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A Comparative Study of Ampoule Breaking and Resultant Injury Among Registered Nurses Natthacha Chiannilkulchai*, Siranee Kejkornkaew

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A Comparative Study of Ampoule Breaking and Resultant Injury Among Registered Nurses Natthacha Chiannilkulchai*, Siranee Kejkornkaew Natthacha Chiannilkulchai and Siranee Kejkornkaew A Comparative Study of Ampoule Breaking and Resultant Injury among Registered Nurses Natthacha Chiannilkulchai*, Siranee Kejkornkaew Abstract : Breaking ampoules can cause serious injuries and a lack of self-confidence among nurses. These injuries can cause nurses to lose working hours and risk their exposure to blood-borne disease. To prevent injury, ampoule openers are recommended. However, such openers may not be available, so the most standard procedure is to open ampoules manually, requiring skill to do so safely. This comparative study evaluated manual methods for breaking ampoules and resultant injury, length of sharp edge, and identified risk factors for ampoule injury among 56 registered nurses. The participants broke ampoules using six methods with two ampoule sizes (2 ml and 10 ml). Each method used material such as a gauze pad, cotton ball or syringe bag and one hand breaking direction (breaking the ampoule tip in an outward or inward direction). The incidence of injuries, length of the sharp edge of the ampoule, and factors predicting injuries were measured. In total, 73 of 672 gloves worn by participants showed damage (glove tears). Breaking an ampoule using a syringe bag and an outward direction showed the lowest incidence of injuries and the shortest length of the sharp edge. Significant predictors of ampoule injury were the breaking method, area of nursing specialty, ampoule size, breaking direction, and length of the sharp edges. These findings suggest that breaking an ampoule in an outward direction and using material wrapping entire the ampoule neck can pro- tect against injury. Pacific Rim Int J Nurs Res 2020; 24(1) 89-101 Keywords: Ampoule, Injury, Incidence, Nursing, Occupational injuries, Risk factors, Sharps injury Received 4 February 2019; Revised 29 June 2019; Accepted 1 July 2019 Correspondence to: Natthacha Chiannilkulchai, RN, PhD, Assistant Professor, Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand. Introduction Email: [email protected] Siranee Kejkornkaew, RN, PhD, Assistant Professor, Ramathibodi Breaking ampoules is the most common cause School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol of sharps injuries that are defined as occupational injuries University, Thailand. Email:[email protected] among healthcare workers (HCWs), especially nurses.1-3 restrict nurses in their work and lessen their self- Ampoule injury among nurses accounts for 20.8%- confidence.5, 6 These injuries may be entry points for 32.5% of sharps injuries and is classified as a high-risk microorganisms and represent the main factor to event.4, 5 Broken edges of ampoules tend to be sharp, expose workers to blood-borne diseases.5 The risk of and often cause severe cuts on nurses’ fingers that can infection includes hepatitis B and C viruses, and Vol. 24 No. 1 89 A Comparative Study of Ampoule Breaking and Resultant Injury among Registered Nurses human immunodeficiency virus.7, 8Although the risk comparison to the incidence of ampoule injuries and of infection, is known, nurses are not paying attention length of sharp edges, and identified risk factors to potential injury. This is because they perceive an influencing the occurrence of ampoule injuries in ampoule injury as a clean injury, with a low-risk of registered nurses (RNs). infection, and afterward, they continue their work.7, 9 The Centers for Disease Control and Prevention (CDC) Literature Review estimate that 62%-88% of sharps injuries can be prevented by using safety devices.10 So to prevent ampoule The literature describes different methods injury, ampoule openers are recommended for use. used for breaking ampoules, including various In developing countries, especially Thailand, ampoule breaking devices and manual methods. the ampoule openers are rarely used because of Several ampoule openers have been developed to promote inadequate budgets for safety devices, and the use of safety for HCWs, including an ampoule snapper15, an such devices is limited to the protection of expensive ampoule opener16, the barrel of a syringe17, and an solutions.11, 12 Various ampoule openers do not fit ampoule breaker.18 These devices have benefits and different sizes of ampoules ranging from 1-30 ml, limitations depending upon their designs and user so they are perceived as not being practical and time- requirements. However, there is no consensus about consuming in a clinical setting. Furthermore, there is recommending which types of ampoule openers are no clear evidence available to nurses about which appropriate to prevent sharp injury among nurses and types of multiple ampoule openers are appropriate for protect patients from glass particle contamination. breaking ampoules to prevent nurses’ injuries and For manual methods, HCWs try to protect promote patient safety regarding glass