Temporal association between implementation of universal precautions and a sustained, progressive decrease in percutaneous exposures to blood

Prevention from Sharp Injuries in the Hospital Sector: An Italian National Observatory on the Implementation of the Council Directive 2010/32/EU before and during the COVID-19 Pandemic

Sharp injuries, determining the risk of bloodborne infections and psychological distress in healthcare workers, may be prevented by a set of strategies, legally enforced in Europe through the Directive 2010/32/EU. To assess its level of implementation in Italy, a national survey was conducted in 2017 and again in 2021, evaluating the progress and possible drawbacks of the COVID-19 pandemic. Altogether, 285 safety managers and 330 nurses from a representative sample of 97 and 117 public hospitals were interviewed using a standardized questionnaire. Knowledge of the Directive requirements decreased significantly, with <60% of participants answering correctly in 2021, and nurses' attendance in specific courses dropped to 25% in 2021 compared to 54% in 2017. Over 75% of hospitals introduced multiple safety-engineered devices (SED), though total replacement occurred in <50% of cases; routine SED availability increased for blood collection (89%) and venous access devices (83%). Incorrect behaviors in handling sharps decreased significantly over time. Nurses' HBV vaccination coverage was high (89% in both surveys); in the last year, 97% were vaccinated against COVID, and 47% against influenza. Average annual injuries per hospital did not increase significantly (32 in 2021 vs. 26 in 2017). In 2017, nurses' perceived safety barriers were working in emergency situations (49%) and lack of resources (40%); in 2021, understaffing (73%), physical fatigue (62%), and handling difficulties while wearing full protective equipment (59%). Safety measures were implemented in Italian hospitals, and although the average injuries per hospital did not show a decrease, these measures could have helped protect healthcare workers during the pandemic, mitigating its potential impact on the increase in situations at risk of injury.

To Study the Awareness about Universal Health Precautions among Nursing Professionals in a Medical College Hospital of India

BACKGROUND

The universal health-care precautions (UHP) aim at preventing health-care workers contact with blood and other body fluids by performing various infection control practices such as handwashing, wearing gloves and mask, safe disposal of infectious waste, and safe cleansing of used instruments.

OBJECTIVE

The study was conducted to assess the knowledge and awareness among nursing professionals regarding UHPs.

METHODOLOGY

It was a cross-sectional study done on nursing professionals across all seniority and from various specialties including superspecialties. A pretested questionnaire consisting of 25 questions was used as a study tool.

RESULTS

There were a total of 550 respondents. The mean knowledge score of the respondents was 17.31 (range: 6-24). The mean score was 69.25% of the total achievable score. In the subgroup analysis, respondents above 60 years of age, married, females, urban residents, and nursing sisters scored better than the middle-aged professionals, unmarried, males, rural residents, and staff nurses.

CONCLUSION

The study concludes important clues for further research and interventions. As the nursing professionals are learning about UHP from practical exposure rather than formal teaching, it is pertinent to address this issue through well-planned formal sessions of training workshops and lecture discussions.

Infection prevention and control: Who is the judge, you or the guidelines?

OBJECTIVES

The aim of this study was to explore the attitudes and behaviours of registered nurses and their colleagues around the adoption of standard precautions in order to determine strategies to promote adherence.

DESIGN

A qualitative exploratory descriptive design used interviews and focus group to collect data.

SETTING

Registered nurses and registered midwifes from a tertiary metropolitan hospital took part in the study.

PARTICIPANTS

A voluntary sample of 29 adults was recruited from the Australian nursing (n = 25) and midwifery (n = 4) workforce. There were six men (mean age = 36.83 years; SD = 8.93) and 23 women (mean age = 41.36 years; SD = 10.25). Participants were recruited through advertisement on notice boards and emails from unit managers.

RESULTS

Thematic analysis revealed five themes but the focus here is on staff judgements which are against the guidelines. Participants indicated that where in their judgement the patient posed no risk and they judged themselves skilled in the procedure, they were justified in deviating from the guidelines. Some staff judgements appeared to be self-protecting, while others were irrational and inconsistent.

CONCLUSIONS

Despite use of standard precautions being mandated, staff often deviated from them based on their own assessment of the situation or the patient. Any deviance from the guidelines is of concern but especially so when staff take it upon themselves to apply their own criteria or judgements. These results also suggest there may be some organisational inadequacies with regards to training and supervision of staff.

Measuring HIV-related stigma among healthcare providers: a systematic review

In the United States, HIV-related stigma in the healthcare setting is known to affect the utilization of prevention and treatment services. Multiple HIV/AIDS stigma scales have been developed to assess the attitudes and behaviors of the general population in the U.S. towards people living with HIV/AIDS, but fewer scales have been developed to assess HIV-related stigma among healthcare providers. This systematic review aimed to identify and evaluate the measurement tools used to assess HIV stigma among healthcare providers in the U.S. The five studies selected quantitatively assessed the perceived HIV stigma among healthcare providers from the patient or provider perspective, included HIV stigma as a primary outcome, and were conducted in the U.S. These five studies used adapted forms of four HIV stigma scales. No standardized measure was identified. Assessment of HIV stigma among providers is valuable to better understand how this phenomenon may impact health outcomes and to inform interventions aiming to improve healthcare delivery and utilization.

Addressing HIV stigma in protected medical settings

Previous studies suggest that the implementation of universal precaution (UP) plays a role in reducing HIV stigma. In this study we investigate the efficacy of a stigma reduction intervention on UP compliance and explore whether UP compliance could potentially influence HIV stigma reduction in medical settings. A randomized controlled intervention trial was conducted in two provinces of China with 1760 healthcare service providers recruited from 40 county-level hospitals. Longitudinal analyses included data collection at baseline, 6-, and 12-month follow-up assessments. Using a hierarchical modeling approach, we estimated the intervention effect for each provider's UP compliance and its potential mediating role on HIV stigma with the bootstrapping method. A significant intervention effect on UP compliance was observed at both the 6- and 12-month follow-up assessments. The intervention effect on provider avoidance intent was partially mediated by the provider's own UP compliance at the two follow-up points. This study provides evidence that UP compliance should be part of HIV stigma reduction programs, especially in resource-restrained countries. Findings suggest that a protected work environment may be necessary but not sufficient to address HIV stigma in medical settings.

