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National Clinical Guideline Centre (UK). Infection: Prevention and Control of Healthcare-Associated Infections in Primary and Community Care: Partial Update of NICE Clinical Guideline 2. London: Royal College of Physicians (UK); 2012 Mar. (NICE Clinical Guidelines, No. 139.)

  • Update information February 2017: A footnote was added to recommendation 22 linking to Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. A footnote linking to a safety alert on chlorhexidine was added to recommendations 1.4.3.1, 1.4.3.8, 1.4.4.1 and 1.4.4.11. Other footnotes were updated with references to revised or replaced British Standards and other regulations. August 2013: A clarification has been made to recommendation 22 on the disposal of used standard needles.

Update information February 2017: A footnote was added to recommendation 22 linking to Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. A footnote linking to a safety alert on chlorhexidine was added to recommendations 1.4.3.1, 1.4.3.8, 1.4.4.1 and 1.4.4.11. Other footnotes were updated with references to revised or replaced British Standards and other regulations. August 2013: A clarification has been made to recommendation 22 on the disposal of used standard needles.

Cover of Infection: Prevention and Control of Healthcare-Associated Infections in Primary and Community Care

Infection: Prevention and Control of Healthcare-Associated Infections in Primary and Community Care: Partial Update of NICE Clinical Guideline 2.

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8Standard principles for the safe use and disposal of sharps

8.1. Introduction

The updated review questions in this chapter are:

  • choice of safety cannulae
  • choice of safety needles.

The choice of safety cannulae and needles were prioritised for update to determine whether newer safety devices available since the publication of the previous guideline are effective at reducing needle stick injury and associated infection.

The evidence and text from the previous guideline that has been superseded by this update is included in Appendices D.6 and D.9.

No new review questions included in this chapter.

Sections not updated in this chapter are the safe handling of sharps (relating to the recommendation on sharps not being passed directly from hand to hand, and handling being kept to a minimum).

Specific recommendations on disposal of sharps are included in this chapter and have been updated following changes to legislation.64,67 General waste disposal recommendations are in chapter 9. Waste disposal recommendations for personal protective equipment are in chapter 7.

This section discusses the evidence and associated recommendations for the safe use and disposal of sharps in community and primary care settings and includes minimising the risks associated with sharps use and disposal and the use of needle protection devices.

8.2. Sharps injuries – what’s the problem?

The safe handling and disposal of needles and other sharp instruments should form part of an overall strategy of clinical waste disposal to protect staff, patients and visitors from exposure to blood borne pathogens.119 The incidence of injuries caused by sharps varies across clinical settings and is difficult to compare due to different denominators for data collection. Audit data suggests that of the occupational injuries that occur in hospitals, 16% are attributable to sharps injuries.179 National surveillance of occupational exposure to bloodborne viruses from 1997–2001 indicates that 68% of percutaneous exposures were caused by sharps. Of the exposures followed up at 6 weeks, 7 percent involved healthcare workers working in community and primary care settings.85 In the first year of data collection the UK EpiNet sharps injury surveillance project provides data on 888 injuries occurring in 12 NHS Trusts identifying that 80% of injuries involve contaminated sharps, with 43% of injuries sustained by nursing staff and 24% by medical staff.223 In general clinical settings, sharps injuries are predominantly caused by needle devices and associated with venepuncture, administration of medication via intravascular lines and recapping of needles during the disassembly of equipment.36 All sharps injuries are considered to be potentially preventable.

The average risk of transmission of bloodborne pathogens following a single percutaneous exposure from a positive source has been estimated to be214:

• Hepatitis B Virus (HBV)33.3 percent (1 in 3)
• Hepatitis C Virus (HCV)3.3 percent (1 in 30)
• Human Immunodeficiency Virus (HIV)0.31 percent (1 in 319)

The GDG acknowledge that there is existing guidance on HIV post-exposure prophylaxis from the Department of Health.66

8.2.1.1. Recommendations

21.

Sharps shoulddd not be passed directly from hand to hand, and handling should be kept to a minimum. [2003, amended 2012]

Recommendations
22.

