** Dry Needling at No More Knots Pack – information accumulated through the Skin Penetration Act, QLD Health’s “Sharp Aware”  information and the Australian Society of Acupuncture Physiotherapists (ASAP)

Aim - To eliminate potential hazards and minimize the health and safety risks that are associated with Dry Needling such as:

• Medical and non-medical waste left in rooms.

• Sharps bins being left unsecured and located in high risk locations.

• Needle container spills.

• Used needles being lost/left in rooms – putting fellow therapists and Clients at serious risk.

• Shortages in equipment.

• A lack of responsibility from practitioners in regards to not respecting the risks involved with Skin Penetration.

• Allowing the confidence to develop for needling practitioners to utilise their skill sets to their full potential, by eliminating concerns and risk factors.

• To eliminate as many greys areas as possible in regards to meeting requirements of the skin penetration act as acupuncture/ dry needling, as opposed to medical practitioners.

 

Dry needling consistency strategy

Each Dry Needling practitioner MUST –

• Read this document.

• Must perform (verbally or written) a Dry Needling quiz consisting of 10 Questions covering topics ranging from clinic practice/contraindications and self-care.

• A 100% pass rate must be obtained to needle in the clinic.

• Stays informed of their own association’s position statements relative to Dry Needling and operate within the grounds of the position statement in co-existence to this policy.

• Ensure their PI/PL Insurance policy covers them for Dry Needling treatments.

• Operate within the framework set out in this document

• If found to be operating outside this framework the practitioner will be required to attend a meeting with clinic management to decide upon a suitable plan of action which for example may include re-training, recommendation of further professional development be undertaken or that the practitioner be prohibited from performing dry needling whilst operating on behalf of the clinic. 

 

‘Key Points to Dry Needling’

 

How does Dry Needling Work?

Dry Needling involves the insertion of dry needles in dysfunctional muscle or connective tissue with the aim to restore appropriate function. This can be done by eliciting –

Inflammation responses (encouraging blood into ischemic tissue)

Altering neuromuscular firing through stimulation

Causing local twitch response through the muscle, which are followed by a relaxation period through the tissue.

 

Safety concerns

When performing any kind of skin penetration, there will always be the risk of blood or fluid transmission between client and practitioner. This can include blood borne virus transmissions (needle stick injury), as well as local site infection. Despite this however, so long as good sharps protocol is followed, there is a minimisation of risk.

 

Some useful facts regarding Risk factors in Skin penetration –

• There are two types of contamination. Via Penetration or Via Fluid contact. Both are easily avoidable

• The risk of Blood Borne Virus being transmitted via a scratch or light spot (such as in needling) is HIGHLY UNLIKELY

• There are 3 conditions that are noted to be passed through blood or penetration contact

• Hep B ( 1-6% risk of transmission)

• Hep C ( 1.8% risk of transmission)

• HIV ( 0.3% chance of transmission)

 

Therapist Responsibilities Surrounding Dry Needling Treatments

• Each therapist must be in a hygienic state, and have thoroughly washed hands with soap and warm water

• Each therapist should be aware that – according to the Skin Penetration Act we should be wearing gloves, however according to the ASAP guidelines, it is recognised that we may choose to not wear gloves, as we are not likely to cause the flow of bodily fluids and wearing gloves may inhibit the therapists ability to perform the treatment technique effectively

• Needling cupboards and stands must be kept in tidy orders, with kidney dishes and tweezers washed with hot soapy water then dried thoroughly.

• It is the responsibility of the practitioners to ensure all waste is disposed of correctly  and surfaces are cleaned before and after dry needling treatment

• It is the responsibility of the practitioners to monitor and notify reception if additional supplies are required.

 

Clinic Policy Surrounding Dry Needling Appointments

• Clients who are attending the clinic for the first time and who have requested dry needling will be booked in as initial clients with a file note to inform the therapist that dry needling has been requested. Please remember to take these clients to a room which is suitable for dry needling.

• It is always at the therapists’ discretion to determine if dry needling is suitable for the client.

• If dry needling is not appropriate therapists must inform and educate the client of the contraindication or reason for not wanting to proceed with a dry needling approach to treatment.

•  In-house clients may be referred to other practitioners for dry needling, so long as they understand the use of dry needling will be discussed initially with the practitioner.

• Dry needling practitioners retain their right to assess and determine whether this technique is appropriate in each individual situation based on their own decision making process for that client.

• New client’s may be told that dry needling is available, and that they will be booked in with a suitable therapist to further discuss their treatment options, and determine whether this technique is appropriate for their particular situation.

•  If dry needling is not indicated, then the appointment will be adjusted as necessary.

 

Dry Needling Treatment Protocol

 

Protocol

• ALL dry needling MUST occur downstairs at Greenslopes in rooms with wash basins and soap.

• The Physio room/Gym at Greenslopes can be used for needling with the use of a dry needling stand (trolley).

