Epidemiology of exposure to blood borne pathogens on a surgical service

BACKGROUND: The goal of this study was to analyze the type and mechanism of blood exposure injuries on the surgical service in order to develop appropriate preventative strategies. METHODS: A retrospective review of all exposure injuries affecting members of the operative care line at a single teaching institution between December 2002 and December 2005 was performed. RESULTS: Of 98 exposure injuries on the surgical service, only 17 (17%) were inflicted by hollow-bore needles. Seventy-four (76%) of these reported injuries occurred in the operating room (OR) and 24 (24%) occurred in other clinical areas. Sharps injuries accounted for 69 (93%) of OR injuries and were inflicted by suture needles (n = 37, 50%), hollow-bore needles (n = 7, 9%), and sharp instruments (n = 25, 34%). Mucocutaneous contamination accounted for 5 (7%) of the OR exposures. Professionals most frequently injured were residents (n = 43, 44%), followed by nurses (n = 28, 29%), students (n = 17, 17%) and other healthcare workers (n = 10, 10%). CONCLUSIONS: Blood exposure prevention strategies should be directed at safety within the surgical field and focused beyond hollow-bore needle stick injuries to include education, mentoring, and competency training.     

Technical Tip: New Tools for Protection from Sharps Injuries

Sharps injuries are an area of concern for healthcare workers. This article discusses clinical use of a blunt suture needle and an absorbable skin staple in upper limb operations. These devices may reduce the need for sharp needles in the surgical field during selected procedures on the upper limb.     

Sharps Injury Reporting Amongst Surgeons

INTRODUCTION

The aim of this study was to evaluate the level of sharps injury reporting amongst surgeons.

SUBJECTS AND METHODS

A total of 164 surgeons completed a questionnaire on the reporting of sharps injuries, on the reasons for not reporting and their practise of universal precautions.

RESULTS

Out of 164 surgeons, only 25.8% had reported all their injuries, 22.5% had reported some and 51.7% had reported none. The top three reasons for not reporting their injuries included perception of low risk of transmission, not being concerned and no time. Of the respondents, 15.9% practised all three universal precautions of double-gloving, face shields and hands-free technique.

CONCLUSIONS

We showed that despite local trust adherence to Department of Health policy, sharps injury reporting rates are inadequate. Further investment into healthcare worker education as well as a facilitation of the process of reporting may be necessary to improve reporting rates.     

Sharpless Surgery: A Prospective Study of the Feasibility of Performing Operations using Non-sharp Techniques in an Urban,University-based Surgical Practice

Context Percutaneous injuries occur frequently during surgical procedures and represent a significant occupational hazard to operating room personnel. Objectives To evaluate the feasibility of performing select general surgical procedures using a combination of non-sharp devices and techniques to replace the conventional use of scalpels and needles. Design, Setting, and Participants Candidate procedures for which sharpless techniques could replace conventional scalpels and suture needles were identified preoperatively in an urban, university-based general surgical practice over a 1-year period (June 2003–June 2004). Non-sharp techniques included monomeric 2-octyl cyanoacrylate adhesive, electrocautery, tissue stapler, and minimally invasive instrumentation. Conventional scalpels and suture needles were readily available and used whenever necessary. Main Outcome Measures We rated the feasibility of performing specific procedures without sharps. We also documented the rate of overall reversion to sharps during operations on patients that had been identified preoperatively as candidates for sharpless surgery. Results Of 358 procedures performed in the general surgery university practice, 91 were identified preoperatively as appropriate for sharpless surgery. Of these, 86.8% (79/91) were completed without the use of sharps, including 13/22 (59.1%) open laparotomy procedures, 20/22 (90.9%) laparoscopic procedures, and 46/47 (97.8%) soft tissue procedures. Intraoperative reversion to sharps occurred in 12 cases when deemed necessary by the surgeon. Conclusions Select common procedures can be performed entirely with sharpless techniques, eliminating the risk to surgical personnel associated with intraoperative percutaneous injuries.     

临床护理人员锐器伤发生环节与受伤部位探讨

目的了解临床护理人员锐器伤发生的环节与受伤部位,为进一步制定职业防护措施提供实证依据。方法采用分层整群抽样的方法,抽取临床一线护理人员458名,填写自行设计的护士锐器伤调查问卷。结果458名护理人员中发生锐器伤1 286人次。41.70%护士经常双手回套针帽,5.68%经常徒手拾取破碎玻璃,30.13%操作时从不戴手套。在锐器伤发生的主要环节中,44.48%的锐器伤发生在操作准备过程,操作中占39.04%,操作后整理用物为8.86%。94.79%的锐器伤发生在双手,其中双手手指占89.42%,右手示指以37.48%的高发率位居首位,其次是右手中指16.33%,左手示指13.53%。结论护理人员锐器伤发生环节主要是掰安瓿,输液/注射/采血/拔针,拔针帽;锐器伤害发生的主要部位是双手,右手多于左手。医院管理者应定期开展锐器伤相关培训教育,使用高效安全的护理用具,制定安全规范的护理操作程序,实施标准预防,减少护理人员潜在的针刺伤危险。     

Epidemiology of sharps accidents in general surgery.