Used needles:

  • must not be bent or broken before disposal
  • must not be recapped.
    In denistry, if recapping or disassembly is unavoidable, a risk assessment must be undertaken and appropriate safety devices should be used. [new 2012]
Relative values of different outcomesThe GDG considered the most important outcomes for making this recommendation to be prevention of needlestick injury, blood contamination and blood borne infection.
Trade off between clinical benefits and harmsThe GDG considered recapping, bending and breaking used needles to put healthcare workers at risk from needlestick injuries and therefore the benefit of this recommendation is to prevent such injuries.
The GDG were aware that a new EU Directive (2010/32/EU48) was introduced in the United Kingdom (UK) in May 2010 entitled: prevention of sharps injuries in hospitals and the healthcare sector. The UK will have until May 2013 to implement the Directive into national legislation. The GDG noted that the Directive aims to set up an integrated approach establishing policies in risk assessment, risk prevention, training, information, awareness raising and monitoring. The Directive states that “Where the results of the risk assessment reveal a risk of injuries with a sharp and/or infection, workers’ exposure must be eliminated by taking the following measures, without prejudice to their order: the practice of recapping shall be banned with immediate effect...”.
Unavoidable situations for recapping, bending or breaking needles were brought to the attention of the GDG by dental colleagues during the stakeholder workshop. The GDG noted DH advice that some syringes used in dentistry are not disposable and needles should be re-sheathed using the needle guards provided.64
Economic considerationsNo relevant economic considerations were identified for this issue. Where avoidable, recapping and disassembly is not considered a valid alternative.
Where unavoidable, ‘appropriate safety devices’, such as portable needle sheath holding devices, are likely to already be present in care settings where re-capping is routine and therefore implementation of this recommendation will be associated with minimal cost.
Quality of evidenceNo clinical evidence was identified. Although a direct question was not asked about recapping, bending or breaking needles, the sharps literature search for other questions was considered to be wide enough to have captured this evidence. No major changes have been made to this recommendation since the last guideline, apart from the addition of situations where recapping or disassembling needles is unavoidable. GDG consensus was that in these cases a risk assessment should take place and appropriate safety devices (such as recapping devices) should be used. This was considered to be especially appropriate and in line with the EU directive noted above.
Other considerationsOther considerations for the GDG included the training of all healthcare workers in the safe management of sharps regardless of type used to aid implementation of this recommendation, see also recommendation 26. In addition, they felt that training should include awareness of safety issues when sharps are kept in a patient’s home.
Recommendations
23.

Used sharps must be discarded immediately into a sharps container conforming to current standardsee by the person generating the sharps waste. [new 2012]

Relative values of different outcomesThe GDG considered the most important outcomes for making this recommendation to be prevention of needlestick injury, blood contamination and blood borne infection.
Trade off between clinical benefits and harmsGDG consensus was that the likelihood of needlestick injury is greatly reduced by the immediate disposal of sharps into an appropriate container. Failure to comply with this recommendation could result in legislative action.
Further recommendations for waste disposal are in chapter 9.
Economic considerationsPeople generating sharps waste should already have access to sharps containers that conform to current standards. If not, then this recommendation will be associated with an implementation cost.
Quality of evidenceThere was no clinical evidence review for this section.
The GDG considered that it was important for any recommendation amendments to conform to the Safe Management of Healthcare Waste Guidelines72 and the relevant EU and UK regulations and HTM-01–05 Decontamination in primary care dental practices.67 The GDG were aware that the Royal College of Nursing had also published guidance in this area.224
Other considerationsThis recommendation has been updated to reflect current legislations and best practices. The GDG considered that this recommendation relates to patient safety and that the consequence of not implementing it mean that the risk of adverse events are so severe, that the use of the word ‘must’ is appropriate in line with the guidance from the NICE Guidelines Manual (2009).182
Clinical waste must be placed in the appropriate receptacle at source. This should always be performed by the person immediately involved in the generation of the waste. Passing used sharps from one person to another increases the risk of injury. The GDG noted that the person generating the sharps waste in a dental setting is the clinician (therefore, dentist, dental therapist or hygienist), and that most sharps injuries in dental surgeries are sustained by dental nurses.238
The GDG also considered that to ensure that risk of injury was minimised it was important that the used sharps should be disposed of immediately after use and made the appropriate amendment to the existing recommendation to reflect this.
ee

At the time of publication of the guideline (March 2012): UN3291 and BS 7320.

Recommendations
24.

