Occupational risk of the acquired immunodeficiency syndrome among health care workers

Acute Workplace Hazards in Orthopedic Surgery: Resident Survey Regarding Splash and Workplace Violence Events

INTRODUCTION

Orthopedic surgery residents are at risk for daily work-related hazards and exposures. Hazards related specific to this specialty includes radiation exposure, smoke inhalation (from electrocautery), and disease transmission through contact with surgical instruments or sharps during procedures. However, minimal research has been focused on other occupational hazard risks in orthopedic surgery including surgical splash events and workplace violence. This study focused on determining (1) whether or not use of protective eyewear in the workplace would be related to the availability of personal protective equipment (PPE); (2) resident education; and (3) the rate of workplace violence toward orthopedic surgery residents during their training.

METHODS

An invitation to participate in a web-based, anonymous survey to 46 US allopathic orthopedic surgery residency programs (1207 potential resident respondents). The survey was conceptually divided into the following areas: (1) demographics; (2) training and attitudes concerning occupational hazards; (3) PPE provision and use; (4) sharps injuries and reporting; and (5) general safety knowledge and violence in the workplace. Those who answered yes to having a splatter event or receiving a threat at the hospital were compared to those who did not. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between these outcomes and selected independent variables of interest. p-Values of <0.05 were considered statistically significant.

RESULTS

From January 18 to March 31, 2016, 518 surveys were received and included for analysis for a response rate of 42.9% (518/1207). One survey was excluded from analysis due to <50% completed response items. Self-reported program types were 64.5% (334/518) public university-affiliated, 23.2% (120/518) private university affiliated, 7.1% (37/518) community, and 5.2% (27/518) military. Residents were 83.0% = male and 17.0% = female. Overall, reported eye protection usage was 95% amongst all residents and 22% of residents reported experiencing a violent threat in the workplace. The risk of experiencing a splatter event was not statistically associated with residency type, gender, or geographic region. Senior residents were at an increased likelihood of experiencing a splatter event (OR 1.22, [95% CI 1.06-1.41], p = 0.006) when compared to PGY-1 residents. The risk of a violent experience at work was not statistically associated with residency type, year of residency training, or gender. Residents in the Northeast were more likely to have a violent experience (OR 2.78 [95% CI 1.41-5.49] p = 0.003). Overall, residents felt that they had adequate training to prevent occupational hazards (mean of 3.9/5 on Likert scale) and respond to hazards (mean of 3.7/5 Likert).

CONCLUSIONS

Occupational hazards are not uncommon in orthopedic surgery training with high rates of improper eyewear PPE use and poor awareness of Occupational Safety and Health Administration and AAOS guidelines. Violence in the workplace impacts over one in 4 residents and training programs and hospitals should improve education and report efforts. Continual yearly PPE training and awareness of AAOS guidelines could be intertwined with duty hour and/or case logs in order to ensure residents are exposed to this material on a regular basis.

Recovery of HIV Antigen in Peritoneal Dialysis Fluid

We investigated the presence of HIV antigen in dialysis fluid of patients with end-stage renal disease (ESRD) undergoing continuous ambulatory peritoneal dialysis (CAPD), previously known to be infected with this virus. Sixteen adult patients and 6 adult volunteers were included in the study in 4 groups as follows: Group A: 3 patients on CAPD, previously known to be positive for serum HIV antibodies; Group B: 7 patients on CAPD, serum HIV negative; Group C: 6 AIDS patients without renal disease; and Group D: 6 healthy volunteers.

Of the 3 patients of Group A, the HIV-1 Ag was positive in dialysis fluid in only 2. In 1, serum Ab and Ag were present, while in the others only serum Ab was detected. The samples from Group B were all negative for the viral antigen in dialysis fluid.

We conclude that dialysis fluid of HIV-infected patients may contain the Ag and is therefore potentially infective. The presence of the HIV antigen was not constant, and was not related to antigenemia. It is possible that the presence of the Ag depends on local factors that influence viral replication or to alterations in the permeability of the peritoneal membrane. We discuss other possible factors that could influence the presence of viral Ag in peritoneal dialysis fluid.

[Occupational and non occupational exposure to viral risk]

The transmission of an infectious disease can occur through exposure to blood or other potentially infectious body fluids, particularly in the event of skin-puncture injuries for healthcare workers, and during sexual intercourse. These situations are known as accidental blood exposures and sexual exposures respectively. Combined actions carried out have allowed to significantly reduce risks, either to healthcare professionals (by standard precautions, provision of safety devices, Hepatitis B vaccination made compulsory in the 1990s, antiretroviral post-exposure prophylaxis that should be initiated as soon as possible after exposure), or to people engaging in unprotected sex (by prevention messages, condom promotion, and antiretroviral post-exposure prophylaxis). In any case, treatment of people infected by chronic diseases such as HBV or HIV, as well as possible drug eradication of HCV, are key for decreasing post-exposure risk of disease transmission. Post-exposure prophylaxis should be initiated as early as possible and intended for use only in patients with high-risk exposures. Knowledge of source person serostatus, information of exposed person on prevention, benefits and risks of treatment, and follow-up procedure are key points. Procedures to be followed in the event of an exposure must be known by all. Arrangements set up to allow risk assessment and management of exposed people rely on hospital services operating on a permanent basis.

Nosocomial Transmission of HIV in Africa: What Tribute Is Paid to Contaminated Blood Transfusions and Medical Injections?

We reviewed the published data on the possible impact of medical injections and blood transfusions on the spread of human immunodeficiency virus (HIV) in Africa. We also compared these results to our experience in Rwanda, central Africa. The importance of medical injections in the epidemic of HIV infection seems to differ from one area to another. The excess of injections experienced by HIV seropositive subjects in Zaire could be secondary to the parenteral treatment of early HIV-related illness or to the treatment of sexually transmitted diseases, rather than being the cause of HIV infection, as suggested by Rwandese studies. In contrast, blood transfusions have been shown to represent an important source of nosocomial HIV infection in many African countries. Effective and relatively inexpensive measures to diminish the iatrogenic spread of HIV infection in developing countries are summarized.

