r\
`
`journal ofAdvanced Nursing, 1 997, 25, 144—154
`
`A critical review of the literature on sharps
`injuries: epidemiology, management of
`exposures and prevention
`
`Anita Hanrahan RN MN
`Epidemiologist, Capital Health Authority, Suite 500, 10216 124 Street, Edmonton
`
`and Linda Reutter RN PhD
`
`Associate Professor, Faculty of Nursing, Clinical Sciences Building, The University of
`Alberta, Edmonton, Alberta, Canada
`
`Accepted for publication ‘16 January 1996
`
`Journal ofAdvanced Nursing 25, 144—154
`HANRAHAN A. (1997)
`A critical review of the literature on sharps injuries: epidemiology,
`p
`management of exposures and prevention
`This article reviews the literature related to the epidemiology, prevention and
`management of sharps injuries in health careworkers, particularly nurses, and
`the subsequent risk of harm. The studies are reviewed chronologically,
`beginning with the efforts to reduce sharps injuries by changing behaviours,
`followed by the introduction of barriers to protect the caregiver, and finally, the
`engineering of safer products. Initial efforts to prevent sharps injuries focused
`on placing rigid, disposal containers at the site where sharps were used and
`instructing health care workers to refrain from the practice of recapping. When
`these interventions were shown to alter the type, but not the overall number, of
`sharps injuries, alternative measures were sought. This search intensified with
`the increasing evidence of the small, but measurable, risk of the transmission of
`human immunodeficiency virus from sharps injuries. The current knowledge of
`the factors related to sharps injuries has been collected primarily through
`retrospective surveillance. This surveillance has been conducted primarily in
`hospital settings and has focused on the type of sharp and the purpose for
`which it was used rather than prospective research. Research is now needed to
`elucidate the organizational and behavioural factors leading to sharps injury
`both within the hospital as well as other health care settings. The implications
`for nursing practice are discussed.
`
`WORKPLACE INFECTIONS
`
`Nurses are at risk of acquiring infections in the workplace
`(Williamson et al. 1988, Hersey & Martin 1994). Blood-
`borne infections may be transmitted occupationally
`through parenteral exposure, mucous membrane exposure
`and exposure through non-intact skin (Centers for Disease
`Control
`(CDC)
`1989). Based on studies conducted
`
`Correspondence: Anita Hanrahan, Capital Health Authority, Suite 500,
`10216 124 Street, Edmonton, Alberta, Canada T5N 4A3.
`’
`
`144
`
`the greatest occupational risk for
`worldwide, however,
`transmitting a blood-borne infection is through parenteral
`exposure - by a penetrating sharps injury -— sustained
`from an infected person (Marcus et a1. 1988, CDC 1989,
`Henderson. et a1. 1990, Gerberding 1994). While many
`infections can be transmitted through a sharps injury,
`hepatitis B virus, (HBV), hepatitis C Virus (HCV) and
`human immunodeficiency virus (HIV) are the most conse—
`quential (Gerberding & Henderson 1992, Lanphear 1994].
`The risk of health care workers sustaining harm from '
`sharps injuries was first described by McCormick 8: Maki
`
`© 1997 Blackwell Science Ltd
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`Occupationa] sharp injuriesW
`
`(1981). Since then there has been a search for strategies to
`prevent sharps injuries, and hence to decrease blood-borne
`infection.
`
`The objective of this paper is to review research findings
`related to the efficacy of measures that have been used to
`prevent sharps injuries. Beginning with an overview of the
`incidence of sharps injuries and a description of the cur—
`rent therapies available for managing sharps injuries when
`they occur, we continue With a chronology of measures
`used to prevent sharps injuries. Finally, we present impli-
`cations for nursing research and practice. In conducting
`this
`literature review,
`the following databases were
`reviewed: Nursing and Allied Health (CINAHL) from 1982
`to October 1995, Health Planning and Administration
`(Health) from 1975 to November 1995, and MEDLINE from
`1976 to December 1995.