particle themselves from ampoule injuries by wrapping a contamination. These days developed countries piece of material (cotton ball, gauze pad, or syringe bag) acknowledge that advanced management and technology around the neck when breaking a glass ampoule.19 are not enough to promote safe behaviors in the Although most glass ampoules are either pre-scored workplace.6 To promote safety and prevent injury is around the neck or dotted at the neck with markers to an essential issue for nurses as well as for patients, indicate where they should be broken, it is difficult to and the typical procedure for opening ampoules in break an ampoule cleanly. The general directions for developing countries requires manual skills. breaking ampoules in both laboratory and clinical In clinical settings, the diversity of nursing settings indicate that the ampoule tip can be broken practice means nurses must think carefully about inwardly or outwardly.20, 21 For the inward direction, ways of enhancing their clinical skills.13 Sharps one hand holds the bottom part below the pre-scored injury among nurses is a result of a lack of awareness, or dotted marker in the back, and the other hand holds lack of training, and outdated safety protocols.14 the tip above the marker. Then, both thumbs are Reporting ampoule injuries and factors associated pressed against the narrow tip to break it inwardly.20 with these is a crucial protocol to decrease the risk of For the outward direction, on the dotted marker in the sharps injury in the future. Although many published front, one thumb is pressed against the narrow tip to studies have reported that breaking ampoules presents break it away from the body.21 Ampoules used in a risk of injury among nurses, limited data are clinical settings include 1, 2, 5, 10, and 20 ml sizes; available regarding methods for breaking ampoules however, 2 and 10 ml are the most common sizes.22 that minimize the risk for injury. Therefore, this Various studies have indicated that breaking ampoules study evaluated methods of breaking ampoules in can cause injury.14, 23, 24 The main cause of most 90 Pacific Rim Int J Nurs Res • January-March 2020 Natthacha Chiannilkulchai and Siranee Kejkornkaew injuries was reported to be behavioural, including correlation sample size described by Browner, practical skills and improper force to crush glass Newman, and Hulley.30 Entering all values into their ampoule.1, 25 A few studies evaluated methods of formula indicated a sample size of 47 was needed, open ampoules between hand and ampoule opener but given an expected attrition rate of 10%, the devices, the result showed that ampoule opener required sample size was then deemed to be 52 reduced the injury.25 However, breaking ampoule by participants. The principal researcher informed the hand is a practical method in a clinical setting and head nurses to gain their cooperation in recruiting there are limited studies evaluating which hand volunteer nurses for the project. Fifty-eight nurses methods are appropriate for HCWs to break ampoules were purposive contacted. The inclusion criteria were safely. working at the hospital and having the prior clinical Among occupational injuries, in nursing staffs experience of at least two years. Two nurses who had with lower working experience have more sharps less than two years of experience were excluded. injury.26 A previous study found that different areas Therefore, 56 RNs participated in this study. It was of working practice had a different incidence of sharps more than estimated sample size; however, the study injuries; for example, nurses working in emergency for testing the association between risk factors and departments have to work fast and may have increased the dichotomous outcome may include the possibility errors and mistakes.6 A risk factor for sharps injury of refusal up to 20% (56.4).31 includes breaking a glass ampoule that then has spikes.27 Ethical considerations: Limited studies are evaluating the time taken to break The research was approved by the Committee an ampoule and causing a sharps injury. However, on Human Rights Related to Research Involving Zhu indicated that breaking an ampoule with a free Human Subjects, Mahidol University (IRB no. hand in a quick and harmful manner easily causes MURA2016/444). Each participant received essential iatrogenic injury.28 Other studies also reported that information about the study purpose, research time constraint was a risk factor that increases the activities, study outcomes, and the option to withdraw incidence of sharps and needle injuries.7, 29 Therefore, from the study at any time without affecting their in this study the researchers included the time taken work. All participants provided written informed to break an ampoule as a factor associated with the consent. A principal concern for the researchers was occurrence of ampoule injury. Included also was the participant safety. First aid care was available to all RN’s work experience, area of nursing specialty, participants in case of injury. The researchers closely break direction, and length of sharp edges from the observed ampoule breaking methods and results.
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