Needlestick Injury: Impact of a Recapping Device and an Associated Education Program

Objective:

To determine the impact of the introduction of a plastic shield-shaped device (Needleguard, Biosafe, Auckland, New Zealand) and education program designed to allow safer recapping, on recorded rates of needlestick injury.

Design:

A before-after trial with a two-year duration of follow-up.

Setting:

Tertiary referral hospital.

Participants:

Nursing and other hospital personnel.

Results:

Prospectively collected baseline data, together with the results of an anonymous questionnaire of 25% of the hospital nursing staff, defined a reported needlestick injury rate of 6.9 per hundred full-time nursing staff per year. In the pre-intervention period, there were 6.7 needlestick injuries per 100 nursing staff members per year reported. This increased to 15.4 (p<.0001) needlestick injuries per 100 nursing staff members per year after the intervention. An anonymous survey undertaken at both time periods suggests that the apparent increase in officially reported needlestick injuries is due to an increase in the willingness of nurses to now report previously unreported needlestick injuries.

Conclusions:

The impact of the safety device and education program was the more accurate reporting of needlestick injuries; many nursing staff continued to resheath needles contrary to hospital policy. Many staff simply did not use the newly designed safety device. Approaches to improving compliance with such safety devices are considered.

Concerns, attitudes, and practices of orthopaedic surgeons towards management of patients with HIV/AIDS in Nigeria

The increasing number of people living with HIV/AIDS is causing concern among surgeons over risk of occupationally acquired HIV infection. This may influence their attitude to such patients. The purpose of this study was to develop a cross-sectional survey of orthopaedic surgeons to assess their concerns, attitudes, and practices towards management of HIV-positive patients in Nigeria. All respondents were males, 55 (73.3%) of them indicated concern over the risk of occupational acquisition of HIV infection and 37 (49.3%) had examined or operated on at least one HIV/AIDS patient. Sixty (79.9%) were willing to be tested for HIV and 51 (67.9%) were previously tested. Fifty-seven (75.9%) would order preoperative HIV screening of high risk patients, and 67 (89.3%) would operate on HIV-positive patients. Most orthopaedic surgeons in Nigeria would operate on HIV-positive patients.

Mental health of healthcare workers who experience needlestick and sharps injuries

Healthcare workers (HCWs) are exposed daily to the risk of injury by needlesticks and other medical instruments. However, the psychiatric impacts of such injuries have not been evaluated. The aim of this study was to evaluate the mental health status of HCWs with experiences of needlestick and sharps injuries. A cross-sectional written survey was performed. The psychological symptoms before injury and current status were measured using the Beck Depression Inventory (BDI), Hamilton Anxiety Scale (HAM-A) and Perceived Stress Scale (PSS). The proportions of HCWs with and without needlestick and sharps injuries were 71.1% (n=263) and 28.9% (n=107), respectively. HAM-A and BDI scores were significantly higher among HCWs with injury experiences (p<0.01). HCWs with injury experiences exhibited higher PSS and BDI scores after the injury and higher levels of anxiety and depression. Particular attention should be directed towards the psychological consequences of needlestick and sharps injuries in HCWs.

Prospective study of glove perforation in obstetrical and gynecological operations: are we safe enough?

OBJECTIVES

To assess the glove perforation rate, efficacy of double gloving, effect of duration of surgery, expertise of surgeon and operative urgency on the glove perforation rate in obstetrical and gynecologic operations.

METHODS

From February to September 2002, double glove protocol was made necessary for all major obstetrical and gynecologic procedures. The operating surgeon, first and second assistant were included in the study. Gloves damage was noted (overt by inspection, occult by hydroinsufflation technique).

RESULTS

Of the 156 procedures included in study, 32 procedures were performed (all emergency operations) single-gloved because surgeons found double gloving clumsy (56%), made it difficult to tie knots due to lack of dexterity (24%), or were too tight (20%). One thousand one hundred and twenty single gloves were examined after each procedure by hydroinsufflation. The overall perforation rate was 13.6% (single versus double outer gloves, 13.8% versus l3.2%, P > 0.05). Matching perforations were found in six cases (4.6%). Thus, the protection offered by double gloves was 95.4% even if the outer gloves were perforated. Four inner gloves had preexisting perforations. Sixty unused gloves checked similarly revealed a perforation rate of 1.6%. Emergency cases had higher perforation rate compared to elective surgeries (16.6% versus 10.8%, P < 0.00 1). Surgeries lasting for more than 40 min had a higher perforation rate compared to those finished in less than or equal to 40 min (18.6% versus 7.6%, P < 0.001). The middle finger of the left hand was the most commonly involved. The surgeon, first assistant and second assistant were involved in 73.6, 23.3 and 3.2% cases, respectively.

CONCLUSION

Double gloving offers considerable protection against exposure to contaminants in the blood and body fluids of the patient and should be made routine, especially in developing countries where HIV, hepatitis B and C are widely prevalent. Double gloving should be made mandatory in emergency procedures, which have a higher perforation rate due to operative urgency, and gloves should be changed in operations lasting for more than 40 min to ensure integrity of barrier.