Prevention of needle-stick injuries in healthcare facilities: a meta-analysis

OBJECTIVE To estimate the summary effectiveness of different needle-stick injury (NSI)-prevention interventions. DESIGN We conducted a meta-analysis of English-language articles evaluating methods for reducing needle stick, sharp, or percutaneous injuries published from 2002 to 2012 identified using PubMed and Medline EBSCO databases. Data were extracted using a standardized instrument. Random effects models were used to estimate the summary effectiveness of 3 interventions: training alone, safety-engineered devices (SEDs) alone, and the combination of training and SEDs. SETTING Healthcare facilities, mainly hospitals PARTICIPANTS Healthcare workers including physicians, midwives, and nurses RESULTS From an initial pool of 250 potentially relevant studies, 17 studies met our inclusion criteria. Six eligible studies evaluated the effectiveness of training interventions, and the summary effect of the training intervention was 0.66 (95% CI, 0.50-0.89). The summary effect across the 5 studies that assessed the efficacy of SEDs was 0.51 (95% CI, 0.40-0.64). A total of 8 studies evaluated the effectiveness of training plus SEDs, with a summary effect of 0.38 (95% CI, 0.28-0.50). CONCLUSION Training combined with SEDs can substantially reduce the risk of NSIs.

Factors Promoting Consistent Adherence to Safe Needle Precautions Among Hospital Workers

Objective:

To examine organizational factors and occupational characteristics associated with adherence to occupational safety guidelines recommending never recapping needles.

Design:

Mail surveys were conducted with healthcare workers (HCWs) and infection control professionals (ICPs).

Setting:

The surveys were conducted at all non-federal general hospitals in Iowa, except one tertiary-care hospital. Survey data were linked to annual survey data of the American Hospital Association (AHA).

Participants:

HCWs were sampled from statewide rosters of physicians, nurses, and laboratory workers in Iowa. Eligible HCWs worked in a setting and position in which they were likely to routinely handle needles. ICPs at all hospitals in the state were surveyed.

Results:

Ninety-nine ICPs responded (79% response rate). AHA data were available for all variables from 84 (85%) of the hospitals. Analyses were based on 1,454 HCWs who identified one of these hospitals as their primary hospital (70% response rate). Analyses were conducted using multiple logistic regression. Positive predictors of consistent adherence included infection control personnel hours per full-time–equivalent employee (odds ratio [OR], 1.03), frequency of standard precautions education (OR, 1.11), facilities providing personal protective equipment (OR, 1.82), facilities using needleless intravenous systems (OR, 1.42), and management support for safety (OR, 1.05). Negative predictors were use of “blood and body fluid precautions” isolation category (OR, 0.74) and increased job demands (OR, 0.90).

Conclusion:

Healthcare organizations can improve staff safety by investing wisely in educational programs regarding approaches to minimize these risks, providing protective equipment, and eliminating the use of blood and body fluid precautions as an isolation policy.

Occupational Exposures and the Prevalence of Blood-Borne Pathogens in a Deployed Setting Data from a US Military Trauma Center in Afghanistan

Objective.

Occupational exposures to blood and other bodily fluids occur in approximately 5 per 100 persons every year in US hospitals. Since the provision of health care in the deployed environment poses unique challenges to hospital personnel, it is important to characterize the rates of occupational exposures and understand the prevalence of blood-borne pathogens (BBPs) in host nations.

Methods.

A retrospective review of public health and laboratory records at a US military trauma center in Afghanistan from October 1, 2010, to March 31, 2012.

Results.

A total of 65 occupational exposures were reported, including 47 (72%) percutaneous and 18 (28%) mucocutaneous, with a yearly rate of 8.6 exposures per 100 persons. During 6-month deployment cycles, the majority of exposures (46.2%) occurred in the first 2 months after arrival in Afghanistan. Physicians reported the most exposures (26%), and the operating room (48%) was the most common hospital location. The prevalence of hepatitis B and hepatitis C among local national source patients (n= 59 ) was 8.9% and 2.3%, respectively, with no cases of HIV or syphilis detected. In contrast, there were no BBPs detected in coalition source (n= 12) or exposed (n = 57) patients.

Conclusions.

The characteristics of occupational exposures in this deployed environment were comparable to those of US-based hospitals. Standard practices used to reduce occupational exposures, such as use of personal protective equipment and safety devices, should continue to be prioritized in the deployed setting. Although BBP rates are not well defined in Afghanistan, our results were consistent with those of prior epidemiologic studies.

HIV-related avoidance and universal precaution in medical settings: opportunities to intervene

OBJECTIVE

To determine the association between adherence to universal precaution (UP) and avoidance attitudes toward patients living with HIV/AIDS (PLH) among service providers.

DATA SOURCES/SETTING

A total of 1,760 health service providers were randomly selected from 40 county hospitals in two provinces of China.

STUDY DESIGN

A self-administered questionnaire was used to collect demographic characteristics, UP knowledge and training, UP adherence, availability of UP supplies at work, and avoidance attitudes toward PLH in a cross-sectional survey.

DATA ANALYSIS

A series of regression models were used to examine associations among the UP-related factors and their relationship to avoidance attitudes toward PLH.

PRINCIPAL FINDINGS

UP training was associated with better knowledge of and adherence to UP and perceived availability of UP supplies in hospitals. UP training, knowledge, and adherence were significantly associated with avoidance attitudes toward PLH in medical practice. Being a nurse was also related to HIV-related avoidance.

CONCLUSION

UP promotion campaigns, including in-service training and reinforcement of UP adherence, could play an important role in the battle against HIV-related avoidance in medical settings. Intervention programs should focus on not only individual providers' attitudes and behaviors but also on structural support for norms shifts in the medical community.

