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Tuesday 27 September 2016
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Management of sharps injuries in general practice

Elizabeth Gates
Freelance Medical Journalist

Living on the Wirral, Elizabeth Gates is a national freelance medical journalist specialising in public and occupational health. She is also an expert in managing change. "I have to be," she says, "I'm a wife, mother and Labrador owner"

Across Europe each year, more than 1 million healthcare workers are stabbed or cut by sharps – needles, scalpels, stitch cutters, glass ampoules, etc.(1)

In the UK, 17% of accidental injuries to healthcare workers – more than 80,000 injuries – involve sharps, making them second only in the ratings to musculoskeletal disorders.(1)

There are also more than 20 possible cross infections from pathogens and disease-carrying parasites transmissible by sharps injuries. Yet the transmission of bloodborne viruses is preventable when appropriate devices are used.(1–3)

NHS Employers' Head of Workplace Health, Julian Topping, admits: "The main incidence of these injuries occurs in acute trusts, where staff members are hurrying – sometimes for some distance – to a sharps disposal bin – and they aren't always paying the attention they should. They take short cuts and accidents happen."

By contrast, the current incidence of sharps injuries in general practice is minimal. Institute of Healthcare Management (IHM) members attribute this in part to their capacity to plan care.

For example, Sally Betts, manager of a semi-rural practice in Lurgan, County Armagh, with 4,500 patients, explains: "Our two practice nurses and a healthcare assistant are responsible for taking bloods and they do this – very regularly – in a dedicated treatment room.

"But there is a sharps' bin in every room where blood-taking or injections could occur – with spares. There aren't the same time pressures as in hospital and each patient can be dealt with completely before beginning on the next. We've just dealt with almost 1,000 flu injections in a few weeks, without any problems."

The new GP contract has meant that, in comparison to five years ago, more procedures involving sharps take place in general practice surgeries. As Ms Betts explains: "There are more preventive health checks – people with coronary heart disease coming in to have their blood cholesterol measured, and so on.

"But even the minor surgery clinic – run in a dedicated space when both doctor and nurse are available by arrangement – is still an instance of planned care. There is no question of someone being expected to turn their hand to cutting out an ingrowing toenail in the middle of normal surgery."

Other managers have similar tales to tell. Practice Manager Kate Watney, of Bromley Primary Care Trust (PCT), remarks: "Smaller organisations tend to use more common sense, keep in touch with each other better, and perhaps even take more personal responsibility.

"In general practice, we sometimes have far from ideal circumstances in which to practise, so perhaps we have to think harder about how to be safe."

As Mr Topping said: "In general practice, there are fewer opportunities for making mistakes … and sharps management is better."

Premises pressure
However, this ideal scenario is already under threat, as Dr John Canning, British Medical Association Chair of the General Practice Contracts and Performance Sub-Committee, warns. Pressure on space in general practice facilities is leading GPs and practice managers to push for larger units. The current situation is, he believes, untenable.

As Dr Canning explains: "You shouldn't ever have a situation where a phlebotomist, for example, finds him/herself having to take blood in a cupboard – even a large one. It's not fit for purpose and could be dangerous. Services should only ever be offered in appropriate places and properly resourced to avoid this.

"But, as the pressure on surgery facilities increases – especially with the move of more procedures from hospitals to GP premises – and the working environment becomes more cluttered and staff more stretched to achieve what is required, there will be an increase in exposure to infection through sharps' injuries.

"And general practice staff offering urgent care services, perhaps away from the surgery and in patients' homes, will also be increasingly exposed."

Safe working environment
Violence-related sharps injuries already cause problems in certain areas. Mr Topping explains: "In general practice, the level of risk depends on where the practice is and who you are dealing with.

"In innercity London, where staff are constantly dealing with drug users, the risk of hepatitis C is high and therefore we would recommend using safer devices. This is the same whether you're working in the trust hospital or the GP surgery across the road."

Drug misuse, notes Practice Manager Duncan Elder, of Ayrshire and Arran PCT, is a potential contributory factor to sharps injuries even in a comparatively rural setting.

Dr Canning insists on the importance of regular and reliable waste disposal. As he says: "Part of requirements of the new GP contract with the PCT involve infection control and a safe working environment.