Jet Injection of Local Anesthetic Decreases Pain of Arterial Cannulation in Awake Neurosurgical Patients

Arterial cannulation through the standard skin wheal of local anesthetic raised with a needle may be painful. The authors compared the efficacy of local anesthetic injected via a 25G needle versus a Bioject jet injector for arterial cannulation in awake neurosurgical patients. After institutional review board approval, 40 patients were randomized to receive 0.3 mL 1% lidocaine adjusted to pH 7.0 with NaHCO3 by Bioject with a 2-cm spacer between the syringe and skin or by 25G needle injection. Two pain assessments were used at the time of local anesthetic injection and at arterial cannulation. Patients rated their pain on a visual analog scale (VAS) (0 = no pain, 100 = worst pain). Observers scored patient response as 0 (no response), 1 (flinch), or 2 (withdrawal). The VAS at injection was 23 +/- 19 for the needle group and 3 +/- 6 for the Bioject group (P < 0.001). The VAS at arterial cannulation was 39 +/- 25 for the needle group and 15 +/- 22 for the Bioject group (P < 0.001). Median observer scores at injection and cannulation were 1 (range 0-2) for the needle group and 0 (range 0-2) for the Bioject group (P < 0.001). Patients in the Bioject group experienced significantly less pain during lidocaine administration and at the time of arterial cannulation by their own and by an observer's assessment than the needle injection group. Jet injection of local anesthetic should be considered prior to arterial cannulation in awake patients.

Occupational risk in health care and research

BACKGROUND

Working in the health care and research sectors has been linked to various hazards.

METHODS

Studies published in the peer-reviewed literature that are pertinent to the exposures or diseases relevant to these fields were reviewed.

RESULTS

The most important exposures include infectious agents, formaldehyde, anesthetic agents, antineoplastic drugs, and ethylene oxide. The best-documented evidence is that of infectious risk primarily among clinical personnel. Monitoring studies of persons occupationally exposed to anesthetics clearly demonstrate behavioral effects, possible risk of reproductive problems, as well as cytogenetic effects of unknown significance. The latter two impairments are also observed among those exposed to antineoplastic drugs and ethylene oxide. Exposure to formaldehyde appears to be associated with nasopharyngeal tumors. Whereas increased risk of cancer of certain sites, particularly the brain and lymphohematopoietic system, is found among research and health care personnel, no specific exposure has been linked to these neoplasms.

CONCLUSIONS

Although some results are inconsistent, continued environmental and biological monitoring will allow better assessment of exposures and of implemented protection measures.

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.

Serial human passage of simian immunodeficiency virus by unsterile injections and the emergence of epidemic human immunodeficiency virus in Africa

There is compelling evidence that both human immunodeficiency virus (HIV) types emerged from two dissimilar simian immunodeficiency viruses (SIVs) in separate geographical regions of Africa. Each of the two HIVs has its own simian progenitor and specific genetic precursor, and all of the primates that carry these SIVs have been in close contact with humans for thousands of years without the emergence of epidemic HIV. To date no plausible mechanism has been identified to account for the sudden emergence in the mid-20th century of these epidemic HIVs. In this study we examine the conditions needed for SIV to complete the genetic transition from individual human SIV infections to epidemic HIV in humans. The genetic distance from SIV to HIV and the mutational activity needed to achieve this degree of adaptation to human hosts is placed within a mathematical model to estimate the probabilities of SIV completing this transition within a single SIV-infected human host. We found that the emergence of even one epidemic HIV strain, following a single human exposure to SIV, was very unlikely. And the probability of four or more such transitions (i.e. HIV-1 groups M, O and HIV-2 subtypes A and B) occurring in a brief period is vanishingly small. We conclude that SIV cannot become a zoonosis, but requires adaptive mutations to become HIV. Some modern event must have aided in the transition of SIV to HIV. Our research indicates that serial passage of partially adapted SIV between humans could produce the series of cumulative mutations sufficient for the emergence of epidemic HIV strains. We examined the rapid growth of unsterile injections in Africa beginning in the 1950s as a biologically plausible event capable of greatly increasing serial human passage of SIV and generating HIV by a series of multiple genetic transitions. We conclude that increased unsterile injecting in Africa during the period 1950-1970 provided the agent for SIV human infections to emerge as epidemic HIV in the modern era.

Puncture wound during CPR from sternotomy wires: case report and discussion of periresuscitation infection risks

Performing resuscitations presents multiple infectious risks to critical care providers. Potential sources for infection include direct contact with blood and other bodily fluids and possible inoculation through needlestick injuries. In this article, we present a case of a cardiac care unit nurse who, while providing cardiopulmonary resuscitation, suffered a puncture wound to her left hand from the patient's sternotomy wires from previous cardiac surgery. The patient died despite these resuscitation efforts. He was seronegative for human immunodefiency virus, hepatitis B, and hepatitis C, and the nurse's wound healed without complications. This is the first reported case of such an injury occurring during a resuscitation. It demonstrates how a subtle, invisible, and unrecognized physical risk could cause infection in critical care providers.

Cost effectiveness of human immunodeficiency virus postexposure prophylaxis for healthcare workers

OBJECTIVE

The United States Public Health Service (USPHS) published recommendations for human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) of healthcare workers in May 1998. The aim of this study was to analyse the cost effectiveness of the USPHS PEP guidelines.

DESIGN AND SETTING

This was a modelling study in the setting of the US healthcare system in 1989. The analysis was performed from the societal perspective; however, only HIV healthcare costs were considered and health-related losses of productivity were not included.

METHODS

A decision tree incorporating a Markov model was created for 4 PEP strategies: the current USPHS recommendations, triple drug therapy, zidovudine monotherapy or no prophylaxis. A probabilistic sensitivity analysis using a Monte Carlo simulation was performed. Confidence intervals (CIs) around cost-effectiveness estimates were estimated by a bootstrapping method.

