Scalpel injury and HIV infection in a surgeon. The Studio Italiano Rischio Occupazionale da HIV (SIROH)

Cut-resistant protective gloves in pathology--effective and cost-effective

Cutting injuries and needle-stitch injuries constitute a potentially fatal danger to both pathologists and autopsy personnel. We evaluated such injuries in a large German institute of pathology from 2002 to 2007 and analysed the effect of the introduction of cut-resistant gloves on the incidence of these injuries. In the observation period, 64 injuries (48 cutting injuries and 16 needle-stitch injuries) were noted in the injury report books. Most injuries were located at the non-dominant hand, preferentially at the index finger and the thumb. Around one fifths of the injuries were at the side of handedness. The average number of injuries per month was 1.22 for the 50 months prior to the introduction of cut-resistant gloves, more than seven times higher than after their introduction (0.158; 19 months; p < 0.001). Considering the medical and administrational costs of such injuries, cut-resistant protective gloves are an effective and cost-effective completion of personal occupational safety measures in surgical pathology and autopsy. We strongly recommend the use of such gloves, especially for autopsy personnel.

Glove tears during arthroscopic shoulder surgery using solid-core suture

PURPOSE

Surgeons have noticed an increased incidence of finger lacerations associated with arthroscopic knot tying with solid-core suture material. This study examines glove perforations and finger lacerations during arthroscopic shoulder surgery.

METHODS

We collected 400 surgical gloves from 50 consecutive arthroscopic shoulder repair procedures using No. 2 solid-core sutures. Two surgeons using double gloves were involved in every case, with one being responsible for tying all knots. Powder-free latex gloves were worn in all cases. Knots consisted of a sliding stitch of the surgeon's preference followed by 3 half-hitches via a knot-pusher instrument. All gloves were inspected grossly and then tested for tears with an electroconductivity meter.

RESULTS

The knot-tying surgeon had significantly more glove tears than the control (P < .01). Tears were localized to the radial side of the index finger of the glove at the distal interphalangeal joint in all cases. Of the tying surgeon's gloves, 68 (34%) were found to have tears. These included 17 inner gloves (17%) and 51 outer gloves (51%). If an inner glove was torn, the corresponding outer glove was torn in all cases. A mean of 3.96 knots were tied in each case. There was a significantly higher incidence of inner glove tears when more than 3 knots were tied (P < .03). There was no significant difference in glove tears between suture types. Finger lacerations did occur in the absence of glove tears. However, in the presence of an inner glove tear, there was a statistically significant association with a finger laceration at the corresponding level (P < .03).

CONCLUSIONS

Intraoperative glove tears and subsequent finger lacerations occur with a high frequency when arthroscopic knots are tied with solid-core suture material. Risk can potentially be minimized by frequent glove changes or use of more durable, less penetrable gloves.

CLINICAL RELEVANCE

This study addresses surgeon and patient safety during arthroscopic shoulder surgery.

Inadequate hepatitis B vaccination and post-exposure evaluation among transplant surgeons: prevalence, correlates, and implications

OBJECTIVES

To identify the proportion of U.S. transplant surgeons who are adequately vaccinated against hepatitis B virus (HBV), identify characteristics associated with inadequate vaccination, and assess the proportion who had been evaluated for immunization following potential HBV exposures.

SUMMARY BACKGROUND DATA

It is unknown what proportion of transplant surgeons are appropriately vaccinated against HBV or evaluated for immunization following operative exposures.

METHODS

We mailed questionnaires and to all active U.S. transplant surgeons. We compared demographic characteristics of responders and nonresponders to evaluate the potential for nonresponse bias.

RESULTS

Of 619 eligible respondents, 347 (56.1%) returned completed questionnaires. Of the 311 surgeons for whom HBV vaccination was indicated (all surgeons with neither a prior history of HBV infection nor a prior adverse reaction to the vaccine itself), 70 (22.5%; 95% confidence interval [CI], 18.0-27.6%) received fewer than the recommended 3 injections. Surgeon characteristics associated with inadequate vaccination included length of clinical practice (odds ratio [OR], 1.5 per 10-year increment in duration of practice; 95% CI, 1.1-2.2), increased fear of infection (OR, 1.2 for each unit increase in fear out of 10; 95% CI, 1.1-1.4), and lack of recent testing for HBV infection (OR, 2.0; 95% CI, 1.1-3.8). Of the 94 surgeons (27.3%) reporting at least one needle-stick exposure while operating on an HBV-infected patient, 14 (14.9%) were inadequately vaccinated; of these 14, only 5 (35.7%) sought appropriate serologic testing and counseling for active immunization. Surgeons underestimated both the risks of percutaneous exposure while operating, and of becoming infected with HBV if exposed.

CONCLUSIONS

Many transplant surgeons are inadequately vaccinated against HBV and fail to seek evaluation following possible exposures. Underestimation of the risks of HBV exposure and transmission may relate to these failures. Requiring documentation of HBV vaccination and immunity to maintain operating room privileges may protect surgeons, their patients, and operating room staff.

