Stuck in the ER

Sharps Safety in Emergency Rooms

By Ron Stoker

A rock flies through the windshield of a car striking the mother of six children in the head. A child holds his hand tightly around a finger trying to keep it from bleeding because the tip was torn off by his bicycle chain and sprocket.  A father pleads for help for his son suffering from a grand mal seizure. A young man shot in the chest because he was fighting over drugs. These are just a few of the many people who end up in the emergency room every day.

The ER is a place where clinicians work 24/7 trying to save lives and minimize suffering.   Physicians and nurses operate at a hectic pace making life-and-death decisions and handling a variety of circumstances.  Each day a multitude of real-life dramas unfold in front of their eyes.  These clinicians see it all--battered children and wives, police officers with gunshot wounds, drunks, drug addicts and accident victims.  

One of the most interesting characteristics of emergency medicine is the variety of conditions that arrive on a daily basis. No other specialty in medicine sees the diversity of conditions that an ER physician sees each week. ER personnel see common injuries such as lacerations and scrapes, broken bones and sprained ankles as well as a variety of exotic illnesses.

Overburdened staffs, overcrowded conditions, and a population ever-more dependent on the ER staff make working there difficult at times.  ER staff not only treats those with severe injuries and illnesses but also operate as a safety net for the more than 40 million uninsured in the United States[1]. There are 31,797 emergency physicians in clinical practice in the United States with an additional 89,300 emergency nurses.  This core of emergency personnel responded to 106,937,286 ER visits in 1999 and more than 108 million in 2000[2].

As the father of a large family, I have made more than a few visits to the ER over the years.  Unfortunately, we ended up waiting for what seemed to be extraordinarily long periods of time while other patients were being seen even when we were sure they came in after us. Although our children’s health seems paramount to us each time, we were probably being seen for minor illness or injury when compared to some of the patients who were there in the ER--but then the principle of triage is that if you have a minor illness or injury, you wait while sicker or more severely injured patients are seen first. 

Although I understand that ERs in the hospital have to use triage and often lack sufficient resources to attend to everyone’s need – it often seemed that as patients we were in the ER for a long time, often several hours before being treated and released.  We were stuck in the ER.

Patients and families are not the only ones that can be stuck in ER.  The ER is a high stress, high activity place. Many people work in and around the ER including doctors, nurses, respiratory therapists, social workers and phlebotomists.  There are a great number of people from outside of the hospital that interact with the hospital staff including firefighters, paramedics, emergency medical technicians (EMTs), police officers and other rescue workers.  The frantic pace of the ER can make it an unsafe place to work because of exposure to bloodborne pathogens and sharps injuries.

The ER might be thought of as a battlefield surgical suite with short, quick little procedures needing to be performed on a never-ending group of patients.  It is not uncommon for emergency physicians to see 30-40 patients during their shift. 

This frenetic pace sometimes makes clinicians feel compelled to cut a few corners and be a little sloppy in their own personal safety.  Oftentimes, universal precautions are ignored for expediency’s sake with the staff rushing to provide care – and overriding their need for self-protection by omitting appropriate protective glasses, goggles or facemasks.

The greatest risks to clinicians in the ER come from exposure to the bodily fluids of patients. Universal precautions should be a mind-set of every clinician.   Every patient should be considered a potential carrier of serious disease.  These ER workers are particularly at risk for exposure to blood, bloodborne pathogens and occupational exposure to infectious materials (OPIM), because of the immediate, life-threatening nature of emergency treatment.  

The following story illustrates methods to provide greater safety for healthcare workers serving in the emergency department of a hospital.

Dr. Brooke had wanted to be a doctor from her earliest years, but this morning, at 2 a.m. in the seventh hour of a 12-hour ER shift, she doubted the rationale of that decision.  She had no fewer than 19 patients who she was attending in the ER!   One of patients was critically ill and had been brought in 20 minutes earlier.  The patient needed to have a central line that would need to be placed quickly. 

Placing a central line is a short surgical procedure where long needles and wires are used to find large veins that are located deep inside the body.  Once the vein is found, a small plastic catheter can be guided into the blood vessel.  Brooke was just placing the needle into the large vessel when patient threw herself against the restraints that held her arms and legs, down plunging the needle into

Brooke’s finger.  Brooke held up her glove and noticed her own blood blending with the blood of her patient. She was barely able to finish the procedure without crying. Brooke walked from the room hoping that her patient would consent to having the necessary blood tests but already knowing that her patient was infected with hepatitis B and C.