RESULTS

The costs (in 1997 US dollars) per quality-adjusted life-year (QALY) save by each strategy were as follows: monotherapy $US688 (95% CI: $US624 to $US750); USPHS recommendations $US5211 (95% CI: $US5126 to $US5293); and triple drug therapy $US8827 (95% CI: $US8715 to $US8940). The marginal cost per year of life saved was: USPHS recommendations $US81 987 (95% CI: $US80 437 to $US83 689); triple drug therapy $US970 451 (95% CI: $US924 786 to $US 1 014 429). Sensitivity testing showed that estimates of the probability of seroconversion for each category of exposure were most influential, but did not change the order of strategies in the baseline analysis. With the prolonged HIV stage durations and increased costs associated with recent innovations in HIV therapy, the marginal cost effectiveness of the USPHS PEP strategy was decreased to $US62 497/QALY saved. All 3 intervention strategies were cost effective compared with no postexposure prophylaxis.

CONCLUSIONS

Current USPHS PEP recommendations are marginally cost effective compared with monotherapy, but the additional efficacy of triple drug therapy for all risk categories is rewarded by only a small reduction in HIV infections at great expense. For the foreseeable future, assuming innovations in therapy that employ expensive drug combinations earlier in the HIV disease course to extend life expectancy and the increasing prevalence of HIV drug resistance, our model supports the use of the USPHS PEP guidelines.

Nurses failure to appreciate the risks of infection due to needle stick accidents: a hospital based survey

One of the most important occupational risks to healthcare workers is exposure is to blood-borne viruses. This study examined nurses' perceptions of risk of contracting infection following single or multiple exposure to blood or body fluids. Two hundred and ninety nurses were surveyed using a questionnaire. One hundred and thirty-three responded; 85 worked in higher risk areas (ITU, Haematology, Haemodialysis and Neonatal Surgical Units) (Group A) and 48 worked in lower risk areas (medical wards, an orthopaedic and an ENT ward) (Group B). Forty-nine percent of subjects from group A and 60% of subjects from Group B believed that a needle stick injury with a needle contaminated with infected blood was an unlikely source of infection. Fifteen percent from group A and 20% from group B thought that infection with a blood-borne virus following a needle stick injury contaminated with Human Immunodeficiency Virus (HIV) infected blood was very unlikely. Twelve percent from group A and 10% from Group B did not know whether resheathing needles between use can provide protection against HIV. Sixty-seven percent from group A and 71% from group B disagreed with the statement that nurses are at higher risk of exposure to HIV/HBV than the other healthcare workers. Thirteen percent from group A and 5% from group B agreed with the statement, whereas 8% from group A and 5% from group B thought that nurses are at less risk. Only 22% from group A and 23% from group B would take more precautions if they knew that the patient had HIV/HBV infection, whilst 11% and 8% respectively admitted that they would take special precautions only when the patient has clinical symptoms of HIV/HBV infection. The findings suggest that these nurses would benefit from further education regarding infection from blood-borne viruses.

Painless intravenous catheterization by intradermal jet injection of lidocaine: a randomized trial

STUDY OBJECTIVE

To compare efficacy and cost of lidocaine cutaneous anesthesia by two jet injectors to routine needle infiltration for pain relief of intravenous (i.v.) catheterization, hypothesizing that jet injection of lidocaine is less painful than its needle infiltration.

DESIGN

Randomized, prospective, controlled trial.

SETTING

University hospital outpatient surgical unit.

PARTICIPANTS

75 surgical patients ASA I and II.

INTERVENTIONS

Three groups of 25 patients each were given intradermal lidocaine anesthesia via conventional 25-gauge needle/syringe; by MedEJet or Biojector jet injector prior to IV catheterization with an 18-gauge Jelco catheter.

MEASUREMENTS AND MAIN RESULTS

Visual analogue pain scores (VAS) (0 = no pain, 10 = intolerable pain) and subjective pain intensity scores (PIS) (0 = not painful, 4 = intolerable pain) at lidocaine application and at i.v. catheterization, were recorded. Cost assessment of each method was made. At local anesthetic application, no pain by proportion of VAS = 0 with MedEJet: 25/25 (confidence interval [CI]: 0.868, 0.999) and Biojector: 24/25 (CI 0.804, 0.991) was noted, but-22 of 25 patients experienced pain with needle administration: (with VAS = 0; 3/25 [CI: 0.044, 0.302]) (posterior probability [PP] > 0.999). The corresponding VAS scores (means +/- SD) were 0.00 +/- 0.00, 0.04 +/- 0.20, and 2.4 +/- 2.23 (p < 0.001). No pain by proportion of PIS = 0 with MedEJet: 25/25 (CI: 0.868, 0.999 and Biojector: 23/25 (0.749, 0.976) was noted, but pain in 20/25 was felt with the needle: 5/25 (CI: 0.090, 0.394) (PP > 0.999). The corresponding PIS scores were 0.00 +/- 0.00, 0.16 +/- 0.55, and 1.24 +/- 1.00 (p < 0.001). At i.v. catheterization, no pain by proportion of VAS = 0 with MedEJet: 22/25 (CI: 0.698, 0.956) or Biojector: 21/25 (CI: 0.651, 0.934) was noted; but pain in 19/25 with needle administration was experienced: 6/25 (CI: 0.116, 0.436) (PP > 0.999). The corresponding scores were 0.12 +/- 0.33, 0.44 +/- 0.20, and 1.64 +/- 1.50 (p < 0.001). No pain by proportion of PIS = 0 with MedEJet: 24/25 (CI: 0.804, 0.991) or Biojector: 24/25 (CI: 0.804, 0.991) was noted, but pain was apparent in 12/25 with needle administration: 13/25 (CI: 0.334, 0.701) (PP > 0.999). The corresponding scores were 0.00 +/- 0.00, 0.00 +/- 0.00, and 0.76 +/- 0.88 (p < 0.001). Cost per application: MedEJet = $0.13; needle/syringe = $0.50; Biojector = $0.94.

