Risk of exposure of surgical personnel to patients' blood during surgery at San Francisco General Hospital

Does every patient with enigmatic lung disease deserve a lung biopsy? The continuing dilemma

STUDY OBJECTIVE

Define the negative predictive factors for survival in patients who undergo open-lung biopsy.

DESIGN

Retrospective analysis from July 1988 through January 1992 (prior to widespread use of video-assisted techniques). Factors included in analysis were: oxygen therapy, requirement for intubation, and HIV status. Also analyzed were the accuracy of the preoperative presumptive diagnosis and the outcome of therapy.

SETTING

University hospital in an urban area with active medical and surgical critical care services.

PATIENTS

All patients who underwent open-lung biopsy during the study design period. Patients excluded were those with lung transplants and one patient who had a thoracoscopic biopsy. Forty-eight lung biopsies were performed and 31 patients without AIDS and 15 with AIDS. Twenty-four (16 without AIDS, 8 with AIDS) were receiving oxygen therapy, met intubation criteria, or were intubated and ventilated at the time of biopsy. The indications were undiagnosed nodular or interstitial lung disease.

INTERVENTIONS

Presurgical evaluation included a preoperative diagnostic algorithm of transthoracic needle biopsy and nodular disease (9 patients) and at least one bronchoscopy with bronchoalveolar lavage and transbronchial biopsy in interstitial disease (22 patients). Seven patients with nodular disease and nine with infiltrate had no preoperative procedures.

MEASUREMENTS AND RESULTS

Lung biopsy obtained at definitive diagnosis in 98 percent of patients. Biopsy significantly altered therapy in 79 percent (81 percent without AIDS, 73 percent with AIDS). Postoperatively, in-hospital mortality was 8 (17 percent): 5 (16 percent) without AIDS and 3 (20 percent) with AIDS p > 0.1. Mortality rates showed patients without respiratory compromise, 4.2 percent (7 percent without AIDS, 0 percent with AIDS); patients receiving oxygen therapy, 6 percent (10 percent without AIDS; 0 percent with AIDS); patients who met intubation criteria, 60 percent (33 percent without AIDS, 100 percent with AIDS); patients who were ventilated, 75 percent (66 percent without AIDS [p < 0.05], 100 percent with AIDS [p < 0.05].

CONCLUSION

We recommend that the decision for lung biopsy be individualized based on respiratory status.

HIV infection and surgeons

The human immunodeficiency virus (HIV) causes acquired immunodeficiency syndrome, which remains uniformly fatal in affected individuals. A common route of HIV transmission is via inoculation of contaminated blood, which may occur during surgical procedures. Surgeons may estimate their risk of HIV infection over a 30-year surgical career based on HIV prevalence among surgical patients, percutaneous injury rate per operation, and seroconversion rate. Surgeons can reduce their risk by various means, but the most pragmatic is by reducing the rate of percutaneous injury through optimal surgical technique and proper precautions.

Prevention of hepatitis B infection: a survey of surgeons and interventional cardiologists

Hepatitis B immunization and the use of protective measures against blood contamination were assessed in a group of clinicians associated with invasive procedures. A self-administered confidential questionnaire was sent to 140 surgeons and interventional cardiologists, of whom 105 (75 per cent) replied. Ninety-five respondents (90 per cent) were immunized against hepatitis B, most (63 per cent) by an occupational health department and the majority within 5 years of this study. Only 80 per cent had had their immunity tested after immunization. Barrier protective techniques were used infrequently, with 30 per cent of respondents wearing impermeable gowns, 14 per cent wearing visors and 9 per cent using double-gloving for all procedures. Department of Health guidelines on protection from hepatitis B were published after this survey and the implementation of these guidelines in an NHS trust hospital is discussed.

