Discussion

Accidental injuries with needles or other sharps are still common among HCWs. Although the risks of developing HIV, HBV, and HCV are small, the consequences of these occupational injuries are serious and worrisome. This present study was conducted at the tertiary teaching hospital in Indonesia to investigate the incidence of voluntarily reported NSSIs and the first in Indonesia to provide real data on NSSIs.

Overall incidence of NSSIs in this study was 13.3 injuries per 1000 HCWs-years. Our result is considered low compared with many other reports. Other studies in Singapore, Korea, Turkey, Poland and Germany have reported higher incidence rates of between 19 and 45 per 1000 HCWs.8–12 However, a study evaluating data from the Malaysian national sharps injury surveillance programme estimated the incidence of NSSIs was 6 injuries per 1000 HCWs, lower than our study.13 These conflicting results might be due to different settings, study designs, and methods for injury reporting. However, since our data were based on a voluntary reporting system, we acknowledge the issue of unreported NSSIs, which might undercalculate the true incidence of NSSIs in our hospital. The unwillingness to report any work-related injuries was still common among HCWs. The under-reporting rates estimated in other studies vary between 42% and 95%.10 14–16 There are several reasons for not reporting injuries: (1) a lack of awareness regarding the reporting system or of the need to report NSSIs, for fear of getting into trouble, (2) concerned about being perceived as lacking clinical skills, (3) embarrassment, (4) perception that the extent of the injury was light or having antibodies conferring protection against disease and (5) dissatisfaction with follow-up investigations by officials after reporting the events.16–19 Further studies are warranted to define the real incidence of NSSIs in our institution, as well as possible reasons for under-reporting, and to find a new and appropriate reporting system to reduce this under-reporting situation.

It was not surprising that the significant number of injuries were reported by nurses (42.7% of total reported case, incidence 15 per 1000 nurses-years). As a common pattern of studies around the world, nurses were more likely to get NSSIs than other professions.10 11 14 15 20 Due to the nature of nursing work, nurses spend more hours in direct contact with the patients and undertake more procedures with hollow-bore needles as the most common device related to NSSIs.21 Nurses are usually responsible for blood collection, administering drug injections and venipuncture, which are also common circumstances for NSSIs in our study (14.3%, 25.9% and 6.6%, respectively), as well as disposing sharp devices. Although in our study, midwives had the highest incidence rate of NSSIs, this finding needs to be interpreted cautiously as it was probably a trend of increasing reportable injuries among an average of 66 midwives in the hospital. However, special training for prevention needs to be addressed in this group since midwives are also likely to have more contact with blood and body fluids during delivery. Apart from managing delivery, midwives have similar duties as nurses such as phlebotomy and drug administration to patients. In Indonesia, midwives’ education programme is not a continuation of the general nursing programme. However, training on infection control standards are included during orientation programmes within the hospital.

In the present study, NSSIs occurred most commonly during surgical procedures (31.3%), followed by blood collection (25.9%). Stitching with suture needles contributed to 14.3% of NSSIs, as a majority of incidents were in surgical room (table 4). Our data correspond with studies in Malaysia, Singapore and Egypt.13 22 23 In a study by Ishak et al, stitching injuries were found to be the result of being stuck with needles placed at inappropriate locations, being stuck with a needle during a collision, related to equipment disposal, or accidentally dropped equipment.13

Another event category that contributed to NSSIs includes injuries during waste cleaning (13.3%), whether by cleaning staff or other professions. The number of injuries occurring during this process depended on the number of needles and sharp devices in the area, as well as the incorrect disposal behaviour by the original users of the items.24 Cleaning staff members in our hospital were outsourced from other companies, hence it was inevitable that personnel changed regularly. Strict controls need to be implemented to properly dispose of needles and sharps device waste.

The majority of the injuries were largely due to hollow-bore needle injuries (66.7%), mainly disposable syringes (45.5%), which is consistent with the results of many previous studies.14 20 23 25 Recapping practices resulted in some NSSIs in our study. Due to limited resources at the hospital, safety-engineered devices (SEDs) were rarely used.

The use of insulin cartridge delivery pens have widely replaced traditional syringe injection since it was introduced in the 1990s. Despite its many benefits, including ease of use and transport, greater dose accuracy and reduction to needle phobia, this type of NSSI in HCWs in a hospital setting is now increasing. Our study indicated that 9.4% of NSSIs in the hospital were related to insulin pen injections. A recent survey among hospital nurses in China reported that the incidence of insulin pen injection-related NSSI was 10.2 per 100 000 injections. About 40% of nurses experienced at least one insulin pen injection-related NSSIs sometime in the past.26 An increasing prevalence of diabetes in Indonesia will have implications on insulin pen injection-related NSSIs in the future. In addition, the use of finger prick lancets for blood glucose monitoring in our hospital also caused a significant number of NSSIs (10.1%). Recently, a study in Malaysia also observed that other non-specific tasks (14%) such as finger prick for blood glucose monitoring or cleaning of devices were important causes of NSSI.22 A pilot implementation study for the use of SED lancets in South Korea demonstrated a promising result in reducing the lancet-related NSSIs to zero incidence.27

However, not all application of needles with an SED will result in a decrease of NSSIs, as shown in a recent study in the Netherlands and a systematic review by Reddy et al.28 29 Findings from previous meta-analysis evaluating effectiveness of different interventions for NSSIs prevention concluded that the most effective intervention is a combination of safety training and proper use of SED.30 Moreover, provision of feedback to the manufacturers to keep improving the design is critical.28

The results of our study should be interpreted in the context of study limitations. The most important limitation was that the data was based on a self-reporting system. We did not investigate the under-reporting rate, the attitude and work practices of HCWs, and other important factors in reporting NSSIs. However, since this is the first study reporting comprehensive data of NSSIs in Indonesia, the baseline data presented here will allow us to improve the reporting system, considering more safety devices and designing more appropriate NSSI prevention training programme for regularly change HCWs within the hospital. Since the introduction of electronic health record system in our hospital, incorporating NSSI reporting system into this electronic system would be the most pragmatic approach. Hopefully sharps injury registry will soon be initiated by policy-makers at a national level.

The study was also limited to situation in tertiary teaching hospital; therefore, the results cannot be generalised to other settings. Nevertheless, this study involved diverse types of HCWs, including cleaning staff members.