Universal precautions are not universally followed

Interdisciplinary differences in needlestick injuries among healthcare professionals in training: Improving situational awareness to prevent high-risk injuries

BACKGROUND

Needlestick injuries among healthcare professionals continue to be an occupational hazard, frequently and incorrectly regarded as low-risk, and exacerbated by underreporting. We aimed to investigate rates of needlestick injury, reasons for underreporting, and how explicit announcements that patients are "high-risk" (i.e., human immunodeficiency virus, hepatitis, or intravenous drug abuse history) might affect the actions of those at risk of sustaining an injury.

METHODS

A cross-sectional survey was administered to medical students (MS), nursing students (NS), and residents.

RESULTS

30/224 (13%) of MS, 6/65 (9%) of NS, and 67/126 (53%) of residents experienced needlestick injuries. 37% of MS, 33% of NS, and 46% of residents attributed "lack of concentration" as cause of injury. Residents had the lowest percentage of underreporting (33%), with rates of 40% and 83% among MS and NS, respectively. Top reasons for non-reporting included the injury being perceived as "trivial" (22%) and patient being "low-risk" (18%). A majority stated pre-operative "high-risk" announcements should be required (91%), and would promote "culture of safety" (82%), reporting of injuries (85%), and increased concentration during procedures (70%).

CONCLUSIONS

We recommend routine announcements during pre-operative time-out and nursing/resident hand-offs that state a patient is "high-risk" if applicable. We hypothesize such policy will promote a "culture of safety," situational awareness, and incident reporting.

Hand Hygiene Practices After Brief Encounters With Patients: An Important Opportunity for Prevention

Objective.

To identify characteristics of encounters between healthcare workers (HCWs) and patients that correlated with hand hygiene adherence among HCWs.

Design.

Observational study.

Setting.

Intensive care unit in a Veterans Affairs hospital.

Participants.

HCWs.

Results.

There were 767 patient encounters observed (48.6% involved nurses, 20.6% involved physicians, and 30.8% involved other HCWs); 39.8% of encounters involved patients placed under contact precautions. HCW contact with either the patient or surfaces in the patient's environment occurred during all encounters; direct patient contact occurred during 439 encounters (57.4%), and contact with environmental surfaces occurred during 710 encounters (92.6%). The median duration of encounters was 2 minutes (range, <1 to 51 minutes); 33.6% of encounters lasted 1 minute or less, with no significant occupation-associated differences in the median duration of encounters. Adherence with hand hygiene practices was correlated with the duration of the encounter, with overall adherences of 30.0% after encounters of ≤1 minute, 43.4% after encounters of >1 to ≤2 minutes, 51.1% after encounters of >3 to ≤5 minutes, and 64.9% after encounters of >5 minutes (P < .001 by the x2 for trend). In multivariate analyses, longer encounter duration, contact precautions status, patient contact, and nursing occupation were independently associated with adherence to hand hygiene recommendations.

Conclusions.

In this study, adherence to hand hygiene practices was lowest after brief patient encounters (ie, <2 minutes). Brief encounters accounted for a substantial proportion of all observed encounters, and opportunities for hand contamination occurred during all brief encounters. Therefore, improving adherence after brief encounters may have an important overall impact on the transmission of healthcare-associated pathogens and may deserve special emphasis in the design of programs to promote adherence to hand hygiene practices.

An 'Academic Detailing' Intervention To Decrease Exposure to HIV Infection among Health-care Workers

This intervention aimed to decrease health-care workers' experience of automatic pilot (mindless functioning) when performing high risk procedures. An academic detailing visit resulted in a significant increase in compliance with safety guidelines and a decreased incidence of other unsafe practices among 80 health care workers of two hospital units. The effects of mindlessness on health behaviour may be far reaching and the model described in this paper can be used to develop appropriate interventions.

Use of personal protective equipment in Canadian pediatric emergency departments

OBJECTIVE

Numerous barriers to maintaining infection control practices through the use of personal protective equipment (PPE) exist in the emergency department (ED). This study examined the knowledge, self-reported behaviours, and barriers to compliance with infection control practices and the use of PPE in Canadian pediatric EDs.