Opportunists and Opportunities: The 2010 SHEA Lecture

My experience as a hospital epidemiologist at the National Institutes of Health Clinical Center has underscored the importance of aggressively managing infection with opportunistic pathogens and of taking advantage of opportunities as they arise (most often as crises). I review selected aspects of my career and use these as examples of the opportunists and opportunities now facing healthcare epidemiology.

Infection control guidelines for prevention of health care-associated transmission of hepatitis B and C viruses

Viral hepatitis was first identified as an occupational hazard for health care workers more than 60 years ago. For the past few decades, hepatitis B has been one of the most significant occupational infectious risks for health care providers. With the increasing prevalence of hepatitis C infections around the world, occupational transmission of this flavivirus from infected patients to their providers has also become a significant concern. Several factors influence the risk for occupational blood-borne hepatitis infection among health care providers, among them: the prevalence of infection among the population served, the infection status of the patients to whom workers are exposed (ie, the source patient's circulating viral burden), the types and frequencies of parenteral and mucosal exposures to blood and blood-containing body fluids, and whether the patient or provider has been immunized with the hepatitis B vaccine. This article reviews patient-to-provider, patient-to-patient, and provider-to-patient transmission of hepatitis B and C in the health care setting. Current prevention strategies, precautions, and guidelines are discussed.

Universal precautions in the era of HIV/AIDS: perception of health service providers in Yunnan, China

With a rising HIV/AIDS epidemic, it has become especially important for health service providers in China to understand and correctly adhere to universal precautions. Using qualitative interview data, perspectives from both health administrators and service providers working at all levels of China's health care system were examined. Service providers admitted selective adherence and non-adherence to universal precautions in their daily medical practice, and gave their explanations for such behaviors. Lack of time to put on protective gear, gear's interference with medical procedures, lack of administrative support, heavy workload in hospitals, inaccurate risk assessment, and beliefs that compliance with universal precautions is unnecessary, time consuming and costly were mentioned as reasons behind noncompliance. Effective universal precaution interventions need to target both administrators and providers, and address both structural barriers and individual attitudinal and behavioral factors.

Universal precaution compliance by orthopaedic trauma team members in a major trauma resuscitation scenario

INTRODUCTION

We determined the compliance rates of orthopaedic trauma team members in applying universal precautions in major trauma resuscitation scenarios and the availability of universal precautions in accident and emergency (A&E) departments throughout England.

MATERIALS AND METHODS

A national telephone survey was implemented contacting the first on-call orthopaedic surgeon and A&E departments in hospital trusts accepting major trauma throughout England. A questionnaire was employed to ascertain current practice, experience and availability of universal precautions when managing a major trauma patient.

RESULTS

Overall, 112 first on-call orthopaedic surgeons and 99 A&E departments responded. There was good compliance for using gloves (99%) and aprons (86%). There was poor compliance in using eye protectors (21%), face masks (18%), shoe covers (4%) and head caps (4%). Trainees applied universal precautions according to the level of risk they subjectively perceived. All A&E departments had gloves and aprons but the availability of the other universal precautions was less. Of trainees, 76 reported that all universal precautions were not readily available in the A&E department.

CONCLUSION

Orthopaedic trauma team members are very compliant in using gloves and aprons, but should be more compliant in using eye protectors. It is questionable whether face masks, head caps and shoe covers need to be used in all trauma scenarios. In general, universal precautions should be more available in the A&E departments. There should be better communication between A&E departments and the trauma team regarding the availability of universal precautions.

Role of safety-engineered devices in preventing needlestick injuries in 32 French hospitals

OBJECTIVES

To evaluate safety-engineered devices (SEDs) with respect to their effectiveness in preventing needlestick injuries (NSIs) in healthcare settings and their importance among other preventive measures.

DESIGN

Multicenter prospective survey with a 1-year follow-up period during which all incident NSIs and their circumstances were reported. Data were prospectively collected during a 12-month period from April 1999 through March 2000. The procedures for which the risk of NSI was high were also reported 1 week per quarter to estimate procedure-specific NSI rates. Device types were documented. Because SEDs were not in use when a similar survey was conducted in 1990, their impact was also evaluated by comparing findings from the recent and previous surveys.

SETTING

A total of 102 medical units from 32 hospitals in France.

PARTICIPANTS

A total of 1,506 nurses in medical or intensive care units.

RESULTS

A total of 110 NSIs occurring during at-risk procedures performed by nurses were documented. According to data from the 2000 survey, use of SEDs during phlebotomy procedures was associated with a 74% lower risk (P<.01). The mean NSI rate for all relevant nursing procedures was estimated to be 4.72 cases per 100,000 procedures, for a 75% decrease since 1990 (P<.01); however, the decrease in NSI rates varied considerably according to procedure type. Between 1990 and 2000, decreases in the NSI rates for each procedure were strongly correlated with increases in the frequency of SED use (r=0.88; P<.02).

CONCLUSION

In this French hospital network, the use of SEDs was associated with a significantly lower NSI rate and was probably the most important preventive factor.

Variation in blood and body fluids exposure when small-gauge needles or peripheral venous catheters were implicated: results of a 4-year surveillance in France

The blood and body fluids exposure (BBFE) risk for health care workers varies according to numerous factors. Based on a needlestick surveillance in 13 French hospitals from 1997 to 2000, we evaluated incidence and temporal trends of BBFE according to medical devices causing needlestick injuries. We observed that the BBFE incidence per 100,000 peripheral venous catheters purchased decreased from 12.9 to 4.9, whereas incidence per 100,000 subcutaneous needles purchased increased from 8.7 to 14.3.

Women's Occupational Dermatologic Issues

With almost 65 million women in the workforce, their representation in various occupational sectors is crucial, as is their health and safety. Female-dominated occupations in health care and cosmetology along with their potential cutaneous exposures are reviewed. Proper evaluation and management are necessary to minimize the disability that can result from these illnesses.

Short-term economic impact associated with occupational needlestick injuries among acute care nurses

PURPOSE

Recent survey data have reported the incidence rate of needlestick injuries (NIs) and NIs which draw blood sustained by nurses caring for patients with diabetes in an in-patient hospital setting. The purpose of this study was to deduce the potential short-term annual economic impact resulting from such NI, and to project the potential national economic burden of NI among this population of health care workers (HCWs).

