Directives governing the protection of HCW from
medical sharps injuries have been implemented
across Europe, with varying degrees of thoroughness,
owing to ever-growing cost constraints,
inconsistencies in reporting and follow-up of NSI,
(sometimes) inadequate training and competing
priorities.
A more in-depth look at the specific preventive
measures required by the Directive across Europe
reveals similarities and difference in greater detail.
Specific measures to prevent NSI
Employees and HCWs must work in an integrated
fashion in creating a safe work environment, through
a combination of prevention and monitoring of
incidents, awareness-raising, and information,
education and training, to create a no-blame culture
in systematic reporting of NSI. The creation of this
safe working environment extends to workplace
design and the placement of sharps containers.
Anyone working in a clinical setting is potentially at
risk of NSI. Nurses are perceived to be at greatest
risk, insofar as they conduct the majority of invasive
procedures involving the use of needle devices, but
risk of contamination is aligned with the clinical
setting of the procedure, and extends to, for example,
surgeons in operating theatres and logistical,
housekeeping and outsourced staff for cleaning and
waste disposal activities. One delegate (Spain) shared
reports of patients bringing unsafe needles with
them to hospital, introducing a new risk for the
healthcare workers when they are not disposed of in
the right way by the patient. Sharps can be found
inappropriately discarded practically anywhere in the
hospital: on the floors, high up on shelves, in lab coat
pockets. And the greater the number of procedures in
any given location in the hospital, the higher the risk
to the housekeeping staff. The only exception to this,
reported in Italy, is the lower risk of infection in
infectious disease departments. This is attributed to
the annual 36-hour mandatory training for all HCW
at risk of blood-borne infection and exposure,
a programme that includes doctors, nurses and
housekeepers.
Those at risk extend to independent, self-
employed nurses (who are not covered by the
Directive) who work outside the hospital, providing
home care (for example), an issue raised especially
in France, where a specific study on this group
has started.
It should never be assumed that there is no risk.
Healthcare workers are predominantly responsible
for the operational avoidance of NSI, with the CEO
and Hospital Board holding ultimate responsibility
for the safety of its employees. In the Irish private
sector here represented, for example, everyone
working with sharps is responsible for their safe
disposal.
Personnel and managers may have
completely different perceptions of the
adequacy of information and training in
their hospital, necessitating frequent
and varied initiatives. All delegates
strongly support the introduction of
training of students in medical and
nursing schools in all aspects of risk
prevention, as well as initiatives to
support temporary staff, whose
access to education and training
may be limited by time constraints.
Regarding the importance of
training/education in the reduction of
NSIs, a meta-analysis reported by the
delegate from Italy showed that
While sharps
safety is a priority,
it is a priority
along with
everything else
being a priority
Debra Adams
a combination of education/training and use of SEDs
is more effective in lowering incidence of NSI than
either on its own. 4 Safety devices reduce the exposure
by modifying and isolating the hazard, while training
modifies the behaviour (e.g. providing instructions on
how to safely manipulate used, blood-contaminated
needles) without modifying the hazard. Both
elements are necessary, as shown by the persistence
of needle recapping despite its explicit banning by
the Directive: Italy reports as many as one-third of
nurses continue to recap.
However, an effective use of SEDs also requires
specific training, e.g. to ensure that SEDs are correctly
activated. In The Netherlands, a train-the-trainer
network of super-users from different departments
has proven very effective in supporting proper use
of SEDs.
The replacement of conventional needles with
SEDs will always be less than 100% in those instances
where existing stock has first to be exhausted: the
delegate from Italy reported that, in a 2017
nationwide survey, fewer than 50% of needles were
originally replaced with SEDs, with one of the main
reasons being the cost implication of losing existing
stock. Additional costs of SEDs were also perceived as
an obstacle to total replacement of conventional
devices.
Regardless of whether conventional or safety
devices are in use, in all instances there should be
the ambition to use fewer needles, as required by
Clause 6 of the Directive. Eliminating the unnecessary
use of sharps when there are alternatives, e.g. not
using a fingerstick for glucose monitoring in diabetic
patients when a subcutaneous electrochemical
glucose sensor can be implanted; or, using buttonhole
technique to access fistula with a blunt needle in
dialysis patients, or sutureless devices to fix central
catheters to the skin. Decreasing the necessary use
should also be a priority, achievable, for example, by
minimising the number of blood drawing/blood tests
through careful planning (several software are
available), only inserting peripheral intravenous
catheters where needed, administering drugs by oral
therapy where feasible. Replacing the necessary
devices with safer alternatives completes the process:
in those instances where needles must be used, SEDs
and training in their use are vital in order to design
out human faults of non-activation prior to disposal.
The delegate from Ireland raised interesting
comparisons between private and public sectors.
Operating currently within the private sector, she
cites mandatory training for all staff (one hour) on
sharps and infection control, driven by the Joint
Commission International (JCI) as being essential for
accreditation – a requirement not reflected in the
public sector. This private/public position on SEDs
is reversed in other countries.
In Italy and France, the uptake of SEDs in the
private sector is lower than that in the public sector,
though only limited data are available; although
every hospital will have a Safety Manager and will
run education and training courses, data collection on
NSI is poor. HCWs in these settings will have private
contracts and may be in fear of losing their jobs if
they report NSIs. In Ireland, data collection in the
private sector is very good because it is driven by JCI
accreditation, without which hospitals receive no
income.
Poland reports no data from the private sector:
hospitals keep their own records, and the employer is
not required to report. Private and public sectors have
implemented the Directive, but data collection is
solely for the hospital’s needs.
In Spain, it was reported that public hospitals
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