`
`by more than half (Mast et a]. 1993). Finally, physicians
`may be reluctant to report sharps injuries, fearing restric-
`tions on their practice (Lanphear 1994).
`first
`The under-reporting of
`sharps
`injuries was
`described in a retrospective study by Hamory (1983), who
`estimated that 40% of sharps injuries in the previous 3
`months and 75% in the last year had not been reported by
`employees at a university hospital. Under-reporting has
`been described by other researchers (Jackson et a]. 1986,
`McGeer eta]. 1990, deVries & Cossart 1994). Jagger & Balon
`(1995) state that sharps injuries occurring in the operating
`room are the least likely of any to be reported. Despite the
`educational efforts of
`the last decade to encourage
`reporting of sharps injuries, Roy & Robillard (1995) esti-
`mated that an alarming 696% of sharps injuries from five
`hospitals were not reported.
`
`THE EXTENT AND CONSEQUENCES OF
`SHARPS INIURIES
`
`McCormick & Maki (1981)'concluded that most sharps
`injuries were reported by nurses. Surveillance studies
`show approximately two—thirds of all reported sharps
`injuries occur in nurses (Ruben et a1. 1983, McCormick
`et a1. 1991, Rowe 8: Giuffre 1991, Weatherly at a]. 1991,
`Dalton et a]. 1992, English 1992, Haiduven et a]. 1992,
`Mellon et a1. 1992, Bowden et a]. 1993). While the absolute
`number of sharps injuries is reportedly higher in nurses,
`the actual rate of occurrence may be higher in physicians
`(Stotka et a]. 1991, de Vries & Cossart 1994, Mercier 1994).
`Summarizing the data from prospective studies of sharps
`injuries, Robert & Bell (1994) report a rate of 1-8 per year
`for physicians and 0-98 for nurses working on the same
`medical wards.
`
`HIV infection
`
`Although the rate of sharps injuries is higher in physicians
`than in nurses, twice as many nurses have been reported
`with occupationally acquired HIV infection (Jagger 1994a).
`In 1994, CDC was following 123 health care workers who
`had reported exposures to blood and bodily fluid in the
`workplace and who were HIV—positive ( Jagger 1994a). Of
`this number, the three highest occupational groups rep—
`resented are nurses and laboratory workers (each compris-
`ing 24% of all seroconversions), followed by physicians
`(12%). The lower number of HIV infections in physicians
`may be a result of several factors. Firstly, there are more
`nurses than physicians working in health care and phys—
`icians’ injuries are more likely to be caused by suture
`needles, which are believedth be less efficient in transmit—
`ting infection than hollow-bore needles (Bennett & Howard
`1994). Physicians also may be more likely to be wearing
`gloves when their exposure occurs; wearing gloves may
`reduce the volume of blood introduced through the injury
`
`The consequences of sharps injuries
`
`HBV is the major infectious threat in health care settings
`(Kane 1993). Health care workers who have a significant
`exposure to HBV but who have not previously received
`hepatitis B vaccine and do not receive post-exposure
`prophylaxis have a 6—30% risk of becoming infected (CDC
`1989, Mauskopf et a1. 1991). Despite the risk of trans-
`mission and the dangers associated with chronic HBV
`infection, many nurses and other health care workers
`failed to accept the seriousness of sharps injuries until the
`risk of HIV transmission by this route was identified
`(Mundt 1992, Henderson 1995).
`The risk of HCV transmission by sharps injury is
`believed to be considerably lower than the risk of transmit-
`ting HBV. Retrospective studies in Japan show the esti—
`mated‘risk of HCV transmission by needle-stick injury was
`between 2-7% (Kiyosawa et a]. 1991) and 10% (Mitsui
`et a]. 1992). Lanphear et a]. (1994) found a seroconversion
`rate of 6% in a study conducted in Rochester, New York,
`By comparison, in a Spanish study of 81 employees who
`had sustained a sharps injury from hepatitis C positive
`individuals, there was no evidence of hepatitis C infec—
`tion 1 year following the injury (Hernandez et a1. 1992).
