Needlestick and Sharps Injuries

Dentistry may not be as dangerous as skyscraper construction or racecar driving, but it has its share of risks.

By Dr. Katherine Schrubbe, RDH, BS, MEd, PhD.

Dental professionals face a constant risk of sharps injuries and exposure to bloodborne pathogens, especially during the delivery of patient care. They are at particular risk for hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV). According to the Centers for Disease Control and Prevention (CDC) studies of healthcare personnel who have sustained injuries from needles contaminated with blood containing HBV, there is a 22 to 31 percent risk of developing clinical hepatitis in cases where the blood is both hepatitis B surface antigen (HBsAg) and HBeAg positive, and a 37 to 62 percent risk of developing serologic evidence of HBV infection. The average incidence of anti-HCV seroconversion after accidental percutaneous exposure from an HCV-positive source is 1.8 percent. And, the average risk of HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated at approximately 0.3 percent.¹ Even a risk that small is too great.

Indeed, the Occupational Safety and Health Administration (OSHA) estimates 5.6 million workers in the healthcare industry and related occupations are at risk for occupational exposure to bloodborne pathogens each year, and the approximately 385,000 needlestick and other sharps-related injuries are sustained by hospital healthcare workers alone. Similar injuries are sustained in other healthcare settings such as dental facilities, nursing homes, emergency centers and clinics.^2,3 When accounting for both hospitals and other health care settings, studies have estimated that between 600,000 and 800,000 needlestick and other percutaneous injuries occur annually to healthcare workers^.4 That said, other studies completed in medical facilities demonstrate that there is considerable underreporting of these injuries^.5

Sharps safety protocols
Dental practices – especially large groups and DSOs – are very busy places with tight patient schedules, and many of the instruments and devices that are used are considered “sharps.”  Sharps is a term for devices with sharp points or edges that can puncture or cut skin or other tissue; dental examples include syringe needles, ortho bands/wires, instruments (i.e. scalers), scalpel blades, burs, files, suture needles and broken glass.³

What steps should be followed when a dental healthcare team member sustains an occupational exposure sharps injury? The procedure and protocol for this demonstrate a perfect example of the interconnection between OSHA, a regulatory agency, the U.S. Public Health Service (USPHS) and the Centers for Disease Control and Prevention (CDC).

First aid and reporting
Dental team members who sustain a needlestick or other sharps injury may think that they should wait until the patient procedure is completed to manage and report these injuries, but that is not the case. When a sharps injury occurs, the first priority should be the team member with the injury.

According to the CDC, “first aid should be administered immediately and as necessary after an occupational injury. Puncture wounds from sharps and other injuries to the skin should be washed with soap and water and no evidence exists that using antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk of bloodborne pathogen transmission; however, use of antiseptics is not contraindicated. Also, the application of caustic agents (e.g., bleach) or the injection of antiseptics or disinfectants into the wound is not recommended. Exposed dental team members should immediately report the exposure to the infection-control coordinator or other designated person, who should initiate referral to the qualified healthcare professional and complete necessary reports.”⁶

According to OSHA, “exposure incidents should be reported immediately to the employer since they can lead to infection with HBV, HCV, HIV or other bloodborne pathogens. When a worker reports an exposure incident right away, the report permits the employer to arrange for immediate medical evaluation of the worker. Early reporting is crucial for beginning immediate intervention to address possible infection of the worker and can also help the worker avoid spreading bloodborne infections to others.”⁷ Thus, it is crucial to manage and report these injuries without hesitation or worry about workplace repercussions; accidental injuries can happen.

Medical evaluation and follow-up
OSHA’s Bloodborne Pathogens standard (29 CFR 1910.1030) requires employers to make immediate confidential medical evaluation and follow-up available for workers who have an exposure incident, such as a needlestick. The standard states this evaluation and follow-up must be:

• Made available at no cost to the worker and at a reasonable time and place.
• Performed by or under the supervision of a licensed physician or other licensed healthcare professional.
• Provided according to the recommendations of the USPHS current at the time the procedures take place. In addition, laboratory tests must be conducted by an accredited laboratory at no cost to the worker.^7,8

The CDC defines and outlines specific information to be included in the exposure incident report, which is recorded in the exposed dental team member’s confidential medical record and provided to the qualified healthcare professional for medical evaluation and follow-up. This includes:

• Date and time of exposure.
• Details of the procedure being performed.
• The type of device used, and how and when it was being used, when the exposure occurred.
• Details of the exposure, including the type and amount of fluid or material and the severity of the exposure.⁶

Additional information should be included in the report as well, including:

• Whether the source material was known to contain HIV or other bloodborne pathogens and, if the source was infected with HIV, the stage of disease, history of antiretroviral therapy and viral load, if known.
• The exposed person’s hepatitis B vaccination and vaccine-response status.
• Details regarding counseling, post-exposure management and follow-up.⁶

The report, along with the job description of the exposed dental team member, must be taken to the medical provider that performs any serological tests. Records of all employees with occupational exposure must be maintained for 30 years after the employee terminates employment.⁸

Serological testing
According to OSHA, a worker who participates in post-exposure evaluation and follow-up may consent to have his or her blood drawn for determination of a baseline infection status of HBV and HIV, but has the option to withhold consent for HIV testing at that time. In this instance, the employer must ensure that the worker’s blood sample is preserved for at least 90 days, in case the worker changes his or her mind about HIV testing.^3,7 Although testing is an option for the exposed and injured dental healthcare worker, it may help to preserve peace of mind during the entire post-exposure process. As an example, although HIV infection following an occupational exposure occurs infrequently, the emotional effect of an exposure often is substantial; therefore, giving an exposed person access to persons who are knowledgeable about occupational HIV transmission and who can deal with the many concerns an HIV exposure might generate is an important element of post-exposure management.⁶  It is a good practice to seek a health clinic or medical provider who specializes in occupational health as the clinic or provider of choice for any post-exposure follow-ups.