Sharps Prevention Needles

Sharps injuries are a common occurrence in emergency departments. The injuries come from a variety of sharps. A disposable syringe with a hollow needle was the culprit in 25% of the cases.  A vacuum tube blood collection needle accounted for the injury 11% of the time, an IV catheter 9% of the time, and prefilled cartridge syringe were responsible 7% [3] . There are so many safety sharp prevention devices available to help protect healthcare workers. There is rarely a need to use a standard needle.  Standard winged blood-collection devices, often called butterfly needles, are one of the top causes of needlesticks.  Safety winged blood-collection systems are available that allow for one-handed safety activation as well as flexible wings for easy insertion.[4]  This protects the healthcare worker and others from being stuck with a blood-filled needle.

Dr. Brooke walked into the Treatment Room #3. There she saw a young man, Jason, 17 years old, who had fallen off his mountain bike onto a large rock.  The laceration across his forearm was five inches long and had small rocks and dirt embedded into it.

 Brooke knew that standard protocol required the irrigation of the wound before closing it. After properly anesthetizing the wound, she picked up the 30 cc syringe with saline and attached the needle to it.  By applying pressure on the syringe plunger, the sterile saline solution was pushed out of the end of the needle and into the wound. This would irrigate and clean the wound nicely.  Unfortunately, the stream of water splashed off of the wound and onto Brooke’s clothes, hands and even up onto her face.

Wound Irrigation

Laceration repair is a routine procedure for most emergency department physicians. Historically that has meant the use of high-pressure irrigation with a syringe and needle (or IV catheter). The syringe and needle are used to generate a stream of saline that provides the optimal 8-12 pounds per square inch (psi) of pressure that is recommended by most leading authorities and literature.

Unfortunately, this high-pressure irrigation also showers the physician with splashed irrigation fluid, contaminated with blood. Physicians should take safety precautions to help minimize their exposure to bloodborne pathogens like HIV and hepatitis. In addition to sharps injuries, mucataneous splashes can also allow seroconversion of these deadly diseases.  ER personnel should wear the appropriate goggles, masks, and impermeable gowns to avoid occupationally acquired. In addition, the clinician can replace the needle with a safety wound irrigation device like the Zerowet Splashshield.[5].

The safety wound irrigation product is attached to the end of the irrigation syringe and is then held lightly on the skin. The physician can then irrigate with maximal force without splashing contaminated blood.

Universal Precautions

Despite the best of precautions, inadvertent needlesticks still happen. The most feared outcome of a needlestick is the transmission of hepatitis B, hepatitis C or HIV. If a patient is infected with all three, the risk of transmission from a needlestick is 30 percent for hepatitis B, 3 percent for hepatitis C and one-in-300 for HIV.

Universal blood and body fluid precautions should be followed by all healthcare workers in the emergency department.  At times, healthcare workers are up to their elbows in body fluid exposure.  A severe automobile or plane accident can have clinicians exposed to liters of fluid.  Protective gowns, masks, goggles and glasses can help minimize exposure. 

“We are never exposed to sharps injuries!”

How often has that been said?  A recent study of more than 3,000 emergency medicine residents indicated that residents were often exposed to needlestick injuries with more 56% of them having at least one exposure and 10% of them having four or more exposures.  These emergency medicine residents were exposed to sharps injuries 72% of the time in the ER. Solid needles or sharp objects accounted for 40% of latest exposures, with hollow bore needles accounting for 31%. Eye splashes made up 17%. At the time of exposure 92% were wearing gloves, 41% eye protection and 30% masks.  It is important, therefore, to plan for the worst and protect ourselves appropriately.

It is also important to set up appropriate procedural steps to minimize potential risks. Sharps safety equipment should be used, unsafe procedures such as the re-capping of needles should be terminated, and needles should be placed into sharps containers as quickly as possible.  By using standard safety protocols, needles will not be left in bedding or on surfaces. There should be an organizational environment and system that encourages and fosters occupational safety.[6]

Prevention of occupational exposures requires an integrated system of personal protective equipment, engineering controls, workplace practices, education and training, surveillance, and risk-reduction programs. It also includes addressing occupational factors such as worker fatigue, insufficient staff and long shifts that can contribute to the risk of occupational exposure.  It is important to engage management and frontline workers in the consultation, review, training and support of sharps safety.  The whole emergency department staff should be involved in the assessing of sharps injury accidents or near-accidents and they should suggest potential solutions. They should also be involved in the implementing and evaluating of these solutions and should assist in the training of engineering controls and routine practices.  Even simple solutions such as leaving bloody shoes in a locker rather than wearing them home to contaminate your family should be addressed. 

By establishing and sticking to safety protocols the risk of needlestick and other sharps injuries can be minimized.  These procedures, protocols and sharps safety equipment can help assure that healthcare workers will not get stuck in ER.

Author bio:

Ron Stoker, a frequent contributor to Managing Infection Control magazine, is the Executive Director of ISIPS, the International Sharps Injury Prevention Society.  He is a frequent speaker on sharps safety and occupational blood exposure at national and international events. For more information about ISIPS and sharps safety products, visit www.isips.org, or email Mr. Stoker at ron@isips.org.