CONCLUSIONS

Almost completely painless i.v. catheterization was carried out by jet injection of lidocaine, but needle infiltration produced discomfort or pain and did not significantly reduce discomfort or pain at the i.v. needle insertion.

Mortality patterns among female nurses: a 27-state study, 1984 through 1990

OBJECTIVES

This study examined the mortality experience of 50,000 nurses using the National Occupational Mortality Surveillance database of death certificates.

METHODS

Proportionate mortality ratios adjusted by race (White, Black, or other) and 5-year age groups were calculated for selected causes of death among female nurses vs all workers and white-collar workers.

RESULTS

Excess deaths among nurses less than 65 years of age were seen in both comparison groups for viral hepatitis, cancer of the nasal cavities, accidental falls, suicide, and drug-related deaths. Among nurses 65 years old or older, deaths due to chronic myeloid leukemia were in excess. Proportionate mortality ratios for breast and colon cancers, diabetes, and heart disease varied by occupational comparison group.

CONCLUSIONS

These findings confirm results of previous studies and identify new associations. Redoubled efforts are called for in overcoming obstacles to reducing workplace hazards.

Risks and issues for the health care worker in the human immunodeficiency virus era

The perception of degree of risk can vary markedly from actual risk. About 5% of the cases of AIDS and HIV infection in the United States have occurred in health care workers, a percentage that has remained stable over time. Nearly all of these infections are related to lifestyle factors, not occupational risk. The rise of occupational transmission is greatest with parenteral injuries. If there is an HIV risk to patients, it appears to be very much smaller than the risk to workers although it has received even more publicity. Apprehension exists concerning the future framework of the medical care delivery system and who will care for whom. The sensitive handling of legitimate fears and the balancing of conflicting risks will continue to be a challenging task in the decades ahead.

A work-systems analysis of compliance with universal precautions among health care workers

Universal precautions are work practices designed to protect health care workers from occupational exposure to HIV and other bloodborne pathogens. However, despite aggressive dissemination efforts by CDC and regulatory action by OSHA, compliance remains less than satisfactory. This article argues that the minimization of risk from bloodborne pathogens requires a multilevel or work-systems perspective that considers individual, job/task, and environmental/organizational factors. The available literature on universal precautions suggests the potential of such an approach and provides insight into the limited success of current worker-focused mitigation efforts. In particular, specific opportunities exist to develop and apply engineering controls, to improve the design and organization of jobs and tasks, and to create organizations that facilitate and reinforce safe behavior.

Compliance with universal precautions among health care workers at three regional hospitals

OBJECTIVE

To assess and characterize self-reported levels of compliance with universal precautions among hospital-based health care workers and to determine correlates of compliance.

DESIGN

Confidential questionnaire survey of 1716 hospital-based health care workers.

PARTICIPANTS

Participants were recruited from three geographically distinct hospitals. A stratified convenience sample of physicians, nurses, technicians, and phlebotomists working in emergency, surgery, critical care, and laboratory departments was selected from employment lists to receive the survey instrument. All participants had direct contact with either patients or patient specimens.

RESULTS

For this study, overall compliance was defined as "always" or "often" adhering to the desired protective behavior. Eleven different items composed the overall compliance scale. Compliance rates varied among the 11 items, from extremely high for certain activities (e.g., glove use, 97%; disposal of sharps, 95%) to low for others (e.g., wearing protective outer clothing, 62%; wearing eye protection, 63%). Compliance was strongly correlated with several key factors: (1) perceived organizational commitment to safety, (2) perceived conflict of interest between workers' need to protect themselves and their need to provide medical care to patients; (3) risk-taking personality; (4) perception of risk; (5) knowledge regarding routes of HIV transmission; and (6) training in universal precautions. Compliance rates were associated with some demographic characteristics: female workers had higher overall compliance scores than did male workers (25% of female and 19% of male respondents circled "always" or "often" on each of the 11 items, p < 0.05); and overall compliance scores were highest for nurses, intermediate for technicians, and lowest for physicians. Overall compliance scores were higher for the mid-Atlantic respondents (28%) than for those from the Southwest (20%) or Midwest (20%, p = 0.001).

CONCLUSIONS

This study supports earlier findings regarding several compliance correlates (perception of risk, knowledge of universal precautions), but it also identifies important new variables, such as the organizational safety climate and perceived conflict of interest. Several modifiable variables were identified, and intervention programs that address as many of these factors as possible will probably succeed in facilitating employee compliance.

Human immunodeficiency virus and hepatitis B virus seroprevalence in an urban trauma population

OBJECTIVE

To determine the seroprevalence of the human immunodeficiency virus (HIV) and the hepatitis B virus (HBV) in patients of an urban level I trauma center.

DESIGN

Prospective, blinded point prevalence study of serum HIV and HBV antibody and antigen.

SETTING

An urban level I trauma center that participates in a trauma system serving three million people.

PATIENTS

The study included 994 (94.8%) of 1049 consecutive trauma service patients treated between June 6, 1988 and September 22, 1988. The patients were 82.2% male and 73.1% black, with a mean age of 28.8 +/- 12.3 years. Blunt trauma was seen in 65.4% of patients, 5.2% were in shock, and 96.2% survived their trauma.

MAIN OUTCOME MEASURES

HIV and HBV seroprevalence, using both antibody and antigen testing.

RESULTS

HIV infection was seen in 43 patients (4.3%); 41 (95.3%) were HIV Ab+ and two (4.7%) were HIV Ab-/HIV Ag+. Infection with the HBsAg was seen in 31 patients (3.1%). Infection with either virus was seen in 70 patients (7%); four patients (0.4%) were infectious for both viruses. Infection was related to age 20 to 49 years, i.v. drug use, a hepatitis or sexually transmitted disease history, prior HIV testing, shock, and death (p < 0.05). Penetrating trauma was not predictive of infection. In a logistic regression model, IV drug use was the single significant predictor of infection (p < 0.05).

