Evaluation of interventions to prevent needlestick injuries in health care occupations

OBJECTIVE

The objective of this study was to evaluate interventions that reduce or prevent needlestick injuries in health care occupations.

METHODS

Cochrane Collaboration search strategies to locate studies that evaluated interventions to reduce needlestick injuries in health care occupations were used. Studies were selected if they met the following criteria: (1) interventions were evaluated in the defined population; (2) interventions were randomized, with a comparison group(s); (3) outcomes were objectively measured and had interpretable data. Eleven studies met inclusion criteria. The main outcomes of interest were changes in the number of glove or skin perforations and changes in amount of skin contamination.

RESULTS

Three studies found a decrease in glove or skin perforations when double gloves or combinations of gloves were used by surgeons and their assistants. One study found an increase in glove perforations but a decrease in hand contamination. Three studies evaluated the effectiveness of specialized needles in reducing needlestick injuries during surgical wound closure with decreases in glove or skin perforations reported. Protective devices were evaluated in three studies and significant reductions in glove perforations were found with the use of a needleless intravenous system and surgical assist device. One study evaluated a "no-touch" technique used by surgeons during wound closure and found a significant decrease in the number of glove perforations compared to the traditional "hand-in" method of closure.

CONCLUSIONS

Few randomized controlled trials have been employed to evaluate the effectiveness of interventions to reduce needlestick injuries in health care occupations. The majority of the studies evaluated interventions during surgical procedures, rather than during patient care on nursing units, probably because the latter is more difficult to observe.

Occupational health surveillance, screening, and prevention activities in occupational health nursing practice

Occupational health nursing practice is broad and encompasses surveillance, screening, and prevention activities as part of the scope of practice. While there has been some controversy about who is responsible for these activities, it is clear occupational health nurses play a pivotal role in overseeing, managing, implementing, and evaluating these programs. In fact, recent OSHA standards have included broad language that permits licensed health care professionals acting within their legal scope of practice to conduct medical and health surveillance activities. While the contributions of occupational health nurses are well documented, little is known about the degree and emphasis in practice related to surveillance, screening, and prevention programs. This study examined the scope of independent and interdependent practice by occupational health nurses related to these activities and found 71% of occupational health nurses had overall responsibility for program management, and the majority performed surveillance, screening, and prevention functions as independent practice. Physician supervision for any of these activities ranged from only 0% to 8% in reporting. The results of this study validate the independent functioning in scope of occupational health nursing practice related to surveillance, screening, and prevention activities while recognizing the contributions all providers make to a healthy work force.

Phase II trial of induction high-dose chemotherapy followed by surgical resection and radiation therapy for patients with marginally resectable non-small cell carcinoma of the lung

The combination of carboplatin and paclitaxel is an active regimen in non-small cell lung cancer (NSCLC). Historically, patients with stage III disease have manifested higher response rates than patients with metastatic disease, and patients achieving a pathologic complete response to induction chemoradiation therapy prior to surgery have shown better long-term outcome. Based upon our pilot data using high-dose carboplatin and paclitaxel, we designed a phase II trial in patients with marginally resectable stage IIIA NSCLC. Ten patients, with bulky nodal stage IIIA disease, initially received etoposide (2 g/m2) and granulocyte colony-stimulating factor (G-CSF) to mobilize peripheral blood stem cells (PBSC). Two cycles, 28 days apart, of carboplatin (AUC 12 in seven patients; AUC 16 in three patients) and paclitaxel (250 mg/m2) were administered with filgrastim (5 microg/kg) and PBSC support. After re-evaluation, patients underwent a thoracotomy followed by radiotherapy (44-60 Gy) if deemed resectable, or radiotherapy alone (60 Gy) if not resectable. The median age was 58.5 years (48-66) with a median ECOG performance status of 0 (0-1). Histology was adenocarcinoma in seven patients; the remainder had either squamous cell, large cell or bronchoalveolar carcinoma. Based on CT radiography, the overall response rate was 40%. Eight of ten patients underwent resection with four right pneumonectomies, three right upper lobectomies and one wedge resection of the right upper lobe. Six patients had a complete resection. Of eight patients resected, four were downstaged by induction therapy, three remained unchanged and one was found to have more extensive disease. The remaining two patients developed metastatic disease while receiving chemotherapy. The median dose of postoperative radiotherapy was 54 Gy (35-66 Gy). Actual median follow-up for all patients was 89 weeks (25 to 136+). The actuarial median overall survival was 124 weeks (25 to 136+) and time to progression was 57 weeks (17 to 136+). The median dose of carboplatin delivered expressed as mg/m2 was 779 (615-1540). Neutropenic fever occurred in two patients during the initial mobilization cycle only. The median number of units of RBC and/or platelets transfused was 0 (0-2 and 0-6, respectively). There were no significant non-hematologic toxicities. High-dose induction chemotherapy with stem cell rescue is feasible and safe with an acceptable response rate. Thoracotomy, including pneumonectomy and postoperative radiotherapy, were well tolerated by patients after undergoing high-dose induction chemotherapy with no apparent increase in peri-operative morbidity. The pathologic complete response rate was low--one out of ten patients. These results indicate that dose escalation of induction chemotherapy does not improve response rates even in this highly selected patient population. Accordingly, the complexity and potential toxicity of high-dose chemotherapy, as delivered in this trial as neoadjuvant treatment of non-small cell lung cancer, is not warranted.

