Needlesticks- a few thoughts

[Rob72, ASN, RN]

Quite a few NS threads lately, so I thought I would share a few things I've learned.

I'm a former phlebotomist/EMT/UAU and lab tech. I was originally hospital-trained, and have a tad over 100,000 veinpunctures performed. I've had 1 NS, in 20 years, and it was an uncapped syringe left in a room- not one I handled.

Body mechanics are a significant part of preventing self-inflicted sticks. I do not sit, when sticking, as the natural reaction, if bumped, is to move the hands up and forward- which will drive a needle neatly into one's hand.

When sticking, first and foremost, the needle goes nowhere but into the patient (or maybe the bed). That means that if the patient moves suddenly, they get jabbed; a bomb goes off in the parking lot, the patient gets jabbed; lights go out, the patient gets jabbed- maybe the mattress, as long as it isn't in the direction of your hand; a fire-nado-caine-alanche comes down and consumes your hosptital, yep, you guessed it.

What we are trying to mitigate is the startle-response. When adrenalized, our bodies experience a systemic contraction and some level of stabilization-response, such as extending/retracting the hands. What you want to train-in is a rigid locking of the sticking arm perpendicular to the torso. Along with this, applying firm, downward pressure with the sticking hand stabilizes your needle entry, and also connects you to the patient.

The untrained response, relating to that connection, when the patient moves or when we are startled, is to draw away from contact with the patient. The problem is that we have lost all foundation at that point. Our desire being to hold the needle in mid-air, so that no one-particularly the patient- is injured, results in a free-floating missle, ready to be driven into any on-coming surface. That surface is typically us, as either we retract our arms and hands to shield our core torso, or we hyper-extend to catch an anticipated fall.

Most of this is situational, but can be addressed by changing how we perceive a situation, rather than hard and fast rules or safety devices. Primarily: how may I best position myself so that I am not readily in-line with my needle? Secondly: your needle always faces your patient. Our gaze is normally a tandem effort, our eyes move in unison in the same direction. Manually, we have (generally) learned to move our hands together. Adapt your sticking so that your mechanics are more parallel, not intersecting. I.e., when sticking, your needle is always between your patient's body and the dominant side of yours, never pointing towards the non-dominant side.

If, for some odd-ball reason, you must move with an exposed sharp, hold it in the dominant hand, across the chest and pointing toward the non-dominant shoulder. Face your dominant side, and move with that side of the body leading. If bumped or startled, the sharp will be pressed parallell to the body, with the head ducking further towards the dominant shoulder, away from the needle.

Regarding gloves/no gloves, I will simply say that is a performance-bias issue. We do what we want to do until we are conclusively shown that it causes problems.

Just a mini-rant, that hopefully will help someone to evaluate their mechanics. I always find it interesting when the practical skills are said to be better suited to OJT, unnecessary, etc., when basic safety is such an issue in this profession.

[CrunchRN, ADN, RN]

Great tips!

[Rob72, ASN, RN]

I'll add this, since I know it will strike a chord with many of you, in varying ways.

Sharps are firearms.

If you've gone hunting, taken a CCW class, or were raised in a family of shooters, you'll understand. If you are fearful of/nervous around firearms, it bears your consideration. Usually when I make this statement in a class, I see lightbulbs coming on.

A needlestick has the potential to be a life-altering event, and I would submit that the odds are pretty much the same between firearm users and needle-drivers. If you really don't learn safe handling and/or are careless, bad things happen. If you're careful, even if something happens, odds are in your favor. If you are careful, and you assess your practice daily, you may not be bullet-proof, but those odds look significantly better.

To modify the Rules Of (Firearm)Safety:

• Treat every needle as if it were capable of infecting you.
  
• Never pass a sharp to another person, or accept a sharp from another person, unless it is needleless or the safety device has been activated and you've personally checked that the sharp is completely unloaded.
  
• Before handling any sticking device, understand its operation.
  
• Never rely on any mechanical device for safety.
  
• Think before sticking: once you pull the trigger you can't take back the shot you've just fired! (See opening post)
  
• Never joke around or engage in horseplay while handling or using needles.
  