A prospective study was carried out of all general surgical operations in one theatre of a teaching hospital over a 6-week period to identify the predisposing factors involved in the occurrence of sharps accidents and their relative importance. Although various predisposing factors have been intimated, the relative importance has never been ascertained. Glove puncture was used as an objective measure of a sharps accident and this was compared with subjective reporting of needlestick injury. The overall rate of sharps accidents per surgeon per operation was 23%. The position at the operating table and medical rank of operator affected the rate of accidents more than duration of operation. The group at most risk of sharps accidents was junior surgeons acting as the principal operator. It is important to recommend inoculation against hepatitis B in this group before starting surgical training. Another method of minimizing the risk to junior surgeons would be compulsory training on surgical rigs. Operations on patients with AIDS or hepatitis B should be carried out by the most senior surgeon available to reduce the risk of sharps injury and disease transmission.     

Needle stick injuries: how can we minimise our risk?

In the United Kingdom (UK) there is inequity in health care workers access to safer sharps and needle free systems. The availability of safer sharps and needle free systems is dependent on the budget manager authorising the purchase of these devices within individual hospitals. This can mean that within the same organisation one department can be using safer sharps and needle free systems, while another department is denied access to such equipment. This is partly due to competing priorities for scarce health care resources, which is becoming more acute, and lack of national guidance to employers to provide such safety equipment for their employees. At the current time the UK does not have a mandatory reporting system for sharps injuries, so the true extend of the problem is not fully understood.     

Hand injuries during hand surgery: a survey of intraoperative sharp injuries of the hand among hand surgeons

An e-mail survey comprising 19 questions was directed towards members of the American Society for Surgery of the Hand (ASSH) to investigate the prevalence and nature of intraoperative injuries to hand surgeons during hand surgery. The responses were collected, statistical analysis was done and trends were extrapolated. Two hundred members of the ASSH completed the e-mail survey. A hand surgeon in practice for greater than 10 years has a 97% chance of sustaining an intraoperative "sharps" injury. The injury is self-inflicted (88%) in most cases and the index finger (94%) of the left hand (87%) is the most likely site. The suture needle was the cause in 91% of cases. Awareness of the risks and factors associated with hand injuries during hand surgery and adopting intraoperative measures are important strategies for preventing these potentially serious and life-threatening accidents.     

An enzyme-mediated assay to quantify inoculation volume delivered by suture needlestick injury: two gloves are better than one

BACKGROUND: Acquiring a blood-borne disease is a risk of performing operations. Most data about seroconversion are based on hollow-bore needlesticks. Some studies have examined the inoculation volumes of pure blood delivered by suture needles. There is a lack of data about the effect of double-gloving on contaminant transmission in less viscous fluids that are not prone to coagulation. STUDY DESIGN: We used enzymatic colorimetry to quantify the volume of inoculation delivered by a suture needle that was coated with an aqueous contaminant. Substrate color change was measured using a microplate reader. Both cutting and tapered suture needles were tested against five different glove types and differing numbers of glove layers (from zero to three). RESULTS: One glove layer removed 97% of contaminant from tapered needles and 65% from cutting needles, compared with the no-glove control data. Additional glove layers did not significantly improve contaminant removal from tapered needles (p > 0.05). For the cutting needle, 2 glove layers removed 91% of contaminant, which was significantly better than a single glove (p = 0.002). Three glove layers did not afford statistically significant additional protection (p = 0.122). There were no statistically significant differences between glove types (p = 0.41). CONCLUSIONS: With an aqueous needle contaminant, a single glove layer removes contaminant from tapered needles as effectively as multiple glove layers. For cutting needles, double-glove layering offers superior protection. There is no advantage to triple-glove layering. A surgeon should double-glove for maximum safety. Additionally, a surgeon should take advantage of other risk-reduction strategies, such as sharps safety, risk management, and use of sharpless instrumentation when possible.     