• In any room at Taringa with the use of a dry needling stand (trolley).

• PRIORITY over private rooms with hand basins to ensure therapists can remain in the room whilst washing hands, if needles are being used.

• Soap, hand gel and medi-swabs must be available and utilised by all therapists who intend to perform dry needling.

• NO dry needling equipment upstairs

• Dry needling stands (trolley) are not to be left in rooms (kept in storage area of Room 2 at Greenslopes and in tea room at Taringa)

• In treatment notes – Therapists must record locations of needle insertions and any concerns

e.g. DNT x2 over the  right proximal  brachioradialis. 0.22 x30.5. 5 mns.dull ache over the distal needle after 3 mins. redness around both needles. no adverse reactions observed or reported following rx. 8/10 to 3/10 pain scale following rx.”

• The use of treatment room allocation to reserve a dry needling compliant workspace (same as private room allocation)

• Practitioners should confine their use of dry needling to treatment of conditions within the scope of practice for which they have training and experience.

 

To minimize the risk of any contamination or error these following points need to be observed.

• THE PERSON WHO USED THE SHARP IS IMMEDIATELY AND SOLELY RESPONSIBLE FOR SAFE DISPOSAL!!!!

• Never touch the shaft of the needle by hand. To reduce infection risks for both yourself and the client

• Make sure there are appropriate disposal sites. A solid plastic container clearly marked as hazardous material that has a sealable lid/cap. Plastic is best, and something that is impenetrable and shatter proof.

• Sharps bins are to be kept at a height at which the therapist can see inside the container and remain closed at all times when not in use.

 

If you find a forgotten needle, dispose of it appropriately immediately.

• Bring the container to the needle rather than carry it around, and if no sharps bins are available, use something similar. E.g. Milk bottle, and then ensure it is disposed of appropriately.

• Wear gloves to avoid any fluid transmission – Gloves will not prevent a needle stick incident

• Grab needle by via the handle or mid shaft – never the sharp tip.

• Place needle into the Sharps Bin and seal the lid.

 

Disposal of Medical Waste

Medical waste is waste that is either putrescible or potentially infectious.

 

When performing Dry Needling this may include but is not limited to:

• Gloves

• Needle cases / plastic guide tube

• Needle Tabs

• Cotton Buds

• Swabs

• Needles

• Sharps Bin

•  

Items such as gloves should be turned inside out and disposed of with the general waste if they are not obviously contaminated. If they are obviously contaminated remove Gloves and turn them inside out, place them in a bag and tie the bag firmly before disposing of in the general waste.

 

Needle Cases, Plastic guide tubes and needle tabs should be disposed of at the end of each session in the general waste.

For items which are likely to come in direct contact with bodily fluid such as needles – they must be placed in a sharps bin immediately after use.

 

For items such as cotton buds and swabs there are 2 options available to therapists.

• Place items in a sealable bag and dispose of them in the general waste.

• Place items inside the sharps bin.

Do not place hands inside sharps bin at any stage.

 

Sharps Bins are only to be filled up to ¾ of available capacity and are to at no stage have any sharps protrude through the opening at any stage. Once a sharps bin is ¾ full seal lid with tape and mark as FULL in permanent marker.

Alert management and administration that sharps bin is full so they can arrange adequate storage and removal.

 

Professional requirements for all therapists who perform Dry Needling

• Ensure that you are fully insured to perform the technique

• Keep specific notes – include – Insertion points, number of needles, muscles effected, angles used, any areas of concern or risks and record consent, take home advice

• Explain warnings and applicable contraindications prior to treatment. Explanation should include;

• Procedure

• How it works

• That we use single use sterile needles

• Possible symptoms including fatigue, twitch, light headedness, aggravation of pain

• Post Rx dizziness, ice, rest

 

Skin preparation (disinfection)

• No prep is needed unless needling into an area that is susceptible to infection, such as a joint or bursa, or if the skin does not appear to be clean. If this is the case, swap the area and allow to dry for 1-2 minutes.

• As the therapist, YOU MUST ensure that your hands and nails are clean with soap and water, your personal hygiene is good and you’re not sweaty. If so wash with soap and water.

• Use gloves where cuts or abrasions are present

 

Skin sterilization

• A sterilizing solution of 2% iodine in 70% alcohol needs to be used on the skin and left to dry for two minutes

• Check for allergies

• Immuno – compromised clients – such as autoimmune, malignancies, S.L.E, R.A etc. will require skin sterilization

 

Disinfect– To reduce the number of bacteria or virus

Sterilization – To remove all forms of life from the skin

 

Location Set Ups

 

Needling stands

• Each trolley should contain –

• Needling Bin (must fit 100mm needles)

• Waste Bin ( for wrappers, swabs)

• Medi-Swabs

• Cotton Wool Balls/Tissues

• Forceps/Flat tipped tweezers ( for needle extraction)

• Kidney Dish

• 1x Box of each size needles (to be replaced when empty)

• Permanent Marker

• Hand sanitiser

• Needle Bins must be placed on the top shelf of the trolley and remain closed at all times.

