requiring the need for speed and confidence. Non-safety devices were used for procedures such as ultrasound guided IV access where there was apparently no suitable alternative. There were also situations where staff felt that conventional devices were better and easier to use. They claimed this use was justified because of their previous training, pressure and time-constraints, and perceived availability. Other key themes that emerged during the interviews related to the risks of sharps injuries during clinical practice. Staff identified situational drivers that predisposed them to sharps injuries. These included inappropriate use of a sharp, typically driven by the need for speed, and the use of sharps for non-designed purposes (Table 4). Sharps disposal for others Despite awareness of the risks and the policy not to dispose of others’ sharps, 25 of the 30 staff interviewed reported this activity. Situations identified where this had occurred included while cleaning up after someone else, in resuscitation or emergent situations, and during assisting or teaching procedures. Haddon’s Matrix This framework [28] was used to inform categorisation of the factors identified by the interviewed staff as risk factors and the time (pre-, during- or post-use) when the factor poses a risk. For this study the ‘host’ is the clinician participant, ‘agent’ the equipment and environment is the surroundings within the study ED. As highlighted in Table 5 in the Host column, clinician risk of sharps injury may be reduced if appropriate pre-event knowledge and education is provided, the device is used correctly during the event, and then disposed of suitably post-event. Similar preventative strategies are identified for the agent (device) and environment in their respective columns. These data can be aligned with sharps availability and usage data to provide a comprehensive picture of staff risk during cannulation and venepuncture. Discussion Despite the real risks of disease transmission and the ready availability of safety devices, percutaneous injury remains an occupational hazard for healthcare workers, particularly in critical care areas such as emergency [29]. This local snapshot of sharps availability and usage reiterates national [29] and international data [2,7–13,16,30–32], that span decades. Completion of the first three phases of the knowledge-to-action framework to contextualise and understand staff (mis)use of safety sharps devices enabled the study to address a major gap in current ED knowledge and published literature that can underpin future interventions. Interviews with nurses and doctors revealed that knowledge of sharps risks and their access to safety devices did not strongly influence the devices they used. For some procedures many staff
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Table 3 Cannulation and venepuncture devices available, reported usage and comments on usage considerations. Device
Preferred by
Used by
Positive comments
Negative comments
Cannulation Device Conventional
3
8
Extra length; more manoeuvrability; easier to determine if in vein through flashback; easier feeding over stylet
Active Safety
7
17
Passive
20
23
Immediate flashback; easier for difficult veins as can get good angles; good success rate; familiar; easy to use; safe; comfortable Wings help to articulate angle and control; ease of use; wings for stability; flashback straight away then blood delay; easy to secure; valve stops the blood flow; manoeuvrability; pressure distribution
Difficult to hold; uncomfortable; not ideal for securing; doesn’t have wings; sharps risk; bleed out; no safety mechanism Hub is too long; unwieldy; not ideal for securing; doesn’t have wings; bleed out; speed of needle retraction; fiddly; harder to use Can’t re-feed stylet; feels blunt; blow veins; difficult to retract; not as good for difficult veins; bulkier
16
22
0
2
3
4
0
3
7
18
0
7
4
n/a
Venepuncture Device Conventional: Standard needle and syringe Conventional: Standard needle with luer lock vacutainer Conventional: Vacutainer shield/needle Conventional: Vacutainer needles and vanish point shield Active Safety: Butterfly with vacutainer shield Active Safety: Butterfly with syringe Undecided or no preference stated
Easier especially with a difficult access; familiarity; high success rate; easy to find equipment
Risks of needlestick injury
Simple and easy to use; easy to handle; good for large samples (many vials); blood contained
Easier to manipulate and more accessible
Table 4 Examples of injury predisposing situational drivers. Inappropriate use of safety devices Using a needle to open a nicotine patch when scissors not available Recapping needles
Suturing clothes Not activating safety device on retractable needles Suturing shoes
Filling gas syringe with needle/syringe instead of direct from patient
High risk of needle stick injury
Devices used for unintended purposes Needle to remove eye foreign body Removal of cannula stylet and using device to flush, paracentesis (difficult airway) Arterial lines done with cannulas Transferring blood with needle/syringe instead of transfer device Using a blood gas syringe by bending needle and making a burr hole in a finger nail 18 G needle used for IMI
preferred to use the equipment they were most or first familiar with. In fact, habit, or initial training was the most common reason cited for why a clinician might choose a non-safety over a safety device, or an unsafe over a safer process. A common secondary reason, particularly for venepuncture, was that the standard needle and syringe were most fit-for-purpose, providing the greatest “feel” and accuracy. Thus, data reported here suggest that sharps usage maybe typically related to long-standing (entrained) behaviour patterns. Habits, often triggering behaviours because of situational or contextual cues, rather than clinical reasoning or focused intentions are cited as a barrier to clinical behaviour change [33,34]. The corollary of this is that behaviour change may require some sort of contextual change (e.g. removing equipment from easy access)
No flashback; can lose vein especially while attaching vials; can’t control blood flow Lack of pressure increases risk of losing vein; bulky; can’t see flashback; unfamiliar; fiddly Fiddly
Table 5 Haddon’s Matrix.