Occupational health nursing research priorities: a changing focus

This article reports a study to reexamine and update the research priorities in occupational health nursing. In this investigation, a 15% geographically proportionate random sample of AAOHN members was surveyed using a two-stage Delphi technique to determine important occupational health related areas needing targeted research. Research participants evaluated 37 potential research priorities in relation to impact on worker health and value to the profession, and 12 priorities emerged.

Ergonomics: CTD management evaluation tool

Cumulative trauma disorder (CTD) occurrences peaked in number in 1994 and although decreasing in 1995, still accounted for 62% of all illness cases reported. A CTD Management Evaluation Tool was developed to assist Occupational Safety and Health Compliance Officers (CSHOs) in program evaluation and documentation of the occupational health management component and the need for an ergonomics program. Occupational and environmental health nurses may use the tool not only to reduce and prevent CTD occurrences, but also as a benchmark for program evaluation.

Spinal cord injuries and attempted suicide: a retrospective review

STUDY DESIGN

A retrospective review examining the cases of 137 individuals with spinal cord injury (SCI) as a result of a suicide attempt between 1951 - 1992.

OBJECTIVE

To ascertain demographic details of this participant sample, explore and identify the type of psychiatric condition evident around the time of injury, and to review outcome information of this sample with specific focus on mortality, especially further evidence of deliberate self harm.

SUMMARY OF BACKGROUND DATA

Research examining suicide rates in SCI populations has found such numbers to be significantly higher than in the general population. However, these studies have typically relied on small samples of individuals and have often failed to distinguish between those individuals who sustained SCI as a result of attempted suicide, and those who first attempted suicide following SCI.

METHODS

An established database comprising details of 137 people with SCI as a result of attempted suicide was reviewed and updated using patient admission records. The subsequent database comprised: cause, level and completeness of injury; height fallen; psychiatric history; psychiatric diagnosis; date of last contact; further suicide attempts; religious affiliation; previous and present employment; date and cause of death; date and place of discharge; and any other relevant details. From this database the three primary objectives of the study were ascertained: demographic detail; psychiatric condition; and outcome information.

RESULTS

The ratio of males to females was 1 : 1 with a mean age of 32. Almost half (48.9%) were single, around a third (32.8%) had children and 42. 3% were employed. Schizophrenia and depression were evident in 32.8% and 27% of cases respectively. Previous suicide attempts had been made by 23% (n=32). The cause of injury in 85% of cases was 'falls'. Thirty-three people are known to have died, of whom eight (24%) committed suicide. During the period between the first and last spinal cord injury examined within this study (1951 - 1992) 1.6% (n=137) of the total sample of patients treated at the rehabilitation centre (n=8347) sustained a spinal cord injury as a result of a suicide attempt.

CONCLUSION

Significant findings include; a high proportion of patients with schizophrenia; similar findings concerning age profile and level of injuries with previous research, but different sex ratio; and information on longer-term outcomes. Recommendations for further research include an adaptation of the psychological autopsy approach which would provide information beyond that normally available in actual suicides.

Phase I trial of multiple cycles of high-dose chemotherapy supported by autologous peripheral-blood stem cells

PURPOSE

To determine the safety and feasibility of delivering multiple cycles of front-line high-dose carboplatin and paclitaxel with hematopoietic peripheral-blood stem cell (PBSC) support.

PATIENTS AND METHODS

Patients were required to have a malignant solid tumor for which they had received no prior chemotherapy. Mobilization of PBSC was achieved with cyclophosphamide, etoposide, and granulocyte-macrophage colony-stimulating factor (GM-CSF). After one cycle of conventional-dose carboplatin and cyclophosphamide with GM-CSF, patients received multiple cycles of high-dose carboplatin (area under the concentration-time curve [AUC], 12 to 20) and paclitaxel (250 mg/m(2)) with PBSC and GM-CSF repeated every 28 days.

RESULTS

Twenty-four of 28 patients were assessable for toxicity and clinical outcome. Dose-limiting toxicities were dehydration, diarrhea, and electrolyte imbalances. The maximum-tolerated dose of carboplatin was AUC 16 (equivalent to a median of 1,189 mg/m(2)). The relationship of target AUC to measured AUC was linear (r(2) =. 29; P =.0011). The overall response rate was 96%, with a complete clinical response rate of 67%. The median time to progression from the first PBSC reinfusion was 49.5 weeks (range, 8 to 156+ weeks).

