Occupational risk of infection with human immunodeficiency virus

Randomized Prospective Study of the Impact of Three Needleless Intravenous Systems on Needlestick Injury Rates

Objective:

To determine the impact of three needleless intravenous systems on needlestick injury rates.

Design:

Randomized controlled trial.

Setting:

1,000-bed tertiary-care Midwestern hospital.

Participants:

Nursing personnel from general medical, general surgical, and intensive-care units.

Interventions:

From June 1992 through March 1994, a metal blunt cannula (MBC), two-way valve (2-way), and plastic blunt cannula (PBC) were introduced into three study areas, and needlestick injury rates were compared to three control areas using traditional needled devices.

Results:

24 and 29 needlestick injuries were reported in study and control areas. Intravenous-therapy-related injuries comprised 45.8% and 57.1% of injuries in each area. Thirty-seven percent and 20.7% of study and control area needlestick injuries were considered to pose a high risk of bloodborne infection. The 2-way group had similar rates of total and intravenous-related needlestick injuries compared to control groups. The PBC group had lower rates of total and intravenous-related needlestick injuries per 1,000 patient-days (rate ratios [RR], 0.32 and 0.24; 95°% confidence intervals [CI95], 0.12-0.81 and 0.09-0.61;P=.02 andP=.003, respectively) and per 1,000 productive hours worked (RR, 0.11 and 0.08; CI95, 0.01-0.92 and 0.010.69;P=.03 andP=.005, respectively) compared to controls.

Conclusions:

Needlestick injuries continued in study areas despite the introduction of needleless devices, and risks of bloodborne pathogen transmission were similar to control areas. The PBC device group noted lower rates of needlestick injuries compared to controls, but there were problems with product acceptance, correct product use, and continued traditional device use in study areas. Low needlestick injury rates make interpretations difficult. Further studies of safety devices are needed and should attempt greater control of worker behavior to aid interpretation.

Human immunodeficiency disease: how should it affect surgical decision making?

BACKGROUND

The ever-increasing prevalence of human immunodeficiency virus (HIV) infection and the continued improvement in clinical management has increased the likelihood of surgery being performed on patients with this infection. The aim of the review was to assess current literature on the influence of HIV status on surgical decision-making.

METHODS

A literature review was performed using MEDLINE articles addressing "human immunodeficiency virus," "HIV," "acquired immunodeficiency syndrome," "AIDS," "HIV and surgery." We also manually searched relevant surgical journals and completed the bibliographic compilation by collecting cross references from published papers.

RESULTS

Results of surgery between noninfected and HIV-infected individuals and between HIV-infected and acquired immunodeficiency syndrome (AIDS) patients are variable in terms of morbidity, mortality, and hospital stay. The risk of major surgery is not unlike that for other immunocompromised or malnourished patients. The multiple co-morbidities associated with HIV infection and the availability of highly active antiretroviral therapy must be considered when assessing and optimizing the patient for surgery. The clinical stage of the patient's disease should be evaluated with a focus on the overall organ system function. For patients with advanced HIV disease, palliative surgery offers relief of acute problems with improvement in the quality of life. When indicated, diagnostic surgery assists with further decision-making in the medical management of these patients and hence should not be withheld.

CONCLUSION

HIV infection should not be considered a significant independent factor for major surgical procedures. Appropriate surgery should be offered as in normal surgical patients without fear of an unfavorable outcome.

Perceptions of orthopaedic surgeons regarding hepatitis C viral transmission: a questionnaire survey

INTRODUCTION

Occupationally acquired hepatitis C viral infection is an important issue in surgery since there are no known vaccines or effective prophylaxis.

MATERIALS AND METHODS

An anonymous questionnaire survey was performed to determine the attitudes and perception of risks of occupational acquired hepatitis C viral transmission in orthopaedic surgeons.

RESULTS

A total of 763 questionnaires were posted to orthopaedic surgeons with various subspecialty interests and 261 surgeons responded (34.2%). Of respondents, 117 (47%) had sustained sharps injuries in the previous 12 months. Only 82 surgeons (33%) always reported such injuries, although 208 (84%) expressed concerns of occupationally acquired hepatitis C viral transmission. Orthopaedic surgeons were mostly unaware of the true prevalence of hepatitis C in high-risk groups, such as intravenous drug abusers.