Sharps containers:

  • mustff be located in a safe position that avoids spillage, is at a height that allows the safe disposal of sharps, is away from public access areas and is out of the reach of children
  • must notff be used for any other purpose than the disposal of sharps
  • must notff be filled above the fill line
  • mustff be disposed of when the fill line is reached
  • should be temporarily closed when not in use
  • should be disposed of every 3 months even if not full, by the licensed route in accordance with local policy. [new 2012]
Relative values of different outcomesThe GDG considered the most important outcomes for making this recommendation to be needlestick injury, blood contamination and blood borne infection.
Trade off between clinical benefits and harmsCompliance with this recommendation will reduce the risk of sharps injuries to healthcare workers, patients, carers and the public. Failure to comply with this recommendation could result in legislative action.
Economic considerationsIndividuals and organisations generating sharps waste should already be compliant with this recommendation. If not, then this recommendation will be associated with an implementation cost.
Quality of evidenceThere was no clinical evidence review for this section.
The GDG noted that any amendments to the original recommendation should conform to the Safe Management of Healthcare Waste guidelines72 and the relevant EU and UK regulations64 and HTM-01–05 Decontamination in primary care dental practices.67 They were also aware that the Royal College of Nursing have published guidance in this area.224
Other considerationsInappropriate disposal of sharps is an important cause of injury. This recommendation is a ‘must’ as it is covered by legislation detailed in the footnote in line with the NICE Guidelines Manual (2009).182
The GDG discussed and considered the following aspects when making the recommendations:
  • Patients cared for at home: The Safe Management of Healthcare Waste72 document makes it clear that sharps containers should be prescribed for patients using sharps (injections/lancets) at home. It is important not to just involve the patient but also other relevant household members in training to ensure proper use of sharps and sharps bins. They felt that it would not be acceptable for this group to dispose of their sharps and lancets into the domestic waste stream e.g. household black bag.
  • Community nursing: For practicality reasons, community nurses may want to use just a single sharps receptacle.
ff

For guidance see (at the time of publication of the guideline [March 2012]): ‘Safe management of healthcare waste’ (2011); available from www​.dh.gov.uk/en/Publicationsandstatistics​/Publications/PublicationsPolicyAndGuidance/DH_126345

8.3. Do safety cannulae reduce sharp injuries compared to standard cannulae?

8.3.1. Review question

This question was asked to determine whether newer safety devices available since the publication of the previous guideline are effective at reducing needle stick injury and associated infection.

What is the clinical and cost effectiveness of healthcare workers using safety needle cannulae vs. standard cannulae on compliance and user preference, infection related mortality and morbidity and sharps injuries?

8.3.1.1. Clinical evidence

Three RCTs were identified, two comparing active (requires pressing a button to trigger the withdrawal of the needle in to a plastic sleeve using a spring) and passive (with a protective shield that automatically covers the needlepoint during its withdrawal) safety cannulae to standard cannulae16,213, and one RCT comparing active safeguarded needles with standard cannulae.47

No studies from the previous 2003 guideline met the inclusion criteria for this review question.

See Evidence Table G.4.1, Appendix G, Forest Plots in Figure 17–19, Appendix I.

Table 32Active safety cannulae vs. standard cannulae - Clinical study characteristics

OutcomeNumber of studiesDesignLimitationsInconsistencyIndirectnessImprecision
Needle stick injury16,2132RCTSerious limitations(a)No serious inconsistencySerious indirectness(b)No serious imprecision
Catheterised on first attempt 16,47,2133RCTSerious limitations(c)No serious inconsistencySerious indirectness(b)No serious imprecision
Blood contamination of patients or healthcare workers (HCWs) 16,47,2133RCTSerious limitation(c)No serious inconsistencySerious indirectness(b)No serious imprecision
Infection related mortality and morbidity0RCT
User preference0RCT
Compliance0RCT
a

Lack of blinding and unclear randomisation and allocation in 1 study.

b

Hospital setting rather than community.

c

Lack of blinding and unclear randomisation in 2 studies.