• Be alert at all times; never stick if you're tired, cold or impaired in any way. Don't mix alcohol or drugs with sticking.(We hope not...!)
  
• Don't sleep with a sharp in your bedroom if you sleepwalk, have nightmares, sleep restlessly or have other sleep problems. (Okay, this was just for fun )
  
• Safeguard your health. Always wear protection. Endeavor to limit your exposure to uncontrolled sharps.
  
• If you see unsafe behavior any time when sharpss are being handled or used, speak up and take action to correct the unsafe behavior at once.
  
• Receive competent instruction from a qualified person before beginning to stick. If questions arise later, after you've been sticking for a period of time, get answers to those questions from a competent authority.
  

There is no guilt, recrimination, I'm not saying anyone is a "dummy", but when an event occurs, be sure to learn from it.

I've had (nursing students in particular) look at me in horror, when I say the patient gets the stick, no matter what. Bottom line, the patient is not going to be exposed to anything new or foreign to them. If, per chance, a needle is actually broken off in someone, a vessel is lacerated, or any of those 1/1,000,000 incidents, you should be able to verbalize the origin of the incident. I.e., "I was drawing blood on the unresponsive OD when they became aroused and folded up their arm. The 1.5" Vaccutainer needle was seen to exit the posterior surface of the R distal tricep, and was withdrawn from the arm intact. Distal radial circulation was intact..." Actual incident, FWIW.

Guess I'll add- when the new button-retracting butterflys came out, I had not previously used them, and they were not notably different than the ones I had previously used. While sticking, I shifted my grip, and activated the safety. Got a nice, "schuuuuuck" from the vacuum tube, a spontaneous pool of blood in the pt's ac space, and a quick consideration of how to explain this and convince the pt that I should be allowed to stick them again. I despise butterflys, hence my unfamiliarity. Point being, i would have had an exposure w/o gloves, and I should have taken the time to examine my equipment.

[BonewaxRN]

That's very good teaching!

[Esme12, ASN, BSN, RN]

I'll add this, since I know it will strike a chord with many of you, in varying ways.

Sharps are firearms.

If you've gone hunting, taken a CCW class, or were raised in a family of shooters, you'll understand. If you are fearful of/nervous around firearms, it bears your consideration. Usually when I make this statement in a class, I see lightbulbs coming on.

A needlestick has the potential to be a life-altering event, and I would submit that the odds are pretty much the same between firearm users and needle-drivers. If you really don't learn safe handling and/or are careless, bad things happen. If you're careful, even if something happens, odds are in your favor. If you are careful, and you assess your practice daily, you may not be bullet-proof, but those odds look significantly better.

To modify the Rules Of (Firearm)Safety:

• Treat every needle as if it were capable of infecting you.
  
• Never pass a sharp to another person, or accept a sharp from another person, unless it is needleless or the safety device has been activated and you've personally checked that the sharp is completely unloaded.
  
• Before handling any sticking device, understand its operation.
  
• Never rely on any mechanical device for safety.
  
• Think before sticking: once you pull the trigger you can't take back the shot you've just fired! (See opening post)
  
• Never joke around or engage in horseplay while handling or using needles.
  
• Be alert at all times; never stick if you're tired, cold or impaired in any way. Don't mix alcohol or drugs with sticking.(We hope not...!)
  
• Don't sleep with a sharp in your bedroom if you sleepwalk, have nightmares, sleep restlessly or have other sleep problems. (Okay, this was just for fun ) :yeah:(beware of residents)
  
• Safeguard your health. Always wear protection. Endeavor to limit your exposure to uncontrolled sharps.
  
• If you see unsafe behavior any time when sharpss are being handled or used, speak up and take action to correct the unsafe behavior at once.
  
• Receive competent instruction from a qualified person before beginning to stick. If questions arise later, after you've been sticking for a period of time, get answers to those questions from a competent authority.
  

There is no guilt, recrimination, I'm not saying anyone is a "dummy", but when an event occurs, be sure to learn from it.

