Management of Sharp Injuries - Assignment Example

Critical Analysis in the Management of Sharp Injuries Sharp instruments include needles, intravascular guide wires, cannulae, stitch cutters, razor blades, scalpels, broken glass and other sharp objects have the potential to cause injury through cuts or puncture wounds (Sharps Management 2006). Many sharps are contaminated with blood or body fluids, microbiological materials, toxic chemicals or radioactive substances, posing a risk of infection or illness when penetrated to the skin (Mumford 2001) leading to serious sharp injuries. Below is a case study showing an incident of a sharp injury happened in a healthcare setting. Lisa Black, a registered nurse, was caring for a patient in the terminal stages of AIDS when she suffered a needle stick injury. She was in the process of irrigating intravenous (IV) infusion tubing that had become occluded with blood by inserting a needle into a rubber port on the patient’s IV line. While attempting to aspirate the coagulating blood and then flush the IV line, the patient became startled and jerked, causing the needle to dislodge from the rubber port of the IV line. The needle punctured the palm of her left hand. Nine months later, Lisa learned that she had become infected with the Human Immunodeficiency Virus (HIV) and in the months following also learned that she was also infected with Hepatitis C. Hepatitis C (HCV) and Human Immunodeficiency Virus (HIV), the virus that causes AIDS are two of the most serious of the 20 blood-borne pathogens that health care workers are exposed to in their daily work caring for the world’s health (Wilburn and Eijkemans 2005). The case study showed that occupational exposure to blood-borne pathogens from sharps or needlesticks is in fact happening. These sharp injuries are serious problems in the health care system (CDC 2004). Health care workers (HCWs) are at a high risk transmission of blood-borne pathogens namely hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HTV) (Smith, 2001). Risk posed by sharp injuries wherein needlesticks and injury from other sharp devices may take place (Sharp Injury Prevention 2007). Hence, prevention of sharp injuries and other blood exposures is an important step in preventing the transmission of bloodborne viruses to healthcare personnel (CDC 2004). According to Centers for Disease Control and Prevention (CDC), estimates of sharp injuries each year results to 385,000 needlesticks and other sharps related injuries sustained by hospital-based healthcare personnel (Panlilio et al. 2000). Similar injuries occur in other healthcare settings, such as nursing homes, clinics, emergency care services, and private homes (CDC 2004). Epidemiologic data on sharps injuries and circumstances associated with occupational transmission of blood-borne viruses are essential for targeting and evaluating interventions at the local and national levels. However, the true magnitude of the problem is difficult to assess because information has not been gathered on the frequency of injuries among healthcare personnel working in other settings such as long-term care, home healthcare, private offices. Although CDC estimates are adjusted for it, the importance of underreporting must be acknowledged. Surveys of healthcare personnel indicate that 50% or more do not report their occupational percutaneous injuries (Roy et al. 1995; CDC 1997; Osborn et al. 1999 Abdel Malak et al. 2000; CDC 2004) giving a decrease of reported data. Data from National Surveillance System for Health Care Workers (NaSH) show that nurses sustain the highest number of sharp injuries. However, other patient-care providers such as the physicians, technicians, laboratory staff, and support personnel (e.g., housekeeping staff), are also at risk (CDC 2004). NaSH data also show that the majority of injuries or 40% occur on inpatient units, particularly medical floors and intensive care units, and in operating rooms. Injuries most often occur after use and before disposal of a sharp device resulted to 41%, during use of a sharp device on a patient 39% of injuries, and during or after disposal only 16% out of 100 percent (CDC 2004). In 1981, McCormick and Maki first described the characteristics of needlestick injuries among healthcare personnel and recommended a series of prevention strategies. These strategies include educational programs, avoidance of recapping, and better needle disposal systems (McCormick and Maki 1981). In 1987, CDC’s recommendations for universal precautions included guidance on sharps injury prevention, with a focus on careful handling and disposal of sharp devices (CDC 1987). Several reports on needlestick prevention published between 1987 and 1991 focused on the appropriate design and convenient placement of puncture-resistant sharps disposal containers and the education of healthcare personnel on the dangers of recapping, bending, and breaking used needles (Ribner et al. 1987; Ribner 1990; Linnemann 1991; Sellick 1991; Edmond 1988; Smith 1991; Haiduven 1992; CDC 2004). Most of these studies documented only limited success of specific interventions to prevent disposal-related injuries and injuries due to recapping (Linnemann 1991; Sellick 1991; Edmond 1988; Smith 1991; CDC 2004). Later studies show that greater success in decreasing injuries was reported if the intervention included an emphasis on communication (Ribner et al. 1987; Ribner 1990; Linnemann 1991; Sellick 1991; Edmond 1988; Smith 1991; Haiduven 1992; CDC 2004). Here it is seen the value of communication through reporting incidence or events to health care setting. Universal precaution also known as standard precaution is an important concept and an accepted prevention approach with demonstrated effectiveness in preventing blood exposures to skin and mucous membranes (Wong et al. 1991; Fahey et al. 1991; CDC 2004). However, it focuses heavily on the use of barrier precautions (i.e., personal protective practices) and work-practice controls (e.g., care in handling sharp devices) and by itself could not be expected to have a significant impact on the prevention of sharps injuries. Although personal protective equipment provide a barrier to shield skin and mucous membranes from contact with blood and other potentially infectious body fluids, most