Reducing the risk of viral transmission at operation by electronic monitoring of the surgeon-patient barrier

A new electronic device designed to detect glove holes, wet gowns and glove permeability was assessed during 50 general surgical operations. The cause of each alarm was recorded and the surgeon's awareness of any breach noted. Some 266 alarms were recorded of which 45 were ascribed to glove holes, 86 to wet gowns, 115 to glove porosity and 20 to other causes. Glove holes occurred in 29 of the 50 procedures; the surgeon was unaware of the hole in almost 70 per cent of cases. Holes were more common in laparotomy than in laparoscopic procedures (P = 0.006). In 20 per cent of instances surgeons did not respond immediately to the alarm (median delay 16 min). Six of eight surgeons who used the device indicated that they would do so regularly for major abdominal surgery. The electronic system accurately detects breaches in the surgeon-patient barrier. Its use should improve surgical discipline in acting to restore the barrier, protecting patient and surgeon alike.

Variables influencing worker compliance with universal precautions in the emergency department

BACKGROUND

Emergency department health care workers frequently provide care to patients who are in unstable condition, bleeding, or in a crisis situation. To identify the variables described in the Health Belief Model affecting health care workers' compliance with practices and devices believed to reduce exposure to patients' blood, the staff of a level II trauma center were surveyed for knowledge, compliance, and training regarding universal precautions.

METHODS

Fifty-three health care workers responded to an anonymous, self-report, 50-item questionnaire. Significant differences in mean scores were determined by use of a two-tailed t test.

RESULTS

Health care workers estimated they were most likely to perform handwashing after contact with body fluids and to wear gloves if contact with blood was anticipated. The most common obstacles to compliance with universal precautions were lack of time, patients perceived to be at lower risk for HIV or hepatitis B infections, and interference with technical skills. Health care workers with more than three perceived obstacles to universal precautions were less likely to use gloves (p < 0.05) if contact with blood was anticipated. Health care workers with a higher number of training experiences in universal precautions were more likely to use gloves if contact with blood was anticipated (p < 0.05) and less likely to recap a needle after giving an intravascular injection (p < 0.05), drawing a blood gas sample (p < 0.05), or injecting medication into an intravenous line (p < 0.05).

CONCLUSIONS

The application of the Health Belief Model to this problem suggests that an integrated approach is appropriate. Such an approach should incorporate engineering controls, cognitive approaches, behavior modification strategies, and training experiences to improve skills and dexterity.

Occupational risk and precautions related to HIV infection among dentists in the Lothian region of Scotland

This retrospective study used a postal questionnaire to measure occupational risks and to assess infection control procedures among 310 dental practitioners. The study comprised general dental practices in the Lothian region of Scotland, Lothian Health Board Community Dental Service and Edinburgh Dental Hospital. Altogether, 217 dental practitioners responded by the due date giving recall of inoculation injuries within the previous 5 years and infection control measures employed. The study revealed that 191 practitioners (88%) had completed a course of hepatitis B vaccination but one-third of them had not been tested for post-vaccination antibody. In 1991, two thirds of dentists (66%: 137 of 207 respondents) wore the same pair of gloves, and 80% of dentists (142 of 177 respondents) wore the same mask, for dealing with more than one patient. The usual practice was to change gloves during sessions (44%: out of 71 dentists) and to change masks for each session or less often (75%: 73 out of 97 dentists). The proportion of dentists who never used gloves fell from 56% in 1981 to 1% in 1991. An autoclave was used for sterilisation by 85% of practitioners in 1991. Reported non-sterile inoculation injuries averaged 1.7 (S.D. = 3.2) injuries per dentist in the previous year with 56% of practitioners having had an injury. The average was 6.8 (S.D. = 15.9) injuries per dentist in the previous 5 years with 76% of practitioners having had an injury. Of recent non-sterile inoculation injuries described by dental practitioners, 30% constituted a moderate or high risk of transmission of infection to the practitioner (43 of 141 described injuries). Combined with HIV seroprevalance rates, probabilities of transmission and numbers of practising dentists, the mean reported number of non-sterile inoculation injuries in the previous 5 years may be used to provide estimates of expected numbers of dental practitioners occupationally infected with HIV in the previous 5 years. U.K. estimates were 0.004 dentists in Lothian region and 0.05 dentists in the Thames region occupationally infected with HIV in the previous five years. Non-sterile inoculation injuries appear to be a common hazard of dental practice. In any year, most dentists are exposed to the risk of blood-borne viral infection. Despite a high reported incidence of such injuries, dental practice within the U.K. appears to carry a low risk of acquiring HIV infection from occupational exposure.