METHODS

A self-administered survey instrument consisting of 21 questions was developed and piloted for this study. The survey was mailed to all individuals listed in the Pediatric Emergency Research Canada database of physicians practicing pediatric emergency medicine in Canada.

RESULTS

A total of 186 physicians were surveyed, and 123 (66%) participated. Twenty-two percent of participants reported that they had never received PPE training and 32% had not been trained in the previous 2 years. Fifty-three percent reported being very or somewhat comfortable with their knowledge of transmission-based isolation practices. Participants were correct on a mean of 4.9 of 11 knowledge-based questions (SD 1.7). For scenarios assessing self-reported use of PPE, participants selected answers that reflected PPE use in accordance with national infection control standards in a mean of 1.0 of 6 scenarios (SD 1.0). Participants reported that they would be more likely to use PPE if patients were clearly identified prior to physician assessment, equipment was accessible, and PPE use was made a priority in their ED.

CONCLUSIONS

Knowledge and self-reported adherence to recommended infection control practices among Canadian pediatric emergency physicians is suboptimal. Early identification of patients requiring PPE, convenient access to PPE, and improved education regarding isolation and PPE practices may improve adherence.

Public attitudes and opinions toward physicians and dentists infected with bloodborne viruses: results of a national survey

BACKGROUND

There has been no recent assessment of public attitudes and opinions concerning risk of bloodborne virus transmission during health care.

METHODS

Seven items in the 2000 annual Healthstyles survey were used to assess current attitudes and opinions about health care providers infected with human immunodeficiency virus (HIV) and the risk of bloodborne virus transmission during health care in a sample of approximately 3000 US households.

RESULTS

Of the 2353 respondents, 89% agreed that they want to know whether their doctor or dentist is infected with HIV; 82% agreed that disclosure of HBV or HCV infection in a provider should be mandatory. However, 47% did not believe that HIV-infected doctors were more likely to infect patients than doctors infected with HBV or HCV. Opinions were divided on whether HIV-infected providers should be able to care for patients as long as they use good infection control: only 38% thought that infected providers should be allowed to provide patient care.

CONCLUSIONS

These findings suggest that improved public education and risk communication on health care-associated bloodborne infections is needed.

Improved compliance with universal precautions in the operating room following an educational intervention

Observation of surgical personnel in four specialties (cardiothoracic, general, gynecologic, and orthopedic) in the operating room was performed prior to implementation of an educational intervention designed to improve compliance with Universal Precautions and at 1- and 2-years post-intervention. Use of protective eyewear and double gloving increased following the intervention, whereas the incidence of documented blood and body fluid exposures decreased.

Hospital bloodborne pathogens programs: program characteristics and blood and body fluid exposure rates

OBJECTIVE

To describe hospital practices and policies relating to bloodborne pathogens and current rates of occupational exposure among healthcare workers.

PARTICIPANTS AND METHODS

Hospitals in Iowa and Virginia were surveyed in 1996 and 1997 about Standard Precautions training programs and compliance. The primary outcome measures were rates of percutaneous injuries and mucocutaneous exposures.

RESULTS

153 (64%) of 240 hospitals responded. New employee training was offered no more than twice per year by nearly one third. Most (79%-80%) facilities monitored compliance of nurses, housekeepers, and laboratory technicians; physicians rarely were trained or monitored. Implementation of needlestick prevention devices was the most common action taken to decrease sharps injuries. Over one half of hospitals used needleless intravenous systems; larger hospitals used these significantly more often. Protected devices for phlebotomy or intravenous placement were purchased by only one third. Most (89% of large and 80% of small) hospitals met the recommended infection control personnel-to-bed ratio of 1:250. Eleven percent did not have access to postexposure care during all working hours. Percutaneous injury surveillance relied on incident reports (99% of facilities) and employee health records (61%). The annual reported percutaneous injury incidence rate from 106 hospitals was 5.3 injuries per 100 personnel. Compared to single tertiary-referral institution rates determined more than 5 years previously, current injury rates remain elevated in community hospitals.