Cutting injuries in an academic pathology department

CONTEXT

Cutting injuries pose an infrequent but serious threat to anatomic pathology personnel. Although cut-resistant gloves may reduce this danger, it is imperative to recognize specific behaviors that increase the chance of an injury.

OBJECTIVE

To examine the incidence of cutting injuries in an academic pathology department and the mechanisms by which such injuries occurred.

DESIGN

Hospital Report of Event forms completed for laboratory incidents of cutting injury from March 1998 to September 2003 were evaluated. Further information regarding the incidents was obtained, when possible, by interviews with those personnel involved.

SETTING

A university-based pathology laboratory was the setting for this study. On average, 505 autopsies and 29,000 surgical specimens were processed each year during the 5.5-year time period.

PARTICIPANTS

Pathology attending physicians, residents, dieners, and pathologists' assistants who performed autopsies and surgical specimen examinations.

RESULTS

Eight scalpel injuries occurred during the study period. No needle-stick injuries were reported. Searching for lymph nodes and cutting firm tissue each accounted for 3 of the injuries. Only 2 of the 8 individuals were in compliance with the departmental policy regarding protective glove wear. Hospital Report of Event forms alone failed to elicit sufficient detail regarding the mechanism of injury.

CONCLUSIONS

A laboratory-based form may be necessary to supplement the hospital form, so as to obtain full details of each injury. This information may then be disseminated to all who handle blades, with the goal of preventing future cutting injuries.

The Greenfield filter as a potential hazard to the operating surgeon

The Greenfield filter and similar devices are placed in the vena cava of patients who have contraindications to anticoagulation, but who would otherwise be at risk of pulmonary embolism without such anticoagulation. Injury to a health care worker from one of these devices has been reported in the case of a pathologist performing a necropsy. To the author's knowledge, injury or near-injury to a member of the surgical team during operation has not been reported in the literature. The authors report on a near-miss injury from such a device to the surgical first assistant during the performance of a pancreaticoduodenectomy. Simple guidelines to avoid similar injuries are provided.

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.

Risk of HIV transmission from patients to surgeons in the era of post-exposure prophylaxis

The HIV prevalence, among patients either undergoing, or with the potential to undergo, surgery were estimated using data from unlinked anonymous HIV surveys of patients in Glasgow hospitals during 1992-1997 in order to quantify the risk of surgeons acquiring HIV occupationally in the era of post-exposure prophylaxis (PEP) availability. A range of prevalence rates was applied to data on other factors influencing risk; these comprised, i) the probability of a percutaneous injury from a sharp instrument used on an HIV infected patient resulting in HIV transmission, ii) the number of injuries sustained and iii) whether or not PEP was administered. On the basis of, for example, a surgeon sustaining three percutaneous injuries over 12 months and not taking PEP after each, the annual risks ranged from 1 in 2,000,000 for urological/renal surgeons to 1 in 200,000 for those performing general surgery/ENT/gynaecological procedures. The administration of PEP after each injury would reduce these rates to 1 in 10,000,000 and 1 in 1,000,000 respectively. The risk of surgeons acquiring HIV occupationally in a city which has an HIV prevalence typical of most urban areas in the UK, is 'minimal' or 'negligible'. In the context of such low risk and our limited knowledge of the adverse effects of PEP, the risk assessment to decide whether or not to give PEP should be well informed and consistent. Current guidelines to help physicians and affected healthcare workers in their decision making need to be improved.

A study of patterns and prevention of blood exposures in OR personnel

The authors conducted a surveillance study of occupational blood exposures in the ORs at six hospitals to identify risk patterns and prevention strategies. For 15 months, trained circulating nurses recorded OR staff members' exposures during all surgical procedures using a modified version of the Exposure Prevention Information Network surveillance system. It was discovered that a high proportion of percutaneous injuries were potentially preventable if safer devices had been used, and the authors estimate that use of blunt suture needles alone could reduce injuries by 30%. Increased use of barrier precautions is indicated to prevent mucocutaneous blood exposures. Health care workers' eyes were identified in the study as being the most vulnerable location for serious blood exposures.

HIV serophobia in the mortuary: an algorithm system for handling high-risk forensic cases

A serophobia of the human immunodeficiency virus type 1 (HIV-1) is very noticeable in mortuaries handling high-risk cases. The morbid anxiety about occupationally acquired HIV infection in the forensic practice has made mortuary workers unduly overcautious. Despite the availability of codes of practice and informed principles of health and safety, there is considerable anxiety that an HIV carrier with no identifiable risk factors may be overlooked or a seronegative body may be inadvertently assumed to be uninfected. In contrast, a false sense of safety can pose a health hazard and has public health implications. An algorithm system is outlined for selective handling of unsuspected or unrecognized high-risk cases. It is necessary that guidelines are reasonably simple and incorporate statutory health and safety regulations and local safe working practice in the mortuary. Although it is not a legal obligation, approval by the coroners should facilitate consistent implementation of a protocol. A common experience in public and NHS hospital mortuaries in the London coroners' jurisdictions is characterized.