Table 33Active safety cannulae vs. standard cannulae - Clinical summary of findings

OutcomeSafety cannulaeStandard cannulaeRelative riskAbsolute effectQuality
Needle stick injury0/304 (0%)0/304 (0%)Not pooledNot pooledLOW
Catheterised on first attempt426/515 (82.7%)374/423 (88.4%)RR 0.96 (0.91 to 1.01)35 fewer per 1000 (80 fewer to 9 more)LOW
Blood contamination of patients or HCWs77/515 (15%)32/423 (7.6%)RR 1.94 (1.32 to 2.86)71 more per 1000 (24 more to 141 more)LOW

Table 34Passive safety cannulae vs. standard cannulae - Clinical study characteristics

OutcomeNumber of studiesDesignLimitationsInconsistencyIndirectnessImprecision
Needle stick injury16,2132RCTSerious limitations(a)No serious inconsistencySerious indirectness(b)No serious imprecision
Catheterised on first attempt 16,2132RCTSerious limitations(a)No serious inconsistencySerious indirectness(b)No serious imprecision
Blood contamination of patients or HCWs16,2132RCTSerious limitations(a)No serious inconsistencySerious indirectness(b)Serious imprecision(c)
Infection related mortality and morbidity0RCT
User preference0RCT
Compliance0RCT
a

Lack of blinding and unclear randomisation and allocation in 1 study.

b

Hospital setting rather than community.

c

The relatively few events and few patients give wide confidence intervals around the estimate of effect. This makes it difficult to know the true effect size for this outcome.

Table 35Passive safety cannulae vs. standard cannulae - Clinical summary of findings

OutcomePassive safetyStandardRelative riskAbsolute effectQuality
Needle stick injury0/301 (0%)0/304 (0%)not poolednot pooledLOW
Catheterised on first attempt278/301 (92.4%)280/304 (92.1%)RR 1 (0.96 to 1.05)0 more per 1000 (37 fewer to 46 more)LOW
Blood contamination of patients or HCWs21/301 (7%)20/304 (6.6%)RR 1.06 (0.59 to 1.92)4 more per 1000 (27 fewer to 61 more)VERY LOW

8.3.1.2. Cost-effectiveness evidence

No cost-effectiveness evidence was identified.

No cost effectiveness evidence was identified in the previous 2003 guideline.

In the absence of any published cost-effectiveness evidence, estimates about the cost and quality of life associated with needle stick injury was obtained from several review articles148150 identified through the economic literature search and presented to the GDG to inform decision making. The GDG were also presented with the current UK cost of standard cannulae and safety cannulae.

Table 36Cost of standard and safety IV cannulae

Type of cannulaAverage cost (£)
Standard cannula0.86 each
Active safety cannula1.05 each
Passive safety cannula2.10 each

Source/Note: Based on average 2010 Supply Chain187 prices. Individual trusts may negotiate different contracts and prices with suppliers.

8.3.1.3. Evidence statements

ClinicalIt is unlikely that there is any difference in success of cannulation on first attempt between active or passive safety cannulae compared to standard cannulae (LOW QUALITY).

There were no sharps injuries for active or passive safety cannulae or standard cannulae (LOW QUALITY).

There is a statistically significant and clinically important increase in blood contamination of patients or HCWs with active safety cannulae compared to standard cannulae (LOW QUALITY).

It is uncertain whether there is any difference in blood contamination of patients or HCWs with passive safety cannulae compared to standard cannulae (VERY LOW QUALITY).

No studies were identified that reported infection related mortality and morbidity, user preference or compliance.
EconomicNo cost-effectiveness studies were identified.

8.3.1.4. Recommendations and link to evidence

The evidence for this review question was considered alongside the evidence for the following question and recommendations were made considering all the evidence. See recommendations at the end of this chapter 8.4.1.4.

8.4. Do safety needle devices reduce sharps injuries compared to standard needles?

8.4.1. Review question

This question was asked to determine whether newer safety devices available since the publication of the previous guideline are effective at reducing needle stick injury and associated infection.

What is the clinical and cost effectiveness of healthcare workers using safety needle devices (needle-free, retractable needles, safety re-sheathing devices) vs. standard needles on compliance and user preference, infection related mortality and morbidity and sharps injuries?

8.4.1.1. Clinical evidence

Five observational studies were identified. Three studies were before and after implementation studies of safety devices for phlebotomy procedures.38,171,221 One study investigates the implementation of a disposable safety syringe for dentistry286 compared to a non-disposable metal syringe. The final study investigates the implementation of a self-retracting glucometer lancet compared to a straight stick non-retracting lancet.198

Three studies from the previous 2003 guideline met the inclusion criteria for this review question.38,198,286

See Evidence Table G.4.2, Appendix G, Forest Plots in Figure 20–29, Appendix I.