Nurses' knowledge, attitudes about HIV, AIDS. A replication study

The AIDS epidemic is now in its second decade and shows no sign of relenting. Unfortunately, however, the AORN study shows that perioperative nurses' knowledge regarding HIV and AIDS is not adequate to enable them to provide patient care while maintaining safe practices. Focused educational programs should be made available to perioperative nurses to help them apply universal precautions and OSHA standards to everyday practice. Perioperative nurses must become knowledgeable about the disease and sensitive to the needs of patients who have this illness. All nurses have a special obligation to care for all patients; education and management strategies that enable exploration of values, fears, and prejudices will help nurses understand their own beliefs and those of other individuals. Recommendations from this study may be viewed as a starting point for this perioperative education.

Barrier protection with examination gloves: double versus single

In a series of experiments, the barrier integrity of single and double vinyl and latex examination gloves were tested for dye and water leaks after being placed under stress. A total of 886 examination gloves (385 vinyl: single, 199; double, 186; and 501 latex: single, 290; double, 211) were tested with a standardized clinical protocol designed to mimic patient care activities. Leakage rates for single or double gloving were significantly higher for vinyl than for latex gloves. Single vinyl gloves were significantly more likely to leak than were double vinyl gloves (51.3% and 19.7%, p < 0.0001). However, there were essentially no differences in leakage rates for single or double latex gloves (4.1% and 3.8%, p = 1). Significantly higher rates of leakage were identified with the water leak test than with the dye test for vinyl (p < 0.001) but not for latex (p = 0.22) gloves. For vinyl but not latex gloves, there were significant differences in leakage rates by brand. We conclude that double gloving offers little advantage during routine procedures associated with minimal stress to the gloves or when latex gloves are worn.

Hepatitis, HIV, and the dermatologist: a risk review

The practice of dermatology has always carried with it the risk of patient-acquired infection. This review covers health risks associated with the care of HIV-infected patients and patients who are chronic carriers of hepatitis B or C virus, protection options to reduce exposure, and protocols should exposure occur. Hepatitis B continues to be a major risk to health care workers, killing approximately 200 per year. In contrast, as of 1990, only 327 total health care personnel had acquired HIV, with no deaths reported. Data are lacking regarding hepatitis C, but it appears to be an increasing concern. Needlesticks are the most common form of occupational transmission, with an infectivity rate of 30% for hepatitis B, 3% for hepatitis C, and 0.3% for HIV. Universal precautions are the cornerstones of safety. Hepatitis B vaccination, zidovudine prophylaxis, and hepatitis C therapy are discussed as postexposure recommendations are reviewed.

The HIV-infected health care worker: legal, ethical, and scientific perspectives

Emergency medical health care workers may face restrictions on their practices as state responses to federal mandates concerning human immunodeficiency virus (HIV) and hepatitis B virus (HBV) evolve. This article presents an analysis of legal, ethical, and scientific considerations for making decisions about the practices of HIV-infected health care workers (HCWs). A four-factor product analysis is proposed for risk assessment, and recommendations are developed related to decreasing the risk of HIV transmission in the health care setting while maintaining HCW rights.

Infection control for health care workers caring for critically injured patients: a national survey

Prevention of transmission of bloodborne pathogens to health care workers (HCWs) involved in resuscitation of critically injured patients presents special challenges. As a step toward creation of a standard, a telephone survey of the infection control practices in this setting of the 100 busiest EDs in the United States (US) was performed. Departmental staff who were knowledgeable about ED infection prevention protocols were questioned about general policy, barrier protection measures, sharps management, and educational programs directed to HCWs. Surveys were completed for 82 EDs. Of these, 56 (68%) either function as primary trauma care facilities for the local community, or are designated level 1 trauma centers by the American College of Surgeons. Specific infection control protocols for trauma resuscitation had been printed and posted by 18 EDs (22%), with the remaining 64 (78%) using the same universal precautions for care of the severely injured as for other patients. A specific policy relating to invasive procedures had been promulgated by 66 EDs (80%). Barrier protection was used by protocol or by custom for care of all critically injured patients by 43 EDs (52%). Impermeable gowns with sleeves were available in 63 EDs (77%). Eye or face protection included face shields by 74 EDs (90%), face masks by 76 EDs (93%), and goggles by 72 EDs (88%). Only 59 EDs (72%) reported that sharp containers were always within arm's reach of HCWs with material to discard. Specially adapted equipment included self-sheathing intravenous catheters (21, 26%) and needle/syringe combinations (16, 20%). Considerable variation exists in infection control practices in busy US EDs during resuscitation of critically injured patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Perioperative blood contact and exposures: a comparison of incident reports and focused studies