`One group of researchers found the risk of transmission
`was higher if the source was infected with both HIV and
`HCV, although the results were not statistically significant
`(Puro et a]. 1995). While there is growing evidence for the
`occupational risk of HCV transmission to health care work-
`ers, much remains unknown about the consequences of
`infection (Alter 1994). However, it is believed that almost
`everyone who has hepatitis C infection will develop
`chronic carriage of the virus and about two-thirds will
`have elevated liver enzymes (Alter 1994).
`The rate of HIV transmission by sharps injury involving
`an infected individual
`is estimated to be between 0%
`(Bowden et a]. 1993) and 2% (Heptonstall et a1. 1993). The
`calculated rate from meta-analysis of worldwide studies is
`
`© 1997 Blackwell Science Ltd, Journal ofAdvanced Nursing, 25, 144—154
`
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`A.C. Hanrahan and LI. ReutterWM
`
`between 0.3 and 04% (Marcus et a1. 1988, Henderson eta].
`1990, Tokars et a1. 1993).
`The risk of seroconversion to HIV may be higher in injur-
`ies sustained following certain sub—categories of sharps
`procedures such as venepuncture or intramuscular injec—
`tion (Heptonstall et a]. 1993). Gerberding & Henderson
`(1992) assert that the risk of HIV transmission may be
`greater if the needle used has a hollow bore, if the worker’s
`injury is deeply penetrating, or if blood is injected during
`the injury. In an effort to quantify a difference in risk,
`Bennett & Howard (1994) found that the amount of blood
`transmitted in a simulated sharps injury from a phleb-
`otomy needle was substantially higher than from a suture
`needle of comparable size. Shirazian et a1, (1992) found
`that the volume of blood conveyed from a 20—gauge needle
`was 30 times greater than the amount from a 27—gauge
`needle.
`The risk of HIV transmission from a needle that has been
`inserted into an intravenous line is probably substantially
`lower than the risk from a needle used to administer an
`
`injection directly. Manian et a1. (1993) examined 501 intra~
`venous ports of peripheral lines, heparin—locks and central
`lines from a convenience sample of hospitalized patients.
`They concluded that the risk of transmission of infectious
`agents by injury from a needle inserted into a peripheral
`intravenous line or the distal port of a central venous line
`was nearly zero.
`
`POST-EXPOSURE MANAGEMENT OF
`SHARPS INJURIES
`
`Blood-borne infections cannot be prevented by pre-
`exposure vaccination, except in the case of HBV, therefore,
`the post-exposure management of sharps injuries is very
`important. Employers of caregivers are advised to have a
`mechanism for the prompt reporting and follow-up of
`every employee who'sustains an injury from a used sharp
`(Gerberding & Henderson 1992, Fahey et a]. 1993). The
`employee who incurs a sharps injury is entitled to coun—
`selling, testing and an explanation of the laboratory results
`(Schultz et a]. 1994). Testing for HBV and HIV is rec—
`ommended at the time of the injury to determine the
`employee’s current status. Testing caregivers who have
`received the three doses of hepatitis B vaccine is also indi-
`cated unless they have had a positive HBV antibody test
`within the past 2 years (National Advisory Committee on
`Immunization 1993). Guidelines for counselling and
`routine testing for HCV are less clear but testing is now
`recommended by at least one authority (Laboratory Centre
`for Disease Control (LCDC) 1995).
`Testing to determine possible HBV, HIV and HCV infec-
`tion in the person who is the source of the sharps injury
`is recommended if the individual consents (Gerberding
`1995). If the source is positive for any of the three infec~
`tions, the exposed employee should have the appropriate
`
`testing repeated over a number of months to determine
`whether infection develops. Laboratory tests will usually
`indicate evidence of infection within 6 months of the expo—
`sure, but Meyohas et a].