Table 37Safety devices for phlebotomy procedures vs. standard devices - Clinical study characteristics

OutcomeNumber of studiesDesignLimitationsInconsistencyIndirectnessImprecision
Needle stick injury171(d)1Observational studiesNo serious limitationsNo serious inconsistencySerious indirectness(a)No serious imprecision
Needle stick injury2211Observational studiesNo serious limitationsNo serious inconsistencySerious indirectness(a)No serious imprecision
Needlestick injury - Winged steel needle381Observational studiesNo serious limitationsNo serious inconsistencySerious indirectness(a)No serious imprecision
Needlestick injury - Bluntable vacuum tube381Observational studiesNo serious limitationsNo serious inconsistencySerious indirectness(a)No serious imprecision
Needlestick injury - Vacuum tube with recapping sheath381Observational studiesNo serious limitationsNo serious inconsistencySerious indirectness(a)Serious imprecision(b)
User preference381Observational studiesNo serious limitationsNo serious inconsistencySerious indirectness(a)No serious imprecision
User preference171(c)1Observational studiesNo serious limitationsNo serious inconsistencySerious indirectness(a)No serious imprecision
Blood borne infection0Observational studies
Infection related mortality and morbidity0Observational studies
Compliance0Observational studies
a

Hospital based rather than community.

b

Wide confidence interval with low event number give a low confidence in the effect size.

c

Taken from survey data, numbers given are those that preferred the safety needle, remaining respondents were assumed to prefer the standard needle.

d

Denominator is the total number of needles delivered to the department.

Table 38Safety devices for phlebotomy procedures vs. standard devices - Clinical summary of findings

OutcomeSafety deviceStandard deviceRelative riskAbsolute effectQuality
Needle stick injury(a)28/436180
(0%)
86/641282
(0%)
RR 0.48
(0.31 to 0.73)
0 fewer per 1000
(0 fewer to 0 fewer)
VERY LOW
Needle stick injury(b)--RR 0.62
(0.51 to 0.72)
-VERY LOW
Needlestick injury - Winged steel needle34/2540500
(0%)
53/1875995
(0%)
RR 0.47
(0.31 to 0.73)
0 fewer per 1000
(0 fewer to 0 fewer)
VERY LOW
Needlestick injury - Bluntable vacuum tube2/501596
(0%)
14/523561
(0%)
RR 0.15
(0.03 to 0.66)
0 fewer per 1000
(0 fewer to 0 fewer)
VERY LOW
Needlestick injury - Vacuum tube with recapping sheath5/628092
(0%)
19/895054
(0%)
RR 0.38
(0.14 to 1)
0 fewer per 1000
(0 fewer to 0 more)
VERY LOW
User preference622/1939
(32.1%)
882/1939
(45.5%)
RR 0.71
(0.65 to 0.76)
132 fewer per 1000
(109 fewer to 159 fewer)
VERY LOW
User preference199/536
(37.1%)
337/536
(62.9%)
RR 0.59
(0.52 to 0.67)
258 fewer per 1000
(207 fewer to 302 fewer)
VERY LOW
a

Denominator is the total number of needles delivered to the department.

b

Relative risk taken directly from paper. Total events and population not given for study period.

Table 39Disposal safety syringe vs. non-disposable syringe - Clinical study characteristics

OutcomeNumber of studiesDesignLimitationsInconsistencyIndirectnessImprecision
Needle stick injury2861Observational studiesNo serious limitationsNo serious inconsistencySerious indirectness(a)No serious imprecision
Blood borne infection0Observational studies
Infection related mortality and morbidity0Observational studies
Compliance0Observational studies
a

Dental school setting rather than community.

Table 40Disposal safety syringe vs. non-disposable syringe - Clinical summary of findings

OutcomeSafety syringeNon-disposableRelative riskAbsolute effectQuality
Needle stick injury0/1000 (0%)21/1000 (2.1%)RR 0.02
(0 to 0.38)
21 fewer per 1000
(13 fewer to 21 fewer)
VERY LOW

Table 41Self-retracting glucometer lancet vs. straight stick non-retracting lancet - Clinical study characteristics

OutcomeNumber of studiesDesignLimitationsInconsistencyIndirectnessImprecision
Needle stick injury1981Observational studiesNo serious limitationsNo serious inconsistencySerious indirectness(a)Serious imprecision(b)
Blood borne infection0Observational studies
Infection related mortality and morbidity0Observational studies
Compliance0Observational studies
a

The denominator used for needlestick injury was worker years rather than the actual number of lancets used.

b

Wide confidence and low event number lead to low confidence in the effect size.