CONCLUSIONS

Healthcare institutions need to commit sufficient resources to Standard Precautions training and monitoring and to infection control programs to meet the needs of all workers, including physicians. Healthcare workers clearly remain at risk for injury. Further effective interventions are needed for employee training, improving adherence, and providing needlestick prevention devices.

Precautions against cross-infection during operations for maxillofacial trauma

One hundred oral and maxillofacial units in the UK were sent a postal questionnaire. Surgical staff of all grades were asked which infection-control measures were taken during the treatment of maxillofacial fractures. Two hundred and ninety-four questionnaires were completed, a response rate of 49%. If the patient was known to be infected by a blood-borne viral disease, significantly more surgeons used standard barrier precautions such as eye protection, fluid-resistant gowns, drapes, ball-ended clips, adhesive tapes and intermediate trays (P<0.0001). Bone-plating techniques were used in preference to wire osteosynthesis (P<0.0001). Only 31 (10.5%) of surgeons routinely used double gloves but 250 (85%) did so if the patient was an infection risk (P<0.0001). Universal precautions were not applied equally to all patients.

Exposure of medical students to body fluids

Three hundred forty-two students at 3 Florida medical schools were surveyed concerning occupational exposures to blood and body fluids during their 3rd-year clerkship. The 16-item questionnaire was anonymously returned by 150 students, and differences among groups were assessed at p < .05. Most of the students complied with universal precautions guidelines (UVPG); 62 reported 101 exposures, including 9 with HIV-positive blood and body fluids. Most of the exposed students knew about the guidelines but regarded the incidents as irrelevant to their safety or supervision training. Noncompliant students reported significantly more exposures than compliant students. Time constraints, inconvenience of using gloves during procedures, and belief that patients were at low HIV risk discouraged adherence to the guidelines. Common practices following exposure were "no action" or "washed area only" without medical follow-up. Medical students' UVPG adherence should be increased by workload modification, user-friendly safety products, and supervised practice training in clinical exposure settings.

Prevention of needle-stick injury. Efficacy of a safeguarded intravenous cannula

One possible method of reducing the incidence of needle-stick injury is to use needles with safeguard mechanisms. The needle of the Insyte AutoGuard intravenous cannula can be retracted into the safety barrel. One hundred patients were randomly allocated to receive either an 18-gauge conventional Insyte intravenous cannula (group C) or the AutoGuard cannula (group AG) to assess the ease of use and efficacy of the AutoGuard device. It was possible to insert the cannula into the vein within two attempts in all patients; there was no significant difference between two groups with respect to ease of insertion. No problems, such as inadvertent withdrawal of the needle, occurred during insertion in any patient. Handling the withdrawn needle was judged significantly safer in group AG than in group C (p < 0.001). Blood contamination often occurred where a withdrawn needle was placed in group C, whereas no blood stain was detected in any case in group AG (p < 0.001). The AutoGuard cannula provides safer handling of a withdrawn needle without reducing its ease of insertion.

Behavioral interventions to improve infection control practices

No single intervention has been successful in improving and sustaining such infection control practices as universal precautions and handwashing by health care professionals. This paper examines several behavioral theories (Health Belief Model, Theory of Reasoned Action and Theory of Planned Behavior, self-efficacy, and the Transtheoretic Model) and relates them to individual factors, also considering interpersonal and organizational factors. Further, this article includes recommendations of individual and organizational components to be addressed when planning a theoretically based intervention for improving infection control practices. A hypothetic framework to enhance handwashing practice is proposed.

Compliance with universal precautions: knowledge and behavior of residents and students in a department of obstetrics and gynecology

OBJECTIVES

To assess the knowledge of universal precautions for the delivery and operating rooms by residents and students and to evaluate their use of universal precautions.

STUDY DESIGN

Obstetrics and gynecology (ob/gyn) residents (n = 30) and students (n = 31) from an inner-city, teaching hospital were polled by anonymous questionnaire to assess their knowledge of the appropriate barrier equipment for certain ob/gyn procedures. To determine actual compliance with universal precautions, 459 ob/gyn procedures were observed. We noted the use of appropriate barrier equipment for each procedure: gloves for pelvic exam and face shields, gowns, gloves, and booties for vaginal delivery, cesarean delivery, and dilation and curettage. The True Epistat statistical software program was used to perform simple regression analysis.