`(1995) describe a delay of
`8 months between exposure and HIV seroconversion
`following sharps injury in one individual.
`
`Susceptible workers
`
`Unimmunized or susceptible health care workers who sus-
`tain a significant exposure to HBV may receive passive
`immunization with hepatitis B immune globulin. A series
`of two doses of this post-exposure intervention, given as
`soon as possible after the exposure and repeated 1 month
`later, is 75% effective in preventing HBV infection (CDC
`1990). Alternatively, a single dose of hepatitis B immune
`globulin plus a series of hepatitis B vaccine may be
`administered to induce extended protection.
`To prevent HIV infection following sharps injury, a
`course of zidovudine, an antiviral medication, may be
`prescribed (Gerberding 8: Henderson 1992), although the,
`support for this therapy has been equivocal (Gerberding
`& Henderson
`1992, Lanphear
`1994). Ricketts
`&
`Deschamps (1992), in reviewing the reported HIV sero-
`conversion among health care workers worldwide, ident-
`ified at least four instances where the administration of
`
`zidovudine failed to prevent HIV infection following
`exposure. Evidence of a protective effect of this drug has
`been demonstrated recently in a case-control study of
`HIV V seroconversion in health care workers following
`sharps injury (CDC 1995).
`No therapeutic measures are recommended currently to
`prevent HCV infection following occupational exposure
`(PHLS Hepatitis Subcommittee 1993, Gerberding 1995).
`Vigorous washing of the wound is recommended following
`any significant exposure to blood or body fluid, including
`a sharps injury (Gerberding 8: Henderson 1992). Promoting
`bleeding at the site is also recommended, although the
`efficacy of this intervention is unknown (Fahey et a1. 1993).
`Interferon has been identified as a possible therapy, but
`presently is not recommended (van der Poel et a1. 1994,
`Gerberding 1995).
`In summary, management following a sharps injury
`cannot always prevent the transmission of HCV, HIV, or
`even HBV using current
`technology (Gerberding &
`Henderson 1992).
`
`PREVENTING SHARPS INJURIE S
`
`Given the serious, and even fatal, consequences of sharps
`injuries and the limited effectiveness of post—exposure
`therapies,
`it is crucial that measures to prevent sharps
`injuries from occurring be found. This section presents a
`chronology of the measures that have been employed since
`McCormick & Maki (1981) outlined the incidence of, and
`
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`Occupational sharp injuries
`WWW—-
`
`the factors related to, sharps injuries. Initial efforts focused
`on altering the behaviour of health care workers.
`Subsequent efforts to prevent sharps injuries included the
`introduction of protective barriers, the engineering of safer
`devices, the substitution of non-invasive procedures and
`the implementation of administrative controls.
`
`Changing risk behaviours
`
`The first efforts to prevent sharps injuries centred around .
`efforts to eliminate the practice of recapping through edu-
`cation and convenient placement of puncture-resistant
`containers for the disposal of used sharps. For more than
`a decade, CDC has recommended that used needles should
`not be recapped and should be placed in puncture—
`resistant containers (CDC 1982, CDC 1987). Comparable
`recommendations were adepted in Canada (LCDC 1987a);
`in the United Kingdom, it has been recommended that a
`used needle not be recapped unless there is a safe means
`of recapping (UK Department of Health 1990).
`Many studies were conducted to assess the efficacy of
`these measures. Several authors were unable to demon—
`
`strate a significant reduction in sharps injuries (Krasinski
`et a1. 1987,Edmond etc]. 1988, Sanborn et a1. 1988, Sellick
`et a]. 1991, Smith et a1. 1992) while others reported an
`increase in the number of sharps injuries (Ribner et a1.
