The risk of needle-stick injury in general practice is high. It’s important that all team members know what course of action to take if someone is injured
The Care Quality Commission’s (CQC) website has an interesting little series of guidance notes called Nigel’s Surgery.¹ The ‘Nigel’ of the title is Dr Nigel Sparrow, senior national GP advisor to the CQC and the guidance notes cover a wide range of issues including such questions as how to record consent to minor surgery and whether surgeries should have carpets in consulting rooms. They all look pretty helpful, and suggestions are invited for topics to be included. Interestingly, there is not one relating to safer sharps.
Perhaps the omission is simply on the grounds of the scale and complexity of this topic. However, risk of needle-stick injury in general practice is high. Legislation specifically on safer sharps has recently been introduced and the impact should be visible in practices by now. What’s lurking out there, waiting to jab us into action?
MindMeter Research, who publishes research on trends in healthcare, published How sharp are we on safety? An assessment of safer sharps adoption in UK hospitals² in October last year. They found that compliance two years after new UK regulations were enacted was “very variable” and that the Health and Safety Executive were issuing improvement notices to a range of healthcare providers.
What’s changed? Plainly, this has relevance for GP practices. In May 2013 the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013³ were enacted. But what does this mean in practice?
Responsibilities under the Health and Safety at Work Regulations
GPs who are employers have responsibilities to uphold under the Health and Safety at Work Act and the Health and Safety at Work Regulations 1999. In terms of working safely with sharps, what has to be put in place?
Assess the risk from sharps and put control measures into place. This needs to be done if staff in the practice:
- Use sharps to provide care to patients.
- Provide services to colleagues who use sharps.
- Handle sharps after use.
- May come across sharps unexpectedly in the course of their work.
The risk assessment (and the control measures put in place) must relate to the level of hazard in the work. This means that, for high-risk procedures such as venepuncture and injection using needles, syringes and phlebotomy needles, your risk assessment of the procedure will need to be detailed. In a GP practice, the senior practice nurse or nurse practitioner will usually be the right person to undertake this risk assessment with support from the practice manager in relation to process and documentation if necessary.
Risk of injury is present during use of a sharp, after use (but before disposal of the sharp), while re-sheathing a needle and during disposal. This means that you should ensure your control measures cover each of these steps.
The Royal College of Nursing’s (RCN) publication Sharps Safety4 says that risk of infection from a needle-stick injury is dependent on a number of factors, including:
- How deep the injury is.
- What kind of sharp was used (hollow bore is higher risk).
- Whether the device was previously in the patient’s vein or artery.
- How infectious the patient is at the time of the injury.
The risk of infection, once all the above factors are taken into account, can be 1:3 for Hepatitis B, 1:30 for Hepatitis C and 1:300 for HIV.
The arrangements you put into place to control the risks associated with sharps should follow the approach set out in the Health and Safety Executive’s web site under the Control of Substances Hazardous to Health Regulations (COSHH) 2002 (see Resources). In general terms, this means that you need to detail what you do to control the risk of injury. This will include:
- Your safe working procedures are.
- Provision of equipment that is suitable for the task.
- Safe storage of sharps.
- Safe disposal of sharps after use.
- What your high-risk clinical waste disposal arrangements are.
- What personal protective equipment you supply and how and when it should be used.
- Training for all staff who use or can come into contact with sharps.
Additional/new actions under the Health and Safety (Sharps Instruments in Healthcare) Regulations 2013
These regulations apply to general practices because our main work is the provision of healthcare. But what is their impact on practices over and above what we already do under the risk assessment and control measures we already have in place?
Consider additional risk control measures
Instruments such as scalpels and needles should only be used when they are actually required. In a GP practice, examples of this might include not using a needle on a syringe for transferring liquid from one container to another and not using a scalpel as cleaning equipment.
Use safer sharps that incorporate a protection mechanism
A range of needles is now available that incorporate a little shield in which the needle can be housed after use. This removes the risk of re-sheathing a needle, but missing the sheath and sustaining an injury. When considering safer sharps, the practice must consider the following issues and incorporate them into the detailed risk assessment:
- Might it compromise patient care?
- How reliable is the device?
- Does it affect how the staff member applies the procedure?
- Is it easy to use?
- Is the safety mechanism simple, integral to the device or automatic? Can you tell if it has been properly activated?
This list is available in more detail in Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.3 Consult with practice staff when considering what kind of devices to introduce and ensure all are trained in their proper use, with that training being recorded.