BACKGROUND

Occupational blood exposures among operating room personnel have been substantially underreported in incident reports. Recent research has indicated several common factors influencing exposure rates: surgical service (thoracic, neurosurgery, orthopedic), length of operation, and emergency status.

METHODS

This report examines further data from a study of 8502 surgical cases in nine hospitals, in which a site coordinator and circulating nurses reported consecutive case information, including blood contacts that occurred during the procedures. For three of the participating hospitals, incident reports of blood exposures among operating room personnel that occurred during a 12-month period before the study were also tabulated.

RESULTS

Incident reports underreported parenteral exposures (punctures, mucous membrane and nonintact skin contact with patient blood) by as much as a factor of 25. Individual hospital rates of occupational surgical blood exposure varied considerably.

CONCLUSIONS

To ensure that resources to prevent occupational blood exposure are allocated appropriately, on the basis of actual risk, among all personnel, hospitals must actively monitor blood exposures in their operating rooms.

Accidental skin punctures during ophthalmic surgery

PURPOSE

Accidental skin puncture carries the risk of both hepatitis B and human immunodeficiency virus transmission. There have been studies of the incidence of these skin punctures in general surgery, but no study has focused on ophthalmic surgery.

METHOD

All incident reports of skin punctures in the Bascom Palmer Eye Institute operating rooms from January 1990 through November 1991 were reviewed retrospectively. The incidence of skin puncture also was studied propsectively from December 1991 through May 1992. During the prospective phase, the healthcare worker was asked to complete an anonymous form regarding the instrument involved, whether it was clean or contaminated, the persons involved, and whether the room lights were on or off.

RESULTS

There were 37 such occurrences in 14,878 operations (0.25%) during the retrospective study and 12 in 4246 operations (0.28%) in the prospective period. In only one case was the instrument contaminated by contact with a patient known to have positive serology for the human immunodeficiency virus. There were no documented seroconversions of healthcare personnel for either hepatitis B or human immunodeficiency virus. In 63% of these occurrences, the penetrating instrument was known to be definitely contaminated with the patient's blood. Only one person was handling the instrument 84% of the time.

CONCLUSION

The low but present danger to ophthalmic personnel during surgical procedures justifies precautions to decrease the occurrence of skin punctures.

Risk of occupational infection with blood-borne pathogens in operating and delivery room settings

Surveillance data and case reports substantiate that health care workers are at risk for occupationally acquired infection with blood-borne pathogens. The risk of transmission of blood-borne pathogens to a health care worker depends on the prevalence of blood-borne pathogen infection among patients, the likelihood of transmission of infection per blood contact, and the nature and frequency of occupational blood contacts. In surgical and obstetrical settings, blood contact varies with occupation, specialty, procedures performed, and precautions used. Many contacts appear to be preventable by changes in technique or instrument design and by use of protective barriers. Studies are needed to assess the impact of such interventions.

Procedure-specific infection control for preventing intraoperative blood exposures

Contemporary intraoperative infection control must address the risk of infection transmission to both patients and their providers. The patient must be protected from intraoperative wound contamination and exposure to blood-borne pathogens during procedures. Providers must be protected from injuries and mucocutaneous exposure to the patient's blood. Procedure-specific infection control precautions, or similar strategies that address this bidirectional potential for infection transmission, may prove successful in accomplishing improved safety for all.