Occupational exposure to blood and body fluids in haemodialysis health care workers: epidemiological data and prevention in France

Health care workers (HCW) in haemodialysis units are confronted with a significant risk of occupational exposure to blood and body fluids. The prevalence of bloodborne viruses is high among haemodialysis patients. The data presented here relates to the extraction of 121 occupational exposures notified to occupational health departments by haemodialysis HCW, documented between January 1995 and December 1999 in a network of 54 volunteer hospitals in Northern France. The exposures notified in haemodialysis wards were needlestick injuries in 85 cases (70.2%), splashes to the eyes or non-intact skin in 30 cases (24.8%) and cuts in 6 cases (5.0%). Connection and disconnection of dialysis catheters to fistulae, blood sampling procedures and injections alone were involved in approximately 3 notified exposures out of 4 (46.3, 14.9 and 11.6% respectively for a total of 72.8%). The principal mechanisms for exposure were the handling of blood-soiled needles and instruments or involved the handling of sharps containers. Haemodialysis fistula needles were involved in only 12 (13.2%) of notified percutaneous injuries. Nearly 2/3 (63%) of 91 notified percutaneous injuries could have been avoided by the observance of universal/standard precautions alone and the use of safety devices which were available at the time. The collection and analysis of occupational exposures can serve as basis for an assessment of practices, devices and safety equipment to increase HCW safety in haemodialysis wards.     

Universal Precautions and Surgery in Sierra Leone: The Unprotected Workforce

Background  Surgical patients and healthcare workers in sub-Saharan Africa are at an increased risk of contracting HIV. Sierra Leone is one of the poorest countries in the world and has a documented HIV prevalence rate of 2%. Because surgeons and other healthcare staff in sub-Saharan Africa are at risk for HIV exposure from their patients, an assessment of protective supplies and equipment was considered essential. Methods   A Society of International Humanitarian Surgeons team in cooperation with the Sierra Leonean Ministry of Health and Sanitation undertook a survey of HIV-protective supplies and equipment at government hospitals in Sierra Leone. The presence of eye protection, sterile gloves, aprons, functioning suction machines, and sharps containers was recorded and compared with a local mission hospital and a local private hospital. Results   Only 20% of government hospitals in Sierra Leone have adequate stores of sterile gloves or eye protection. Suction pumps and aprons are available in only 30–40% of facilities, respectively, and only half have functioning sterilizers and sharps containers. The mission and private hospitals were fully stocked. Conclusions   Although surgical healthcare workers are at risk for exposure to HIV, resources for their protection at government hospitals in Sierra Leone are severely lacking. The Society of International Humanitarian Surgeons is developing a program to provide protective supplies and equipment to hospitals in Sierra Leone, but additional efforts by other organizations working to decrease the spread of HIV are essential.     

Coalition for medical education—A call to action: A proposition to adapt clinical medical education to meet the needs of students and other healthcare learners during COVID-19

With the ongoing coronavirus, journals and the media have extensively covered the impacts on doctors, nurses, physician assistants, and other healthcare workers. However, one group that has rarely been mentioned despite being significantly impacted is medical students and medical education overall. This piece, prepared by both a medical student and a cardiothoracic surgeon with a long career in academic medicine, discusses the recent history of medical education and how it has led to issues now with distance-based learning due to COVID-19. It concludes with a call to action for the medical education system to adapt so it can meet the needs of healthcare learners during COVID-19 and even beyond.     

Mechanism and prevention of facial pressure injuries: A novel emergent strategy supported by a multicenter controlled study in frontline healthcare professionals fighting COVID‐19

Numerous healthcare professionals fighting COVID‐19 worldwide are suffering from the protective respirators related facial pressure injuries. This study explored the mechanism and prevention of such injuries and devised a novel emergent strategy, which was supported by a multicenter self‐controlled study in 1161 frontline healthcare professionals. In this study, according to the anatomy of the face and the characteristics of facial pressure injuries, a respirator liner was designed using a polyurethane foam to redistribute the pressure across the face. A preclinical crossover trial was performed on eight participants to evaluate its efficacy. The strategy was then widely applied among 11 100 healthcare workers in seven frontline hospitals, and 1161 of them were sampled for a questionnaire investigation. The preclinical crossover trial showed that the novel strategy was very effective in preventing facial pressure injuries. The questionnaire investigation showed that pain score, wearing disturbance, and the incidence of pressure injury in the healthcare professionals were significantly correlated with wearing time (all ρ = 0.986). The new strategy significantly reduced the incidence of pressure injury from 84.7% to 11.1%, pain score IQR from 5 (2) to 1 (2), and wearing disturbance rate from 91.6% to 6.3%, and the results analyzed according to individual hospitals or different wearing time showed similar trends (all P < .0005). The protective respirators related facial pressure injuries can be effectively mitigated with this emergent strategy, which has also been applied in some European hospitals and can be popularized to help more healthcare professionals who are combating COVID‐19 on the frontlines.     

