Emergency department management of blood and body fluid exposures

The Urban Emergency Department: A Potential Increased Occupational Hazard for Sharps-related Injuries

OBJECTIVES

Health care workers are at risk for sharps-related injuries while working in the clinical arena. The authors sought to quantify and compare the frequency of these injuries for all health care personnel between the urban and community emergency department (ED).

METHODS

A retrospective review was performed on the institutional human resources database of all self- or supervisor-reported sharps-related injuries that occurred to ED personnel in a single health system from January 2010 through September 2014. The health system was composed of a single urban academic Level I trauma center and seven community EDs, two of which were academic Level III trauma centers. Each sharps-related injury was reviewed for site of injury, job class, and type of instrument causing the injury.

RESULTS

There were 171 sharps-related injuries reported during 447,986 urban and 1,350,623 community patient visits. Of the 171 injuries, 44.4% occurred to physicians, 39.2% to nurses, 12.9% to support staff, and 3.5% to physician assistants. Injuries occurred more frequently at the urban academic medical center when compared to the pooled community sites: 20.3 per 100,000 patient visits (n = 91) versus 5.9 per 100,000 patient visits (n = 80), respectively (odds ratio = 3.43, 95% confidence interval = 2.54 to 4.63, p < 0.001). They also occurred more frequently at the urban site when individually compared to each community site.

CONCLUSIONS

Physicians accounted for the largest proportion of health care workers reporting sharps-related injuries. These injuries occurred more frequently in the urban ED than in the community EDs.

Reducing needlestick injuries through safety-engineered devices: results of a Japanese multi-centre study

BACKGROUND

Quantitative information on the effectiveness of safety-engineered devices (SEDs) is needed to support decisions regarding their implementation.

AIM

To elucidate the effects of SED use in winged steel needles, intravenous (IV) catheter stylets and suture needles on needlestick injury (NSI) incidence rates in Japan.

METHODS

Japan EPINet survey data and device utilization data for conventional devices and SEDs were collected from 26 participating hospitals between 1 April 2009 and 31 March 2014. The NSI incidence rate for every 100,000 devices was calculated according to hospital, year and SED use for winged steel needles, IV catheter stylets and suture needles. Weighted means and 95% confidence intervals (CI) were used to calculate overall NSI incidence rates.

FINDINGS

In total, there were 236 NSIs for winged steel needles, 152 NSIs for IV catheter stylets and 180 NSIs for suture needles. The weighted NSI incidence rates per 100,000 devices for SEDs and non-SEDs were as follows: winged steel needles, 2.10 (95% CI 1.66-2.54) and 14.95 (95% CI 2.46-27.43), respectively; IV catheter stylets, 0.95 (95% CI 0.60-1.29) and 6.39 (95% CI 3.56-9.23), respectively; and suture needles, 1.47 (95% CI -1.14-4.09) and 16.50 (95% CI 4.15-28.86), respectively. All devices showed a significant reduction in the NSI incidence rate with SED use (P < 0.001 for winged steel needles, P = 0.035 for IV catheter stylets and P = 0.044 for suture needles).

CONCLUSION

SED use substantially reduces the incidence of NSIs, and is therefore recommended as a means to prevent occupational infections in healthcare workers and improve healthcare safety.

Occupational injuries prone to infectious risks amongst healthcare personnel in Kuwait: a retrospective study

OBJECTIVE

The study aimed at determining the prevalence of incident occupational exposure to blood and other potentially infectious materials (OPIM) among healthcare personnel (HCP) during 2010 and at evaluating the factors associated with these incidents.

SUBJECTS AND METHODS

An epidemiological, retrospective, record-based study was conducted. All self-reported incidents of occupational exposure to blood and OPIM among HCP from all healthcare settings of the Kuwait Ministry of Health during 2010 were included.

RESULTS

The total number of the exposed HCP was 249. The prevalence of incident exposure was 0.7% of the HCP at risk. Their mean age was 32.31 ± 6.98 years. The majority were nurses: 166 (66.7%), followed by doctors: 35 (14.1%), technicians: 26 (10.4%) and housekeeping personnel: 22 (8.8%). Needle stick injury was the most common type of exposure, in 189 (75.9%), followed by sharp-object injury, mucous-membrane exposure and contact with nonintact skin. The majority of needle stick exposures, i.e. 177 (93.7%), were caused by hollow-bore needles. Exposure to blood represented 96.8%, mostly during drawing blood and the insertion or removal of needles from patients [88 (35.4%)] and when performing surgical interventions [56 (22.6%)]. Easily preventable exposures such as injuries related to 2-handed recapping of needles [24 (9.6%)] and garbage collection [21 (8.4%)] were reported. Exposures mainly occurred in the inpatient wards [75 (30.1%)] and operating theaters [56 (22.6%)]. Among the exposed HCP, 130 (52.2%) had been fully vaccinated against hepatitis B virus (HBV).

