Needlestick and Sharps Safety in the Dermatology Practice

Because of the procedural nature of dermatology practice, needlestick and sharps injuries (NSI) are the leading cause of morbidity and mortality for dermatologists.^1,2 The most common infections resulting from NSI are HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV).¹ Depending on the location and patient population, Zika virus may also present a risk.^1,3

Since the passage of the Needlestick Prevention and Safety Act of 2000, which required safety syringes, NSIs have decreased by 40%.² However, sharps injuries during dermatologic surgery have increased by 6.5%.²

More troubling still is that 64% of all dermatology NSIs continue to go unreported.⁴ Dermatology residents are somewhat better at reporting — only 45.2% of residents admit to not having reported their sharps injuries.⁵ Why the reluctance to report NSIs? Clinicians most often cite the perceived low risk by the source patient and that reporting is too time-consuming.²

“Dermatology has an incredibly high rate of needlestick injuries. We are tied with general surgery as having the highest rate of all NSIs,” Christopher B. Rizk, MD, a dermatology resident at Baylor College of Medicine in Houston, Texas, told Dermatology Advisor. “I wanted to bring awareness to the topic and make suggestions for preventive techniques.”

Dermatologists say that safety measures have gotten better, claiming that more residency programs are paying attention to safety training.¹ Yet, in a survey of 142 dermatology residents from the United States and Canada, 78% said they witnessed their attending physicians disregard safety guidelines and procedures such as not wearing safety goggles or gloves.⁵

Erik J. Stratman, MD, survey author and director of the dermatology residency program at the Marshfield Clinic in Wisconsin, uncovered these crucial missing elements of residency training while surveying an audience of upper-level residents. “I have spoken with several program directors who used the gaps identified in the paper to have local conversations with their residents,” Dr Stratman said in an interview. “These gaps in safety have been highlighted in larger audiences of dermatologists, like American Academy of Dermatology Annual Meeting plenary talks on patient safety gaps.”

How NSIs Occur

More than 90% of dermatologists admit that their own actions were responsible for NSIs.² Specifically, many dermatologists claim their own awkward movements and “being rushed” contributed to the mishaps.² In rank order, the most common dermatologic device injuries are from suture needles, scalpel blades, and syringes.²

Factors that could increase the likelihood of transmitting infection from patient to clinician are deep injury, visible blood on the sharps, needlesticks from an artery or vein, hollow-bore needle injury, and large-volume splashes.¹

The risk for occupational HIV exposure is 0.3% (95% CI, 0.2%-0.5%) for percutaneous injuries and 0.09% (95% CI, 0.01%-0.50%) for mucosal exposure.¹

For HBV, the risk for transmission from a contaminated needle is 1% to 6%.¹ The risk for contracting HBV from a source patient is 22% to 31% when the blood is positive for both hepatitis B surface antigen and hepatitis B e antigen.¹  

Three quarters of HCV occupational exposure is caused by NSI. The remainder of cases of HCV transmission from patient to clinician occur when contaminated blood splashes into the clinician’s conjunctiva.¹ The overall risk for HCV transmission is 1.8%.¹

Although the Zika virus is primarily transmitted by infected mosquitoes, the risk for occupational exposure remains unknown.⁶ Clinicians could be exposed to Zika through body fluids including blood, saliva, urine, amniotic fluid, and semen.^3,6

Pointed Advice on Prevention

Safety precautions need not be costly or bureaucratic. Below, dermatologists in private and academic practice offer their common-sense approaches to avoiding NSIs:

“We use a needle uncapper/recapper and syringe holder during procedures,” said Lauren Eckert Ploch, MD, MEd, FAAD, from Augusta, Georgia. “This prevents having loose sharps on the tray and it also eliminates the risk of needlesticks while capping and uncapping needles. We also keep sharps containers close to the patient tables in the examination rooms. This minimizes reaching over or across other things to throw sharps away and facilitates easy disposal of sharps during and immediately after a procedure.”

Dr Stratman advised, “Use verbal instructions when working as a leader of a cutaneous procedure involving sharps rather than assuming all can predict your thoughts and movements.”

“Getting enough sleep certainly can assist in preventing fatigue and easy distractibility. Have the patient positioned and everything prepped before starting,” added Adam Friedman, MD, associate professor and dermatology residency program director at George Washington University in Washington, DC.

Even before an accidental needlestick occurs, dermatologists should develop an algorithm for pre- and post-exposure procedures¹:

• Establish a contact person to direct the healthcare worker in case of exposure. In the absence of an individual or department nearby, call the Centers for Disease Control and Prevention.
• Identify a source for the worker to receive post-exposure prophylaxis medications.
• Check with the laboratory when serologic testing is available.
• Provide HBV vaccines to all colleagues and document the series of 3 injections.

Should an exposure occur, the dermatologist should:

• Wash the contaminated site with soap and water.
• Assess the severity of exposure.
• Ascertain the injured colleague’s HBV vaccination status.

References

1. Brewer JD, Elston DM, Vidimos AT, Rizza SA, Miller SJ. Managing sharps injuries and other occupational exposures to HIV, HBV, and HCV in the dermatology office. J Am Acad Dermatol. 2017;77(5):946-951.e6.
2. Rizk C, Monroe H, Orengo I, Rosen T. Needlestick and sharps injuries in dermatologic surgery: a review of preventative techniques and post-exposure protocols. J Clin Aesthet Dermatol. 2016;9(10):41-49.
3. Jimenez A, Shaz BH, Bloch EM. Zika virus and the blood supply: what do we know? Transfus Med Rev. 2017;31(1):1-10.
4. Donnelly AF, Chang YH, Nemeth-Ochoa SA. Sharps injuries and reporting practices of US dermatologists. Dermatol Surg. 2013;39(12):1813-1821.
5. Swary JH, Stratman EJ. Practice gaps in patient safety among dermatology residents and their teachers: a survey study of dermatology residents. JAMA Dermatol. 2014;150(7):738-742.
6. Olson CK, Iwamoto M, Perkins KM, et al. Preventing transmission of Zika virus in labor and delivery settings through implementation of standard precautions — United States, 2016. MMWR Morb Mortal Wkly Rep. 2016;65:290-292.