CONCLUSION

Multiple cycles of high-dose carboplatin (AUC 16) and paclitaxel (250 mg/m(2)) can be safely administered with GM-CSF and PBSC support. Although this regimen is safe, feasible, and active, the use of multiple cycles of high-dose chemotherapy as front-line treatment remains experimental and should only be used in the context of a clinical trial.

Comparison of clinical staging algorithms and 111indium-capromab pendetide immunoscintigraphy in the prediction of lymph node involvement in high risk prostate carcinoma patients

BACKGROUND

The pretherapy prediction of occult lymph node involvement and the avoidance of otherwise futile and potentially morbid definitive local therapy is paramount in men with newly diagnosed prostate carcinoma. To identify patients with prostate carcinoma who likely have lymph node involvement and would benefit from staging lymphadenectomy prior to definitive local therapy, the authors compared the ability of several predictive staging algorithms and a radiolabeled monoclonal antibody scan to predict lymphatic metastases prior to treatment.

METHODS

Between August 1991 and June 1994, 198 men with clinical T2 or T3 classified (TNM) prostate carcinoma (bone scan negative) who were at high risk of lymph node involvement underwent a 111In-capromab pendetide scan prior to staging lymphadenectomy. Several predictive models based on preoperative prostate specific antigen level, biopsy Gleason score, and clinical stage were selected to predict those men having a > or =20% probability of lymph node involvement. The ability to predict pathologic stage using several clinical algorithms and the monoclonal antibody scan was compared with pathologic examination of the lymph nodes.

RESULTS

Overall, 39% of the pelvic lymph node specimens were positive for metastatic disease by pathologic analysis. Published algorithms predicting lymph node metastases had a positive predictive value (PPV) ranging from 40.5% to 46.6% and an area under the receiver operating characteristic curve (AUC) ranging from 0.52 to 0.61. The monoclonal antibody scan had a PPV of 66.7% and an AUC of 0.71. The differences between the PPV and the AUC for the individual clinical algorithms when compared with immunoscintigraphy were statistically significant. Combining the radiolabeled monoclonal antibody scan with clinical predictive models, a PPV of up to 72.1% could be obtained.

CONCLUSIONS

These data suggest that the PPVs for the clinical predictive algorithms are similar and that the PPV of the radiolabeled monoclonal antibody scan alone or in combination with the algorithms has additional value in predicting lymph node involvement in prostate carcinoma patients at high risk of regional disease spread. These algorithms and the 111In-capromab pendetide scan may be used for the appropriate selection of candidates for definitive local therapy in men with clinically localized prostate carcinoma and significant risk of lymph node involvement.

Growth of preterm infants with cystic periventricular leukomalacia

Etiology of the high rates of growth failure in children with cerebral palsy (CP) remains unclear. The purpose of this study was to evaluate the relation between growth failure in preterm infants with cystic periventricular leukomalacia (CPVL) and neonatal health complications. The population consisted of all preterm infants (51) with a gestational age of <33 weeks who were admitted to the Children's Hospital of Buffalo from 1988 to 1993 and who had CPVL. Out of the 41 survivors with CPVL who were followed, 39 developed CP and 18 developed growth failure during infancy. At the time of greatest growth failure, the majority (72%) of infants had signs of undernutrition as defined by the Waterlow (1972) classification. Oral feeding impairment was the sole risk factor for the occurrence of growth failure. Undernutrition appears to be important in the occurrence of growth failure in preterm infants with CPVL and CP.

Multicenter radioimmunoscintigraphic evaluation of patients with prostate carcinoma using indium-111 capromab pendetide

BACKGROUND

Optimum therapy for prostate carcinoma patients requires accurate staging, but computed tomography (CT) and magnetic resonance imaging (MRI) have limitations as methods for detecting soft tissue metastases. In this study, radioimmunoscintigraphy (RIS) was evaluated for its ability to identify sites of metastatic disease in lymph nodes.

METHODS

RIS was evaluated in 51 prostate carcinoma patients at high risk for metastatic disease. An intravenous infusion of indium-111 capromab pendetide was given, followed by nuclear medicine imaging on two separate dates. Bilateral, open pelvic lymph node dissection was performed with additional exploration and biopsy of scan positive extraprostatic regions. Histologic evaluation of removed tissue confirmed the accuracy of RIS. In addition, results were compared with other standard methods for diagnosing patients prior to surgery.