METHODS

Data were obtained from a recently published, IRB-approved, Internet-based survey in which nurses routinely treating patients with diabetes self-reported outcomes of their experience with NI (N = 400). A micro-costing approach was adopted. Direct costs comprised post-exposure testing (PET) for infection, post-exposure health care services utilization, and NI-induced post-exposure prophylactic (PEP) drug utilization. Indirect costs were derived from missed workdays and associated lost productivity. These data were combined with data related to the national epidemiology and total incidence of NIs among HCWs and risk-associated populations to project the national burden.

RESULTS

Among 400 nurses, 110 sustained at least one NI in the past year, with 73 punctures drawing blood. The ensuing total short-term costs of these NIs were calculated to range from 25,896 US dollars to 36,066 US dollars. Indirect costs accounted for 44-62% of this total cost. Average short-term costs per NI ranged from 145 to 201 US dollars, and average short-term costs of NI per injured nurse ranged from 235 to 328 US dollars. Assuming mean values from published literature on the incidence and distribution of NI among nursing populations, an annual national burden of 65 million US dollars was calculated for costs in the immediate period following NI.

CONCLUSIONS

These data suggest substantial economic burden immediately following NI on a national and individual hospital level occurring among acute-care nurses treating patients with diabetes. Long-term treatment costs would add to the overall economic burden.

Rights and duties of HIV infected health care professionals

In 1991, the CDC recommended that health care workers (HCWs) infected with HIV or HBV (HbeAg positive) should be reviewed by an expert panel and should inform patients of their serologic status before engaging in exposure-prone procedures. The CDC, in light of the existing scientific uncertainty about the risk of transmission, issued cautious recommendations. However, considerable evidence has emerged since 1991 suggesting that we should reform national policy. The data demonstrates that risks of transmission of infection in the health care setting are exceedingly low. Current policy, moreover, does not improve patient safety. At the same time, implementation of current national policy at the local level poses significant human rights burdens on HCWs. Consequently, national policy should be changed to ensure patient safety while protecting the human rights of HCWs. This article proposes a new national policy, including: (1) a program to prevent bloodborne pathogen transmission; (2) a responsibility placed on infected HCWs to promote their own health and well-being and to assure patient safety; (3) a discontinuation of expert review panels and special restrictions for exposure-prone procedures; (4) a discontinuation of mandatory disclosure of a HCW's inflection status; and (5) the imposition of practice restrictions if a HCW is unable to practice safely because of a physical or mental impairment or failure to follow careful infection control techniques. A new national policy, focused on management of the workplace environment and injury prevention, would achieve high levels of patient safety without discrimination and invasion of privacy.

[Work-related accidents, with biological materials, in health care workers in public hospitals in Brasilia, Brazil, 2002/2003]

This study evaluates the knowledge and acceptance of biosafety measures by health care professionals in light of the potential risk of occupational transmission of HIV. The survey assessed 570 health care workers from 6 hospitals, randomly selected from all hospitals in the Federal District (Brasilia), Brazil. The sample corresponds to 15.0% of the all health professionals in the selected hospitals. These professionals answered a semi-structured questionnaire on knowledge of biosafety and universal precautions, risk of occupational HIV transmission, work-related accidents, use of personal protective equipment (PPE), and acceptance of chemoprophylaxis and HIV testing. The overall accident coefficient was 39.1. Dentists, physicians, and laboratory technicians were those who most frequently suffered such accidents. The accident coefficient was inversely proportional to the hospital capacity. The professionals' knowledge of biosafety concepts and the fact that written norms were displayed in their workstations did not positively affect the work accident coefficient.

Needlestick injury in acute care nurses caring for patients with diabetes mellitus: a retrospective study

OBJECTIVE

To quantify the incidence and assess the risk of needlestick injury (NI) in nurses caring for patients with diabetes mellitus.

METHODS

A total of 400 nurses caring for patients with diabetes in 381 different hospitals throughout the United States over a period of at least 1 year voluntarily completed an Internet-based data collection instrument. The nurses self-reported comprehensive data on their experience with NI, focusing on those occurring within the past year. If respondents experienced multiple NI during this period, detailed data were collected on the most recent event.

RESULTS

Of the 400 nurses, 313 (78.3%) reported experiencing at least one NI, 110 (27.5%) reported at least one NI within the last 12 months, and 44 (40% of 110) reported multiple NI. Nearly two-thirds of these injuries (n = 73/110; 66.4%) were punctures that drew blood, resulting in one case of contracted hepatitis C. The cumulative annual incidence of NI events was 448 NI per 1000 nurses. Nurses reported the injury in adherence with existing regulations and policies in only 21.8% of the cases. Disposable syringes were involved in 88 (80%) of the NI events. In half of the injuries (n = 55), the needled device was equipped with a safety feature that was ineffective, primarily because it was not fully activated (n = 47/55; 85.5%) or it malfunctioned (n = 2-5; 3.6-9.1%). NI most commonly occurred while nurses were injecting insulin (n = 33; 30%). In the 2 weeks following their NI, 60.1% of nurses noted that they were more afraid of needled devices than before the injury and 41.8% felt anxious, depressed, or stressed. As a direct result of the NI, nurses missed 77 days of work.

CONCLUSIONS

This study is the first to show the relatively high risk both of NI and of NI that draws blood among nurses injecting insulin with a disposable syringe and confirms previous incidence estimates of NI among nurses. Additionally, this study reveals significant post-NI emotional distress, suggests significant under-reporting of NI to hospital officials, and demonstrates the need for a more effective needle safety device.

Postexposure chemoprophylaxis for occupational exposure to human immunodeficiency virus in traveling health care workers

BACKGROUND

There has been little research on the use of human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) for occupational exposure in traveling health care workers (HCWs). Although PEP is the standard of care for occupational exposure to HIV in the United States, in third-world countries such medications are often unavailable and risks to the HCW may be higher. The aims of this study were to assess the incidence and types of blood and body fluid exposure and subsequent use of PEP in traveling HCWs seen at a large travel clinic prior to travel.

