Effectiveness and Cost-Effectiveness of a Management Approach to Prevent Needlestick Injuries Among Healthcare Workers Employed in an Emergency Department in Italy

Needlestick injuries (NSIs) often are incurred by people handling needles in the medical setting and are a risk to healthcare workers (HCWs) worldwide.(1-3) The World Health Organization estimates that every year three million healthcare workers experience percutaneous injuries.(4) The National Institute for Occupational Safety and Health in the United States has defined NSIs as injuries caused by needles such as hypodermic needles, IV stylets, and needles used to connect parts of IV delivery systems.(5) The frequency of such events has been estimated to be about 600,000 to 800,000 cases annually in the United States,(6) 100,000 in the United Kingdom,(7) and 500,000 in Germany.(8) These data underline that HCWs are at significant risk of acquiring bloodborne diseases; in fact, the literature estimates that among HCWs the risk for acquiring infections with the hepatitis C, hepatitis B, and human immunodeficiency viruses attributable to occupational exposure to percutaneous injuries is 39%, 37%, and 4.4%, respectively.(9) The economic cost of NSIs among HCWs varies from country to country, due to different study methodologies; based on available reports the estimated cost per year in Germany is between €4.6 million and €30 million, €6.1 million in France (considering nurses alone), and €72 million in Italy (not considering long-term treatment, compensation, or indirect costs).(10)

The cost per reported NSI(11,12) is due to interventions such as:

• Testing for infection in the injured worker and, if known, the patient on whom the sharp was used;

• Postexposure prophylaxis to prevent or manage potential bloodborne virus transmission;

• Short- and long-term treatment of chronic bloodborne viral infections that were transmitted to injured workers;

• Staff absence and replacement;

• Counseling for injured workers; and

• Legal consequences (e.g., litigation and compensation claims).

HCWs employed in the emergency department (ED) are at particularly high risk of incurring NSIs, due to specific occupational risk factors linked with the ED, such as high exposure to physical and biological risks, variable workloads, increasing and unpredictable job demand, and three-shift work.(1,11-13) In a recent study, Weaver et al.(14) observed an association between shift length and the risk of occupational injury and illness among emergency medical services shift workers. The risk of injury was 60% greater (RR 1.60; 95% CI 1.22-2.10) for employees who worked shifts between 16 and 24 hours long. Stressful working conditions, lack of organization at work, and lack of support from colleagues at work may contribute to increase the risk of NSI among HCWs.(15-19) Furthermore, Loerbroks et al.(18) recently reported that the occurrence of NSIs is a predictive factor of a less favorable perception of psychosocial work .

A study conducted among Japanese nurses showed that the hospital’s safety climate has an important influence on NSI injury rates and reporting behavior among nurses.(19) Interventions that focused on the context area of the work, such as having nurses involved in health and safety matters and being properly trained in risk control procedures, were associated with a reduced NSI risk. In our recent study,(20) we revealed the efficacy of primary-level interventions focused on work context areas to minimize work-related stress; the interventions were focused on team development, on implementing safety training programs, and on adopting an ethics code for HCWs (Table 1). Based on this evidence, we conducted a retrospective analysis of the occurrence of NSIs among the nurses employed in a hospital ED in Salento, Italy, before and after the implementation of such organizational interventions. The aims of this study were: (1) to investigate the interactions between organizational level interventions focused on work-related stress and the occurrence of NSIs among ED nurses; and (2) to determine the impact of such interventions on the economic burden of NSIs.

Methods

In the period December 2011 to December 2012, we conducted an observational study to detect and analyze in different work settings the level of work-related stress among the HCWs (physicians and nurses) in the emergency department of the Local Health Authority in Salento, Italy, resulting from organizational changes.(20)

The study was conducted using the multidimensional validated tool developed by the Italian Network for the Prevention of Work-related Psychosocial Disorders, in accordance with the Consultative Committee’s specific requirements.(21-23) In that study(20) we showed that the implementation of improvement interventions focused on team development and safety training programs effectively and significantly reduced the work-related stress risk in the workplace, from medium to low. The results of the investigation highlighted that “work context” was the priority area of organizational interventions aimed to reduce work-related stress (Table 1). We compared the NSI occurrence among the nurses employed in the ED in the period January 2013 through December 2015 with the period January 2010 to December 2012—after and before, respectively, the adoption of organizational improvement interventions. The study population was the same before and after these improvement interventions (Table 2). The study was conducted in an ED that had more than 100,000 admissions annually. The medical safety devices used to prevent percutaneous exposure injuries caused by needles were the same in the two periods examined and included blood collection systems, IV systems, injection systems, and sharps containers. The economic impact of NSIs was defined as:

• The direct cost of baseline and follow-up laboratory testing of each exposed HCW;

• The direct cost of testing the source patient; and

• The cost of postexposure prophylaxis and other treatment that might be provided.