RESULTS

Nineteen patients (37%) had evidence of lymph node involvement with RIS. Fifteen of the 19 positive patients had pathologic evidence of cancer in the biopsied lymph nodes. Sensitivity, specificity, accuracy, and the positive predictive value for detection of extraprostatic disease were 75%, 86%, 81%, and 79%, respectively. CT, MRI, and ultrasound of the pelvis demonstrated a combined accuracy of only 48% in detecting lymph node disease. Twenty-five previously undetected sites were deemed positive with RIS. Fourteen of these were biopsy-proven tumor sites, seven were probable tumor sites, and four were assumed to be false-positive.

CONCLUSIONS

RIS had an impact on patient management through its detection of occult disease in more than 50% of prostate carcinoma patients studied, and it provided information concerning the likelihood that lymph node metastases would be found during surgery.

Bacteria lacking a multidrug pump: a sensitive tool for drug discovery

Microorganisms express multidrug resistance pumps (MDRs) that can confound antibiotic discovery. We propose the use of mutants deficient in MDRs to overcome this problem. Sensitivity to quinolones and to amphipathic cations (norfloxacin, benzalkonium chloride, cetrimide, pentamidine, etc.) was increased 5- to 30-fold in a Staphylococcus aureus mutant with a disrupted chromosomal copy of the NorA MDR. NorA was required both for increased sensitivity to drugs in the presence of an MDR inhibitor and for increased rate of cation efflux. This requirement suggests that NorA is the major MDR protecting S. aureus from the antimicrobials studied. A 15- to 60-fold increase in sensitivity to antimicrobials also was observed in wild-type cells at an alkaline pH that favors accumulation of cations and weak bases. This effect was synergistic with a norA mutation, resulting in an increase up to 1,000-fold in sensitivity to antimicrobials. The usefulness of applying MDR mutants for natural product screening was demonstrated further by increased sensitivity of the norA- strain to plant alkaloid antimicrobials, which might be natural MDR substrates.

Prostate cancer abdominal metastases detected with indium-111 capromab pendetide

To provide appropriate therapy for prostate cancer, accurate staging of the patient's disease is essential. Determination of tumor size, location, periprostatic extension and metastatic disease in the skeleton and soft tissue are needed to stage properly. Current diagnostic modalities may lead to understaging in 40%-70% of prostate cancer. Detection of metastatic disease, both at the time of initial diagnosis and in patients with suspected local recurrence, can significantly alter the type of therapy given. Clinical studies using the (111)In radiolabeled immunoconjugate, MAb 7E11-C5.3-GYK-DTPA (capromab pendetide), have shown the superiority of radioimmunoscintigraphy over other diagnostic modalities in the detection of both primary and metastatic prostate cancer. Radioimmunoscintigraphy with capromab pendetide depends on expression of tumor-associated antigen rather than lesion size. Earlier detection of extraprostatic invasion and metastases by means of radioimmunoscintigraphy provides valuable information for treatment decisions. A case of metastatic prostate cancer in the abdomen of a patient without local disease, in which the extent of disease was confirmed at autopsy after sudden cardiac arrest, is presented.

'Best clinical practice': assessment of processes of care and of outcomes in the US Military Health Services System

The National Quality Management Program of the Military Health Services System of the United States has undertaken a series of projects whose objective is the active, on-going monitoring and improvement of the effectiveness and efficiency of the care provided to a broad population that encompasses troops on active duty, retirees and dependents. The analytic activities consist of (1) identification by clinical panels of conditions and procedures of interest; (2) collection of data from electronic repositories and from charts to characterize the patients, how they are managed, the clinical outcomes they experience, the resource costs their care entails, and, from questionnaires, their functional status and level of satisfaction, and (3) generation of 'report cards' that inform organizational units down to the level of the hospital of the characteristics of their patients, their practices, and the risk-adjusted outcomes they achieve. The patterns of care employed by the hospitals that obtain the best risk-adjusted outcomes and resource utilization ('best clinical practice') are identified and made known. In addition, (4) a systematic process of developing outcomes-based practice guidelines has been devised. It intent is to serve as a decision-support tool for clinicians. Initial estimates have been obtained of the probable consequences of the application of this tool to operative interventions in childbirth. Use of the tool would result in a higher occurrence of elective Caesarean sections, a reduced rate of emergency Caesarean sections and much lower use of forceps, with an overall improvement in outcomes and lower resource costs. This program is currently in the early phases of implementation. The two principal requirements for the immediate future are (1) education of the clinical and administrative communities in the use of the data and the decision-support tools and (2) evaluation of the consequences of the use of the data by the clinical and administrative communities.

Expanding horizons. Integrating environmental health in occupational health nursing

1. Environmental hazards are ubiquitous. Many exist in the workplace or occur as a result of work process exposures. 2. Environmental health is a natural component of the expanding practice of occupational health nursing. 3. AAOHN's vision for occupational and environmental health will continue to set the standard and provide leadership in the specialty.