Percutaneous blood exposure among Danish doctors: exposure mechanisms and strategies for prevention

Are we putting ourselves in danger? Occupational hazards and job safety for orthopaedic surgeons

As physicians, we strive to meet the needs of our patients. In doing so, we are often exposed to hazards that have the potential to not only compromise our health, but also our ability to deliver the best possible healthcare. Occupational hazards specific to the field of orthopaedics include infectious organisms, radiation, surgical smoke, chemicals, hazardous noise, musculoskeletal injury, and psychosocial stressors. Even though orthopaedic surgeons acknowledge the risk, most lack in-depth knowledge of the associated long-term harm associated with these hazards and ways of reducing risk of exposure. Orthopaedic surgeons should increase awareness, follow established guidelines, and integrate preventative measures to create the safest possible work environment. It is our hope that by improving our own health, we will be better equipped to address the health concerns of those we serve-our patients.

HIV post-exposure prophylaxis in the Emergency Department: a perspective from Singapore

Background:

Exposures to human immunodeficiency virus (HIV) commonly arrive at the Emergency Department (ED) for evaluation of transmission risk and the necessity for post-exposure prophylaxis (PEP). PEP aims to prevent HIV after exposure. International recommendations exist to guide eligibility assessment and standardise prescribing practices.

Objective:

The primary objective was to describe the patient cohort receiving HIV PEP at the ED. The secondary objective was to assess the ED physicians’ adherence to the 2005 guidelines provided by US Centers for Disease Control and Prevention for HIV PEP.

Methods:

This retrospective study identified patients prescribed with PEP after presenting with potential HIV exposure to a tertiary hospital ED in Singapore over 2 years. The exposure type and characteristics, source patient characteristics, indications for PEP, HIV status on presentation and on follow-up were assessed. Institutional guidelines recommended tenofovir/emtricitabine (Truvada) and raltegravir as HIV PEP.

Results:

Twenty-seven patients received HIV PEP during the study period. The majority (81.5%) presented after occupational exposure, with fresh needlestick injury (44.4%) being the most common cause. Amongst all recipients, PEP was indicated in 22.2% and not in 18.5%.

Conclusions:

With international guidelines simplifying eligibility assessment and prescribing practices, accurate and evidence-based PEP provision should be implemented at the frontline in the ED. These may be encouraged by enforcement of specific workflows and physician education.

The Prevalence of Accidental Needle Stick Injury and their Reporting among Healthcare Workers in Orthopaedic Wards in General Hospital Melaka, Malaysia

ABSTRACT

Background :Accidental needle-stick injuries (NSIs) are a hazard for health-care workers and general public health. Orthopaedic surgeons may be more prone to NSIs due to the prevalence of bone spikes in the operative field and the use of sharp orthopaedic instruments such as drills, saws and wires. A hospital-based cross sectional study was conducted in the orthopedic wards of Melaka General Hospital. The prevalence of NSIs was 32 (20.9%) and majority of it occurred during assisting in operation theatre 13(37.4%). Among them six (18.8%) were specialist, 12(37.5%) medical officer, 10 (31.2%) house officer and four staff nurses (12.5%). Among the respondents 142 (92.8%) had been immunized against Hepatitis B and 148 (96.7%) participants had knowledge regarding universal precaution. The incidence of NSI among health care workers at orthopaedics ward was not any higher in comparison with the similar studies and it was found out that the prevalence was more in junior doctors compared with specialist and staff nurses and it was statistically significant.

KEY WORDS

Needle sticks injury, health care workers, and standard precaution.

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.

The incidence and reporting of sharps exposure among medical students, orthopedic residents, and faculty at one institution

OBJECTIVE

To compare the incidence of sharps injuries among medical students, orthopedic residents/fellows, and orthopedic faculty at one institution and to determine the rate of reporting exposures.

DESIGN

Cross-sectional survey. Surveys were completed by 44% (53/120) of medical students, 76% (23/30) of residents/fellows, and 56% (17/30) of full-time faculty.

SETTING

Academic medical center.

PARTICIPANTS

Medical students, orthopedic surgery residents/fellows, full-time academic orthopedic surgery faculty.