METHODS

To determine the utility of PEP, we retrospectively evaluated all HCWs presenting for counseling prior to travel for health care delivery. All employees who were seen at the Mayo Travel and Tropical Medicine Clinic from 1999 until July 2002 were included. Analysis was conducted via a chart review as well as an approved questionnaire mailed to all employees still at the Mayo Clinic.

RESULTS

Eighty-six HCWs were included in the analysis, and 58 responded to the questionnaire. Of the 86 HCWs reviewed, 55 (64%) were determined to be at high risk for occupational exposure to HIV. Seventy-eight percent of the high-risk HCWs were documented to have been counseled about needlestick avoidance, and 55% brought PEP with them. In the 58 HCWs who returned the questionnaire, there were no reported deep needlesticks. One of the 39 high-risk HCWs who returned the questionnaire (2.6%) had a superficial needle exposure, but the source patient had pretested negative for HIV and therefore the HCW did not use PEP. Nine of the 39 (23%) had a blood splash onto intact skin, and one of these involved a large volume. This source patient also had pretested negative for HIV. None of the HCWs exposed to blood splash took PEP. Two HCWs (5.1%) at high risk had an exposure that would have required PEP if the source patient had not been pretested.

CONCLUSIONS

Needlestick exposure and HIV PEP counseling is important for HCWs traveling for health care delivery. Exposure risks appear low but high enough to warrant supplying high-risk HCWs with PEP. HCWs are able to use the recommendations appropriately. Pretesting of surgical patients decreases the likelihood of starting PEP. Carrying a common supply of PEP for a larger group can decrease the cost of PEP.

Blood and body fluid exposure risks among health care workers: results from the Duke Health and Safety Surveillance System

BACKGROUND

Health care workers (HCWs) are at risk of exposures to human blood and body fluids (BBF). Needlestick injuries and splashes place HCWs at risk for numerous blood-borne infections including human immunodeficiency virus (HIV), hepatitis B (HBV), and hepatitis C (HCV). Utilizing a new comprehensive occupational health surveillance system, the objective of this research was to better define the BBF exposure risk and risk factors among employees of a large tertiary medical center.

METHODS

A population of 24,425 HCWs employed in jobs with potential BBF exposures was followed for BBF exposure events from 1998 to 2002. BBF exposure rates were calculated for strata defined by age, race, gender, occupation, work location, and duration of employment. Poisson regression was used for detailed analyses of risk factors for BBF exposure.

RESULTS

The study population reported 2,730 BBF exposures during the study period, resulting in an overall annual rate of 5.5 events/100 FTEs and a rate of 3.9 for percutaneous exposures. Higher rates were observed for males, persons employed less than 4 years, Hispanic employees, and persons less than 45 years of age. Much higher rates were observed for house staff, nurse anesthetists, inpatient nurses, phlebotomists, and surgical/operating room technicians. Poisson regression results strengthened and extended results from stratified analyses. Rates of percutaneous exposures from hollow needles were found to decrease over the study period; however, exposure rates from suture needles appear to be increasing.

CONCLUSION

While continued training efforts need to be directed toward new HCWs, our data also suggest that employees who have been in their job 1-4 years continue to be at higher risk of BBF exposures. This research also points to the need for better safety devices/products and work practices to reduce suture-related injuries.

Critical incidents of nonadherence with standard precautions guidelines among community hospital-based health care workers

OBJECTIVE

To identify, categorize, and assess critical incidents of nonadherence to standard precautions.

DESIGN

Qualitative and quantitative analysis of a written, mail-out survey.

SETTING

Community hospitals.

PARTICIPANTS

Statewide stratified random sample of community hospital-based health care workers at risk for blood exposure. MAIN VARIABLE: Responses to the question: "Think of an incident during the past year when you didn't adhere to universal precautions. Please describe the situation and why you didn't adhere."

RESULTS

Reasons given for not using precautions included: belief that stopping to use standard precautions would have put the patient at risk (22%); using precautions would have interfered with patient care (20%); precautions were not warranted in a specific situation (14%); did not anticipate the potential for exposure (14%); and high job demands that had caused respondent to be in a hurry (11%). Less often, equipment was not available (7%), respondent forgot (6%), respondent thought that the patient did not pose a risk (4%), or the available equipment was not effective (3%). In terms of overall exposure rates, 34% of those who described an incident had experienced a sharps injury during the previous 3 months and 42% had experienced a mucocutaneous exposure. In terms of overall nonadherence, 44% wore gloves less than 100% of the time, while 61% washed their hands less than 100% of the time. Needlestick injuries were lowest among those who had forgotten to use precautions, while mucocutaneous exposures were highest among those who had not anticipated potential exposure while performing the task. Failure to wear gloves routinely was highest among those who said that following precautions interfered with their ability to provide care and among those who believed a particular patient to be low risk; failure to wash hands routinely was also highest among the latter group and lowest among those who said necessary equipment was not available.

CONCLUSIONS

Using specific information about local incidents of nonadherence to standard precautions may enhance training, especially if the program identifies incidents of unanticipated exposure and helps workers plan for them in the future. Closer examination of job demands and responsibilities that interfere with standard precautions may increase the likelihood of adherence.