`1987, Linnemann et a]. 1991). Linnemann et a1. (1991)
`questioned whether participation in the study enhanced
`health care workers’ awareness, resulting in increased
`reporting of sharps injuries. Some authors reported a
`reduction in the rate ‘of recapping (Ribner & Ribner 1990,
`Makofsky 8: Cone 1993), but Only one study revealed a
`significant decrease in overall sharps injuries (Haiduven
`et a]. 1992). One important difference between this study
`and the others described is the additional intervention of ’
`
`reporting summaries of sharps injuries to staff, thereby
`increasing the awareness of injuries in their institution. In
`a descriptive study of injuries related to the disposal of
`used sharps, Weltman et a1. (1995) found that sharps con-
`tainers located more than 4 feet above the ground, lack of
`attendance at
`in—service education on universal
`pre—
`cautions, and ironically, being within 5 feet of the nearest
`disposal container were predictive factors for sharps
`injuries.
`Research revealed that modifying behaviour failed to
`reduce overall sharps injuries, and it was concluded that
`it was necessary to seek other meansvof prevention, pref-
`erably safer devices (jagger 1987, Birnbaum et a]. 1990,
`McGeer et a]. 1990, Holloway 1992, Gerberding 1992).
`Jagger 8: Pearson (1991) assert that sharpsmay be used
`unnecessarily, and that sharps should be used only when
`it
`is necessary to pierce the skin of an individual.
`Sharps injuries are related not only to recapping and
`improper disposal but also to thedevice itself (Gershon
`et a1. 1994).
`
`Using protective barriers
`
`Some believe that sharps injuries can be reduced by the
`introduction of barriers placed between the sharp and the
`individual using it. For instance, it hasbeen estimated that
`devices with passive safety mechanisms that do not have
`to be triggered by the user can reduce between 48 and 67%
`of sharps injuries (Mendelson et a1. 1993). By comparison,
`devices with mechanisms that must be activated by the
`user are estimated to reduce only between 17 and 28% of
`injuries. Few studies exploring the use of barriers to pre-
`vent sharps injuries have been reported. No recent studies
`are reported from the United States, where recapping or
`removing used needles from a syringe are now prohibited
`unless the employer can demonstrate that no other
`option is available (Occupational Safety and Health
`Administration (OSHA) 1991).
`Four studies assessed the efficacy of recapping devices.
`In a Canadian study, Ng et a1. (1991) reported no sharps
`injuries after the introduction of a safety paddle, but these
`authors fail to report the number of injuries occurring
`before the intervention and do not indicate whether the
`
`findings are significant. Goldwater et a]. (1989) report a
`decrease in injuries following the use of a recapping device
`in a study where subjects were self-selected into the study
`and control group, thereby potentially biasing the results.
`Wright 8: Ferrer (1993) found a significant decrease in
`sharps injuries in an acute care facility following the intro-
`duction of a needle cover that Can be applied using one
`hand. However, Whitby et a1. (1991) found that reported
`sharps injuries more than doubled at an acute care facility
`following the implementation of a recapping device
`coupled with an educational campaign. The researchers
`attributed their findings to improved reporting.
`While there have been only a few studies published
`assessing the effectiveness of protective barriers, recently
`greater efforts have been devoted towards the development
`of safer devices and the substitution of non-invasive
`procedures to prevent sharps injuries.
`
`Engineering safer devices or substituting non-
`invasive procedures
`
`]agger et a1. (1988) reviewed the rates of sharps injuries
`in a hospital in Virginia, USA, to determine the frequency
`of injuries by specific device used and the point at which
`the injury occurred during the procedure. While the
`greatest number of injuries were caused by disposable
`syringes,
`the highest rates of injury were caused by
`devices
`that
`required
`disassembly
`following
`use.
`Caregivers incurred nearly 17% of their injuries before or
`during use of the device, 70% while preparing it for
`disposal and 13% after disposal. This study was the
`catalyst for shifting the emphasis from modifying the
`behaviour of health care workers to seeking engineering
`
`© 1997 Blackwell Science Ltd, journal of Advanced Nursing, 25, 144—154
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`AC. Hanrahan and L1. Heutter
`
`olutions or substitution for the prevention of sharps
`injuries (Lanphear 1994).