CONCLUSIONS

Greater awareness of all aspects of hepatitis C infection and its risks to the practice of surgery is required. Further debate is necessary on the role of routine testing of surgeons and patients.

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.

Anonymous pilot study of hepatitis C virus prevalence in liver transplant surgeons

The risk of hepatitis C virus (HCV) transmission to surgeons is related to the HCV prevalence in the surgical patient population. As HCV-related cirrhosis is the commonest indication for liver transplantation in Europe and North America, liver transplant surgeons are at particular risk. The prevalence of HCV infection in liver transplant surgeons is unknown. The aim of this study was to estimate the prevalence of HCV infection in liver transplant surgeons attending the 9th Congress of the International Liver Transplantation Society using unlinked anonymous testing for HCV. Surgeons attending the conference were invited to complete an anonymised questionnaire regarding their surgical and transplant practice and provide an unlinked anonymised blood spot sample by finger prick. Samples were screened for antibodies to HCV (enzyme-linked immunosorbent assay III, Ortho Diagnostics, Raritan, NJ). Polymerase chain reaction testing for HCV RNA was performed on reactive samples.A total of 117 liver transplant surgeons (79 European, 16 North American, 10 Asian, 9 South American, 3 Australasian) provided a blood spot sample. Two (1.7%) surgeons had antibodies to HCV, 1 (0.8%) had detectable HCV RNA (genotype 1a). Assuming that both infections were acquired during surgery, the estimated maximum rate of HCV transmission is 1 per 743 to 1,045 years of surgical (0.96 to 1.35 HCV transmissions per 1,000 years of general surgical practice) and 449 to 683 years of liver transplant practice (1.46 to 2.23 HCV transmissions per 1,000 years of liver transplantation practice). In conclusion, risk of HCV transmission to liver transplant surgeons appears to be low despite the particular risks associated with frequently operating on HCV infected patients.

Mastoidectomy and trans-corneal viral transmission

The incidence of chronic middle ear disease is falling in Britain, and in adults, is currently approximately 2.6% (inactive) and 1.5% (active). The incidence of HIV and hepatitis C is, however, rising. With this in mind, the chances of operating on a patient with undiagnosed infection is increasing. Operations involving the drilling or cutting of bone in patients with bloodborne communicable diseases are inherently dangerous to surgeons. In the pre-antibiotic era, many orthopaedic surgeons succumbed to infection and septicemia after being pierced with a spicule of bone during the execution of their duty. With the advent of the antibiotic era, the phenomenon is no longer life threatening where a bacterium is the offending microorganism. The principle, however, may be just as valid today with regard to viral communicable diseases. The world medical literature is full of reports of transmission of HIV from doctor to patient or dentist to patient. Very little is written about the reverse. This study attempted to address the apparent imbalance in the debate over exactly who is most at risk of iatrogenic transmission of potentially lethal viruses. We took fish eyes and held them in place around a mastoid cavity during drilling of a temporal bone. The eyes were then stained with fluorescein and a blue light shone over them to identify any spicules and corneal tears. Also, during this study, the maximum distance of bone dust scatter from an in vivo mastoid operation was measured from the cavity in all directions and documented. The HIV and hepatitis C virus are discussed and the importance of protection to staff highlighted.

[Risk knowledge and management of blood exposure in operative room: results of a French national survey]

OBJECTIVES

To assess knowledge of risk factors of blood exposure in operative room and management after blood exposure.

METHODS

A national survey was conducted towards 5000 surgeons drawn with hazard.

RESULTS

The knowledge of the risk of viral contamination stay imperfect and the management after blood exposure is doubtful, and this last point is probably favoured by the absence of regulation in spite of guidelines from professional associations or societies.

CONCLUSION

Knowledge of risk factors and more clear regulations could permit a better attitude in case of blood exposure.