Assessing the risk of blood exposure in the operating room

During the past 3 years, a great deal of new information has been published on the risk of blood exposure and injury in the operating room. In addition, detailed information about the effectiveness of barrier materials, operating room garments, and gloves has also become available. On the basis of this information, it has become possible to recommend strategies, barrier materials, and garments that should reduce the risk of contracting a blood-borne infection in the operating room. Further attempts to decrease the risk of blood exposure and injury require thorough evaluation of all risk-reduction strategies and careful selection of protective apparel and barriers on the basis of well-designed studies performed in the operating room environment.

Preoperative HIV testing: is it less expensive than universal precautions?

Universal precautions are officially recommended to prevent HIV transmission in health care settings but for elective surgery some advocate routine preoperative HIV testing. These strategies have not been tested in clinical trials but universal precautions are very expensive and not cost-effective. Thus, for elective surgery, routine testing might save resources by permitting selective use of additional barrier precautions. We performed an economic evaluation to compare both strategies, using a simple approach to determine if routine testing (RT) is less expensive than universal precautions (UP). Conservatively assuming equal effectiveness in preventing HIV transmission, we compared a minimized estimate for the average cost of RT with a maximized estimate for the average cost of UP per elective operation. The minimized estimate for RT (US$57) was greater than the maximized estimate for UP (US$36) per procedure. Results were stable or strengthened by sensitivity analysis. Routine HIV testing is not a valid economic alternative to UP for elective surgery. The simple methodology used in this study can be a preliminary strategy to review other strategies for preventing HIV transmission. This method is particularly useful when data are inadequate for a formal economic evaluation to determine the utility of collecting the detailed information necessary for a full comparison.

Role of infection control practitioners in human immunodeficiency virus testing. APIC Bloodborne Pathogens Committee

BACKGROUND

As a result of the HIV epidemic, the role of the ICP has changed; acute care settings have developed a variety of policies regarding patient and health care worker (HCW) HIV testing and issues related to the HIV-infected HCW. APIC conducted a survey to determine the extent to which ICPs were involved in HCW and patient HIV testing and counseling, the prevalence of routine HIV testing for patients, institutional policies on HIV testing of patients and HCWs, and the management of HIV infected HCWs.

METHODS

In 1990, a questionnaire was sent to ICPs in a simple random sample of 1300 acute care hospitals (approximately 20%) in the United States.

RESULTS

Response rate was 52.8%. Of the 686 respondents, 54.8% provided counseling to the HCW after an exposure incident. ICPs were involved not only in HIV testing and counseling for patients and HCWs but also in institutional policy development for HIV-related issues. Most facilities (73.8%) obtained written consent for testing from the patient after an employee exposure. When a direct care giver was known to be HIV positive, 61.5% of the respondents evaluated each case individually.

CONCLUSIONS

The ICP has a significant role in the development and implementation of institutional policies on HIV testing and counseling and on the management of HIV-infected workers. These findings affirm the need for APIC to provide educational opportunities on the issues related to HIV testing and counseling.

Blood contact and exposures among operating room personnel: a multicenter study

Blood exposures are increasingly recognized as a risk for health care workers in the operating room. Trained circulating nurses supervised by site coordinators queried surgical team members about blood contact and collected data on 8502 surgical procedures from seven community and two university hospitals in 1992. Blood contact occurred during 864 cases (10.2% case-contact rate) in 1054 health care workers (12.4% person-contact rate). The parenteral exposure (punctures or cuts, mucous membranes, nonintact skin) rate was 2.2% and the cutaneous exposure (intact skin) rate was 10.2%. Blood contacts were twice as likely to be parenteral among surgeons as among other operating room personnel (odds ratio, 2.0; 95% confidence interval, 1.4 to 2.9). Of cutaneous exposures, 46.9% were from unknown sources or were surprise spatters. Logistic regression analyses indicated that risk factors associated with any blood contact (parenteral or cutaneous) were length of procedure (odds ratio, 1.51; 95% confidence interval, 1.46 to 1.56), emergency versus scheduled status (odds ratio, 1.44; 95% confidence interval, 1.21 to 1.66), selected surgical services, and the hospital. Logistic regression analyses of parenteral exposures, as compared with cases in which no contact occurred, indicated that risk factors were length (odds ratio, 1.39; 95% confidence interval, 1.31 to 1.47), thoracic surgery (odds ratio, 2.79; 95% confidence interval, 2.18 to 3.40), and university hospital versus community (odds ratio, 2.26; 95% confidence interval, 1.89 to 2.63). Parenteral exposures are clear risks to health care workers; however, it is also important to study all contact with blood in the operating room to appreciate potential risks and develop appropriate intervention strategies.