The source individual 
The source individual is any patient whose body fluid is involved in the exposure incident.³ According to the CDC, if the HBV, HCV and/or HIV infection status of the source is unknown, the source person should be informed of the incident and tested for serologic evidence of bloodborne virus infection as soon as possible. Procedures should be followed for testing source persons, including obtaining informed consent in accordance with applicable state and local laws. Any persons determined to be infected with HBV, HCV, or HIV should be referred for appropriate counseling and treatment. Confidentiality of the source person should be maintained at all times.⁶

Counseling
When dental team members sustain a sharps injury and have possible exposure, OSHA requires that post-exposure follow-up include counseling the worker about the possible implications of the exposure and his or her infection status, including the results and interpretation of all tests and how to protect personal contacts. In addition, post-exposure prophylaxis for HIV, HBV and HCV, when medically indicated, must be offered to the exposed worker according to the current recommendations of the U.S. Public Health Service.⁷

The written opinion
Once the medical healthcare provider has evaluated the employee and source patient’s test results, a written opinion is generated. According to OSHA’s standard, the employer must obtain and provide the injured employee with a copy of the evaluating healthcare professional’s written opinion within 15 days of completion of the evaluation. The written opinion should only include whether hepatitis B vaccination was recommended for the exposed worker; whether or not the worker received the vaccination; and that the healthcare provider informed the worker of the results of the evaluation and any medical conditions resulting from exposure to blood or OPIM, which require further evaluation or treatment. Any findings other than these are not to be included in the written report.⁷ All other medical information must remain confidential per HIPAA laws.

Although the process may seem cumbersome, if policies and protocols are in place, managing a sharps injury should be a streamlined and seamless process. Again, in large group practices and DSOs the infrastructure for a standard operating procedure or protocol should be in place. The flow-chart below illustrates the process for post-exposure evaluation and follow-up in a straightforward manner.⁹   This can be used as an initial resource for practices that are working to establish a protocol.

Source: American Dental Association

Dental team members and practice management teams should not take the risk of sharps injuries lightly. In the provision of dental care, risk is present and any needed follow-up from an occupational exposure sharps injury must be completed in a timely and efficient manner. The CDC recommends that all dental practices establish written, comprehensive programs that include hepatitis B vaccination and post-exposure management protocols.^1,10 The safety and health of the dental team members must be a priority in all practice settings.

References:

1. Centers for Disease Control and Prevention. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV and HIV and Recommendations for Postexposure Prophylaxis. MMWR Morbid Mortal weekly Rep 2001;50(RR-11). Available at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm. Accessed September 17, 2018.

2. US Department of Labor – Occupational Safety and Health Administration. Healthcare Wide Hazards- Needlestick/Sharps Injuries. Available at https://www.osha.gov/SLTC/etools/hospital/hazards/sharps/sharps.html. Accessed September 13, 2018.

3. Miller CH, Palenik CJ. Infection Control and Management of Hazardous Materials for the Dental Team. 5th ed. St. Louis: Mosby Elsevier; 2013;198.

4. American Nurses Association. Fact Sheet. Available at https://www.nursingworld.org/~48de3c/globalassets/docs/ana/snsl-fact-sheet_final110110.pdf. Accessed September 14, 2018.

5. John Hopkins Medicine. Medical Students Regularly Stuck by Needles, Often Fail to Report Injuries. Available at https://www.hopkinsmedicine.org/news/media/releases/medical_students_regularly_stuck_by_needles_often_fail_to_report_injuries_. Accessed September 14, 2018.

6. Centers for Disease Control and Prevention. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV and HIV and Recommendations for Postexposure Prophylaxis. MMWR Morbid Mortal Weekly Report 2001;50(RR-11). Available at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm. Accessed September 17, 2018.

7. Occupational Safety and Health Administration. Fact sheet: Bloodborne Pathogens Exposure Incidents, 2011. Available at https://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact04.pdf. Accessed September 17, 2018.

8. US Department of Labor. Occupational Safety and Health Administration. Bloodborne Pathogens Standard; 1910:1030. Available at https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030#1910.1030(b). Accessed September 14, 2018.

9. American Dental Association. Employer Obligations After Exposure Incidents OSHA. Available at https://www.ada.org/en/science-research/osha-standard-of-occupational-exposure-to-bloodbor#Flow. Accessed September 18, 2018.

10. Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings — 2003. MMWR 2003;52(No. RR-17);13.

Editor’s note: Dr. Katherine Schrubbe, RDH, BS, M.Ed, PhD, is an independent compliance consultant with expertise in OSHA, dental infection control, quality assurance and risk management.  She is an invited speaker for continuing education and training programs for local and national dental organizations, schools of dentistry and private dental groups. She has held positions in corporate as well as academic dentistry and continues to contribute to the scientific literature. Dr. Schrubbe can be reached at [email protected].