Health and safety at necropsy

The postmortem room is a source of potential hazards and risks, not only to the pathologist and anatomical pathology technician, but also to visitors to the mortuary and those handling the body after necropsy. Postmortem staff have a legal responsibility to make themselves aware of, and to minimise, these dangers. This review focuses specifically on those hazards and risks associated with the necropsy of infected patients, with foreign objects present in the body, and with bodies that have been contaminated by chemicals or radioactive sources.

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.

Potential role of famciclovir for prevention of herpetic whitlow in the health care setting

Oral famciclovir was initiated in a health care worker immediately after an accidental percutaneous injury involving a needle freshly removed from a patient's herpes labialis vesicles. In follow-up, the health care worker remained seronegative for herpes simplex I and II antibodies (IgG and IgM) and did not develop herpetic whitlow, supporting the potential role of famciclovir in the prevention of herpetic whitlow in a health care setting.

Hospital safety climate and its relationship with safe work practices and workplace exposure incidents

BACKGROUND

In the industrial setting, employee perceptions regarding their organization's commitment to safety (i.e., safety climate) have been shown to be important correlates to both the adoption and maintenance of safe work practices and to workplace injury rates. However, safety climate measures specific to the hospital setting have rarely been evaluated. This study was designed to develop a short and effective tool to measure hospital safety climate with respect to institutional commitment to bloodborne pathogen risk management programs and to assess the relationship between hospital safety climate and (1) employee compliance with safe work practices and (2) incidents of workplace exposure to blood and other body fluids.

METHODS

A questionnaire, which included 46 safety climate items, was developed and tested on a sample of 789 hospital-based health care workers at risk for bloodborne pathogen exposure incidents.

RESULTS

A 20-item hospital safety climate scale that measures hospitals' commitment to bloodborne pathogen risk management programs was extracted through factor analysis from the 46 safety climate items. This new hospital safety climate scale subfactored into 6 different organizational dimensions: (1) senior management support for safety programs, (2) absence of workplace barriers to safe work practices, (3) cleanliness and orderliness of the work site, (4) minimal conflict and good communication among staff members, (5) frequent safety-related feedback/training by supervisors, and (6) availability of personal protective equipment and engineering controls. Of these, senior management support for safety programs, absence of workplace barriers to safe work practices, and cleanliness/orderliness of the work site were significantly related to compliance (P<.05). In addition, both senior management support for safety programs and frequent safety-related feedback/training were significantly related to workplace exposure incidents (P<.05). Thus the most significant finding in terms of enhancing compliance and reducing exposure incidents was the importance of the perception that senior management was supportive of the bloodborne pathogen safety program.

CONCLUSIONS

Hospital safety climate with regards to bloodborne pathogens can be measured by using a short, 20-question scale that measures 6 separate dimensions. Whereas all 6 dimensions are essential elements of overall safety climate, 3 dimensions are significantly correlated with compliance, and 1 dimension (senior management support) is especially significant with regard to both compliance and exposure incidents. This short safety climate scale can be a useful tool for evaluating hospital employees' perceptions regarding their organization's bloodborne pathogens management program. In addition, because this scale measures specific dimensions of the safety climate, it can be used to target problem areas and guide the development of intervention strategies to reduce occupational exposure incidents to blood and other body fluids.

Precautions against cross-infection during operations for maxillofacial trauma

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

The impact of multifocused interventions on sharps injury rates at an acute-care hospital

OBJECTIVE

To determine the impact of a multifocused interventional program on sharps injury rates.

DESIGN

Sharps injury data were collected prospectively over a 9-year period (1990-1998). Pre- and postinterventional rates were compared after the implementation of sharps injury prevention interventions, which consisted of administrative, work-practice, and engineering controls (ie, the introduction of an anti-needlestick intravenous catheter and a new sharps disposal system).

SETTING

Sharps injury data were collected from healthcare workers employed by a mid-sized, acute-care community hospital.

RESULTS

Preinterventional annual sharps injury incidence rates decreased significantly from 82 sharps injuries/1,000 worked full-time-equivalent employees (WFTE) to 24 sharps injuries/1,000 WFTE employees postintervention (P<.0001), representing a 70% decline in incidence rate overall. Over the course of the study, the incidence rate for sharps injuries related to intravenous lines declined by 93%, hollow-bore needlesticks decreased by 75%, and non-hollow-bore injuries decreased by 25%.