Reprocessing endoscopes: United States perspective

Endoscopes are used frequently for the diagnosis and therapy of medical disorders. For example, greater than 10000000 gastrointestinal endoscopic procedures are performed each year in the United States. Failure to employ appropriate cleaning and disinfection/sterilization of endoscopes has been responsible for multiple nosocomial outbreaks and serious, sometimes life-threatening, infections. Flexible endoscopes, by virtue of the site of use, have a high bioburden of microorganisms after use. The bioburden found on flexible gastrointestinal endoscopes following use has ranged from 10(5) to 10(10)CFU/ml, with the highest levels being found in the suction channels. Cleaning dramatically reduces the bioburden on endoscopes. Several investigators have shown a mean log(10) reduction factor of 4 (99.99%) in the microbial contaminants with cleaning alone. Cleaning should be done promptly following each use of an endoscope to prevent drying of secretions, allow removal of organic material, and decrease the number of microbial pathogens. Because the endoscope comes into intimate contact with mucous membranes, high-level disinfection is the reprocessing standard after each patient use. High-level disinfection refers to the use of a disinfectant (e.g., FDA-cleared chemical sterilant or high-level disinfectant) that inactivates all microorganisms (i.e., bacteria, viruses, fungi, mycobacteria) but not high levels of bacterial spores. The disinfection process requires immersion of the endoscope in the high-level disinfectant and ensuring all channels are perfused for the approved contact time (e.g., for ortho-phthaladehyde this is 12 min in the US). Following disinfection, the endoscope and channels are rinsed with sterile water, filtered water, or tapwater. The channels are then flushed with alcohol and dried using forced air. The endoscope should be stored in a manner that prevents recontamination. A protocol that describes the meticulous manual cleaning process, the appropriate training and evaluation of the reprocessing personnel, and a quality assurance program for endoscopes should be adopted and enforced by each unit performing endoscopic reprocessing.

Percutaneous injury, blood exposure, and adherence to standard precautions: are hospital-based health care providers still at risk?

To examine factors associated with blood exposure and percutaneous injury among health care workers, we assessed occupational risk factors, compliance with standard precautions, frequency of exposure, and reporting in a stratified random sample of 5123 physicians, nurses, and medical technologists working in Iowa community hospitals. Of these, 3223 (63%) participated. Mean rates of hand washing (32%-54%), avoiding needle recapping (29%-70%), and underreporting sharps injuries (22%-62%; overall, 32%) varied by occupation (P<.01). Logistic regression was used to estimate the adjusted odds of percutaneous injury (aOR(injury)), which increased 2%-3% for each sharp handled in a typical week. The overall aOR(injury) for never recapping needles was 0.74 (95% CI, 0.60-0.91). Any recent blood contact, a measure of consistent use of barrier precautions, had an overall aOR(injury) of 1.57 (95% CI, 1.32-1.86); among physicians, the aOR(injury) was 2.18 (95% CI, 1.34-3.54). Adherence to standard precautions was found to be suboptimal. Underreporting was found to be common. Percutaneous injury and mucocutaneous blood exposure are related to frequency of sharps handling and inversely related to routine standard-precaution compliance. New strategies for preventing exposures, training, and monitoring adherence are needed.

Managing occupational risks for hepatitis C transmission in the health care setting

Hepatitis C virus (HCV) infection is a significant contemporary health problem in the United States and elsewhere. Because it is primarily transmitted via blood, hepatitis C infection presents risks for both nosocomial transmission to patients and occupational spread to health care workers. Recent insights into the pathogenesis, immunopathogenesis, natural history, and treatment of infection caused by this unique flavivirus provide a rationale for the use of new strategies for managing occupational hepatitis C infections when they occur. This article reviews this developing information. Recently published data demonstrate success rates in the treatment of "acute hepatitis C syndrome" that approach 100\%, and although these studies are not directly applicable to all occupational infections, they may provide important clues to optimal management strategies. In addition, the article delineates approaches to the prevention of occupational exposures and also addresses the difficult issue of managing HCV-infected health care providers. The article summarizes currently available data about the nosocomial epidemiology of HCV infection and the magnitude of risk and discusses several alternatives for managing exposure and infection. No evidence supports the use of immediate postexposure prophylaxis with immunoglobulin, immunomodulators, or antiviral agents. Based on the very limited data available, the watchful waiting and preemptive therapy strategies described in detail in this article represent reasonable interim approaches to the complex problem of managing occupational HCV infections, at least until more definitive data are obtained.

Sharps injury reduction using Sharpsmart--a reusable sharps management system

Sharps containers are associated with 11-13% of total sharps injuries (SI) yet have received little attention as a means of SI reduction. A newly developed reusable sharps containment system (Sharpsmart) was trialed in eight hospitals in three countries. The system was associated with an 86.8% reduction of container-related SI (CRSI) (P=0.012), a 25.7% reduction in non-CRSI (P=0.003), and a 32.6% reduction in total SI (P=0.002) compared with historical data. The study concludes that the Sharpsmart system is an effective engineered control in reducing SI.

A review of sharps injuries and preventative strategies

Exposure to bloodborne pathogens from sharps injuries continues to pose a significant risk to healthcare workers (HCW). The number of sharps injuries sustained by HCW is still unclear, primarily due to under-reporting. In this review a mean rate of 4.0% (range 1.0-6.2%) sharps injuries per 10000 HCW was calculated from eight studies involving more than 7000 HCW. Nurses and doctors were most at risk of sharps injuries, frequently from hollow-bore needles. Approaches to reduce this risk have included education and training on the safe handling and disposal of sharp devices, awareness campaigns and legislative action. More recently, preventative strategies have focused on needle protective devices, which may reduce the rate of sharps injuries. Introducing needle protective devices should be considered particularly in high-risk areas, after training, education, evaluation and cost-benefit analysis.

Occupationally acquired human immunodeficiency virus (HIV) infection: national case surveillance data during 20 years of the HIV epidemic in the United States

OBJECTIVE

To characterize occupationally acquired human immunodeficiency virus (HIV) infection detected through case surveillance efforts in the United States.

DESIGN

National surveillance systems, based on voluntary case reporting.

SETTING

Healthcare or laboratory (clinical or research) settings.

PATIENTS

Healthcare workers, defined as individuals employed in healthcare or laboratory settings (including students and trainees), who are infected with HIV.

METHODS

Review of data reported through December 2001 in the HIV/AIDS Reporting System and the National Surveillance for Occupationally Acquired HIV Infection.

RESULTS

Of 57 healthcare workers with documented occupationally acquired HIV infection, most (86%) were exposed to blood, and most (88%) had percutaneous injuries. The circumstances varied among 51 percutaneous injuries, with the largest proportion (41%) occurring after a procedure, 35% occurring during a procedure, and 20% occurring during disposal of sharp objects. Unexpected circumstances difficult to anticipate during or after procedures accounted for 20% of all injuries. Of 55 known source patients, most (69%) had acquired immunodeficiency syndrome (AIDS) at the time of occupational exposure, but some (11%) had asymptomatic HIV infection. Eight (14%) of the healthcare workers were infected despite receiving postexposure prophylaxis (PEP).