RESULTS

Thirty residents (100%) knew the appropriate barrier equipment required for each type of procedure performed. One student (< 1%) did not know that booties were appropriate for the surgical procedures. Rationale for lack of compliance with universal precautions elicited by the questionnaire included time constraints (64%), inconvenience (52%), and presumption that patient was not infected (34%). The observed rate of compliance with universal precautions by participants indicates that individual compliance was inversely related to the years of experience (overall compliance rate of students was 96%; for first-year residents, 92%, second-year residents, 89%, third-year residents, 84%, fourth-year residents, 78%; r = -0.9918, P = 0.0009).

CONCLUSIONS

Knowledge regarding universal precautions was nearly 100%, while overall observed compliance was only 89%. Compliance with universal precautions was better among students (96%) than among residents (88%). Compliance with universal precautions was inversely related to years of experience.

Compliance with gloving in anesthesia: an observational study of gloving practice at induction of general anesthesia

STUDY OBJECTIVE

To gather direct observational data on anesthesiologists' compliance with universal precautions' gloving standards during induction of general anesthesia.

DESIGN

Prospective, observational study.

SETTING

Operating theaters of an Israeli government teaching hospital.

SUBJECTS

Over a four-month period, all "first case of the day" general anesthetics were observed to determine if the anesthesiologist directly administering patient care wore gloves during the period of anesthetic induction. All anesthesia department members were observed and none was aware of the ongoing study.

MEASUREMENTS AND MAIN RESULTS

Resident anesthesiologists were found to be more compliant with gloving policy than their attendings (61.8% vs. 33.7%, p < 0.0001). However, the lower compliance among the attendings was entirely attributable to the most senior staff members (over age 55 years) whose compliance rate was 11.5% versus 55.6% for attending staff below age 55 years (p < 0.0001). Departmental compliance as a whole was 49.6%. Compliance in pediatric cases averaged 10% and was equally poor among all department staff.

CONCLUSIONS

Although glove use remains inconsistent, in less than one and one half years since institution of a departmental gloving policy, a substantial degree of compliance was achieved. Nevertheless, further efforts are still needed to improve compliance with universal precautions. In this study, glove use was particularly deficient in pediatric cases and among senior staff aged 55 years and older. Pinpointing specific areas of greatest deficiency may prove useful in guiding additional efforts to improve compliance with universal precautions.

Effectiveness of computer-assisted instruction in increasing the rate of universal precautions--related behaviors

BACKGROUND

With widespread noncompliance to universal precautions well established, an experimental study was designed to compare the rate of universal precautions--related behaviors between nurses who participate in computer-assisted instruction. This study also explored the relationship between rates of universal precautions--related behaviors and subjects' demographic and experiential characteristics and history of occupational blood-borne exposure.

METHODS

Data were collected by using a questionnaire to elicit information as to subjects' demographic and experiential characteristics and history of occupational blood-borne exposure. The Universal Precautions Assessment Tool was used to gather data on rates of universal precautions--related behaviors on two groups of registered nurses with 30 subjects per group.

RESULTS

By using analysis of variance, the null hypothesis was rejected. The intervention used in this study did increase universal precautions--related behaviors. Multiple regression was used to analyze the research question and none of the variables were significant. Forty (67.8%) subjects reported receiving a needlestick or cut caused by a needle or sharp that was actually or potentially contaminated with blood or body fluids. Of these exposures, only one patient was known to be HIV antibody positive.

CONCLUSION

Replication studies using computer-assisted instruction interventions are needed as are studies aimed at exploring other potentially effective interventions.

Universal precautions: costs for protective equipment

BACKGROUND

The amount and costs of protective equipment used to implement universal precautions in Thailand have not previously been studied.

METHODS

A cross-sectional study was done to determine the frequency of clinical and laboratory procedures requiring universal precautions and the amount of protective equipment needed for each.

