Managing Sharps Injuries and Splash Incidents

Blood-borne viruses (BBV) are those that are transmitted from the blood of one person to the blood of another person. Of particular concern are hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). A sharps injury can be defined as exposure to blood or body fluids caused by laceration or puncture of the skin (these can include bites or scratches by sharps). Sharps include needles, scalpels, broken glass, or any items that may lacerate or puncture the skin. A splash incident can be defined as where blood or body fluids come into contact with the eyes, mouth, broken skin or mucous membranes.¹

Although the number of sharps injuries each year is relatively high, only a small number have caused infections that have led to serious disease.² Healthcare workers are particularly at risk from exposure to BBV. Accidental exposure to blood or other body fluids from patients can lead to infection if the patient is infected with a blood-borne virus such as HIV, HBV or HCV. Infection is not only damaging for health, but it could also prevent certain work within the healthcare setting.

Incidence

A survey carried out in 2008 of 4,407 nurses found that just under half (48%) had been injured with a needle or sharp previously used on a patient, and that 52% of those surveyed feared an injury. In addition, a significant number felt that they had received no or little training from their employer.³ A similar survey carried out among a group of UK surgeons in 1991 showed that 44% anonymously admitted to having a needle-stick injury. Only three of the 33 (9%) who sustained a needle-stick injury said that they followed the agreed local policy.⁴ Data compiled by Public Health England in December 2014 warned that healthcare workers remain at risk from BBV.⁵

A government report examined 8,765 BBV exposures from healthcare workers between 1997 and 2018, which suggested a risk of transmission (Table 1).⁶ A new survey, carried out on behalf of the Royal College of Nurses and published in May 2021, stated that out of 7,500 members, 96% had experienced a blood or body fluid exposure and 63% had experienced a sharps injury. The reason for the high incidence of events was difficult to ascertain in the UK; however, it was deemed to be likely related to COVID-19 workloads.⁷

Minimising the risk

Vaccination

HBV infection can be effectively avoided by vaccination, but there is currently no vaccine available for HCV or HIV. Vaccination must be offered free of charge by their employer to all workers and students delivering healthcare with exposure to blood or body fluids.⁸ In the event of a sharps or splash injury, it is useful if the healthcare worker can provide their most recent HBV antibody titer.

General measures

Policies and procedures must be in place and available for all healthcare workers, and employers must organise and provide mandatory training to workers on a regular basis considering monitoring, modernisation and improvements.

These policies should include:⁸

• Washing hands before and after contact with each patient and before putting on and after removing gloves.
• Changing gloves between patients.
• Cover any existing wounds, skin lesions and all breaks in exposed skin with waterproof plasters or dressings. Always wear gloves if hands are extensively affected.
• Wear gloves when contact with blood can be anticipated.
• Avoid sharps usage where possible.
• Where sharps usage is essential, exercise care in handling and disposal.
• Avoid wearing open footwear in situations where blood may be spilt or where sharp instruments or needles are handled.
• Clear up spillage of blood promptly and disinfect surfaces.
• Pre-employment occupational health assessment should identify those with damaged skin (e.g. fissured hand eczema) who may be at higher risk of occupational acquired infection and ensure that advice is given about minimising any occupational health risk to which they may be exposed.
• Wear gloves when cleaning equipment prior to sterilisation or disinfection, when handling chemical disinfectant and when cleaning up spillages.
• Follow safe procedures for disposal of contaminated waste.
• All sharps or splash injuries need to be reported to the employer/designated person.