CONCLUSION

Needle stick injuries are the most common exposure among HCP in Kuwait, and nurses are the most frequently involved HCP category. A good proportion of exposures could be easily prevented. HBV vaccination coverage is incomplete.

The comparison of heparinized insulin syringes and safety-engineered blood gas syringes used in arterial blood gas sampling in the ED setting (randomized controlled study)

INTRODUCTION

The arterial blood gas measurement process is a painful and invasive procedure, often uncomfortable for both the patient and the physician. Because the patient-related factors that determine the difficulty of the process cannot be controlled, the physician-related factors and blood gas measurement techniques are a modifiable area of improvement that ought to be considered. Many hospitals use insulin syringes or syringes washed with heparin for the purpose of blood gas measurement because they do not have blood gas-specific syringes. In this prospective cross-sectional study, we aimed to compare safety-engineered blood gas syringes and conventional heparinized syringes used during the arterial blood gas extraction process in terms of ease of operation, the physician-patient satisfaction, laboratory appropriateness, and complications.

METHODS

Our study included patients whose arterial blood gas needed to be measured in the emergency department and who agreed to participate in the study. Patients were randomly divided into 2 groups. The arterial blood gas of the patients from the first group was measured by using conventional heparinized syringes, whereas safety-engineered blood gas syringes were used to measure the arterial blood gas of the patients from the second group. The groups were compared in terms of demographic data, the number of attempts, the physician and patient satisfaction, early and late-term complications, and laboratory appropriateness of the taken sample.

RESULTS

A total of 550 patients were included in our study in a 2-month study period. There were no significant differences between patients in terms of sex, age, weight, height, body mass index, and wrist circumference. In addition, the number of attempts (P=.489), patients' pain level during the procedure (P=.145), and the degree of difficulty of the procedure according to the patient (P=.109) and physician (P=.554) were not significantly different between the groups. After arterial blood gas extraction procedure, 115 patients (20.9%) developed complications. In the conventional heparinized syringe group, the complication rate (n=69; 25.1%) was significantly higher compared with the group that used safety-engineered blood gas syringes (n=46; 16%; P=.0211). Localized pain, which is one of the most common early complications, was more frequent in the conventional heparinized syringe group (19.3%). Complications in women (P=.003) and local pain (P=.01) developed lesser in the second group that used safety-engineered blood gas syringes, and the patient-physician satisfaction was higher in that group, as well. In the evaluation 48 hours after the procedure, the ratios of infection and local hematoma were higher in the conventional heparinized syringe group (P=.0213 and P < .0001).

CONCLUSION

In this study, we did not find any significant differences between the conventional heparinized syringes and safety-engineered blood gas syringes in terms of ease of operation, physician and patient satisfaction, and appropriateness of the taken sample. However, patients whose arterial blood gas was extracted by using safety-engineered blood gas syringes felt less pain and experienced fewer infections and hematomas at their puncture site.

Immune response and immunologic memory in medical personnel vaccinated with hepatitis B vaccine

The occupation-related nature of Hepatitis B viral infection in medical personnel has been well documented in a lot of studies. The only reliable way of prevention of this infection is immunisation with hepatitis B vaccine.

AIM

To follow-up the primary immune response after immunisation with recombinant vaccine and its duration in adult immunocompetent subjects.

MATERIALS AND METHODS

One hundred sixty-five health-care workers working at St. George University Hospital, Plovdiv in 2009/2010 were included in the study and allocated to two groups. Group 1 (N1 = 70) was followed up for the primary immune response after immunization; group 2 (N2 = 95) was with documented immunization in 1998/1999 (n = 81) and in 1994/1995 (n = 14). Tests based on ELISA for quantitative determination of anti-HBs in mIU/ml were used. The measurement were performed at the National Reference Laboratory of Viral Hepatitis at the NCIPD, Sofia. Descriptive statistics, non-parametric and parametric tests, qualitative correlation were used to analyse data.

RESULTS

Group 1 mean age was 40.3 +/- 2.6 years; anti-HBs concentration of > or = 10 mIU/ ml was found in 92.8%. No association between the immune response and the commonly involved factors such as gender, age, overweight, smoking, etc., was found. In group 2, anti-HBs concentration of > or = 10 mIU/ml was found in 77.9%: it was in 75.3% in those immunized 10 years before, and in 92.9% in those immunized 15 years before (t = 0.24, p > 0.05). A booster dose of the vaccine was received by 15/21 subjects from group 2 (those immunized 10 years before that) with anti-HBs < 10 mIU/ml. After the booster, 9/15 produced anti-HBs in protective concentrations (anamnestic immune response). The actual level of seroprotection among the immunized more than 10 years ago was 92%.

CONCLUSION

This study and the documentation of the primary postvaccinal immunity in high-risk medical personnel will help specify if additional hepatitis B vaccine shots are needed.

Effect of the introduction of an engineered sharps injury prevention device on the percutaneous injury rate in healthcare workers

OBJECTIVE

To evaluate the effect of introducing an engineered device for preventing injuries from sharp instruments (engineered sharps injury prevention device [ESIPD]) on the percutaneous injury rate in healthcare workers (HCWs).