RESULTS

The study was performed in 24 government hospitals in Thailand in December 1993. Totaling 6549 beds, these hospitals had provided service to 357,391 inpatients and 3,411,122 outpatients during the previous year. The annual number of procedures performed in these hospitals was estimated at 17.5 million, with expenditures for protective equipment of $2.4 million (U.S.) per year. The average overall cost for protective equipment was U.S. $5.37 for one inpatient stay and U.S. $0.15 for one outpatient visit. The projected national expense for these barriers was U.S. $41.5 million per annum. The cost for these barriers after the implementation of universal precautions was 2.5 times the cost before implementation.

CONCLUSIONS

Overuse of sterile and examination gloves and gowns and underuse of heavy-duty gloves, masks, aprons, goggles, and boots were discovered during the study. Appropriate use of disposable and reusable universal precautions equipment would free health care dollars for other purposes.

Compliance with universal precautions among physicians

This study characterized and assessed self-reported levels of compliance with universal precautions (UP) among hospital-based physicians, and determined significant factors associated with both compliance and noncompliance. The physicians (n = 322) were a subgroup of a larger study population of hospital-based health care workers recruited from three geographically distinct locations (n = 1746), and were surveyed using a detailed confidential questionnaire that assessed personal, work-related, and organizational factors. Compliance with UP was measured through 11 items that examined how often physicians followed specific recommended work practices. Compliance was found to vary among the 11 items: they were high for certain activities (eg, glove use, 94%; disposal of sharps, 92%) and low for others (eg, wearing protective clothing, 55%; not recapping needles, 56%). Compliance with all items was low (31% to 38%). Stepwise logistic regression revealed that noncompliant physicians were likely to be age 37 or older, to report high work stress, and to perceive a conflict of interest between providing patient care and protecting themselves. Compliant physicians were more likely to be knowledgeable and to have been trained in universal precautions, to perceive protective measures as being effective, and to perceive an organizational commitment to safety.

The routine wearing of gloves: impact on the frequency of needlestick and percutaneous injury and on surface contamination in the operating room

The impact of wearing gloves on surface contamination and on the incidence of percutaneous injury were prospectively compared for two 4-mo periods in a single anesthesia department. Period I was immediately prior to the institution of mandatory glove wearing, and Period II followed a 1-mo adjustment period of mandatory glove use. Recording of all needlestick and other percutaneous injuries was performed on an ongoing basis, and incident reporting was actively and regularly solicited. During the final week of each period, 12 specific sites at each of nine anesthetizing locations were tested for occult blood. The incidence of needlestick injury was 0.28% for Period I versus 0.10% for Period II (P = 0.10) and the incidence for all percutaneous injuries was 0.60% for Period I and 0.27% for Period II (P = 0.06). If the one needlestick that occurred during noncompliance with gloving during Period II is eliminated, then there was a significant reduction in both needlestick and overall percutaneous injury (P < 0.05). Of 109 operating room sites, 42.2% were contaminated after Period I versus 31.2% after Period II (P = 0.07). The implementation of a mandatory glove use policy was associated with nonsignificant trends toward reduction in the incidence of needlestick and other percutaneous injury and in the level of surface contamination in the anesthesia workplace. Compliance with glove use resulted in a significant reduction in needlestick injury and overall percutaneous injuries.

Effect of intravascular surveillance and education program on rates of nosocomial bloodstream infections

BACKGROUND

Because of high proportions of central line-related bloodstream infections (BSIs), an intravascular surveillance and education program (IVSP) was instituted in the study institution in 1987.

METHODS

A 6 1/2-year historical prospective study was conducted to evaluate the effects of the IVSP on incidence of nosocomial BSIs. With use of Centers for Disease Control and Prevention criteria, concurrent data on nosocomial BSIs were collected by two infection control professionals before, during, and for 3 years after the IVSP.

RESULTS

Hospital-wide BSIs during the 3-year IVSP and for 3 years after were 0.9% and 0.9% (p = 0.58) or 1.4 and 1.2/1000 patient-days (p = 0.24). Central line-related BSIs represented 29%, 24%, and 29% of the total BSIs 6 months before, 3 years during, and 6 months after the intervention, respectively (p = 0.62).

CONCLUSIONS

The IVSP resulted neither in a reduction in the total intravascular catheter-related BSIs nor in a change in the proportion of potentially preventable central line-related BSIs. To be successful, an intervention must include the authority to mandate practice changes; education and feedback without such authority were inadequate.

