Among the various types of occupational exposures to blood-borne pathogens, accidental needlestick injuries constitute the single greatest risk to health-care workers.
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This problem is especially perilous for phlebotomists. The frequency of exposure from percutaneous injuries during collection of blood specimens is actually lower than accidents arising from other procedures involving the use of needles or other sharps. The absolute number of percutaneous needlestick injuries associated with phlebotomy, however, is relatively high simply because of the sizable number of venipunctures performed. Between 13 and 62% of all accidents reported to hospital employee health services are associated with needlestick injuries that occur during the process of blood collection.2
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Although transmission of hepatitis B virus can be almost completely prevented by vaccination, the risk of viral hepatitis C infection from needlestick injuries is still a major concern. Furthermore, of the 51 well-documented cases of human immunodeficiency virus (HIV) infections transmitted from patients to health-care workers, 20 (39%) have been associated with phlebotomy.4
Thus, although venipuncture is relatively harmless for the patient, it can be hazardous to the phlebotomist. Exposure to potentially life-threatening infectious agents is frightening and stressful for the employee and costly for the institution. Reducing the danger of needlestick accidents during collection of blood specimens should be among the highest of infection-control priorities.5
Rates of Injuries
Results from a retrospective study involving 683 healthcare facilities demonstrated that the median rate of needlestick injuries associated with phlebotomy was slightly less than 1 per 10,000 venipunctures.
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Among the institutions studied, however, the frequency varied by more than 100-fold. fold. Sources of variation were not examined, but the data illustrate that broad differences in practices affect the risk of accidental needlestick injuries. The same report indicated that the incidence of phlebotomists' needlestick injuries did not change during the 3-year study period (1990 through 1992). The high level of variation in needlestick injury rates among institutions and the lack of improvement over time suggest a state of complacency toward this problem. Perhaps the relatively low rate of needlestick accidents among phlebotomists has led to the mistaken conclusion that advances in current practices have reached a point of diminishing returns. This false sense of security may be further compounded by low estimates of injury rates from underreporting.Mayo Experience
In this issue of Mayo Clinic Proceedings (pages 611 to 615), Dale and associates describe how accidental needlestick injuries were reduced among members of the Phlebotomy Service at Mayo Clinic Rochester. What we learn from their experience with tackling this problem is that no single or simple solution is available. Numerous practice changes were implemented, including use of a one-handed recapping block, automatic disposal of plastic tube holders after each use, modification of phlebotomy chairs, intensive safety training, elimination of a doubleneedle technique for collecting blood culture specimens, and optional use of resheathing needles. This effort led to a remarkable decline in accidental injuries. It is not uncommon for a busy phlebotomist to collect blood from more than 50 patients per day. Thus, during the course of a year, a hard-working phlebotomist may perform as many as 10,000 venipunctures. With the assumption that the median needlestick injury rate is about 1 per 10,000 venipunctures, then, on the average, a phlebotomist will have about 1 accidental percutaneous blood exposure per year. Reducing the incidence to just 0.2 per 10,000, as accomplished in the study by Dale and associates, would put even the busiest phlebotomist at risk of only about 1 exposure every 5 years, an extraordinary accomplishment. As a result, phlebotomists at the Mayo Clinic now enjoy a safer work environment, and the institution avoids thousands of dollars in recurring costs from reduction in exposure-related expenditures. Best of all, the authors claim that no one on the phlebotomy team has ever acquired an infection despite the large number of phlebotomies performed.
Safety Devices and Practices
Occupational exposure to infectious agents associated with phlebotomy is an important risk-management issue that affects the safety and well-being of employees. Health-care facilities should follow the lead of Dale and coworkers and consider every possible measure to eliminate the risk of needlestick injuries associated with phlebotomy. Newer safety devices for preventing percutaneous injuries are now available, including resheathable winged steel needles (Safety-Lok, Becton Dickinson), bluntable collection needles (Punctur-Guard, Bio-Plexus, Inc), and hinged recapping sheath needles (Smith Industries). These devices have been shown to decrease injury rates by about 70%
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but are more expensive and may be associated with greater technical difficulties and adverse patient effects in comparison with standard collection devices, as pointed out by Dale and colleagues. We need more experience with these devices, but the approach taken by the authors is prudent-make the newer safety devices available and let the phlebotomists decide which tools are most useful and effective for doing their job in the most cost-effective manner. Elimination of the double-needle technique for blood culture collection is another good idea. Although a meta-analysis has shown this method to have marginally significant influence on reducing blood culture contamination,7
the benefits simply do not outweigh the risks incurred from having to change needles. Furthermore, safety guidelines issued by the Centers for Disease Control and Prevention recommended that needles never be removed from disposable syringes.8
Finally, the authors' recommendation to discard tube holders after each use may seem wasteful, but it does reduce the risk of needlestick injury. Consider the results of another study that showed that of 24,153 blood tube holders that were in current use, 9.6% were visibly contaminated with blood.6
This finding should be reason enough to designate plastic blood tube holders as single-use items.Advantages of Phlebotomy Services
Use of an experienced and well-trained phlebotomy service for all collection of blood specimens is important for many reasons, not the least of which is to minimize the risk of occupational exposures to needlestick injuries.