protective equipment is easily penetrated by needles. Thus, although strategies used to reduce the incidence of sharps injuries it is still important to have additional interventions when needed (CDC 2004). Control of infectious disease is an important element of its overall risk management efforts. All health care providers must comply with federal, state and municipal rules and regulations, to the hospital's policies and procedures regarding the control of infectious disease. Some of the aspects of infectious disease control include preventing and reporting communicable diseases, universal blood and body fluid precautions, needlestick precautions and proper medical waste disposal (Infectious Disease Control 1997). These strategies would be further discussed in the following paragraphs. Preventing and reporting communicable disease In recent years, healthcare organizations have adopted a prevention model the hierarchy of controls concept used by the industrial hygiene profession to prioritize prevention interventions. In the hierarchy for sharps injury prevention, the first priority is to eliminate and reduce the use of needles and other sharps where possible. Next is to isolate the hazard, thereby protecting an otherwise exposed sharp, through the use of an engineering control. When these strategies are not available or will not provide total protection, the focus shifts to work-practice controls and personal protective equipment (CDC 2004). Prevention of needle stick injuries is the most effective way to prevent infection. Control measures to prevent needle stick injury following the traditional hierarchy of controls from most effective to least effective include the following (American Nurses Association, 2002): Hazard elimination. Instead of using injections, administer medications another way, can be done by using tablets, inhalers, or transdermal patches. Needleless intravenous systems, such as jet injectors, can be substituted for syringes and needles. If injections are used, minimize the number by eliminating all unnecessary injections. Remove unnecessary sharps (e.g. towel clips) and needles from the workplace (Rapiti et al. 2005). Engineering controls. These are technological devices that include needles that retract, sheathe, or blunt immediately after use. The technology of these devices has improved over the last decade, and they are widely available in North America and Europe. They are required by law in the USA (Rapiti et al. 2005). Administrative controls. These include policies and training programs aimed at limiting exposure to the hazard, such as Universal Precautions, allocating resources to demonstrate a commitment to the safety of health-care workers, instituting a needlestick prevention committee, formulating an exposure control plan, and having consistent training programs (Rapiti et al. 2005). Work practice controls. These include rules that prohibit the recapping of needles; placing sharps containers at eye-level and at arms reach; checking sharps disposal containers on a schedule and emptying them before they become full; and establishing the means for safely handling and disposing of sharps devices before beginning a procedure (Rapiti et al. 2005). Personal protective equipment. These are protective barriers and filters between the worker and the hazard. Examples include eye goggles, face shields, gloves, masks and gowns (Rapiti et al. 2005). Multi-component Prevention Approaches. Experts agree that safety devices and work practices alone will not prevent all sharps injuries (Davis 1999; Gerberding 1993; Hanrahan et al. 1997; Wugofski 1992; Zafar et al. 1997; Gershon et al. 1999; AHA 1999; CDC 2004). In this, to make a significant decline in sharps injuries the multi-component prevention approach is as follows: Education, A reduction in the use of invasive procedures (as much as possible), A secure work environment, and An adequate staff-to-patient ratio. (CDC 2004) Another program by CDC 2004 recommends to decrease needlestick injuries involves simultaneous implementation of multiple interventions: Formation of a needlestick prevention committee for compulsory in-service education programs; Out-sourcing of replacement and disposal of sharps boxes; Revision of needlestick policies; and Adoption and evaluation of a needleless IV access system, safety syringes, and a prefilled cartridge needleless system (Gershon et al. 1999). Education, administrative and work practice controls have been shown to reduce up to 80% of needle stick injuries. Engineering controls can reduce over 90% of needle stick injuries. Lisa Black’s injury and infection could have been prevented with the use of Intravenous (IV) needle less system or an automatically sheathing needle. A supplementary needle to irrigate the Intravenous (IV) line was an unnecessary hazard (Rapiti et al. 2005). In cases there is sharp or needlestick injuries happened, policies require all physicians and hospitals to report cases, carriers or persons infected with specified communicable diseases. Several of the more common diseases include botulism, chicken pox, dysentery, encephalitis, rubella, gonorrhea, Hepatitis (A, B, Non-A, Non-B), Lyme disease, meningitis, rabies, Streptococcal sore throat, syphilis, tuberculosis, and whooping cough. Reporting procedures will vary somewhat as between the states (Infectious Disease Control 1997). Universal Blood and Body Fluid Precautions Since a medical history, examination or laboratory testing cannot reliably identify all patients infected with HIV, Hepatitis B or other blood borne pathogens, health care providers must utilize universal blood and body fluid precautions in caring for all patients (Infectious Disease Control 1997). These universal blood and body fluid precautions recommend hands to be thoroughly washed before and after contact with patients, even with the used of gloves to reduce risk to patients as well as to health care workers; if hands, or other parts of the body, come in contact with blood, body fluids or human tissue, they should be immediately washed with soap and water; gloves must be worn when contact with blood, body fluids or a contaminated surface is expected; gowns or plastic aprons are indicated if blood splattering is likely; masks and protective goggles must be worn if aerosolization or