Risk taking by health care workers

HEALTH CARE WORKERS (HCWs) are at risk for acquiring infections such as human immunodeficiency virus, hepatitis B virus, hepatitis C, and tuberculosis from blood and body fluids. The Centers for Disease Control established guidelines known as universal precautions (UPs) to prevent transmission of blood-borne pathogens in hospital settings, but UPs are not universally followed. CNSs are in a unique position to enhance the practice of UPs and decrease the HCW's risk-taking behavior. CNSs need to identify risk-taking behaviors and help HCWs make the right decision in risky situations. Reasons cited for noncompliance with UPs were habit, forgetfulness, influence of the nurse manager, and perceptions that barrier precautions hinder the ability to perform procedures successfully. Suggestions for improving compliance with UPs were better enforcement of guidelines, a policy mandating compliance, easy and available access to supplies, replacement of hazardous devices with safer ones, and discussion with HCWs on decision making in risky situations. CNSs possess the credibility in the clinical arena to effect change through clinical expertise, role modeling, and collaboration with HCWs.

Prevention of blood exposure. Body and facial protection

Regardless of the specific clinical setting in the operating room, it is clear that better protection of all personnel is an appropriate objective in the current environment. Better protection through improved PPE and modification of operational practices is essential. A prompt response to blood contact when it does occur is likewise appropriate. With conscientious applications of methods to reduce blood exposure, it is hoped that the operating room can become a safer place with respect to occupational infections from bloodborne pathogens.

G. Adesão às precauções universais: uma análise do comportamento de equipe de enfermagem

A possibilidade de aquisição do vírus de imunodeficiência humana (HIV) por profissionais de saúde tornou mais preocupante a questão dos riscos ocupacionais. As precauções universais (PU) surgiram como tentativa de aumentar a segurança do profissional de saúde. No entanto, existe certa resistência por parte dos profissionais de saúde em adotar as medidas de proteção. Os objetivos deste estudo são: 1. obter um indicador da adesão da equipe de enfermagem de um hospital geral de São Paulo às precauções universais, 2. identificar a percepção dos riscos e os conhecimentos que os profissionais possuem sobre as PU; e 3. apresentar e discutir hipóteses explicativas do comportamento de não-adesão.

Compliance with universal precautions among health care workers at three regional hospitals

OBJECTIVE

To assess and characterize self-reported levels of compliance with universal precautions among hospital-based health care workers and to determine correlates of compliance.

DESIGN

Confidential questionnaire survey of 1716 hospital-based health care workers.

PARTICIPANTS

Participants were recruited from three geographically distinct hospitals. A stratified convenience sample of physicians, nurses, technicians, and phlebotomists working in emergency, surgery, critical care, and laboratory departments was selected from employment lists to receive the survey instrument. All participants had direct contact with either patients or patient specimens.

RESULTS

For this study, overall compliance was defined as "always" or "often" adhering to the desired protective behavior. Eleven different items composed the overall compliance scale. Compliance rates varied among the 11 items, from extremely high for certain activities (e.g., glove use, 97%; disposal of sharps, 95%) to low for others (e.g., wearing protective outer clothing, 62%; wearing eye protection, 63%). Compliance was strongly correlated with several key factors: (1) perceived organizational commitment to safety, (2) perceived conflict of interest between workers' need to protect themselves and their need to provide medical care to patients; (3) risk-taking personality; (4) perception of risk; (5) knowledge regarding routes of HIV transmission; and (6) training in universal precautions. Compliance rates were associated with some demographic characteristics: female workers had higher overall compliance scores than did male workers (25% of female and 19% of male respondents circled "always" or "often" on each of the 11 items, p < 0.05); and overall compliance scores were highest for nurses, intermediate for technicians, and lowest for physicians. Overall compliance scores were higher for the mid-Atlantic respondents (28%) than for those from the Southwest (20%) or Midwest (20%, p = 0.001).

CONCLUSIONS

This study supports earlier findings regarding several compliance correlates (perception of risk, knowledge of universal precautions), but it also identifies important new variables, such as the organizational safety climate and perceived conflict of interest. Several modifiable variables were identified, and intervention programs that address as many of these factors as possible will probably succeed in facilitating employee compliance.