Preevent
Event
Post -event
Host = Clinician
Agent = Device
Environment
Safe sharp techniques knowledge Education Safe operation of device
Safety mechanism for sharps
Sharp container accessibility
Appropriate disposal
Needleless devices Availability of sharps with safety mechanism
Easy retraction or trigger of safety feature – non-complicated mechanism
Agitated patient Emergency/ Resuscitation situation Sharps bin placement and non-frequent emptying
or incentive to undertake vigilant monitoring of behaviours [34]. Researchers exploring implementation science suggest “There is a need to explore intervention strategies that account for the habitual nature of clinical practice by investigating various means of contextual changes or disturbances to break unwanted habits and/or achieving behavioural repetition in consistent contexts to promote formation of desired habits.” [33, pg 5]. Involving frontline healthcare staff in the selection of safety devices and thus self-initiating contextual change is one of the consensus recommendations from the International Safety Center (formerly, the International Healthcare Worker Safety Center) [35]. This is echoed by the Australian Alliance for Sharps Safety and Needlestick Prevention in Healthcare [36] and others [37]. The data presented herein, coupled with recent review evidence, sug-
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gests that even allowing for positive publication bias, safety devices are only one important part of a multifactor solution [2,5,33,38]. Our data suggests that there is unlikely to be further change until conventional sharps are either available only with limited access or removed from clinical spaces. This would require prioritising staff safety over equipment costs, as safer devices are usually more expensive than conventional devices. In the USA, Occupational Health and Safety Administration (OSHA) regulations dictate use of sharps injury prevention devices. Data pre- and post the Needlestick Safety and Prevention Act (2000) shows that safety devices positively impact on injury rates [32,38,39], although these effects are slow to emerge. Our results echo a Canadian study where despite a regulatory framework, needlestick injuries continued to occur and injuries were associated with the (lack of) ease of use of safer devices, unpredictable patient interactions and non-compliance with intended device use [10]. Emergency staff maybe at greater risk of exposure to percutaneous injuries than many of their professional colleagues [17,22], or they may just be more likely to report such injuries [16,34]. High staff workload is often cited as a factor in the incidence of percutaneous injury rates [38,39]. Such risks may relate to the number of clinical activities undertaken in EDs that require use of a range of sharps (devices) and so a greater opportunity for nonspecified (non-safe) use of conventional and safety devices; such as some of those reported herein. This is unlikely to change without a positive intervention. The clinical literature is replete with examples of evidence-based innovations or care pathways that are not adopted, or only partially adopted because of poor evidencetranslation [19,24,25]. It is clear that while education is an effective adjunct [2,39], it is not a complete solution. This small study would suggest that adoption of systematic implementation of behaviour change strategies, using a validated implementation science framework such as the theoretical domains framework, is required to enhance staff safety with sharps in busy EDs. Specifically recommended is exploring what staff use, why they use what they do and ensuring staff practice with newly introduced equipment until they are comfortable with using them in their regular practice.
Limitations The study was limited to one site which may not be representative of other hospital EDs. The doctor nurse staff (ratio 3:2) available for interview was lower than that of review participants (1:3). Staff may have misrepresented their actions, particularly when discussing actions that contravened policy, however data was collected in a deidentified manner by research staff – not involved in direct patient care or staff management. Risks and risk interpretation by staff may be impacted by workload and departmental stress which vary widely across time, day of the week and seasonally.
Conclusions This study used a review and survey methodology to produce a greater understanding of the types of sharps devices available to ED staff, the use and misuse (intentional and unintentional) of sharps within the ED, and the rationales for sharps usage which, when added to the knowledge to act action cycle, will assist in the development of policies and processes to help reduce the risk and incidence of sharps injury. Culture change, ongoing skills development and repeated practice (habit building) with preferred safety equipment is required. This might help to overcome entrenched procedures and increase voluntary engagement with safer sharps devices and clinical processes using these devices.
