On May 11, this year, a new law came into force that will affect every dental practice in the country. These new regulations build on the existing law and provide specific detail on requirements that must be met by employers and their staff.
Needlestick injuries are common, and many go unreported, so it is difficult to get exact figures. However, information from the Royal College of Nursing suggests that there are about 100,000 needlestick injuries per year in the NHS, while a survey among US dentists indicated that they on average sustain three injuries a year, a third of which are related to needles. In Scotland a study showed that non-sterile inoculation injuries occurred at a yearly rate of 1.7 and about 30 per cent of these constituted a moderate or high risk of transmission of infection to the dentist. Sharps injuries can of course be sustained from probes and other instruments, but overwhelmingly they occur in dentistry during resheathing/recapping and disposal of the needle after use in order for the syringe to be dismantled and the appropriate parts sterilised.
Safer sharps
The aspects of the new regulations that most clearly apply in dentistry refer to the use and disposal of sharps (section 5). They require that employers consider the following additional risk control measures:
- Avoid the unnecessary use of sharps. Needles, scalpels and so on will always be essential tools for medical and dental care but the employer should ensure they are only used when required, substituting needle-free equipment now available for certain medical procedures where appropriate.
- Where it is not possible to avoid the use of medical sharps, the new regulations require employers to use ‘safer sharps’ where it is reasonably practicable to do so. The regulations define a ‘safer sharp’ as one which incorporates features or mechanisms to prevent or minimise the risk of accidental injury.
The following factors should be considered when looking at such devices:
- the device must not compromise patient care;
- the reliability of the device;
- the care-giver should be able to maintain appropriate control over the procedure;
- other safety hazards or sources of blood exposure that use of the device may introduce;
- ease of use (taking into account the existing clinical practices commonly in use by the relevant health professionals – but not assuming custom and practice is safest);
- is the safety mechanism design suitable for the application?
The following factors are also relevant:
- if activation of the safety mechanism is straightforward, it is more likely to be used;
- if the safety mechanism is integral to the device it cannot be lost or misplaced;
- for many uses a single-handed or automatic activation will be preferable;
- an audible, tactile or visual signal that the safety mechanism has correctly activated is helpful to the user; and the safety mechanism is not effective if it is easily reversible.
The regulations concede that a safer sharp will not completely remove the risk of an injury, for example if the patient moves unexpectedly, but should reduce it. However, a London teaching hospital introduced disposable needles and syringes and brought needlestick injuries down to zero, even among trainees learning to use them.
If a suitable safer sharp is not available to reduce the risk of injury, the employer should ensure that safe procedures for working with and disposal of the sharp are in place.
Re-capping/resheathing
According to the regulations (section 5; 1: c), needles must not be recapped after use unless the employer’s risk assessment has identified that recapping is itself required to prevent a risk (for example to reduce the risk of contamination of sterile preparations). In these limited cases, appropriate devices to control the risk of injury to employees must be provided.
Martin Foad, regulatory manager at Septodont, believes that there should be no place for resheathing of needles in dentistry, and notes that the new regulations don’t make specific mention of dentistry and its differences with medical practice. “One-handed recapping of a dental needle is not possible in the same way,” he commented. “If a practice decide to go down the road of still using the standard dental syringe, and say they have done a risk assessment and identified that recapping is safe, by using a needle-block such as Aim-Safe, they need to minute that, because if a CQC inspection should observe and query it they will need very robust reasons to defend it.”
Seeking clarity for dentists on this, Martin has checked with the HSE directly. “It has stated that recapping should occur only when exceptional circumstances dictate, and that otherwise it is expected that an alternative device will be used which incorporates a safety mechanism within the syringe,” he confirmed. “I do not believe that there is any case for not using one.”
The new regulations require that secure containers and instructions for disposal should be placed close to the work area. Staff should be fully trained in the use of safer sharps and their disposal (section 6), and procedures for recording, notifying, investigating and following up should be in place in the event of an injury (sections 7 and 8), and known to all involved. All these procedures should be regularly reviewed.
Disposable syringes
Some dental syringes can be modified to conform to the new regulations, although the metal syringe cannot. Alternatively, some major manufacturers and suppliers have new single-use cartridge syringes specifically designed to overcome the risks, but they are not yet widely used in practice. One of the reasons for this may be cost, though the London Hospital trial found that once the cost of the syringe and its sterilisation had been taken into account, the disposable syringes and needles were actually cheaper (18p compared to 25.8p).
A variety of disposable needles and syringes featuring safety devices to minimise the risk of needlestick injury are already available, with new designs under development.
Tony Reed, the executive director of the British Dental Trade Association reassured dentists that “the dental supply chain is working hand in hand with dental teams to ensure that surgeries are able to fully meet the requirements of the new Sharp Instruments legislation.” But don’t doubt it, these new regulations are not just advice or guidance, they are now law, and will be enforced. Are your sharps safe?
References available on request.