Compliance with handwashing and barrier precautions

Compliance with handwashing and barrier precautions remains suboptimal in all health care settings and among all types of staff. Interventions to increase compliance include educational and motivational programmes, providing individual and group feedback on performance, modifying and improving equipment available, changing administrative policy and sanctions, and increasing staff commitment with role modelling. Single, isolated interventions are unlikely to meet with sustained success. A theory-based, multifaceted approach is indicated.

Barrier precautions in trauma resuscitations: multivaried analysis of factors affecting use

STUDY OBJECTIVES

To determine the relative importance of factors affecting use of barrier precautions by trauma team members.

DESIGN

Prospective, nonblinded review of barrier precaution use by trauma team members over three periods. A multivaried analysis of factors affecting use then was conducted.

SETTING

A 615-bed Level I trauma center in New York State with an accredited surgical residency program.

TYPE OF PARTICIPANTS

Trauma team members involved in resuscitating multitrauma patients in the trauma room.

INTERVENTIONS

Period 1: June to August 1991, barrier precaution use before interventions; period 2: September 1991 to January 1992, educational seminars held and material access improved by designated cart; period 3: February to June 1992, legislation mandating barrier precaution use introduced.

MAIN RESULTS

Barrier precaution compliance improved significantly in periods 2 and 3. The improvement was seen in all providers studied. Improvement in barrier precaution use correlated significantly with education, materials access, and legislation.

CONCLUSION

Improved compliance with barrier precaution use can be affected by education, improving materials access, and legislation. The relative importance of education versus materials access requires further study.

Use of universal precautions in interventional radiology: results of a national survey

OBJECTIVE

To determine current use of universal precautions by practicing interventional radiologists in the United States.

METHODS

National survey mailed to interventional radiologists, conducted anonymously in November 1991. Of 1530 survey forms mailed to practicing interventional radiologists, 817 (53%) were returned and 804 (52%) were completed and evaluable. Both academic and private practice settings were represented.

RESULTS

Eighty-five percent of respondents had changed their use of infection control measures in the previous 10 years. Of these, 96% cited personal concerns about AIDS as a reason for making changes. Sixty-two percent made changes in response to Centers for Disease Control and Prevention and Occupational Safety and Health Administration recommendations as well. Use of barrier precautions was quite variable. Although 86% of respondents always wore a sterile gown during procedures, only 32% routinely wore a face mask or shield and only 29% of those who did not wear corrective glasses routinely wore protective eye gear during procedures. Seven percent of respondents routinely double gloved for procedures. Twenty percent of reported percutaneous injuries occurred during recapping of used sharps; an additional 6% were related to improper disposal of used sharps.

CONCLUSIONS

We conclude that use of universal precautions by interventional radiologists in the United States is variable. Some practices that may lead to preventable injury to health care workers remain common.

Adverse exposures and use of universal precautions among perinatal nurses

OBJECTIVE

To identify the level of protective barrier use by perinatal nurses, the numbers of exposures experienced, and the factors influencing barrier use.

DESIGN

Descriptive correlational study.

PARTICIPANTS

A random sample of 560 perinatal nurses practicing in Arizona were sent questionnaires; 306 nurses responded.

MAIN OUTCOME MEASURES

The nurses indicated frequency of barrier use, on a Likert-type scale, for 15 common obstetric procedures involving risk for blood or body fluid exposure. The nurses also reported number of exposures and barrier failures experienced in the preceding year. Two other scales were used to identify factors influencing barrier use and nonuse.

RESULTS

A low frequency of barrier use and a high frequency of exposures were reported. A relationship was found between barrier use and exposures (r = -.29, p < .0001): As barrier use increased, exposures to body fluids decreased somewhat. Suspicion that a patient was a member of a high-risk group (e.g., an intravenous drug user) was a strong motivator for barrier use. Poorly fitting gloves and the need for quick action were strong influences for barrier nonuse.

CONCLUSIONS

Perinatal nurses were inadequately protected from bloodborne disease.

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).