CONCLUSIONS

Young urban trauma patients, because of drug-related intentional violence, are 15.3 to 17.6 times more likely to be HIV infected and 3.9 to 7.9 times more likely to be infectious for HIV or HBV than the trauma population overall. The 12 to 21% infection rates in critically injured patients who require shock resuscitation and/or die reinforces the need for mandated universal precautions and for clear policies which govern the performance of procedures by physicians in training. Primary HIV infection in critically injured patients may worsen their outcome and may adversely affect the exposed health care worker. Emergency departments and trauma units should develop a referral system to HIV primary care services (HIV counselling and testing) for high risk patients and for adversely exposed health care workers.

Risk for occupational transmission of HIV infection among health care workers. Study in a Spanish hospital

The aim of this study was to evaluate the HIV seroconversion rate associated with different types of occupational exposures in health care workers. A longitudinal study was conducted from January 1986 to October 1992 in a teaching hospital in Spain, where HIV infection is prevalent among patients. Each health care worker was asked to complete a questionnaire regarding age, sex, staff category, lace of exposure, other exposures, type of exposure, body fluid, infected material and HIV status of source patient. These health care workers were then followed up at 6 weeks, 3 months, 6 months and 12 months with repeated test for HIV antibody. Four hundred twenty three reports of occupational exposure were analysed. Nursing was the profession with more exposures (42.8%). Ninety five percent of total exposures were percutaneous, 4% mucous membrane contacts and 1% skin contacts, 88.3% were described as blood contact and 71.8% had resulted from needlestick and suture needles. Exposures from HIV-positive patients comprised 23.2% of occupational exposures. There was a significant difference in the length of follow-up in physicians (p = 0.00009) and nurses (p = 0.00001), when we compared HIV-positive patients with patients in whom the HIV status was unknown or negative. The HIV seroconversion rate was 0.00%. We consider that the risk of acquiring HIV infection via contact with a patient is low, but not zero. Well documented cases of seroconversion have been published.(ABSTRACT TRUNCATED AT 250 WORDS)

Development of a numeric Health Care Worker Risk-Assessment Scale to evaluate potential for blood-borne pathogen exposures

BACKGROUND

An attempt to develop a Health Care Worker Risk Assessment Scale to evaluate potential for exposure to blood-borne pathogens was made in late 1989 through 1990. The research questions were as follows: (1) Can a scale be developed to assign weights to variables that influence health care workers' risk of exposure to blood-borne pathogens? (2) If so, what variables would be included?

METHODS

A five-round Delphi technique was used with 26 panel members from 15 U.S. states and the United Kingdom who were recognized experts in strategies to reduce health care workers' risk of exposure to blood-borne pathogens. The scale included four elements, each scored up to 40 points. Elements were as follows: (1) potential route of exposure, (2) experience of health care worker and cooperation of patient, (3) prevalence of blood-borne pathogens, and (4) difficulty in managing the situation. A minimum score of 20 indicated an extremely low-risk situation; a maximum score of 160 indicated an extremely high-risk situation.

RESULTS

Consensus was achieved among the panel members in identifying the elements that contributed to risk for exposure to blood-borne pathogens and in applying the scale to carefully worded vignettes. This required several modifications of both the scale and the vignettes to ensure consistent interpretation of the terms used. In all vignette situations, the risk-abatement strategy was specific to the situation depicted in the vignette and not to the task itself; the value of a numeric scale is thus questionable.

CONCLUSIONS

Even with the participation of 26 expert panelists, we were unable to develop a numeric scale to objectively quantify risk in such a way that risk-reduction strategies could be based on the scale rather than on the specific risk elements in a situation. Instead of attempting to use a scale such as this to quantify risk objectively, educators or clinicians may be better advised to teach health care workers the four scale elements so that health care workers can subjectively use these elements to evaluate and modify their own risk situations.

What's new in managing health hazards in pathology departments

Health hazards related to activities performed in pathology departments have represented, in recent years, an increasing concern among pathologists and pathology technicians. The major occupational health problems encountered in pathology departments are reviewed. They include biological hazards (tuberculosis, hepatitis, HIV, other infectious diseases), chemical hazards (formaldehyde, xylene(s), aromatic amines, methacrylates, glutaraldehyde, latex) and physical hazards (cut injuries, accidental fires, radiation). Current data suggest that infections (particularly, tuberculosis and hepatitis) still represent the more relevant risk. Exposure to HIV and Creutzfeldt-Jakob agent may be highly harmful but containment measures have been proven to be effective. The actual adverse effects due to chemicals seem to be less alarming than was previously believed. Attaining a safe work environment is an inherent element of good quality assurance management. This task is largely a matter of information, education, organization and common sense. Well-designed premises, efficient equipment and well-trained personnel are the keys to preventing and minimizing hazardous exposures. In order to provide current information that may be used by pathology staff to implement the functional quality of the workplace, organizational and preventive measures are described.

The reluctance of house staff to perform mouth-to-mouth resuscitation in the inpatient setting: what are the considerations?

OBJECTIVE

Medical house staff are required to perform cardiopulmonary resuscitation (CPR) as part of their job responsibilities. Previously it has been shown that house staff are reluctant to perform mouth-to-mouth resuscitation (MMR) in an out of hospital setting. Therefore, whether reluctance to perform MMR extends to the inpatient setting, and, if so, the reasons for this reluctance were investigated.

DESIGN

All 74 internal medicine house officers of a large metropolitan hospital responded to presentations of hypothetical inpatient cardiac arrest scenarios to assess their willingness to perform MMR.

SETTING

A 1200 bed university-affiliated teaching hospital in Los Angeles, California.

SUBJECTS

All categorical internal medicine house officers at this hospital.