"As managers of a practice, we have a responsibility to employees and the public under health and safety legislation – regarding the management of sharps – and we are subject to inspection by the Health and Safety Executive (HSE) and the local environmental health officer.

"But we are also dependant on local arrangements with the PCT for sharps disposal. Safety sometimes depends on how often the sharps bins are emptied. And the inclination is to overfill these – especially if the collections are infrequent."

Practice managers put their trust in common sense, consideration for others and clear briefing of all concerned. But, as Mr Elder adds, costs of course need to be considered: "It would be going overboard to handle domestic waste the same way clinical waste or sharps containers are handled just in case there might be an incorrectly disposed of needle."

Risk assessments
Dr Canning believes the provision of occupational health services is an important element in general practice sharps management. As he explains: "Local variations in NHS Occupational Health Service (OHS) provision impacts not only on the management of any injuries but also on the follow-up for the patient and the lessons to be learned by practice management in general.

"This independent view is important. A GP should not be managing a sharps injury incident as a clinician as well as practice manager – although this sometimes happens in rural and remote areas. The patient should be referred to the local A&E and the hospital OHS."

Yet Ms Betts says: "If a sharps' injury were to happen, we are only about five miles away from a major hospital – 30 minutes by car between us and the acute service. And we can also – although we rarely do – ask the OHS at the same hospital for advice. We know where they are. But another practice in a country district might not have that support."

Wherever the practice is, Dr Canning warns: "There must be appropriate policies in place. You must do proper risk assessments. And you must have the proper arrangements established for dealing with an incident when it occurs."

Legislation
So, the exemplary record of general practice regarding sharps management is not necessarily a "given". Could measures be put in place to ensure it is? And if so, what are these measures?

In July 2006, a European Parliament Resolution was passed to protect healthcare workers against sharps injuries. But, much to the concern of healthcare unions, the UK government remains unlikely to legislate specifically on this issue.

Mr Topping argues in favour of this UK government stance. "NHS Employers do not feel there is a need for another layer of legislation," he says. "We should make what we have already in this country work for us. We have the best – some would say, too much – health and safety legislation in the European Union (EU).

"And the 2006 EU proposals are already enacted in our basic health and safety laws, which provide for proper risk assessment and the use of the safest needles available when the level of risk – from staff member to patient and from patient to staff member – is assessed as high enough to warrant it."

Arguments turn on this notion of "acceptable risk". Bromley practice manager Kate Watney says:  "In this general practice, we have had two minor needlestick injuries in 15 years and both were caused by carelessness rather than not knowing what to do or someone else having not done as they should – that's a perfectly acceptable risk level."

Dr Canning feels general practice, in a suitable working environment fit for purpose, is low risk. Ms Betts feels that when all the necessary precautionary measures have been put in place, the risk is "acceptable".

And NHS Employers takes the pragmatic view: "Of course, we support the use of safer needles when there is a risk of infection from deadly blood borne viruses. But we do not support the use of safer needles everywhere.

"Firstly, the cost would be prohibitive and secondly, you have to be protecting yourself from a hazard. If it's just a case of stopping yourself from pricking yourself on a needle – you can't reinfect yourself with anything – there are no grounds for an obligatory across-the-board supply of 'safer devices'."

Instead of more legislation, NHS Employers would prefer better public education and staff training. The NHS Employers' Healthy Workplaces Handbook – published in October 2007 – updates good practice and employers' responsibilities. Chapter 34, in particular, recommends measures that, if taken, could prevent at least 80% of these sharps injuries.

IHM members, however, are wary of "more guidance". Ms Betts warns more leaflets, adding to the clutter in the waiting room, would be a "disgusting waste of resources" – as would safer needles for every occasion. But, she says: "A cache of safer needles to be used at the nurse's discretion – when they know the patient to be high risk – would be helpful."

References
1. Elder A, Paterson C. Sharps injuries in UK health care: a review of injury rates, viral transmission and potential efficacy of safety devices. Occ Med 2006;56(8):566-74.
2. NHS Employers. Health and Safety: needlestick injury [homepage on the internet]. Available from: http://www.nhsemployers.org/practice/practice-3466.cfm
3. Health Protection Agency. Eye of the Needle: United Kingdom surveillance of significant occupational exposures to bloodborne viruses in healthcare workers. London: HPA; 2006. Available from: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1205394781623