Preliminary experience with polyethylene fibre glove liners in oral and maxillofacial surgery

The poor performance of latex gloves in preventing penetrating injury is well established. Oral and maxillofacial surgeons face the additional problems associated with wiring techniques and high-speed rotary instruments. A pilot study is presented assessing the efficacy of high-strength polyethylene fibre gloves, used in a triple-gloving technique, in preventing inner glove perforation. The results showed that there were fewer perforations of the inner glove in the surgeon wearing the glove liner, but the difference was not significant.

Occupational exposure to the human immunodeficiency virus and other blood-borne pathogens. A six-year prospective study

OBJECTIVE

To prospectively study occupational exposures to human immunodeficiency virus (HIV) and other blood-borne pathogens.

DESIGN AND SETTING

Detailed clinical information was collected and follow-up was performed on all health care workers with occupational exposures to potentially infected substances at Fairfield Infectious Diseases Hospital during the period January 1985 to September 1991.

RESULTS

There were 230 occupational exposures reported. One hundred and forty-one were considered "significant" or "potentially significant"; these involved exposure (or the potential for exposure) to blood or body fluids by the parenteral route or contamination of non-intact skin or mucous membranes. Needle/syringe assemblies accounted for 59% of the "significant" injuries, "butterfly" needles for 21% and lancets for 8%. "Butterfly" needles were over-represented relative to their degree of use. Seventy-seven of the 230 exposures were HIV-related and 27 of these were considered "significant". The number of HIV positive patients attending the hospital increased progressively over the survey period but the rate of HIV-related exposures fell during that time. After 1988, 13 individuals with "significant" exposure to HIV received a six-week prophylactic course of zidovudine. No health care workers seroconverted for HIV, hepatitis B or hepatitis C during the survey period.

CONCLUSIONS

The risk of acquiring HIV (and other blood-borne diseases) through occupational exposure is very low and this risk can be further reduced by adopting safe work practices.

Body fluid exposure in an urban tertiary care medical center

The increasing prevalences of the human immunodeficiency (HIV) and hepatitis B viruses have focused attention on the risks that health care workers face when exposed to potentially infective body fluids. This study establishes a profile of 320 parenteral exposure incidents and 47 exposure incidents to mucous membranes or abraded skin, reported in our medical center between July 1988 and July 1990. We found that 102 (27.8%) of the incidents involved an HIV-positive patient, that 130 (35.4%) of the reporting employees had completed their hepatitis B vaccination at the time of the incident, and that, although the majority of incidents involved employees with patient contact, unfortunately, service workers also were represented (4.6%, n = 17). Factors contributing to incidents included recapping (10.9%, n = 40), full needle-boxes (7.6%, n = 28), and inappropriate disposal (13.1%, n = 48). A health fair featuring walk-in hepatitis B immunization attracted 260 participants, 90% of whom completed the entire immunization series. This significantly improved the immunization rate of employees subsequently reporting body fluid exposure.

The thrifty genotype and non-insulin dependent diabetes

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Surgical issues in the management of the HIV-infected patient

As of 1992, approximately 1,000,000 Americans are infected with HIV. The natural history of the illness includes a relatively long latent period (about 10 years) between infection and development of AIDS. Surgeons are called on to participate in the management of these patients, usually for diagnostic biopsies, supportive measures, or intraabdominal events. Precautions and safe surgical practices will minimize the risk of HIV transmission from patient to surgeon (or surgeon to patient).

HIV and interventional radiology: a national survey of physician attitudes and behaviors

PURPOSE

The frequency of parenteral and cutaneous exposure to blood or body fluid during interventional radiologic procedures, current use of barrier precautions by interventional radiologists, and physician attitudes about testing for the human immunodeficiency virus (HIV) and related issues were assessed.