METHODS

We undertook a controlled, interventional, before-after study during a period of 3 years (from January 1998 through December 2000) at a major medical center. The study population was HCWs with potential exposure to bloodborne pathogens. HCWs who sustain a needlestick injury are required by hospital policy to report the exposure. A confidential log of these injuries is maintained that includes information on the date and time of the incident, the type and brand of sharp device involved, and whether an ESIPD was used.

INTERVENTION

Introduction of an intravenous (IV) catheter stylet with a safety-engineered feature (a retractable protection shield), which was placed in clinics and hospital wards in lieu of other IV catheter devices that did not have safety features. No protective devices were present on suture needles during any of the periods. The incidence of percutaneous needlestick injury by IV catheter and suture needles was evaluated for 18 months before and 18 months after the intervention.

RESULTS

After the intervention, the incidence of percutaneous injuries resulting from IV catheters decreased significantly (P<.01), whereas the incidence of injuries resulting from suture needle injuries increased significantly (P<.008).

CONCLUSION

ESIPDs lead to a reduction in percutaneous injuries in HCWs, helping to decrease HCWs' risk of exposure to bloodborne pathogens.

Infection control practices among correctional healthcare workers: effect of management attitudes and availabiity of protective equipment and engineering controls

OBJECTIVES

To determine the relation of the availability of personal protective equipment (PPE) and engineering controls to infection control (IC) practices in a prison healthcare setting, and to explore the effect on IC practices of a perceived organizational commitment to safety.

DESIGN

Cross-sectional survey.

SETTING

The study population was drawn from the 28 regional Correctional Health Care Workers Facilities in Maryland.

PARTICIPANTS

All full-time Maryland correctional healthcare workers (HCWs) were surveyed, and 225 (64%) of the 350 responded.

METHOD

A confidential, self-administered questionnaire was mailed to all correctional HCWs employed in the 28 Maryland Correctional Health Care Facilities. The questionnaire was analyzed psychometrically and validated through extensive pilot testing. It included items on three major constructs: IC practices, safety climate (defined as the perception of organizational commitment to safety), and availability of IC equipment and supplies.

RESULTS

A strong correlation was found between the availability of PPE and IC practices. Similarly, a strong correlation was found between IC practices and the presence of engineering controls. In addition, an equally strong association was seen between the adoption of IC practices and employee perception of management commitment to safety. Those employees who perceived a high level of management support for safety were more than twice as likely to adhere to recommended IC practices. IC practices were significantly more likely to be followed if PPE was always readily available. Similarly, IC practices were more likely to be followed if engineering controls were provided.

CONCLUSION

These findings suggest that ready availability of PPE and the presence of engineering controls are crucial to help ensure their use in this high-risk environment. This is especially important because correctional HCWs are potentially at risk of exposure to bloodborne pathogens such as human immunodeficiency virus and hepatitis B and C viruses. Commitment to safety was found to be highly associated with the adoption of safe work practices. There is an inherent conflict of "custody versus care" in this setting; hence, it is especially important that we understand and appreciate the relation between safety climate and IC practices. Interventions designed to improve safety climate, as well as availability of necessary IC supplies and equipment, will most likely prove effective in improving employee compliance with IC practices in this healthcare setting.

Trends in bloodborne pathogen exposure and follow-up at an urban teaching hospital: 1987 to 1997

Health care workers (HCWs) risk occupational exposure to bloodborne pathogens. Effective postexposure treatment and testing depend on compliance with follow-up, but compliance rates are poorly understood. We examined trends in exposure and follow-up at a large teaching hospital after interventions to improve compliance. We reviewed exposures from October 1987 to September 1988 (group 1) and July 1996 to June 1997 (group 2). Data were analyzed for HCW demographics, source patient characteristics, and follow-up outcomes. We found that group 2 source patient serologic data were obtained more often. Group 1 source patients were more likely to be positive for the human immunodeficiency virus (HIV). Group 2 HCWs were more likely to be immune to hepatitis B virus, to agree to HIV testing, and to comply with follow-up. Follow-up rates remained suboptimal, even after high-risk exposures. Non-licensed HCWs were less likely to accept postexposure testing than physicians or nurses in group 2. General and targeted interventions to improve compliance and follow-up are still needed.

Pharmacologic management of HIV/STD exposure

Emergency physicians must be familiar with management of occupational exposures to HIV-infected bodily fluids. Victims of sexual assault also may be exposed to HIV and other sexually transmitted diseases. The Centers for Disease Control and Prevention guidelines for the management of occupational exposures include recommendations for administration of combination antiretroviral therapy to reduce the risk for HIV transmission. Antiretroviral therapy also may be indicated for certain types of sexual exposure to HIV. Drugs that are used to treat sexually transmitted diseases also may be given to prevent infection after possible exposures. This article reviews current recommendations for prophylaxis against HIV and other sexually transmitted diseases and the scientific basis for these recommendations.