Table 42Self-retracting glucometer lancet vs. straight stick non-retracting lancet - Clinical summary of findings

OutcomeSelf-retractingNon-retractingRelative riskAbsolute effectQuality
Needle stick injury2/477 (0.4%)16/954 (1.7%)RR 0.25
(0.06 to 1.08)
13 fewer per 1000
(16 fewer to 1 more)
VERY LOW

8.4.1.2. Cost-effectiveness evidence

The update search conducted as part of this review identified two studies; neither met inclusion criteria. A cost analysis by Glenngard et al (2009)103 was excluded because costs were presented nationally rather than individually and were considered specific to Sweden. A cost-effectiveness analysis from Madagascar78 was excluded because neither the comparator nor the setting was relevant to this question.

One study identified by the clinical evidence review in the previous 2003 guideline met inclusion criteria for the update economic review. Peate and colleagues (2001)198 conducted a basic cost analysis in their comparison of the use of self-retracting glucometer lancets to straight stick non-retracting lancets among emergency medical system workers in the United States.

Additional estimates of the cost and quality of life impact associated with needle stick injury were obtained from several review articles148150 identified through the economic literature search and presented to the GDG to inform decision making. The GDG were also presented with the current UK cost of various standard and safety needles.

Table 43Self-retracting glucometer lancet vs. straight stick non-retracting lancet - Economic study characteristics

StudyLimitationsApplicabilityOther Comments
Peate 2001198Potentially serious limitations (a)Partial applicability(b)
a

Resource use not reported, unit costs and cost source not reported, observational before-after study.

b

USA setting.

Table 44Self-retracting glucometer lancet vs. straight stick non-retracting lancet - Economic summary of findings

StudyIncremental cost (£)Incremental effectsICERUncertainty
Peate 2001198Self-retracting lancets cost £363 more per year than non-retracting lancets (department-wide)Self-retracting lancets resulted in fewer needlestick injuries (RR 0.25)Self-retracting lancets resulted in a department-wide net savings of £14 014 due to averted treatment costsN/R

Table 45Cost of standard and safety needles

Type of needleAverage cost (£)
Hypodermic syringes
Standard hypodermic syringe with standard needle0.07 per 1ml syringe
Safety hypodermic syringe with retractable needle0.17 per 1ml syringe
Safety hypodermic syringe with hinged shield needle0.25 per 1ml syringe
Insulin syringes
Standard insulin syringe with standard needle attached0.08 per 1ml syringe
Safety insulin syringe with retractable needle0.25 per 1ml syringe

Source: Based on average 2010 Supply Chain187 prices. Individual trusts may negotiate different contracts and prices with suppliers.

8.4.1.3. Evidence statements

ClinicalPhlebotomy devices
There is a statistically significant and clinically important reduction in needlestick injuries with the safety devices compared to standard devices (VERY LOW QUALITY).
There is a statistically significant and clinically important increase in user preference with the safety devices compared to standard devices (VERY LOW QUALITY).
Dental syringe
There is a statistically significant and clinically important reduction in needlestick injuries with the safety devices compared to standard devices (VERY LOW QUALITY).
No studies were identified that reported blood borne infection, infection related mortality and morbidity, or compliance.
Safety lancet
It is uncertain whether there is any difference in needlestick injuries with the safety devices compared to standard devices (VERY LOW QUALITY).
EconomicThere is some evidence to suggest that safety lancets are more cost-effective than standard lancets in certain settings (POTENTIALLY SERIOUS LIMITATIONS AND PARTIAL APPLICABILITY). No other cost-effectiveness evidence was identified.

8.4.1.4. Recommendations and link to evidence

Recommendations
25.