`Similarly, in a longitudinal study of 12 hospitals in Italy,
`Ippolito et a1. (1994) found that devices requiring manipu-
`lation, such as intravenous catheter stylets, were associ—
`ated with higher rates of sharps injuries. The authors note
`that the use of needles to access intravenous (IV) lines has
`been a hazardous practice exclusive to the United States
`and English-speaking Canada. On the other hand, needle-
`less access to IVs has been standard practice in other devel—
`oped countries. In studies from both countries, however,
`the greatest number, but the lowest rate, of sharps injuries
`were associated with disposable needles and syringes
`(Jagger et a1. 1988, Ippolito et a1. 1994).
`Bowden et a]. (1993) found that sharps injuries were
`twice as likely to be caused by lancets as by needle and
`syringe assemblies. Eisenstein & Smith (1992) found scal-
`pel blades and lancets were associated with the highest
`rates of sharps injuries. Stotka et a]. (1991) cautioned that
`nurses specifically are the frequent recipients of sharps
`injuries when using lancets to obtain blood for glucose
`readings.
`Numerous studies involving needle~less IV-access sys—
`tems have been conducted. All found a reduction in sharps
`
`injuries following the introduction of needle-less IV—access
`systems (Beason et al. 1992, Dugger 1992, Gartner 1992,
`Rutowski 8: Peterson 1993, Skolnick et a1. 1993, Prince
`et a1. 1994, D’Aroo & Hargreaves 1995, Yassi et a1. 1995).
`One of the studies did not assess whethersharps injuries
`were reduced, but instead assessed caregivers’ satisfaction
`with the device (Savino & Napolitano 1994). Several stud—
`ies discuss the economic impact of safer devices (Dugger
`1992, Gartner 1992, Rutowski & Peterson 1993, Yassi et a1.
`1995). Dugger (1992) and Gartner (1992) report a cost-
`savings, while Rutowski & Peterson (1993) claim that any
`increased cost is offset by the reduced need for follow—up
`of injured workers. Yassi et a]. (1995) argue that additional
`costs or savings of the needle—less system are dependent
`upon the type of patients receiving care.
`There have been only a few products introduced as sub-
`stitutions for needles and other sharps. A needle-less
`medication and vaccine injector is described in a compre-
`hensive review of devices for preventing sharps injuries
`(ECRI 1994). A limitation of this device, however,
`is
`that only 1 ml of medication can be administered at a
`time, One of the primary uses of this device may be in
`immunization procedures.
`In summary, needle-less IV—access systems appear to be
`the most effective measure currently available for reduc—
`ing sharps injuries. Further,
`they are the only safer
`devices for which scientific studies have been published.
`However, injuries from needle-less IV~access systems may
`be the least
`likely to transmit blood—borne infections.
`Additional measures, such as administrative controls, are
`also needed.
`
`W s
`
`Administrative controls
`
`Policies that outline measures to be taken to prevent, or
`' procedures to be taken in the event of, a sharps injury are
`examples of administrative controls. In the United States,
`the Occupational Exposure to Bloodborne Pathogens;
`Final HuIe is an administrative control intended to educate
`
`and protect all who may be exposed occupationally to
`blood and body fluids (Barlow 8: Handelman 1992).
`Important components of
`this Standard include the
`employer’s need to have a written plan for controlling
`exposures, to provide hepatitis B immunization to staff, to
`provide relevant training and to have a protocol for post-
`exposure evaluation of injuries (OSHA 1991, Barlow &
`Handelman 1993), The employer is tetally responsible for
`staff of hospitals who fail to comply with precautions to
`prevent exposure.
`Critics of the Standard question if it will have a detri—
`mental impact upon the occurrence of infections that are
`transmitted by modes other than blood exposure and if it
`will affect the cost of caring for patients (CDC 1994). Either
`is a possibility if preventing exposures to blood or body
`fluids becomes the entire focus of infection prevention, or
`if caregivers wear gloves or other protective clothing
`excessively in situations where exposure is unlikely. The
`language of the Standard is prescriptive and permits little
`discretion (Decker 1992). For example, caregivers are
`required to wear gloves in certain situations and only rare
`exceptions are permitted (OSHA 1991). ‘One of
`the
`strengths of the Standard may be the requirement for
`evaluating exposure incidents.