I've had (nursing students in particular) look at me in horror, when I say the patient gets the stick, no matter what. Bottom line, the patient is not going to be exposed to anything new or foreign to them. If, per chance, a needle is actually broken off in someone, a vessel is lacerated, or any of those 1/1,000,000 incidents, you should be able to verbalize the origin of the incident. I.e., "I was drawing blood on the unresponsive OD when they became aroused and folded up their arm. The 1.5" Vaccutainer needle was seen to exit the posterior surface of the R distal tricep, and was withdrawn from the arm intact. Distal radial circulation was intact..." Actual incident, FWIW.

Guess I'll add- when the new button-retracting butterflys came out, I had not previously used them, and they were not notably different than the ones I had previously used. While sticking, I shifted my grip, and activated the safety. Got a nice, "schuuuuuck" from the vacuum tube, a spontaneous pool of blood in the pt's ac space, and a quick consideration of how to explain this and convince the pt that I should be allowed to stick them again. I despise butterflys, hence my unfamiliarity. Point being, i would have had an exposure w/o gloves, and I should have taken the time to examine my equipment.

I like this.......and I agree! A needle is a loaded weapon. I have worked in inner city ED's and other ED's for a lifetime with prisoners and drunks,druggies and psycho's........ If anybody is getting stuck it's the patient.....first and foremost.....If anyone is getting stuck it's them NOT ME!!!!! Always handle your own sharps and don't handle anyone elses. Make the residentMD clean up his own mess! I tell MD's I'll remove the garbage but It will remain until you get rid of your needles! I have no idea where the set them on the tray.....they can take the 2 seconds it takes to get rid of the needled or the tray stays as it is.....they get sarcastic I tell them they need to sign my release that they are accepting full responsibility financial and otherwise when I get stuck by their needle as they would if they had stuck themseleves.......they relent, albeit unhappily but they relent.....

Sorry.....as a nurse and strating IV's....I like butterflies..... and I have the two fingers on my "feeling hand" tore off......my bad:o........after working soooo many years without gloves it was really hard to learn to use them especially on kids.....

[Rob72, ASN, RN]

Sorry.....as a nurse and strating IV's....I like butterflies..... and I have the two fingers on my "feeling hand" tore off......my bad:o........after working soooo many years without gloves it was really hard to learn to use them especially on kids.....

I definitely understand, it is a different model. Hospital phlebs use(d) Vaccutainers because they are about 1/2-1/3 the cost of butterflys. I dislike them because they are a misunderstood tool that gives patients bias against other tools & methods that may provide cleaner, more viable, specimen collection. Learning placement w/o the "flash" is a big hurdle for many people.

I was finishing my training just as gloves were becoming the standard, so I'm a "Michael Jackson" sticker.:sofahider This brought about some learning changes for me, since if I had a bleed incident, I had to use my sticking hand to plug the site, and reach for bandaging/gauze, etc., with the left. This is why I emphasize the training, if it isn't automatic, you may panic and get yourself all a-slather in blood.

[Esme12, ASN, BSN, RN]

I definitely understand, it is a different model. Hospital phlebs use(d) Vaccutainers because they are about 1/2-1/3 the cost of butterflys. I dislike them because they are a misunderstood tool that gives patients bias against other tools & methods that may provide cleaner, more viable, specimen collection. Learning placement w/o the "flash" is a big hurdle for many people.

I was finishing my training just as gloves were becoming the standard, so I'm a "Michael Jackson" sticker.:sofahider This brought about some learning changes for me, since if I had a bleed incident, I had to use my sticking hand to plug the site, and reach for bandaging/gauze, etc., with the left. This is why I emphasize the training, if it isn't automatic, you may panic and get yourself all a-slather in blood.

I like that "Michael Jackson sticker!!!" too funny....It is a different model....when I started learning IV's we used butterflies so for me it is my equiptment of choice and my bigger risk of being stuck is vacutainer......so to everyone......everyone has their own quirks for what works and one is not better than the other except for the person that practices it. This will probaly bring on comments......even if it's an aterial line....the patient will not bleed to death in a matter of minuets.....YES......red is very red on a white sheet:eek: and YES........the patient and family will be shocked....but they will have to deal........PUT YOUR GLOVES ON......