CONCLUSIONS

Prevention strategies for occupationally acquired HIV infection should continue to emphasize avoiding blood exposures. Healthcare workers should be educated about both the benefits and the limitations of PEP, which does not always prevent HIV infection following an exposure. Technologic advances (eg, safety-engineered devices) may further enhance safety in the healthcare workplace.

A training programme for prevention of occupational exposure to bloodborne pathogens: impact on knowledge, behaviour and incidence of needle stick injuries among student nurses in Changsha, People's Republic of China

BACKGROUND

Although the human immunodeficiency virus (HIV) epidemic in China is expanding rapidly, the principles of universal precautions (UP) are not widely disseminated in Chinese hospitals. Lack of training about occupational prevention of bloodborne pathogens (BBP) may place student nurses at risk when they are in clinical practice.

AIM

To examine the impact of structured training on prevention of occupational exposure to BBP on knowledge, behaviour, and incidence of medical sharp injuries among student nurses in Changsha, China.

METHODS

A quasi-experimental study evaluated changes in knowledge, self-reported UP behaviours, observed adherence to UP, and needle stick/sharp injuries during a 4-month follow-up period. The study population consisted of 106 student nurses in two classes. One class served as the experimental group, while the other served as a control group. Students in the experimental group participated in a structured training intervention consisting of lectures and demonstrations.

RESULTS

At 4 months, the group that received the BBP training scored significantly higher than the standard education group on both knowledge (P < 0.001) and behaviour (P = 0.002). Although students in the experimental group were not observed to practise UP significantly more frequently than those in the control group, they were less likely to experience needle stick/sharp injuries (OR = 0.29; 95% CI 0.11, 0.74; P = 0.004).

CONCLUSION

Structured training in prevention of occupational exposure to BBP improved knowledge and behaviour and reduced the number of needle stick/sharp injuries among Chinese student nurses, compared with students who did not receive the training. Training in the techniques of UP could play a role in reducing the risk for occupational exposure to BBP among Chinese future nurses. In view of the accelerating HIV epidemic, implementation and evaluation of such training programmes are urgently needed.

Análise dos acidentes com agulhas em um hospital universitário: situações de ocorrência e tendências

Os acidentes com agulhas constituem um dos principais riscos de transmissão ocupacional de infecções por via sangüínea (AIDS, hepatite B e C). É prioritário, portanto, discutir estratégias de intervenção baseadas nas fontes de risco. O objetivo deste estudo foi analisar os acidentes com agulhas ocorridos em um hospital universitário. A construção de um banco dados dos acidentes notificados, entre 1990 e 1996, permitiu identificar as situações de ocorrência e as tendências ao longo dos anos. Os resultados indicam que a maioria dos acidentes estava relacionada à realização ou auxílio de procedimentos. A implantação das primeiras medidas preventivas (precauções universais) aponta para a redução no total de acidentes com perfurações. Não foram observadas alterações nas taxas de acidentes relacionados à prática de reencapar agulhas. Discute-se o uso de diferentes estratégias de intervenção: introdução de materiais de design seguro; mudança de enfoque no treinamento e reorganização do ambiente e das práticas de trabalho.

Transmission of HIV in the dental clinic and elsewhere

This review focuses on the risk of transmission of HIV in dental practice in developed and developing countries; and as a result of oral sex, perinatal transmission and breast feeding. Postexposure prophylaxis (PEP) and practical measures to control cross-infection with TB are also discussed. There are few data from resource-poor countries where prevalence of HIV and risk of infection are higher--issues that deserve priority. Available information indicates that the risk of HIV transmission in the dental office is very low. Transmission of HIV from three healthcare workers to patients has been confirmed, including a dentist who infected six patients. There are >300 reports (102 confirmed) of occupational transmission to healthcare workers, including nine dental workers (unconfirmed). Exposure to HIV has been reported by 0.5% dentists/year. The risk of HIV infection after percutaneous exposure (0.3%) can be reduced by 81% with zidovudine PEP. However, risk assessment is required to assess the need and appropriate regimen. The risk of HIV transmission associated with orogenital sex exists, but is considered extremely low: barrier protection is recommended. Conversely, the proportion of babies who acquire HIV from untreated HIV-seropositive mothers is 15-25% in developed countries and 25-45% in developing countries. The frequency of HIV transmission attributable to breastfeeding is 16%. Airborne transmission of TB can be avoided by the prompt referral of known/suspected cases of active TB for chemotherapy, deferral of elective procedures until patients are not infectious, and the use of appropriate standard/isolation precautions including adequate ventilation of treatment areas.

Nurses' knowledge of and compliance with universal precautions in an acute care hospital

A cross-sectional survey was conducted to investigate the nurses' knowledge of and compliance with Universal Precautions (UP) in an acute hospital in Hong Kong. A total of 450 nurses were randomly selected from a population of acute care nurses and 306 were successfully recruited in the study. The study revealed that the nurses' knowledge of UP was inadequate. In addition, UP was not only insufficiently and inappropriately applied, but also selectively practiced. Nearly all respondents knew that used needles should be disposed of in a sharps' box after injections. However, nurses had difficulty in distinguishing between deep body fluids and other general body secretions that are not considered infectious in UP. A high compliance was reported regarding hand-washing, disposal of needles and glove usage. However, the use of other protective wear such as masks and goggles was uncommon. The results also showed no significant relationships between the nurses' knowledge and compliance with UP. It is recommended that UP educational programmes need to consider attitudes in conjunction with empirical knowledge. Nurse managers and occupational health nurses should take a leadership role to ensure safe practices are used in the care of patients.

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.

Risk of exposure to bloodborne infection for Italian healthcare workers, by job category and work area. Studio Italiano Rischio Occupazionale da HIV Group

OBJECTIVE

To analyze the rate of occupational exposure to blood and body fluids from all sources and specifically from human immunodeficiency virus (HIV)-infected sources among hospital workers, by job category and work area.