INTERVENTIONS

This study is a survey which concerns whether the house officer would perform mouth-to-mouth resuscitation in different hypothetical cardiac arrest scenarios.

RESULTS

Forty-five percent would perform MMR on an unknown patient and 39% would perform MMR in the elderly patient scenario. Only 16% would do MMR on a patient with a small amount of blood on his lips and only 7% would perform MMR on a patient with presumed acquired immunodeficiency syndrome. Medical housestaff were much more reluctant to perform MMR on elderly, trauma, or presumed immunodeficient patients in an inpatient setting than in an outpatient setting. All house staff that indicated their unwillingness to perform MMR cited fear of human immunodeficiency virus infection as their reason.

CONCLUSION

Medical housestaff are quite reluctant to perform MMR in an inpatient setting. Thus, educating the medical house staff about the percent of patients that survive inpatient cardiac arrest and the actual risks of contracting infectious diseases, especially HIV infections, from MMR and preventative measures, such as effective barrier masks, should result in an increased willingness of physicians to perform MMR or mouth-to-mask ventilation on inpatients.

Complications of laparoscopy and thoracoscopy

Laparoscopy was first performed at the turn of the century, but it was not until the introduction of laparoscopic cholecystectomy that the procedure became widely adopted by general surgeons. Since then, traditional open procedures, including cholecystectomy, exploratory laparotomy, colectomy, hernia repair, and appendectomy, are being widely performed laparoscopically. The advantages of laparoscopic surgery, including less postoperative pain due to smaller surgical incisions, shorter hospital stay, quicker return to preoperative activity, and superior cosmesis, resulted in widespread popularity with both surgeons and patients. In certain situations, the traditional method may be superior to the laparoscopic approach, as may be the case with laparoscopic hernia repair. It is difficult to justify converting a local, extraperitoneal, 45-minute, outpatient inguinal hernia repair in a virgin groin into a general anesthetic, transperitoneal, 2-hour plus, possibly inpatient laparoscopic procedure with the implantation of mesh. However, data may indicate that this operation does indeed have benefits. We must, therefore, carefully study such new operations. With the advent of a new surgical procedure, both surgeons and anesthesiologists must be familiar with the various complications unique to this technique. If recognized early, potentially life-threatening complications, including gas embolization and tension pneumothorax, can be corrected.

Compliance with universal precautions and needle handling and disposal practices among emergency department staff at two community hospitals

BACKGROUND

To describe rates of needle disposal and barrier use within the emergency departments at two privately owned community hospitals in two suburbs of Minneapolis, a study was conducted. This study consisted of direct observation of a cohort of emergency department personnel providing patient care followed by a self-administered survey of the same personnel.

METHODS

From June through August 1990, seven specially trained registered nurses observed emergency department personnel for a total of 400 hours. The observers documented the appropriate rates of use of gowns, goggles, masks, and gloves. Observers also noted methods of needle disposal and frequency of needle recapping. After observation, surveys that included items requesting estimates of rates of use for each barrier, as well as estimates of the rates and methods of needle recapping and disposal, were distributed. For each observed and corresponding self-reported behavior, 95% confidence intervals were calculated and compared.

RESULTS

A total of 1,822 procedures were recorded. Gloves were observed to be used when appropriate 67.2% of the time, followed by goggles (50.7%), masks (16.0%), and gowns (15.3%). Self-reported barrier rates were slightly higher in all cases except for goggle use. About one third (34.4%) of the needles were recapped; 78.1% of these were recapped two-handed.

CONCLUSIONS

Previous studies have documented low universal precautions compliance rates at urban teaching hospitals. Our data indicate less than optimal levels of compliance also at community hospitals, and show that personnel are less than fully aware of their own noncompliance.

HIV infection and the dentist. 1. The presence of HIV in saliva and its implications to dental practice

The human immunodeficiency virus (HIV) has been detected in all body fluids. The presence and the detection of HIV virus in human saliva are reviewed. Modes of HIV transmission are discussed with particular reference to the possibility and risk of virus transmission via saliva. This risk is considered to be extremely low. The relevance of this information to the practising dentist is discussed and some practical suggestions in infection control are made.

Infection control for health care workers caring for critically injured patients: a national survey

Prevention of transmission of bloodborne pathogens to health care workers (HCWs) involved in resuscitation of critically injured patients presents special challenges. As a step toward creation of a standard, a telephone survey of the infection control practices in this setting of the 100 busiest EDs in the United States (US) was performed. Departmental staff who were knowledgeable about ED infection prevention protocols were questioned about general policy, barrier protection measures, sharps management, and educational programs directed to HCWs. Surveys were completed for 82 EDs. Of these, 56 (68%) either function as primary trauma care facilities for the local community, or are designated level 1 trauma centers by the American College of Surgeons. Specific infection control protocols for trauma resuscitation had been printed and posted by 18 EDs (22%), with the remaining 64 (78%) using the same universal precautions for care of the severely injured as for other patients. A specific policy relating to invasive procedures had been promulgated by 66 EDs (80%). Barrier protection was used by protocol or by custom for care of all critically injured patients by 43 EDs (52%). Impermeable gowns with sleeves were available in 63 EDs (77%). Eye or face protection included face shields by 74 EDs (90%), face masks by 76 EDs (93%), and goggles by 72 EDs (88%). Only 59 EDs (72%) reported that sharp containers were always within arm's reach of HCWs with material to discard. Specially adapted equipment included self-sheathing intravenous catheters (21, 26%) and needle/syringe combinations (16, 20%). Considerable variation exists in infection control practices in busy US EDs during resuscitation of critically injured patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Commentary: a call for authoritative CDC guidelines for HIV-infected health care workers

Recent court decisions imposing liability on physicians who fail to inform patients that they carry the human immunodeficiency virus (HIV) before performing invasive procedures create an urgent need for the Centers for Disease Control and Prevention (formerly the Centers for Disease Control) to reopen the issuance of guidelines and to address authoritatively the question of the appropriate limits within which HIV-infected health care providers can treat patients.