A prospective look at the burden of sharps injuries and splashes among trauma health care workers in developing countries: True picture or tip of iceberg

Objectives

Health care workers (HCWs) face constant risk of exposure to cuts and splashes as occupational hazard. Hence, a prospective observational study was conducted to observe the exposure of HCWs to various sharp injuries and splashes during health care and to work up a baseline injury rate among HCWs for future comparison in trauma care set ups.

Methods

A 2 year and 5 month study was conducted among the voluntarily reported exposed HCWs of the APEX trauma centre. Such reported cases were actively followed for 6 months after testing for viral markers and counselled. The outcomes of such exposed HCWs and rate of seroconversion was noted. To form a future reference point, the injury rate in trauma care HCWs based on certain defined parameters along with the rate of under reporting were also analysed in this study.

Results

In our study, doctors were found to have the highest exposure (129, 36.2%), followed by nurses (52, 14.6%) and hospital waste disposal staff (27, 7.6%). Of the source patients, a high number of them were HBV positive (11, 3.1%), followed by HIV positive patients (8, 2.2%). No seroconversion was seen in any of the exposed HCWs. Injuries by sharps (303, 85.1%) outnumber those due to splashes (53, 14.9%) which were much higher in those working in pressing situations. Underreporting was common, being maximally prevalent in hospital waste disposal staff (182, 51.1%).

Conclusions

High rates of exposure to sharp injuries and splashes among HCWs call for proper safety protocols. Proper methods to prevent it, encouraging voluntary reporting and an active surveillance team are the need of the hour.     

Needlestick injuries among anesthesia providers from a large US academic center: A 10-year retrospective analysis

Study objectiveAnesthesiologists are at high risk for needlestick injury. Such injuries pose a serious health threat from exposure to bloodborne pathogens. This retrospective analysis aimed to examine needlestick injury rate among anesthesia providers between 2010 and 2020 at the University of California Los Angeles, Department of Anesthesiology and Perioperative Medicine to determine specialty-specific factors associated with these injuries.DesignRetrospective analysis.SettingAcademic Anesthesiology Department.Patients and interventionsNone.MeasurementsAll reported incidents of needlestick injuries to employees are sent to the Injury and Illness Prevention Committee. We included all anesthesia residents, fellows, nurse anesthetists, solo anesthesiologists, and supervising anesthesiologists.Main resultsThe overall rate of reported needlestick injuries was 5.3%. The rates for anesthesia residents were 2.1%, 13.5%, 7.9%, and 6.7% for post graduate year 1–4 (PGY 1–4) residents. The rates were 14.3%, 4.7%, 2.1%, and 6.9% for fellows, nurse anesthetists, supervising anesthesiologists, and solo anesthesiologists, respectively. We found that PGY2 residents had a higher injury rate than PGY1 residents (p-value<0.001). When grouping PGY2, PGY3, and PGY4 residents together, they had a collective rate of 9.4%. Furthermore, residents had a higher needlestick injury rate than supervising anesthesiologists (p-value <0.001).ConclusionsPGY2 residents and fellows had the highest rate of needlestick injury. Our study highlights the trend of increasing sharps injuries after PGY1 while supervising anesthesiologists had the lowest rate. Proposed mechanisms for the increased sharps injuries include residents' transition from medicine-based internship to the operating room environment with increased exposure to potentially injurious equipment, overnight call, and increased work-related and cognitive stress. Improving understanding of institution-specific prevention programs, raising awareness during their initial high-intensity training period with one-to-one supervision when habits are formed, and reducing exposure to sharps using a needleless system are some steps toward reducing the incidence of sharps injuries in a field where the risk remains high.     

Best practice for needlestick injuries

Purpose

Needlestick injuries (NSIs) are a significant health hazard. Occupational transmission of bloodborne pathogens among healthcare workers (HCWs) is rare but has been repeatedly reported in the literature.

Methods

In October 2010, new regulations were introduced for medical aftercare of HCWs following NSIs at the University Hospital Frankfurt. In June 2013, a university hospital-wide early intervention program was introduced that gives HCWs immediate 24/7/365 access to an HIV postexposure prophylaxis kit after confirmed or probable occupational HIV exposure.

Results

Interdisciplinary collaboration between the attending surgeon and occupational health as well as infectious disease specialists facilitates optimal postexposure medical treatment of HCWs who suffer NSIs. Complete reporting of NSIs is a prerequisite for achieving optimal treatment of the affected HCWs.