Provide appropriate sharps disposal bins
Sharps bins should be positioned close to where the staff member is working so that the needle can be placed straight into the bin and not re-capped. Staff visiting patients in their own homes should have an additional risk assessment completed and be provided with a portable sharps bin, training in its use and information about collecting a new bin once that is full and how to dispose of the old one.
Provide information and training
In a GP practice, information is likely to take the form of at the very minimum a written procedure available in hard copy or on the practice intranet. Safety posters/guides are useful adjuncts. The Sharps Regulations3 stipulate that the information must include:
- Risk of injury from sharps.
- What the legal duties are of the practice as an employer.
- What the duties are of the staff member in following procedures for keeping themselves and others safe.
- What the practice has agreed is good practice.
- Information about immunisation.
- What the practice’s responsibilities are towards an injured staff member.
Training must ensure that staff know how to work safely with equipment, how to minimise risk, and what the procedure is that they must follow. The sharps regulations3 stipulate that training must include:
- How to use safe sharps correctly.
- How to dispose of safe sharps correctly.
- What to do in the case of an accident or injury.
- What the employer’s health and safety arrangements are and what arrangements are in place for instance in relation to immunisation.
What happens in the case of injury?
Under the sharps regulations3, practices must have a procedure in place in case of injury so that they can respond appropriately. The injured employee must inform the employer of the accident as soon as possible. They must provide sufficient information for the practice to investigate the accident. If, for instance, your employees visit patients in their homes, remember to incorporate this into your procedure.
The practice must:
- Record the injury immediately, who was injured, when and where, what kind of sharp was involved and at what stage of the procedure the injury occurred.
- Investigate what happened. The extent of the investigation will be related to the risk involved in the accident itself ie, its seriousness or potential seriousness. The investigation will highlight how well the practice’s control measures worked and lessons to be learned.
- Consider the risk of exposure to infection and take action if there is a risk. This will include knowing the infection status of the patient. If this information is shared with, for example, occupational health, then the patient’s confidentiality should be protected.
- Provide immediate medical advice for the injured staff member. This may be provided by a doctor or occupational health service. Additional advice may be available from a local hospital’s communicable diseases department and this should be in your procedure. The practice must ensure that the staff member is offered relevant post-exposure medical treatment or prophylaxis and consider whether on-going counselling might be required.
- Adhere to local reporting arrangements (eg, Datix toolkits)
- Report the accident under Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (see Resources) if appropriate.
Keep on top of it all
All health and safety arrangements need to be kept under review. In addition to a standard review, the Sharps Regulations3 require the practice to:
- Make sure that sharps use is minimised as far as is practical.
- Use safer sharps when sharps are actually needed.
- Ensure needles are not recapped.
- Provide written instructions and clearly marked sharps bins close to where staff are working with sharps.
- Review compliance as well as gaps in procedures and injuries/incidents.
- Consult with staff.
For many practices, there may be cost implications in moving to safer sharps. If this is the case in your practice, you will need to consider the impact of this on your sharps procedures. Further useful information is contained in particular in Sharps Safety: RCN Guidance to support the implementation of The Health and Safety (Sharp Instruments in Healthcare Regulations) 2013.4 This document will provide a good basis for detailed discussion with your nursing team and an opportunity to ensure you are fully compliant with these regulations.
Fiona Dalziel has been involved in primary healthcare management for 25 years.
References
1. CQC. Nigel’s Surgery: Tips and mythbusters for GP practices – see
full list cqc.org.uk/content/nigels-surgery-tips-and-mythbusters-gps (accessed 23 March 2016).
2. MindMeter Research. How sharp are we on safety? An assessment of safer sharps adoption in UK hospitals. October 2015.
mindmetreresearch.com/wp-content/uploads/2015/10/Sharps_H1_2015_Report-FINAL1.pdf (accessed 23 March 2016).
3. Health and Safety Executive. Health and Safety (Sharp Instruments in Healthcare) Regulations 2013, March 2013.
hse.gov.uk/pubns/hsis7.pdf (accessed 23 March 2016).
4. Royal College of Nursing. Sharps Safety: RCN Guidance to support the implementation of The Health and Safety (Sharp Instruments in Healthcare Regulations) 2013. 2.rcn.org.uk/__data/assets/pdf_file/0008/418490/004135.pdf (accessed 23 March 2016).
Resources
Control of Substances Hazardous to Health Regulations (COSHH) 2002
hse.gov.uk/coshh/
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 hse.gov.uk/riddor/
