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Best practices for phlebotomy needlestick prevention


September 1, 2012

Best practices for phlebotomy needlestick prevention

A recent webinar looks at the past, present, and future of preventing needlestick injuries

Since the passage of the Needlestick Safety and ­Prevention Safety Act in November 2000, the healthcare sector has made significant progress in reducing the number of needlestick injuries among frontline employees, particularly nurses; however, phlebotomy procedures are still an area of concern for healthcare workers.

A recent webinar entitled "Reducing Needlestick ­Injuries During Phlebotomy," hosted by Advance for Nurses magazine on June 13, offered some ­perspective on these procedures. ­Presenters Janine ­Jagger, MPH, PhD, professor of medicine at the ­University of Virginia School of Medicine in ­Charlottesville, Va., and Anita Yanik, MSN, RN, a care consultant for BD Diagnostics' Preanalytical Systems division in Franklin Lakes, N.J., discussed leading causes of needlesticks during phlebotomy procedures based on current data, and ­reviewed the available ­safety-engineered technologies.


Where we've come

Statistics show that since the passage of the Needlestick Safety and ­Prevention Act, needlestick-related injuries have nosedived, dropping 38%, Jagger said in the webcast. The law required ­facilities to have safety-engineered devices in the workplace for all procedures in which healthcare workers were at risk for a needlestick injury.

"The picture we're looking at today is that picture after the implementation of the Needlestick Prevention and Safety Act, which is actually very unique to the United States and was a very significant factor in bringing us nationally to the forefront of addressing this issue of preventions of occupational transmission of bloodborne pathogens," she said.

The law was particularly beneficial for those performing phlebotomy procedures, reducing phlebotomy needlesticks by nearly 60% from 2001 to 2004, based on data from The Exposure Prevention Information ­Network (EPINet™) through the University of Virginia.

From 2005 to 2009, EPINet data produced the following statistics that give an accurate portrayal of the current state of needlestick prevention for phlebotomy procedures:

  • Venous blood drawing injuries account for ­nearly 12% of all needlestick injuries. Of that 12%, 9% of the injuries were from conventional devices.
  • Phlebotomists account for nearly 40% of needlestick injuries during venous blood drawings using safety devices; nurses represent nearly 40% as well.
  • More than half of venous blood drawing injuries ­occurred in the patient room, and a quarter occurred in the ED and the ICU.
  • More than half of venous blood drawing ­injuries ­occurred during use of the device, while 35% ­occurred after use, and only 5% occurred ­after disposal. "That's what we hope to see and what we want to see-that there is a shift such that there are fewer and fewer injuries occurring after use, when those devices are designed to be in effect," Jagger said.
  • Disposable syringes made up 35% of injuries ­during venous blood draws; winged steel needles made up 45%.
  • 62.7% of injuries occurred before the safety ­feature was activated, 21.2% occurred during ­activation of the safety feature, and 16.1% occurred when it was ­activated, meaning most injuries took place during, not after, the ­performance of the procedure.


What technology is right for you?

There are seven different classes of safety devices since 2000, according to Jagger:

  • Spring-loaded retraction or manual retraction
  • Shielding devices
  • Hinged cap
  • Articulated
  • Unfolding shield
  • Sliding shield
  • Conventional


Each design has different limitations. Some are ideal for certain procedures but not for others, so hospitals need to evaluate which device works best for which procedure. For example, retracting needles, both manual and spring-loaded, should not be used for blood drawing because the safety feature cannot be put into effect to protect the needle before expelling the contents, eliminating the purpose of the safety device for blood draws. Hinge cap syringes, on the other hand, allow the needle to be capped and removed after the blood enters the syringe.

"You really need to think very carefully," Jagger said. "If you have to use a syringe, you need to think very carefully about its configuration and its use for blood drawing."

Yanik indicated that thanks to the progression of technology, four categories of safety devices that are specifically used for phlebotomy procedures have been developed:

  • Manually activated sliding sleeve devices: These represented the initial breakthrough of safety devices, but users had to use two hands to activate the safety device, which put them at risk.
  • One-handed activation: This device features a shield that slides over the tip of the needle and only needs one finger or thumb to activate the device when it is ­removed from the patient's vein.
  • User-activated retracting devices: This device takes the next step to minimize or eliminate the amount of time the ­needle is exposed once removed from the patient. In fact, with many user-activated devices, the needle can be retracted back into the device before it is removed from the vein.
  • Passive or automatic retraction: This is the Rolls Royce of safety devices since it takes all risk out of the hands of the user. This device is ­automatically ­activated so the user cannot overlook, delay, or ­circumvent the safety feature. However, there is a lot of discussion surrounding ­passive needles: Since it takes so much control away from the user, it could result in premature retraction or an additional blood draw.

"In other words, based on the assessment of the ­clinician, this may not be the type of device you want to use on every single patient," ­Yanik said. "It really ­depends on who the patient is and what the assessment of the situation is."


Unsafe blood collection methods

Now, even blood transfer devices have safety ­elements built in to minimize or eliminate exposure to bloodborne pathogens. There are some situations-like a fresh-start IV-in which healthcare workers need to use a syringe to draw blood. In these situations ­hospitals should have some kind of needleless transfer device to ­transfer the blood into an appropriate container. You don't want to transfer a syringe full of blood by putting the needle through the top of a blood collection tube, Yanik said.

Needle transfers put employees at risk in two ways:

  • There is a much higher risk for needlestick injuries
  • There is a high risk for blood exposure because the pressure of the vacuum tubing can cause blood to come out when the needle is removed


A third reason not to do needle blood transfers is the greater risk for hemolysis to the sample, Yanik said, which would force the employee to redraw from the patient.

Yanik closed with the reminder that nurses have a say in their facility's devices since OSHA requires hospitals to consult frontline staff members as part of their sharps safety device review. "I think it's come such a long way from the days nurses weren't included in the decision-making process," she said. "Medical facilities are allowing them to be on committees and have a voice and say, 'This doesn't work in our area and this is the reason why.' "

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