RESULTS

Twenty-eight percent of medical students, 83% of residents/fellows, and 100% of faculty had been exposed to a sharps injury at some point in their career; 42% of residents/fellows had experienced a sharps exposure within the past year. The most common single instrument responsible for sharps injuries among all groups was the solid-bore needle; students and residents were significantly more likely than faculty to have a sharps injury from a solid-bore needle than all other devices combined (p = 0.04). Medical students were more likely to ignore the exposure than residents/fellows (p = 0.004) or faculty (p = 0.036). Only 12.5% of medical students followed all the steps of the postexposure protocol.

CONCLUSION

Sharps exposures occur among orthopedic surgeons and their trainees. Interventions are needed to increase safety among residents and medical students. Further research should evaluate factors suppressing medical student reporting of sharps exposures.

Safety syringes and anti-needlestick devices in orthopaedic surgery

BACKGROUND

The American Academy of Orthopaedic Surgery (AAOS), The Joint Commission, the Occupational Safety and Health Administration (OSHA), and the Needlestick Safety and Prevention Act encourage the integration of safety-engineered devices to prevent needlestick injuries to health-care workers and patients. We hypothesized that safety syringes and needles could be used in outpatient orthopaedic injection and aspiration procedures.

METHODS

The study investigated the orthopaedic uses and procedural idiosyncrasies of safety-engineered devices, including (1) four safety needles (Eclipse, SafetyGlide, SurGuard, and Magellan), (2) a mechanical safety syringe (RPD), (3) two automatic retractable syringes (Integra, VanishPoint), (4) three manual retractable syringes (Procedur-SF, Baksnap, Invirosnap), and (5) three shielded syringes (Safety-Lok, Monoject, and Digitally Activated Shielded [DAS] Syringe). The devices were first tested ex vivo, and then 1300 devices were used for 425 subjects undergoing outpatient arthrocentesis, intra-articular injections, local anesthesia, aspiration biopsy, and ultrasound-guided procedures.

RESULTS

During the clinical observation, there were no accidental needlesticks (0 needlesticks per 1300 devices). Safety needles could be successfully used on a Luer syringe but were limited to ≤1.5 in (≤3.81 cm) in length and the shield could interfere with sonography. The mechanical safety syringes functioned well in all orthopaedic procedures. Automatic retractable syringes were too small for arthrocentesis of the knee, and the plunger blew out and prematurely collapsed with high-pressure injections. The manual retractable syringes and shielded syringes could be used with conventional needles for most orthopaedic procedures.

CONCLUSIONS

The most effective and reliable safety devices for orthopaedic syringe procedures are shielded safety needles, mechanical syringes, manual retractable syringes, and shielded syringes, but not automatic retractable syringes. Even when adopting safety-engineered devices for an orthopaedic clinic, conventional syringes larger than 20 mL and conventional needles longer than 1.5 in (3.8 cm) are necessary.

Prevalence and prevention of needlestick injuries among health care workers in a German university hospital

OBJECTIVE

Health care workers (HCWs) are exposed to bloodborne pathogens, especially hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV) through job-related risk factors like needlestick, stab, scratch, cut, or other bloody injuries. Needlestick injuries can be prevented by safer devices.

METHODS

The purpose of this study was to investigate the frequency and causes of needlestick injuries in a German university hospital. Data were obtained by an anonymous, self-reporting questionnaire. We calculated the share of reported needlestick injuries, which could have been prevented by using safety devices.

RESULTS

31.4% (n = 226) of participant HCWs had sustained at least one needlestick injury in the last 12 months. A wide variation in the number of reported needlestick injuries was evident across disciplines, ranging from 46.9% (n = 91/194) among medical staff in surgery and 18.7% (n = 53/283) among HCWs in pediatrics. Of all occupational groups, physicians have the highest risk to experience needlestick injuries (55.1%-n = 129/234). Evaluating the kind of activity under which the needlestick injury occurred, on average 34% (n = 191/561) of all needlestick injuries could have been avoided by the use of safety devices. Taking all medical disciplines and procedures into consideration, safety devices are available for 35.1% (n = 197/561) of needlestick injuries sustained. However, there was a significant difference across various medical disciplines in the share of needlestick injuries which might have been avoidable: Pediatrics (83.7%), gynecology (83.7%), anesthesia (59.3%), dermatology (33.3%), and surgery (11.9%). In our study, only 13.2% (n = 74/561) of needlestick injuries could have been prevented by organizational measures.