MATERIALS AND METHODS

An anonymous survey of interventional radiologists was conducted by mail in November 1991.

RESULTS

Of 1,530 surveys, 819 (54%) were returned and 806 (53%) were completed and evaluable. Ninety-six percent of respondents (763 of 794) perform procedures in patients infected with HIV. Sixty-nine percent oppose mandatory testing of physicians for HIV. Eighty-seven percent (693 of 797) reported at least one procedure-related injury (range, 0-99; mean, four). Fifty-eight percent of injuries occurred with use of a sharp instrument (381 of 662), 20% were due to needle recapping (133 of 662), and 7% (44 of 662), to improper disposal of a sharp instrument. Contact between a physician's blood and a patient was reported in only one case (0.2%). Eighty-five percent of respondents (671 of 789) changed their use of barrier precautions in the last 10 years; concerns about HIV were cited by 96% as a reason for change. Reported use of barrier measures was highly variable.

CONCLUSION

Exposure to patients' blood or body fluid is not infrequent during interventional radiologic procedures. Exposure of patients to the blood or body fluid of health care workers is rare. Use of recommended precautions in interventional radiology is variable, and practices that could lead to preventable injury remain common. Strategies should be developed to reduce risks even further and to encourage universal compliance with government guidelines.

Occupational risk to surgeons of unrecognized HIV infection in a low-prevalence area

Data are available on the occupational risk to surgeons of the human immunodeficiency virus (HIV) for areas of high HIV prevalence but not for low-risk areas and particularly for unrecognized HIV infection. The 40-year cumulative occupational risk to surgeons caring for patients with unknown HIV serologies in a low-prevalence area was estimated. From May 1989 to May 1991, 4119 consecutive patients with unknown HIV status, hospitalized in our department, were proposed for testing; 100% complied. Acquired immunodeficiency syndrome (AIDS) patients and known seropositive patients operated on during this period were excluded from the study. The prevalence of unknown HIV infection was 0.07%. Taking into account the rate of parenteral injuries, the rate of contamination after an infected parenteral injury, and the total number of operations performed during a 40-year career, we estimated the cumulative risk of unknown HIV infection in our area to be 1%. This risk must be added to those of caring for known infected patients. In high-risk areas (cumulative risk 10%), a high standard of infection control is required for every surgical procedure, even if it is expensive or of doubtful efficacy. It is unrealistic to apply this standard in a low-risk area. HIV testing with informed consent of the patient is an imperfect guard against infection but has the advantage of alerting the surgeon to the risk of contamination on a case-by-case basis; it also offers the seropositive patient the best possibility for a longer life expectancy.

Effects of steam sterilization on the contents of sharps containers

BACKGROUND

One form of medical waste known to be capable of transmitting disease is the contaminated sharp. Safe handling and disposal of sharps is an essential element of any infection control program. Many areas allow the on-site treatment of sharps containers. However, little information currently exists as to the most effective sterilization procedures and container designs.

METHODS

This study was intended to evaluate the effect treatment with various autoclaves had on bacterial endospores present on strips or needled syringes. Strips contained 1.7 x 10(5) Bacillus stearothermophilus spores; syringes were soiled with equal numbers of spores or with spores plus blood. Syringes were tested capped and uncapped. A gravity-displacement autoclave and a high-vacuum autoclave were used. Strips and syringes were placed within sharps containers three quarters filled with representative materials. Six types of containers were tested. Containers were processed sitting up or on their sides. Processed strips and needles were aerobically cultured at 56 degrees C for 7 days. If sterilization was not accomplished initially, additional exposure time was added.

RESULTS

(1) Soiled syringes were more difficult to sterilize than strips. (2) Capping or the presence of blood did not affect sterilization efficiency. (3) Container positioning was important only for the gravity-displacement autoclave. (4) Additional exposure time was required in the gravity displacement autoclave when sterilizing soiled syringes but not strips. (5) High-vacuum autoclaving killed all spore challenges within the normal processing interval.

CONCLUSIONS

The data indicate that processing of sharps containers within a gravity-displacement autoclave appears to require extended exposure intervals to achieve sterilization.