Needlestick Injuries

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Introduction   

Each day, nurses are tasked with managing needles and other sharps, such as scalpels, scissors or blades, which puts them at increased risk for needlestick injuries (NSI). The Centers for Disease Control (CDC) defines needlestick injury as “a penetration of the skin by a needle or other sharp object that has been in contact with another person’s blood, tissue, or other body fluid before the injury” [1].  

The CDC estimates that 385,000 healthcare workers in the U.S. are affected by a needlestick injury annually. However, it should be noted that this number may not be accurate as it’s estimated that half of the injuries go unreported.  

Needlestick injuries can affect anyone working in healthcare; however, due to the nature of a nurse’s duties, they are at increased risk [2]. NSIs can happen in any number of environments, not just hospitals, including nursing homes, outpatient surgery centers, clinics, and urgent cares. 

The CDC reports that many NSIs occur to healthcare personnel while performing in fast-paced, understaffed, and strenuous work environments. For example, when nurses are working long. shifts without adequate breaks and still need to complete their tasks, they can become fatigued, angry, and frustrated, leaving them more vulnerable to injury [3].  

Unsafe practices also lead to accidental NSI injuries. This includes “passing sharps hand-to-hand between team members, placing sharps in an overfilled disposal container, failing to use a safer device or failing to identify a safer alternative (e.g., blunt tip sutures, alternate skin closure devices/technologies) [3]. 

There are several other risk factors that increase sharps injury, including using equipment improperly, using equipment without updated safety features, ignoring safety protocols, or not engaging in universal precautions.  

Several different devices are commonly responsible for penetration, puncture, or cuts to the skin. Disposable syringes account for 27% percent of NSIs (these are the most common culprits for injuries to nurses), suture needles account for 25% of injuries with scalpel blades, intravenous stylets, and winged steel needles accounting for the remaining NSIs reported annually. These particular devices also increase the risk of blood or body fluid exposure to their user.  

Etiology 

Needlestick injuries came into the collective awareness of healthcare workers in the early 1980’s when human immunodeficiency disorder (HIV) was initially identified. Present day, it has been learned that nurses are at higher risk of contracting Hepatitis B or C than HIV. Both Hepatitis B, C, and HIV are spread through blood or body fluids, thus making transmission from a sharps injury possible [3]. 

HIV is a systemic disease affecting all organ systems and leaves clients vulnerable to a myriad of infectious diseases, cancer, and severe wasting. The virus eventually evolves into acquired immune deficiency syndrome (AIDS), where CD4 and infection-fighting cells are attacked and can lead to grave health outcomes [3].  

Fortunately, studies show that developing HIV post-needlestick injury is very rare. According to the CDC, the risk of contracting HIV from an NSI when working with an infected client is approximately 1 in 300. “The CDC has reported 57 documented cases and 140 possible cases of HIV transmission to U.S. health care workers between 1981 and December 2006. Of the 57 documented cases, 48 were associated with percutaneous injury (puncture/cut injury)” [4]. A majority of those who were, however, infected with HIV from a sharps injury were nurses. [4]. 

There have been studies denoting that HIV transmission is actually much higher among nurses and that it is a serious occupational hazard following an NSI. The CDC no longer tracks data on HIV transmission in healthcare workers [4] so it’s important to note transmission may be much higher and nurses should always adhere to strict universal precautions along with antiviral therapy if indicated (universal precautions and post-exposure will be discussed later in the course). 

Hepatitis B is a serious virus that can cause severe liver damage and can prove to be fatal. It is also transferred through blood and body fluids, so nurses are especially at risk when managing clients with hepatitis B. In addition to liver damage, it can cause jaundice, abdominal pain, fever, and nausea [4].  

The risk of contracting hepatitis B from an NSI presents an increased risk of transmission compared to HIV. It’s estimated that 6-30% percent of healthcare workers will contract hepatitis B from an infected sharp when injury is present. The good news is the rate of infection has significantly declined since there has been a massive push for nurses and healthcare workers to vaccinate themselves against hepatitis B. Like the occupational hazard of HIV transmission from NSI, the CDC is no longer tracking data. Hence, transmission rates are not exactly known [5].  

Hepatitis C also poses an occupational hazard to nurses if they experience a sharps injury with infected blood or body fluids. Hepatitis C also affects the liver, but unlike hepatitis B, there is no vaccine, making it a pathogen with great significance in terms of healthcare worker exposure [5].  

Hepatitis C virus causes severe liver damage and can be fatal. Chronic hepatitis C can cause liver carcinoma, cirrhosis, or hepatic decompensation. Nurses working with clients who have hepatitis C need to use enhanced precaution and follow protocol to the letter should they have an NSI or sharps injury. Nurses should also take into account that hepatitis C is most commonly spread through intravenous drug use, so if caring for clients in this population, take extra precautions [5].  