splattering is likely to occur, such as dental and surgical procedures, wound irrigations, post mortem examinations and bronchoscopy; to minimize the need for emergency mouth to mouth resuscitation, mouth pieces, resuscitation bags or other ventilation devices must be available for use in areas where the need for resuscitation is predictable; sharp objects, such as needles and glass, must be handled with care to prevent accidental cuts or punctures; used needles should not be bent, broken, reinserted into their original sheaths, recapped, or unnecessarily handled; after use, these needles should be immediately discarded intact in puncture resistant needle disposal containers; all needle stick accidents, mucosal splashes or contamination of open wounds must be reported immediately; blood spills should be cleaned up promptly with a disinfectant solution; all patient specimens should be considered bio-hazardous and bagged for transport to laboratories. These precautions may minimize transmission of disease from patient to health care provider and decrease the likelihood of easy transmission of organisms to other patients (Infectious Disease Control 1997). Needle Sticks Precautions Occupational exposure to, and the transmission of, Hepatitis B (HBV) and human immunodeficiency virus (HIV) are of the utmost importance from a risk management standpoint because of the need to protect health care workers, patients and visitors from these viruses. Needlestick injuries are the largest source from which occupational exposures to these agents arise in the hospital workplace (Infectious Disease Control 1997): Since all hospital workers are at risk of needlestick injury, adherence to the following practices is useful in preventing needlesticks such as avoid rushing when handling needles; avoid pulling hard when encountering resistance in withdrawing needles from patients; seek assistance when using a needle in caring for an uncooperative patient; avoid recapping under all circumstances, but never recap a needle that has been used on a patient; dispose of needles properly in puncture resistant containers; never leave needles on beds, stretchers, or bedside tables since they may injure staff, patients, or visitors and o not throw them into regular garbage containers where they may injure housekeeping staff; never put needles in your pocket; never try to remove anything from a needle container or force needles into a full container; pick up improperly discarded needles with care and dispose it in a puncture-resistant container (Infectious Disease Control 1997). In the event a needlestick does occur, promptly wash the area with soap and water, record the patient's name and hospital number, prepare an incident form and report the event. Attempts to "milk" the wound to express contaminants are ineffective and only damage tissues further. It is important to consider appropriate testing for hepatitis and HIV along with any recommended prophylaxis (Infectious Disease Control 1997). Proper medical waste disposal The improper disposal of medical waste not only has the potential to cause injury to health care workers, patients and visitors, but can have widespread public health effects. A number of federal, state and local regulatory agencies, in addition to hospitals, have promulgated regulations and policies governing medical waste disposal with which all health care workers should be familiarize (Infectious Disease Control 1997). Sharps shall be placed into a sharps container as soon as possible after use. To avoid needlestick injuries, needles shall not be re-sheathed. Sharps containers need to be rigid, impervious containers which are discarded when full. When full, sharps containers holding contaminated sharps shall not be placed into the general rubbish stream. They are to be included in the hazardous waste collection service provided by the Risk Management. Collection of full sharps containers and other hazardous waste is arranged through the departmental waste. Improper disposal of medical waste could expose the hospital to significant risk, penalties and corrective action (Mumford 2001). Post Exposure Prophylaxis In case the health care worker injured himself from sharps, the injured area or damaged skin should be washed thoroughly but without scrubbing, and covered with a dressing. Exposed mucous membranes or conjunctivae should be irrigated abundantly with water. If there has been a puncture wound, free bleeding should be encouraged and make sure not to suck the wound (Sharps Management and Inoculation Injuries 2006). An effective sharps injury prevention program prevents healthcare personnel from suffering needlesticks and other sharps related injuries. It is therefore essential to follow safe procedures when using and disposing of sharps in order to protect health care workers from sharps injuries (Mumford 2001). Overall, sharp injuries and exposure to blood and body fluids are a serious risk to health care workers and a threat to quality of life to patient care. These sharp injuries resulting infections are largely preventable with the implementation (Wilburn and Eijkemans 2005) of risk management. These include adherence to universal or standard precautions, appropriate use of safety devices and a needle disposal system to limit sharps exposure. Training for health care workers in safe sharps practice should be ongoing. Information on preventive measures must be provided to all staff with potential exposure to blood and blood products. Policies which are in keeping with the local and national guidelines must include screening of patients, disposal of sharps and wastes, protective clothing, managing inoculation accidents, sterilization and disinfection. Post exposure prophylaxis should be started immediately as per recommended guidelines (Introduction to Standard (Universal) Precautions n.d.).Hence, these various strategies of risk management reduce or mitigate sharp injuries incidents in healthcare setting. These strategies prevent occupational exposure of health care workers like Lisa Black to blood-borne pathogens and infections. Bibliography Abdel Malak, S., Eagan, J., Sepkowitz, KA. 2000. Epidemiology and reporting of needle-stick injuries at a tertiary cancer center [Abstract P-S2-53]. 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