Specific measures

The use of new, single-use disposable equipment for all injections is highly recommended, and reusable equipment should only be considered if single use is not available and if the sterility can be documented according to the manufacturer’s instructions with appropriate audit (e.g. time and temperature indicators). Practitioners should ensure to discard contaminated sharps immediately and without re-capping in puncture and liquid proof sharps containers, as well as documenting the quality of the sterilisation for all medical equipment used for percutaneous procedures.⁸ 

It’s important to make sure that hands are being washed with soap and water before and after procedures, that all clinicians use protective barriers such as gloves, gowns, aprons, masks, and goggles for direct contact with blood and other body fluids, and that they disinfect instruments and other contaminated equipment.8 Practitioners should wear gloves and a disposable apron when handling soiled linen and keep contact to a minimum. Soiled linen should be transported in a suitable leak proof bag. Cleaning should occur outside patient areas, using detergent and hot water. Use sharps with safety-engineered protection mechanisms if a risk assessment has indicated that they will provide safer systems of working for healthcare workers, carers, and patients.⁸

More detailed advice, including use of blunt-tipped needles, and ‘neutral zones’ for passing of sharps during surgery, are available in the Department of Health’s ‘Guidance for Clinical Health Care Workers’.⁹

NICE recommendations

The National Institute for Health and Clinical Excellence (NICE) has several recommendations for keeping practitioners and patients safe in its clinical guidance titled ‘Healthcare-associated infections: prevention and control in primary and community care’.¹⁰

Safe use and disposal of sharps

Handling of sharps should be kept to a minimum and they should not be passed directly from hand to hand. Used needles must not be bent or broken before disposal and must not be recapped. Used sharps must be discarded immediately by the person generating the sharps waste into a sharps container conforming to current standards.^10,11

Sharps containers

Sharps containers must be in a safe position that avoids spillage, at a height that allows the safe disposal of sharps. They must be kept away from public access areas, out of the reach of children, and must not be used for any other purpose than the disposal of sharps. Containers should not be filled above the fill line and should be disposed of when the fill line is reached. When not in use, sharps containers should be temporarily closed, and they should be disposed of every three months even if not full by the licensed route in accordance with local policy.¹⁰

Management of a sharps injury

If a sharps injury occurs, practitioners should encourage the wound to gently bleed, ideally placing it beneath running water – applying pressure above the wound may induce further bleeding from the wound.¹¹ You should then wash the wound with running water and plenty of soap, as disinfectant agents may provide greater risk reduction (such as 10% iodine, 70% alcohol or hypochlorite solutions). You should not scrub or suck the wound. After washing, dry the wound and cover it with a waterproof plaster or dressing.⁶

We advise that you seek urgent medical advice as you may need post-exposure prophylaxis in a private healthcare setting. This may mean contacting your local infectious disease consultant or an Accident and Emergency department or genitourinary medicine department. There should be no delay as ideally, prophylaxis should be commenced within an hour of injury.¹¹ The final step is to report the incident to your employer, manager, or occupational health department. In certain situations, a sharps injury may need to be reported to HSE (Health and Safety Executive) under the Reporting of Injuries, Disease and Dangerous Occurrences Regulations 1995.¹²

Following exposure to blood or body fluids contaminated with a BBV, it may take six months for seroconversion to occur, and the healthcare worker should be tested at six weeks, three months and six months.¹¹ The practitioner does not need to refrain from work during this time as the risk of seroconversion and passing on the infection from occupational exposure is too low to consider. However, they should practice safe-sex and refrain from blood donation.⁹

Policies and procedures must be in place and available for all healthcare workers, and employers must organise and provide mandatory training to workers on a regular basis

Identify patients at high-risk

In the event of a sharps or splash injury, the healthcare worker should ascertain the level of risk associated with the injury. There are some very personal and confidential questions that can be asked to identify high-risk patients; these are often best asked by a senior and separate practitioner (Table 2). Ideally a sample of blood is taken from the patient to test for BBVs. However, the patient is not obliged to answer any questions or to provide a sample and undue pressure should not be applied.

Take care of yourself and your staff

BBVs are a particular concern to healthcare professionals, and those working in aesthetics should take the necessary precautions to minimise the risk of infection. Employers should ensure to implement the appropriate measures to protect both members of staff and patients, and in the event of a sharps injury practitioners should follow the above guidelines.

This article was written based on the newest ACE Group World guidelines on managing sharps injuries and splash incidents.