Use sharps safety devices if a risk assessment has indicated that they will provide safer systems of working for healthcare workers, carers and patients. [new 2012]

Relative values of different outcomesThe GDG considered the most important outcomes for making this recommendation to be needlestick injury, success of cannulation on first attempt, blood contamination and blood borne infection.
Trade off between clinical benefits and harmsThe GDG noted that active safety cannula devices caused more blood contamination of the surroundings, healthcare worker and/or the patient and therefore passive devices with a simpler design could be considered. However the GDG also noted that increased blood contamination was possibly related to previously unidentified training needs and unfamiliarity with the new devices.
Risk assessment may require additional resources (time etc), but that the potential reduction in needlestick injuries outweighs this and provides a safer working environment for healthcare workers.
Training is required to ensure safety devices are used correctly, and the evidence showed that if implemented correctly these devices do reduce needle stick injuries.
The GDG were aware that there is anxiety amongst healthcare workers associated with taking a blood test to detect the presence of a blood borne virus’ (for example, HIV, Hepatitis B and C). The GDG felt that minimising needlestick injury from such tests using safety devices would be an additional benefit.
Economic considerationsSafety devices are more costly than standard devices. However, given the high cost of investigation and treatment of needle stick injuries, the level of healthcare worker anxiety associated with these injuries, and the frequency with which they occur, the GDG agreed that the use of safety devices may prove cost-effective in high risk situations or situations where risk assessment has indicated their use.
Quality of evidenceThree RCTS were identified comparing safety cannulae with standard cannulae, which were all of low quality. Evidence from these studies was downgraded as the studies were all in hospital settings and data was of low or very low quality. No RCTs were identified for safety needle devices, but several observational studies were identified. Before and after implementation studies were identified; three for safety phlebotomy needles, one for safety lancet and one study for safety disposable dental syringes. These studies had several limitations and were all very low quality. In particular, the study implementing the disposable dental syringe 286 was sponsored by the manufacturer which introduced a large bias and excluded the first year of implementation from the analysis as the authors stated a lack of training. In addition the study implementing the safety lancet198 which had one relevant outcome, needlestick injury, was downgraded for indirectness and imprecision.
Other considerationsThe GDG were aware that there are problems obtaining accurate needlestick injury data due to under reporting of and possible reluctance to report injuries. They felt that further information could support the implementation of their recommendation and discussed what a risk assessment should include to determine the need for a safety device. The GDG considered the Health and Safety Executive document: Five Steps to Risk Assessment116 and how it might contribute to supporting the implementation of risk assessment in the following areas:
  • the number of incidents and types of injuries
  • the procedure and the environment in which it is undertaken
  • the patient population’s demographics
  • waste management and disposal
  • availability of alternative products
  • training.
Recommendations
26.

Train and assess all users in the correct use and disposal of sharps and sharps safety devices. [new 2012]

Relative values of different outcomesThe GDG considered the most important outcomes for making this recommendation to be needlestick injury, blood contamination and blood borne infection.
Trade off between clinical benefits and harmsThe GDG noted that incorrect use and unfamiliarity with a new safety device can lead to sharps injuries, as demonstrated by the clinical studies identified. The GDG were also aware from considering the evidence in review question 8.3.1 that poor familiarity with device operation may lead to increased blood contamination of the clinical area and healthcare workers. As shown by the evidence review above, implementation of safety devices did not lead to the complete elimination of sharps injuries. The GDG discussed the contribution that training, along with assessment, could have on healthcare workers in becoming familiar with the correct use of a device and correspondingly minimising the risk to themselves or patients. The GDG felt that training should also be available for those patients and carers who use sharps in the community.
Economic considerationsThe GDG considered that training would be necessary in order to ensure that the potential cost-effectiveness or cost savings associated with safety devices is realised. When included as part of ongoing staff training programmes, implementation of this recommendation should not be associated with any additional cost.
Quality of evidenceFive observational implementation studies were identified and were all very low quality. The type of training varied across studies, for example hands on simulated insertions and annual training updates171; and training sessions and pamphlets in each ward221.
Other considerationsIn considering the poor quality of the evidence reviewed, the GDG used consensus to develop a recommendation on training. Training should be considered for new staff and when new devices are implemented for all users.

Footnotes

dd

The updated recommendation contains ‘should’ rather than ‘must’ (which is in the 2003 guideline) because the GDG considered that this is not covered by legislation (in accordance with the NICE guidelines manual, 2009).

Copyright © 2012, National Clinical Guideline Centre.

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