`Worldwide, programmes for the surveillance of health
`care workers exposed occupationally to HIV have been
`instituted in a number of countries. The United States was
`
`the first to initiate a programme of national surveillance
`in 1983 (Marcus et a1. 1988). A programme in the United
`Kingdom began during 1984 (Heptonstall et al. 1993), fol-
`lowed by a programme in Canada in 1985 (LCDC 1987b)
`and in Italy in 1986 (Ippolito et al. 1993). In Canada, a
`recommendation has been made recently to expand the
`surveillance programme to include HCV (LCDC 1995), The
`purpose of any surveillance programme is to identify the
`magnitude of a problem using the measures of person,
`place and time to facilitate the development of prevention
`and control measures (Thacker 1994).
`
`Jagger (1994b) states that in order to provide a safer
`workplace, it is essential to provide timely information to
`health care workers who provide care directly. She advo»
`cates the use of the Exposure Prevention Information
`Network (EPINet), a computerized system for data collec—
`tion, analysis and reporting of sharps injuries, as an effec-
`tive tool for surveillance. The system allows analysis at a
`local or national level. Locally, hazards specific to a site
`can be identified (Hospital Employee Health 1994).
`Nationally, data can be compiled from many sites to
`
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`etermine more quickly the rates of sharps injuries from
`devices used infrequently (Hospital Employee Health 1993).
`Although the relative emphasis of various measures to
`reduce sharps injuries may have changed over time, a com—
`bination of strategies is required. Wugofski (1992) states
`that the. incidence of sharps injuries can be reduced by
`substitution, engineering controls, administrative controls
`and personal protective equipment. Jackson 8: Lynch
`[1991) claim that sharps injuries result from a combination
`of four factors: design deficiencies, inadequate training,
`inadequate management training, and lack of appropriate
`supplies. Collectively, these concepts can be categorized
`into engineering, organizational and behavioural factors
`and are illustrated in Table 1 below.
`
`ISSUES TO BE RESOLVED
`
`A number of issues remain to be resolved in the prevention
`of sharps injuries. First,
`the efficacy of new products
`should be evaluated. Due to the widespread understanding
`that sharps injuries can best be prevented by engineering
`controls, new products that are touted as safer devices are
`being marketed. However, there is only evidence to sup-
`port
`the
`efficacy of needle-less
`lV-access
`systems
`(Rutowski 8: Peterson 1993, Skolnick et a1. 1993, Prince
`et al. 1994, Yassi et a1. 1995). Generally, the occurrence of
`a sharps injury is relatively infrequent compared to the
`number of devices used and it is impractical to determine
`a device’s effectiveness before it
`is approved for sale
`(Tereskerz 1995). Post-marketing studies are essential,
`therefore, not only to evaluate effectiveness, but also to
`determine any unanticipated problems.
`Second, the cost-effectiveness of, new products should
`be determined. Those who are responsible for the purchase
`of hospital products need to be aware that sharps injuries
`1 may be categorized as either high or low risk for transmit-
`ting infection (Owens-Schwab & Fraser 1993). Because of
`high costs associated with safer devices, it may be more
`cost-effective to purchase devices that will prevent high
`risk injuries, For example, Owens-Schwab & Fraser (1993)
`note that, while as many as one<quarter of all sharps injur-
`ies are related to IV—access systems, the risk of transmitting
`infections from these injuries is low in comparison to the
`
`Occupational sharp injuries
`
`risk from needles that have been used for venepuncture 0r
`intramuscular injection.