Conclusion

An NSI is an emergency and needs to be evaluated immediately and, if necessary, treated as soon as possible. A standardized algorithm for initial diagnostic and treatment has proven to be helpful.     

Safety syringes can reduce the risk of needlestick injury in venous thromboembolism prophylaxis

Patients undergoing major orthopaedic surgery of the lower extremities are at high risk of developing venous thromboembolism (VTE). Pharmacologic thromboprophylaxis has greatly reduced the likelihood of VTE. The most effective medications are administered once or twice daily by subcutaneous injection, a drug delivery route associated with an increased risk of needlestick injury. Awareness of the potential lethality of needlestick injuries has increased during the past decade, resulting in the development of national safety guidelines from the Occupational Safety and Health Administration on the handling and management of needles and other sharps. This article reviews the potential risks and costs associated with needlestick injury during the administration of VTE prophylaxis in patients undergoing major orthopaedic surgery. The development of novel anticoagulants and accompanying devices to prevent needlestick injury is also discussed.     

降低医护人员职业暴露风险的综合干预

目的探讨预防医护人员职业暴露的有效干预措施。方法对全院医护人员实施防范职业暴露的综合干预措施,包括宣教与培训、硬件配备、监督与反馈3个主要环节。比较实施前后医护人员职业暴露发生情况。结果实施综合干预措施后,医护人员职业暴露发生率逐年递减(P<0.01),操作针头所致的职业暴露逐年降低。结论采取综合干预措施可显著降低护士的职业暴露,但医生的职业防护意识和行为仍有待加强。     

Devastating injuries in healthcare workers: description of the crisis and legislative solution to the epidemic of back injury from patient lifting

The purpose of this report is to describe a crisis in healthcare, disabling back injuries in US healthcare workers. In addition, outlined is the proven solution of safe, mechanized, patient lifting, which has been shown to prevent these injuries. A "Safe Patient Handling--No Manual Lift" policy must be immediately instituted throughout this country. Such a policy is essential to halt hazardous manual patient lifting, which promotes needless disability and loss of healthcare workers, pain and risk of severe injury to patients, and tremendous waste of financial resources to employers and workers' compensation insurance carriers. Healthcare workers consistently rank among top occupations with disabling back injuries, primarily from manually lifting patients. Back injury may be the single largest contributor to the nursing shortage. Reported injuries to certified nursing assistants are three to four times that of registered nurses. A national healthcare policy for "Safe Patient Handling--No Manual Lift" is urgently needed to address this crisis. Body mechanics training is ineffective in prevention of back injury with patient lifting. Mandated use of mechanical patient lift equipment has proven to prevent most back injury to nursing personnel and reduce pain and injury to patients associated with manual lifting. With the national epidemic of morbid obesity in our country, innovative devices are available for use in emergency medical systems and hospitals for patient lifting and transfer without injury to hospital personnel. The US healthcare industry has not voluntarily taken measures necessary to reduce patient handling injury by use of mechanical lift devices. US healthcare workers who suffer disabling work-related back injuries are limited to the fixed, and often inadequate, relief which they may obtain from workers' compensation. Under workers' compensation law, healthcare workers injured lifting patients may not sue their employer for not providing mechanical lift equipment. Discarding healthcare workers disabled by preventable back injuries is an abuse which legislators must remedy. In addition, Medicare reimbursement policies must also be updated to allow the disabled community to purchase electrically operated overhead ceiling lifts. The US lags far behind countries with legislated manual handling regulations and "No Lifting" nursing policies. England and Australia have had "No Lifting" nursing policies in place since 1996 and 1998, respectively. The National Occupational Research Agenda (NORA) recognized a model in 2003 for reduction of back injuries to nursing staff in US healthcare facilities. Also in 2003, the American Nurses Association called for elimination of manual patient handling because it is unsafe and causes musculoskeletal injuries to nurses. The first state legislation for safe patient handling passed both houses in California but was vetoed by the Governor in September 2004. California and other states are preparing to (re)introduce legislation in January 2005. A national, industry-specific policy is essential to quell the outflow of nursing personnel to disability from manual patient lifting.     

Treatment of patients with acquired immunodeficiency syndrome in a podiatric emergency situation.

All patients should be considered seropositive, and protective measures always should be taken. The mainstays of universal precautions are the use of barrier techniques and protection from inadvertent sharps exposure. Various studies show that emergency room or trauma patients have a higher HIV prevalence than the population as a whole. Several studies of health care workers with known parenteral and mucous membrane exposure to HIV positive patients indicate that the risk of seroconversion is less than 1%. This low percentage, however, should not be used to justify nonadherence to universal precautions.