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Blood collection by a phlebotomy team also results in fewer mislabeled or improperly collected specimens, greater protection of venous access, and enhanced patient satisfaction.10
Unfortunately, phlebotomists have another risk-unemployment. In the drive to reduce health-care costs, short-sighted administrators are eliminating comprehensive phlebotomy services in order to decrease payroll expenses. In many facilities, responsibility for inpatient blood collection has been assigned to nurses, patient-care technicians, or others who do not have the same high level of skill or commitment to training as does a specialized phlebotomy team. Consider the effect of a phlebotomy service on costs associated with blood cultures. Each blood culture contaminant is estimated to be associated with excess charges of $5,000 (adjusted for inflation since the study was published) from extra hospital days, additional laboratory testing, and more antibiotic usage.11
If one generalizes from this estimate, a predicted $5 per specimen in excess expenditures would be avoided for every 0.1% reduction in the frequency of false-positive blood culture results from contamination during the collection procedure. A large multi-institutional study found that the median blood culture contamination rate was about 0.4% lower among facilities that used a phlebotomy team to collect blood culture specimens.12
On the basis of this level of reduction in blood culture contamination rates, the typical savings associated with using a phlebotomy service can be predicted to be about $20 per blood culture specimen collected. This is just one of several examples that illustrate how comprehensive phlebotomy services decrease costs and improve quality.Outcome of Safety Efforts
Dale and associates provide insight into not only what can be done but also what must be done to reduce the danger of needlestick accidents among phlebotomists. The investigators had the advantage of managing these safety improvements with the help of members of a motivated phlebotomy team who are responsible for almost all venipunctures performed at the institution. I would predict, however, that implementing a similar safety program among a diverse group of health-care workers at other facilities that do not have an equally well-managed and comprehensive phlebotomy service will be much more challenging and less likely to be as successful.
References
- Occupational risk of the acquired immunodeficiency syndrome among health care workers.N Engl J Med. 1986; 314: 1127-1132
- Epidemiology of needlestick injuries in house officers.J Infect Dis. 1990; 162: 961-964
- Epidemiology of hospital sharps injuries: a 14-year prospective study in the pre-AIDS and AIDS eras.Am J Med. 1991; 91: 301S-307S
- Evaluation of safety devices for preventing percutaneous injuries among health-careworkers during phlebotomy procedures-Minneapolis-St. Paul, New York City, and San Francisco, 1993–1995.MMWRMorb Mortal Wkly Rep. 1997; 46: 21-25
- Percutaneous injury analysis: consistent categorization, effective reduction methods, and future strategies.Infect Control Hosp Epidemiol. 1995; 16: 582-589
- Phlebotomists' safety practices: a College of American Pathologists Q-Probes study of 683 institutions.Arch Pathol Lab Med. 1994; 118: 957-962
- The significance of changing needles when inoculating blood cultures: a meta-analysis.CUn Infect Dis. 1995; 21: 1103-1106
- Recommendations for prevention of HIV transmission in health-care settings.MMWR Morb Mortal Wkly Rep. 1987; 36: 1S-18S
- Risk of needlesticks and occupational exposures among residents and medical students.Arch Intern Med. 1992; 152: 1451-1456
- Venepuncture: the medicolegal hazards.Postgrad Med J. 1996 Jan; 72: 23-24
- Contaminant blood cultures and resource utilization: the true consequences of false-positive results.JAMA. 1991; 265: 365-369
- Blood culture contamination: a College of American Pathologists Q-Probes Study involving 640 institutions and 497,134 specimens from adult patients.Arch Pathol Lab Med. 1998; 122: 216-221
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© 1998 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