`A third issue in relation to preventing sharps injuries is
`evaluating the effectiveness of policies and other adminis-
`trative controls. The success of the American Standard on
`blood-borne pathogens remains to be demonstrated (CDC
`1994). Further,
`the breadth of the Standard may be
`insufficient with the move toward the provision of more
`frequent and more invasive care in the community setting.
`A Court of Appeals in the United States has ruled that the '
`employers of caregivers working in the home cannot be
`held responsible for staff who fail to use measures to pre-
`vent exposure to blood and body fluids (OSHA 1994). The
`approach recommended by De Laune (1990), which
`describes mutual responsibilities of both the employer and
`the employee, may be a more balanced approach. The role
`of nursing is likely to be critical to the success of any
`administrative controls that are implemented.
`Finally, although the emphasis is now on engineering
`controls, these measures alone are insufficient to prevent
`all sharps injuries, and efforts to modify risky behaviour
`should continue. Early studies assessing behavioural
`changes to prevent sharps injuries were conducted when
`the risk of occupational transmission of HIV from sharps
`injury was considered remote. Initially, results from pro—
`spective surveillance studies showed no HIV seroconver—
`sions in health care workers exposed to HIV-infected
`blood or body fluids (CDC 1985, LCDC 1987b, McEvoy
`et al. 1987, LCDC 1988). Caregivers who do not perceive
`themselves at risk may not be motivated to change their
`behaviour. Mercier (1994) contends that monitoring expo—
`sures and reporting this information to health care work—
`ers are integral to preventing sharps injuries. It may also
`be important
`to inform employers, because hospital
`administrators may have misperceptions regarding the
`incidence of sharps injuries in their facilities (Treloar
`et a1. 1994).
`
`IMPLICATIONS FOR NURSING RESEARCH
`AND NURSING PRACTICE
`
`The environmental factors associated ,with sharps injuries
`in the hospital setting have been clearly delineated.
`
`W d
`
`W B
`
`ehavioural factors
`Organizational factors
`Engineering factors
`
`
`Table 1 Factors related to
`
`sharps injuries
`
`Design of sharps
`
`Barrier devices
`
`Substitution
`
`Availability of supplies
`
`Reporting policies
`
`Recapping
`
`Disposal—related
`issues
`
`Protocols for
`controlling exposures
`
`(e.g. needle—less
`IV—access system,
`vaccine injector)
`W
`
`© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 144—154
`
`149
`
`BD 1028
`
`BD 1028
`
`

`

`A.C. Hanrahan and L1. Heutter
`WW—
`
`Hazards pertaining to specific areas of the hospital includ—
`ing the emergency department (Tandberg et a1. 1991,‘
`Henderson
`1995),
`the
`operating room (Telford
`8;
`Quebbeman 1993), the delivery suite (Short & Bell 1993),
`the dialysis unit (Petrosillo eta]. 1995), and anaesthesiol-
`ogy (Berry & Greene 1992) have been published.
`However,
`the studies of measures to prevent sharps
`injuries have been largely atheoretical in nature. A few
`authors have considered the use of the Health Belief Model
`
`to help us understand the use, or lack thereof, of preventive
`behaviours to decrease sharps injuries (Becker et a1. 1990,
`Henry et a]. 1994, Williams eta]. 1994). Nursing research
`is needed to understand the organizational and behav-
`ioural factors that may be pertinent to sharps injuries. The
`determinants of risk behaviours may be better elucidated
`through the use of one of the many behaviour change
`models. The Theory of Reasoned Action (Ajzen 8: Fishbein
`1980), the Theory of Planned Behaviour {Ajzen 1982) and
`the Health Belief Model (Rosenstock‘ 1974) are examples
`of models that could be utilized. Research using an organ-
`izational perspective to prevent sharps injuries could
`address the salient organizational issues.
`Moreover, there is a need for epidemiologic research
`which addresses the risk for nurses working in the com-
`
`munity (Smith 8: White 1993, White 8: Smith 1993,
`Backinger & Koustenis 1994). As the delivery of services
`provided in the home gr