CONCLUSION

The implementation of a multifocused interventional program led to a significant and sustained decrease in the overall rate of sharps injuries in hospital-based healthcare workers.

Exposure of medical students to body fluids

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

Issues complicating the implementation of postexposure prophylaxis

Occupational exposures to blood-borne pathogens occur regularly in diverse settings and involve multiple groups of healthcare workers. Current compliance of healthcare workers with behavioral controls is poor, and additional engineering and work-practice controls for exposure prevention are inadequate and/or underutilized. Barriers to effective postexposure management include deficient knowledge and fear and denial among healthcare workers, the diverse risks associated with different exposures, the costs and personnel necessary for providing exposure management 24 hours a day, variable levels of expertise in postexposure prophylaxis strategies, and administrative requirements for standardized policies and procedures. In the current environment, healthcare institutions are largely ill equipped to provide timely and effective postexposure prophylaxis. Widespread worker education, simplified reporting mechanisms, and availability of prompt source and worker testing along with timely, free postexposure prophylaxis is central to an institution's postexposure program. Postexposure management programs should be comprehensive and provide standardized procedures, expand workers' access to postexposure prophylaxis by establishing responsible parties in diverse areas, disseminate program information to all workers, and ensure confidentiality in the care and follow-up of exposed workers. To implement such programs, it may be necessary to merge resources and link local management of exposures with regional expertise to provide up-to-date counseling in a rapidly changing field. Careful surveillance of occupational exposures is essential to evaluate program efficacy, direct prevention efforts, and to determine necessary resources to ensure continued successful delivery of postexposure prophylaxis.

Hospital nurses' occupational exposure to blood: prospective, retrospective, and institutional reports

OBJECTIVES

This study examined nurses risk of exposure to blood resulting from injuries with needles and sharps, the methods of estimating those risks, and the factors affecting risks.

METHODS

Nurses on 40 medical units in 20 hospitals in cities with a high incidence of AIDS were studied. Percutaneous injuries were documented for every shift during a 30-day period. These prospective reports were compared with retrospective and institutional reports. Factors affecting the likelihood of injuries were explored.

RESULTS

Based on the prospective reports, the rate of injuries to staff nurses was 0.8 per nurse-year. Prospective and retrospective rates were similar, while institutional rates were significantly lower. Factors associated with increased injuries included recapping needles and temporary work assignments. Working in hospitals characterized by professional nurse practice models and taking precautions to avoid blood contact were associated with fewer injuries.

CONCLUSIONS

Injuries from needlesticks are more common than institutional reports suggest and do not occur at random. Diminishing the frequency with which nurses recap needles, increasing precautions they take, reducing use of temporary nursing personnel, and implementing organizational changes may lower the odds of nurses being injured.

Transmission of Human Immunodeficiency Virus Infection in the Surgical Setting

The emergence of the human immunodeficiency virus (HIV) has highlighted the need for orthopaedic surgeons to understand the epidemiology of percutaneous injuries and other blood exposures in the surgical setting. The American Academy of Orthopaedic Surgeons and the Centers for Disease Control and Prevention have worked to increase understanding and prevent transmission of blood-borne viral diseases in orthopaedic surgery. This article addresses the risk of HIV transmission in the surgical setting, with a focus on surveillance efforts to monitor the extent of occupational HIV infection, specific risk factors, and postexposure management. Health-care worker-to-patient transmission and patient-to-patient transmission are also addressed.

Preventing bloodborne pathogen transmission from health-care workers to patients. The CDC perspective

The development of recommendations to manage the risk of bloodborne pathogen transmission from health-care workers to patients during invasive procedures has been difficult, primarily because of the limitations of available scientific data. Ultimately, both health-care workers and patients will be protected best by compliance with infection control precautions and by development of new instruments, protective equipment, and techniques that reduce the likelihood of intraoperative blood exposure without adversely affecting patient care.