• You should always be able to see inside the needling bin whilst it is open.

• They should only be opened as required to dispose of sharps/needles.

 

Needling in designated clinic rooms

• Each Room should contain –

• Needling Bin (must fit 100mm needles)

• Waste Bin ( for wrappers, swabs)

• Swabs

• Cotton Wool Balls/Tissues

• Forceps/Flat tipped tweezers ( for needle extraction)

• Kidney Dish

• 1x Box of each size needles (to be replaced when empty)

• Permanent Marker

• Hand sanitiser

• Needle Bins must be placed on the Bench Top and not in elevated spaces such as shelves and remain closed at all times.

• You should always be able to see inside the needling bin whilst it is open.

• They should only be opened as required to dispose of sharps/needles.

 

Danger regions and contraindications

Lungs

• Upper Trapezius (this is the most common point associated with Pneumothorax) – reason being, the lungs extend 2-3cm above the clavicle line in the majority of people. Hence exposing them beyond the bony structures of the ribs

• Lungs Anterior/Lateral Aspect – from mid rib 6 running laterally to mid axillary rib 8

 

Pleura

• Rib 8 (mid clavicular) down to rib 10-12 (mid axillary)

• Posteriorly – Rib 10-rib 12 – lateral border of ES GROUP

 

Other sites

• Where there are known neurovascular bundles

• Sub occipital triangle

• Scalenes

• Infrascapular fossa – can lead to pneumothorax – needle obliquely and superficial

• Over the Thorax – Needle oblique/Transverse and direct needle point over cartilage/bone

• LB/Organ – needle superficially and oblique/transverse

 

Avoid

Sites of Pathology including:

• Varicose Veins

• Acute Inflammation

• Sites of Infection

• Lymphodaema

• Pregnancy avoid – traps, entire Lx group, lower TX group, abdominal region.

NOTE: According to the ASAP, 1 in 4-5 pregnancies abort naturally, therefore risks need to be fully outlined and best to seek written consent

• Needling over the spinal cord – The spinal cord is approximately 2.5-4.5cm deep, so ensure that you choose appropriate needle length and observe thoroughly when needling between SP’s

 

Pneumothorax – Penetration into the pleura/lungs.  

Warning signs include:

• Shortness of breath on exertion

• Chest pain

• Dry Cough

• Decreased Breath sound

 

Conditions to consider

• Diabetes – limited peripheral circulation and/or sensory feedback. Needle with care and attention

• Pacemakers – NO electrotherapy

• Bleeding Disorders (e.g. Haemophillia) or clients on Anticoagulants (e.g. Warfarin). When withdrawing needle apply pressure over site of insertion. It is best to consider using a lower gauge needle where possible. Avoid needling into joints to reduce risk of hemoarthrosis (bleeding into a joint)

• Blood Borne Diseases – it is within your rights to ask if there is any disease present, and your right to wear gloves. Observe good hygiene – higher risk of infection due to compromised immune system

• Cancer – Risk of Aggravation – use all usual procedures and questioning for Cancer and Doctors approval. In addition make sure very thorough hygiene procedure is followed, to reduce infection. Cancer clients are at a much higher risk of infection due to immune suppression

 

General management

• Pain following treatment – ice or heat

• Bleeding – Apply pressure

• Fainting – Causes nervous tension, hunger, fatigue, incorrect position, excessive stimulation. To avoid, explain risks prior to rx, and if fainting occurs – remove needles and follow First Aid

 

Stuck needle

• Caused by muscle spasm, too much stimulation, too much rotation in one direction causing the fibres to bind, altering the body position with the needle inserted.

 

To manage –

• Relax the muscle with massage/ice/distal heat

• Rotate needle in the opposite direction

• Insert 1-2 superficial needles around the stuck needle site

 

Bent needle

• Caused by striking hard muscle, change in body position or strong muscle contraction.

To manage –

• Follow the above procedure

• Remove the needle, following the line of the bend.

 

Broken needle

• Incredibly rare

• As a result of old or poor quality needles, contraction of muscle or sudden movement.

• Very rare with single use sterile needles – it is reusable needles that go in an autoclave that are the risk.

• If it occurs – remove the needle with tweezers if visible

• If not visible – press the skin down around the insertion point until visible then remove

• If unable to remove – CIRCLE the INSERTION point with PERMANENT marker, then refer to doctor ASAP for removal

NEEDLE STICK INJURY

• In the occurrence of a needle stick injury (skin penetration from a used needle) Wash the area thoroughly with soap etc. and ENCOURAGE Bleeding. Follow this up with blood tests from your Dr.

• It is encouraged to ensure all your injections of blood borne viruses are up to date.

• If abrasions are present on the skin, therapist should use gloves.