DESIGN

Multicenter prospective study. Occupational exposure data (numerator) and full-time equivalents ([FTEs] denominator) were collected over a 5-year period (1994-1998) and analyzed.

SETTING

18 Italian urban acute-care hospitals with infectious disease units.

RESULTS

A total of 10,988 percutaneous and 3,361 mucocutaneous exposures were reported. The highest rate of percutaneous exposure per 100 FTEs was observed among general surgery (11%) and general medicine (10.6%) nurses, the lowest among infectious diseases (1.1%) and laboratory (1%) physicians. The highest rates of mucocutaneous exposure were observed among midwives (5.3%) and dialysis nurses (4.7%), the lowest among pathologists (0%). Inadequate sharps disposal and the prevalence of sharps in the working unit influence the risk to housekeepers. The highest combined HIV exposure rates were observed among nurses (7.8%) and physicians (1.9%) working in infectious disease units. The highest rates of high-risk percutaneous exposures per 100 FTE were again observed in nurses regardless of work area, but this risk was higher in medical areas than in surgery (odds ratio, 2.1; 95% confidence interval, 1.9-2.5; P<.0001).

CONCLUSION

Exposure risk is related to job tasks, as well as to the type and complexity of care provided in different areas, whereas HIV exposure risk mainly relates to the prevalence of HIV-infected patients in a specific area. The number of accident-prone procedures, especially those involving the use of hollow-bore needles, performed by job category influence the rate of exposure with high risk of infection. Job- and area-specific exposure rates permit monitoring of the effectiveness of targeted interventions and control measures over time.

Monitoring adherence to Standard Precautions

BACKGROUND

Health care workers (HCWs) do not consistently follow Standard Precautions (SP). This is a serious problem because inadequate compliance is associated with increased blood exposure thus predisposing HCWs to bloodborne pathogen transmission.

METHODS

The primary goal of this study was to identify institutional factors associated with adequacy of HCW training to monitor coworkers' adherence to SP. Surveys were sent to all community hospital infection control practitioners (ICPs) in Iowa and Virginia. ICPs indicated on a 5-point Likert scale, ranging from strongly disagree to strongly agree, their assessment of HCW training adequacy. Data from another statewide survey of HCWs in Iowa were assessed to validate this outcome measure. Multiple logistic regression models were developed to identify predictors of assessed training adequacy. Independent variables included methods of education, training, approaches to SP compliance assessment, provision of SP reinforcement by clinical leaders, and organizational data.

RESULTS

A total of 149 institutions (62%) participated. Models of training program adequacy varied across occupations. Management commitment to SP training programs, leadership support, frequency of providing bloodborne pathogen information, and safety climate were important institutional predictors of assessed adequacy of training. The outcome was validated by demonstrating an association between the ICPs' assessment of HCW training and workers who reported having sufficient information to comply with SP (P <.05).

CONCLUSIONS

Institutional safety climate, leadership support, and frequency of education play an important role in HCWs' training adequacy to monitor coworkers' adherence to SP. Occupational groups should be considered independently when strategies are developed to increase compliance. Interventions based on modifiable factors identified by this study may reduce bloodborne pathogen exposure among HCWs.

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.

Bloodborne viral infections in patients attending an emergency room in Mexico City: estimate of seroconversion probability in healthcare workers after an occupational exposure

The frequency of hepatitis C (HCV), hepatitis B (HBV), human immunodeficiency virus (HIV), and human T-cell lymphotropic virus (HTLV) I/II was determined in the emergency room of a teaching hospital. Of 909 patients, 19% had at least one infection; 7.8% had HCV, 6.9% HBV, 3.3% HIV, and 2.8% HTLV I/II. The probability that a healthcare worker would have an accident with an infected patient and seroconvert was 4.99 to 24.9 per 100,000 venipunctures for HBV, 5.6 to 8.4 for HCV, and 0.12-0.16 for HIV in our emergency room.

Risk and management of blood-borne infections in health care workers

Exposure to blood-borne pathogens poses a serious risk to health care workers (HCWs). We review the risk and management of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections in HCWs and also discuss current methods for preventing exposures and recommendations for postexposure prophylaxis. In the health care setting, blood-borne pathogen transmission occurs predominantly by percutaneous or mucosal exposure of workers to the blood or body fluids of infected patients. Prospective studies of HCWs have estimated that the average risk for HIV transmission after a percutaneous exposure is approximately 0.3%, the risk of HBV transmission is 6 to 30%, and the risk of HCV transmission is approximately 1.8%. To minimize the risk of blood-borne pathogen transmission from HCWs to patients, all HCWs should adhere to standard precautions, including the appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments. Employers should have in place a system that includes written protocols for prompt reporting, evaluation, counseling, treatment, and follow-up of occupational exposures that may place a worker at risk of blood-borne pathogen infection. A sustained commitment to the occupational health of all HCWs will ensure maximum protection for HCWs and patients and the availability of optimal medical care for all who need it.

Risk and management of blood-borne infections in health care workers

Exposure to blood-borne pathogens poses a serious risk to health care workers (HCWs). We review the risk and management of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections in HCWs and also discuss current methods for preventing exposures and recommendations for postexposure prophylaxis. In the health care setting, blood-borne pathogen transmission occurs predominantly by percutaneous or mucosal exposure of workers to the blood or body fluids of infected patients. Prospective studies of HCWs have estimated that the average risk for HIV transmission after a percutaneous exposure is approximately 0.3%, the risk of HBV transmission is 6 to 30%, and the risk of HCV transmission is approximately 1.8%. To minimize the risk of blood-borne pathogen transmission from HCWs to patients, all HCWs should adhere to standard precautions, including the appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments. Employers should have in place a system that includes written protocols for prompt reporting, evaluation, counseling, treatment, and follow-up of occupational exposures that may place a worker at risk of blood-borne pathogen infection. A sustained commitment to the occupational health of all HCWs will ensure maximum protection for HCWs and patients and the availability of optimal medical care for all who need it.