In Italy the average cost of such postexposure interventions was estimated to be €850 per reported injury(24); such cost does not consider long-term treatment, compensation, or indirect costs. In this study the authors estimated the direct cost of NSIs per 100 FTE positions (nurses) over three years.

Statistical analysis

The statistical analysis of the data was based on the calculation of the average, the standard deviation, the distribution, and the range in accordance with the nature of individual variables. The differences between the percentages and the averages were compared using, respectively, the chi-square test and Student’s t-test for continuous data. Differences were considered significant for values of p < .05.

Results

The cumulative three-year incidence of NSIs after the implementation of management stress interventions (2013–2015) was significantly lower than the cumulative three-year incidence during the period 2010 through 2012, before such implementations (10.77 injuries per 100 FTE positions vs. 26.15 injuries per 100 FTE positions; p <.01 chi-square test; Figure 1). The organizational interventions were effective in minimizing the occurrence of NSIs (OR = 0.34; 95% CI = 0.17-0.67). No significant differences were found in gender distribution of the NSIs or in age and years of work of injured nurses in the two periods investigated (p >.05; Table 3). The number of patients coming to the ED for treatment in the three-year periods analyzed did not show significant differences (p >.05). Cost savings from managing fewer NSIs in the three-year period 2013 through 2015 compared with those for the three-year period 2010 through 2012 were estimated at €13.073,00 per 100 FTE nurses (Figure 2).

Discussion

In this study, the organizational level interventions, which aimed to minimize work-related stress through improving the work context area, were effective in minimizing the occurrence of NSIs among the ED nurses. The aim of the interventions was to encourage participatory solution-oriented steps involving managers and workers in primary prevention and in improving working conditions. In particular, proactive interventions focused on the area of “function and organizational culture” in the form of occupational safety training for head physicians and head nurses. The goals were: (1) implementation of an organizational model based on the achievement of occupational safety objectives; (2) implementation of a management style focused on support of workers and on developing listening skills; and (3) implementation of a safety system managed by head physicians and head nurses. The company management established, in addition, a code of ethics for healthcare workers. In order to inform everyone about the interventions regarding their “role within the occupational organization,” the authors organized training for all HCWs designed to explain work roles and to encourage the involvement of workers in the decision-making process. Improvement in the issues related to the area of relationships at work was obtained by training of head physicians and head nurses with the following objectives:

• To improve communication skills;

• To ensure reflective dialogue and feedback among workers; and

• To manage conflict constructively.

Head physicians and head nurses also were trained in supervising workers in regard to occupational hazards, including work-related stress (Table 1).

The evaluation suggested that we should train head physicians and head nurses in a supportive leadership style, because such support can help reduce the stressors to which HCWs are exposed. One factor in the success of this improvement intervention was certainly the high motivation of head physicians and head nurses to embrace change.

Conclusion

Our findings suggest a link between safety and well-being, and show that an integrated approach is needed to better protect workers’ health and safety. Furthermore, the study shows that the proactive, integrated, and comprehensive management of work-related stress at the workplace brings benefits to employees and reduces the burden of the occurrence of NSIs. As a result of the reduced NSI frequency, the overall costs for follow-up of injured workers were reduced. In fact, we estimated a reduction of such direct economic costs from €22,227.50 per 100 FTE positions over three years, to €9154.50 per 100 FTE positions over three years, resulting in significant cost saving (Figure 2). In this study, the NSI occurrence represented an indicator of effective work-related stress management in the healthcare sector and also stressed the need for new interventions to reduce the risk of NSIs.

The study has some limitations: (1) the period investigated is too short to draw strong conclusions about the relation between stress management interventions and the occurrence of NSIs; (2) the analysis was conducted on a small sample; and (3) the results of this study are specific to NSIs and do not take into account other types of injuries.

Further longitudinal studies will be necessary to clarify the relation between stress management interventions and the occurrence of NSIs.

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