CONCLUSION

There is a high rate of needlestick injuries in the daily routine of a hospital. The rate of such injuries depends on the medical discipline. Implementation of safety devices will lead to an improvement in medical staff's health and safety.

Transmission and prevention of occupational infections in orthopaedic surgeons

Microorganisms are transmitted in hospitals mainly by contact, droplet, and airborne routes. Orthopaedic surgeons have a substantial occupational risk of contracting a blood-borne infection because of frequent handling of sharp instruments and objects during operative procedures. Aerosolization means the formation of aerosols and droplets when blood or other body fluids are mechanically disturbed. Smaller particles (<5 microm) will remain suspended in air. Pathogens that can survive in these small airborne particles may cause infection if they are inhaled. Aerosol-generating procedures in patients with tuberculosis or severe acute respiratory syndrome (SARS) may facilitate airborne transmission. The Hospital Infection Control Practices Advisory Committee and the Centers for Disease Control and Prevention have established guidelines for isolation precautions in hospitals.

Percutaneous injury, blood exposure, and adherence to standard precautions: are hospital-based health care providers still at risk?

To examine factors associated with blood exposure and percutaneous injury among health care workers, we assessed occupational risk factors, compliance with standard precautions, frequency of exposure, and reporting in a stratified random sample of 5123 physicians, nurses, and medical technologists working in Iowa community hospitals. Of these, 3223 (63%) participated. Mean rates of hand washing (32%-54%), avoiding needle recapping (29%-70%), and underreporting sharps injuries (22%-62%; overall, 32%) varied by occupation (P<.01). Logistic regression was used to estimate the adjusted odds of percutaneous injury (aOR(injury)), which increased 2%-3% for each sharp handled in a typical week. The overall aOR(injury) for never recapping needles was 0.74 (95% CI, 0.60-0.91). Any recent blood contact, a measure of consistent use of barrier precautions, had an overall aOR(injury) of 1.57 (95% CI, 1.32-1.86); among physicians, the aOR(injury) was 2.18 (95% CI, 1.34-3.54). Adherence to standard precautions was found to be suboptimal. Underreporting was found to be common. Percutaneous injury and mucocutaneous blood exposure are related to frequency of sharps handling and inversely related to routine standard-precaution compliance. New strategies for preventing exposures, training, and monitoring adherence are needed.

Epidemiology of biological-exposure incidents among Spanish healthcare workers

OBJECTIVE

To determine the frequency and the epidemiological characteristics of biological-exposure incidents occurring among healthcare personnel.

DESIGN

Prospective surveillance study.

SETTING

Participating Spanish primary-care and specialty centers from January 1994 to December 1997.

PARTICIPANTS

70 centers in 1994, 87 in 1995, 97 in 1996, and 104 in 1997.

METHODS

Absolute and relative frequencies were calculated for several variables (position held, area of care, type of injuring object, activity, etc) and for the different categories of each variable.

RESULTS

There were 20,235 registered incidents. Annual incidence rates were as follows: 1994, 51 per 1,000; 1995, 58 per 1,000, 1996, 54 per 1,000; and 1997, 59 per 1,000. Mean age of accident victims was as follows: 1994, 35.68 (standard deviation [SD], 16.26); 1995, 33.6 (SD, 11.9); 1996,38.2 (SD, 17.27); and 1997, 36.7 (SD, 16.33) years. Of the 20,235 incidents, 15,860 (80.7%) occurred to women; 50% (9,833) accidents were among nursing staff. The type of incident most frequently reported was percutaneous injury (81.1%). The highest frequency of accidents was seen in medical and surgical areas (28% and 25.6%, respectively). Blood and blood products were the most commonly involved material (87.6%). Administration of intramuscular or intravenous medication was the activity associated with the highest accident rate (20.3%). The most frequent immediate action in response was rinsing and disinfecting (65.6%).

CONCLUSIONS

The incident registry was highly stable in terms of incidence rates over the observation period and served to highlight the large number of incidents recorded each year. The potential implications of the results are the need to explore reasons for increased exposures in certain areas, with the aim of focusing prevention efforts, and, similarly, to establish the factors associated with diminished incidence rates to model successful measures.