Treatment 

Should a nurse have the unfortunate experience of a needlestick or sharps injury, they should take specific steps to minimize harm. According to the CDC the following steps should be taken for harm reduction and nurse safety [6]: 

1. Wash the injured area thoroughly for 15 minutes with soap and water. Be sure to know where clean wash stations are at all times. 
2. Control bleeding and cover the area appropriately. 
3. Seek medical attention. Know your facility policy or who to contact should an NSI occur. If working in a hospital most facilities have their nurses seek care from the emergency department. 
4. Report the exposure immediately. This also allows the medical staff to potentially find out if the client involved has any communicable bloodborne pathogens and can undergo labs if necessary. 
5. Complete an incident report so safety measures can be improved and hopefully prevent similar events from occurring. 

Nurses should be thoroughly evaluated to see if post-exposure prophylaxis (PEP) is warranted. The evaluation and treatment are different for HIV and viral hepatitis. Determining whether a nurse should be treated with PEP for HIV after an exposure can be difficult to determine. If the client’s HIV status is negative, the CDC does not recommend PEP. If the client’s status is unknown, clinical judgement must guide the response [2].  

If the client’s HIV status is determined to be positive, several factors need to be examined, such as the volume of blood on compromised/open skin, the type of needle involved, and if it was used to obtain a blood specimen from a vein or artery along with a client’s viral load and CD4 count [2].  

Should it be determined the nurse needs antiviral therapy the CDC recommends three different antivirals for four weeks duration [2]. 

In the case of hepatitis B, many healthcare workers are mandated to be vaccinated. If they have an exposure to hepatitis B a vaccinated nurse should be tested for protection levels. If they still have robust immunity no further action is needed. However, if titers return low hepatitis B, immunoglobulin should be administered [2]. 

If the nurse is unvaccinated and the client has positive hepatitis B status, the nurse should receive HBV immunoglobulin and should be encouraged to get the hepatitis B vaccine 14 days later [2]. 

Hepatitis C exposure requires monitoring and testing of the nurse 12-48 hours later should they be exposed to a client who is positive. The CDC does not recommend immediate anti-viral therapy as they state effectiveness and duration of treatment have not yet been established [7]. 

Nursing Implications 

Nurses work in very high-stakes environments and occupational hazards such as dealing with clients who are violent, lifting heavy equipment, and potential injury from blood and body fluids can certainly add to their stress.  

If a nurse has to undergo PEP treatment for a sharps injury, the emotional toll can be very upsetting. In many situations, implementing antivirals post exposure is not a clear-cut decision. If treatment is employed, the antivirals can cause fatigue, nausea, vomiting and other unwelcome symptoms. This can lead to missed work days, causing financial stress. The nurse must also have continuous lab testing which is time intensive and can prove unpleasant [2].  

The nurse’s family life may be greatly impacted while they wait for infection status. It may not be safe for them to be sexually active or they might need to use a barrier method otherwise not needed. Potentially infected nurses may need to delay pregnancy for many months. One of the worst consequences of NSI is the waiting and not knowing their disease status for some time. This is especially true with HIV, as seroconversion can take months [2].  

Prevention 

Unfortunately, NSIs are an occupational hazard in nursing and can happen no matter how careful a nurse might be. It may be no fault of their own and can occur due to another member of the healthcare team or improper management of the sharps container. However, nurses should make every effort to keep themselves, their co-workers and clients safe by practicing sharps and needlestick safety [2].  

According to the CDC the following safety guidelines should be followed for injury prevention [8]: 

1. Wear gloves appropriately 
2. Avoid using needles if other alternatives are readily available 
3. Use devices with safety features. If they are new to you, seek instruction how to use them 
4. Make a plan in advance on how to safely dispose of needles/sharps 
5. Avoid the recapping of needles 
6. Immediately dispose of sharps in an appropriate container 
7. Check sharps containers to make sure they are filled only to a safe level before using 
8. Participate in training related to bloodborne pathogens 

Nurses should also be empowered to make safety changes in their environment and be given lead roles to increase safety measures when they identify something isn’t working. They should be able to report injuries without fear of retribution and use those opportunities to increase safer working conditions for all [2]. 

Conclusion

Needlestick and sharps injuries are a constant occupational hazard for nurses across clinical settings. Should an NSI occur nurses should know how to clean the area thoroughly and the protocol for proper reporting. HIV and viral hepatitis can be serious threats to the nurse’s health and mental health, so seeking out proper care is paramount.  

Nurses should make every effort to facilitate a safe work environment and ensure they and those around them employ safe sharps practices. They are in a unique position to identify situations that are potentially harmful and can help lead initiatives to prevent NSIs and sharps injuries.  

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