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Funding The study was funded in part by Queensland Health, Health Improvement Unit. Provenance and conflicts of interest The authors declare no conflict of interest and that this manuscript is not under consideration for any other journal. Acknowledgements The researchers thank the nurses and doctors in the ED who gave up their time to participate in this study. References [1] Rapiti E, Prüss-Üstün A, Hutin YJ (WHO Environmental Burden of Disease Series, No. 11). Available at Sharps injuries: assessing the burden of disease from sharps injuries to health-care workers at national and local levels. Geneva: World Health Organization; 2005 https://www.who.int/quantifying ehimpacts/publications/ebd11/en/. [2] Hasak JM, Novak CB, Patterson JMM, Mackinnon SE. Prevalence of needlestick injuries, attitude changes, and prevention practices over 12 years in an urban academic hospital surgery department. Ann Surg 2018;267:291–6. [3] Centre for Disease Control and Prevention, Available at Sharps injury prevention workbook. Atlanta: CDC; 2004 https://www.cdc.gov/sharpssafety/ . [4] Mannocci A, De Carli G, Di Bari V, Saulle R, Unim B, Nicolotti N, et al. How much do needlestick injuries cost? A systematic review of the economic evaluations of needlestick and sharps injuries among healthcare personnel. Infect Control Hosp Epidemiol 2016;37:635–46. [5] Cooke CE, Stephens JM. Clinical, economic, and humanistic burden of needlestick injuries in healthcare workers. Med Devices (Auckl) 2017;10:225. [6] Loveday H, Wilson J, Pratt R, Golsorkhi M, Tingle A, Bak A, et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 2014;86:S1–70. [7] Laramie AK, Pun VC, Fang SC, Kriebel D, Davis L. Sharps injuries among employees of acute care hospitals in Massachusetts, 2002–2007. Infect Control Hosp Epidemiol 2011;32:538–44. [8] Jagger J, Perry J, Gomaa A, Phillips EK. The impact of US policies to protect healthcare workers from bloodborne pathogens: the critical role of safety-engineered devices. J Infect Public Health 2008;1:62–71. [9] Adams D, Elliott T. Impact of safety needle devices on occupationally acquired needlestick injuries: a four-year prospective study. Can J Infect Control 2006;64:50–5. [10] Stringer B, Astrakianakis G, Haines T, Kamsteeg K, Danyluk Q, Tang T, et al. Conventional and sharp safety devices in 6 hospitals in British Columbia, Canada. Am J Infect Control 2011;39:738–45. [11] Azar-Cavanagh M, Burdt P, Green-McKenzie J. Effect of the introduction of an engineered sharps injury prevention device on the percutaneous injury rate in healthcare workers. Infect Control Hosp Epidemiol 2007;28:165–70. [12] Lamontagne F, Abiteboul D, Lolom I, Pellissier G, Tarantola A, Descamps J, et al. Role of safety-engineered devices in preventing needlestick injuries in 32 French hospitals. Infect Control Hosp Epidemiol 2007;28:18–23. [13] Ballout RA, Diab B, Harb AC, Tarabay R, Khamassi S, Akl EA. Use of safety-engineered devices by healthcare workers for intravenous and/or phlebotomy procedures in healthcare settings: a systematic review and meta-analysis. BMC Health Serv Res 2016;16:458. [14] Lavoie MC, Verbeek JH, Pahwa M. Devices for preventing percutaneous exposure injuries caused by needles in healthcare personnel. Cochrane Database Syst Rev 2014;3. [15] Mitchell A, Parker G, Kanamori H, Rutala W, Weber D. Comparing non-safety with safety device sharps injury incidence data from two different occupational surveillance systems. J Hosp Infect 2017;96:195–8. [16] Dulon M, Lisiak B, Wendeler D, Nienhaus A. Causes of needlestick injuries in three healthcare settings: analysis of accident notifications registered six months after the implementation of EU Directive 2010/32/EU in Germany. J Hosp Infect 2017;95:306–11. [17] Nagi MLF, Kazmi STH, Saleem AA, Khan D, Afsar HH, Akhtar HS. Needlestick and sharps injuries; frequency and the factors contributing among healthcare workers of a tertiary care private hospital. Lahore Prof Med J 2017;24:11–5. [18] Elseviers MM, Arias-Guillén M, Gorke A, Arens HJ. Sharps injuries amongst healthcare workers: review of incidence, transmissions and costs. J Renal Care 2014;40:150–6. [19] Tosini W, Ciotti C, Goyer F, Lolom I, L’Hériteau F, Abiteboul D, et al. Needlestick injury rates according to different types of safety-engineered devices: results of a French multicenter study. Infect Control Hosp Epidemiol 2010;31:402–7. [20] Mendelson MH, Lin-Chen BY, Solomon R, Bailey E, Kogan G, Goldbold J. Evaluation of a safety resheathable winged steel needle for prevention of
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