Public fear of HIV-infected physicians (polls show 80 to 90 percent of patients surveyed want to know if their physicians are HIV-infected) were kindled by reports, beginning in 1990, that Dr. David Acer, an HIV-infected dentist, had infected a number of his patients. However, great skepticism has arisen as to whether Dr. Acer’s patients were infected as a result of procedures conducted in accordance with universal precautions against transmission. Moreover, look back studies have failed to identify even one patient, among the thousands who have undergone procedures administered by HIV-infected physicians, who contracted the virus directly from his/her physician.

Willingness of male homosexuals to perform mouth-to-mouth resuscitation

BACKGROUND

Providing mouth-to-mouth resuscitation (MMR) during cardiopulmonary resuscitation (CPR) is a proven effective lifesaving procedure. However, the perceived risk to the rescuer of contracting infectious diseases, especially acquired immunodeficiency syndrome (AIDS), by performing MMR on a possibly human immunodeficiency virus (HIV) positive individual is probably affecting the number of people willing to perform MMR. Physicians and nurses constitute a major part of citizen cardiopulmonary resuscitation (CPR) responders and serve as CPR educators and resource personnel. Currently, the fear of physicians and nurses of contracting infectious disease has dampened their willingness to perform MMR, and thus has reduced the number of strangers who will receive MMR. Homosexual males, like the medical community, have an increased perceived risk of acquiring infectious diseases, especially AIDS, and have been the target of intense educational efforts concerning the transmission of HIV. By (a) determining the willingness of various groups to perform MMR, (b) elucidating the factors which affect their willingness to perform MMR, and (c) comparing this willingness to the actual, not perceived, risk of acquiring HIV by performing MMR, either appropriate changes can be made to educate people in the performance of MMR, by informing them of the actual risks of contracting infectious diseases, or alternative methods of resuscitation, involving 'lay-on' masks, can be recommended. Thus the willingness of homosexual males to perform MMR was determined and compared to the previously determined actual reluctance of the medical community to perform MMR in similar hypothetical scenarios.

METHODS

During interviews, 200 male homosexuals in Los Angeles were asked to assume that they knew how to perform CPR and MMR and to indicate how they would respond to four hypothetical cardiac arrest scenarios. These scenarios included cardiac arrests of a child, a trauma victim, a young man in a gay neighbourhood, and a victim of unknown history. Demographical data concerning the respondents was also obtained.

RESULTS

Of the homosexual men surveyed, 93 and 85% stated they would perform MMR on a stranger of unknown history, if they, the rescuer, were HIV negative or positive, respectively, (P < 0.001). Similarly, a high percentage of the presumed HIV negative and HIV positive respondents stated a high willingness to perform MMR in response to hypothetical cardiac arrest scenarios involving a trauma victim, a child, and a young man in a gay neighbourhood.

CONCLUSIONS

The willingness of male homosexuals to perform MMR is high, in contrast to the general reluctance of internists and medical nurses to perform MMR in the same outpatient scenarios. The different perceived risks of male homosexuals and physicians acquiring infectious diseases by performing MMR is probably responsible for the difference in willingness of these two groups to perform MMR. The high perceived risk of acquiring infectious diseases due to performance of MMR currently held by physicians in general may be lowered by increasing educational efforts. CPR courses should (a) discuss actual and perceived risks of acquiring infectious diseases by MMR, (b) discuss and weigh a small, and possibly not valid, risk of contracting an infectious disease while performing MMR on a victim, and (c) emphasize techniques involving 'lay-on' barrier masks. The availability of effective 'lay-on' barrier masks' should also be increased.

Incidência de acidentes de trabalho relacionada com a não utilização das precauções universais

Entrevistados todos (57) os funcionários do serviço de enfermagem de um hospital geral governamental de São Paulo, que sofreram acidentes de trabalho relacionados a materiais pérfuro-cortantes, ou que tiveram contato com sangue ou fluidos corpóreos contaminados no período de janeiro a setembro de 1992. Desses, 15,8% (9) eram enfermeiras, 49,1% (28) auxiliares de enfermagem, 33,3% (19) atendentes de atendentes de enfermagem e 1,8% (1) escriturária, que apresentavam idade inferior a 40 anos. 66,1% possuiam 2º grau completo ou superior e entre 4 a 7 anos de experiência na função. Em relação ao turno de trabalho, 49,1% dos acidentes ocorreram pela manhã e 38,7% durante a noite, principalmente no Pronto Socorro (36,8%). Materiais pérfuro-cortantes foram responsáveis por 71 ,9% dos acidentes, sendo 75,0% entre os auxiliares de enfermagem. Os funcionários acidentados atribuiram a causa do acidente: a fatalidade, ao descuido ou imprudencia da equipe medica e ao reencape de agulhas. Quanto as consequencias, 57,0% dos acidentados por. respingo de secreção nos olhos desenvolveram conjuntivite e uma das funcionárias, Hepatite B. Este estudo mostrou que 78,1 % dos acidentes poderiam ter sido evitados, 57,0% apenas com o uso das Precauções Universais.

Eye protection for the vascular surgeon

Contamination occurring during vascular surgery was studied prospectively using a surgical mask incorporating a Splashguard visor. Over a 16-week period 78 vascular procedures were included; 44 were of < 2 h duration and 34 were of > or = 2 h. Contamination on both mask and visor from blood spots was recorded at the end of each procedure. Overall, 51 per cent of principal surgeons' visors were contaminated, with contamination of the mask itself in 32 per cent. When two surgeons were operating the contamination rate for the second was also high: 36 per cent for the visor and 42 per cent for the mask. Assistants had a contamination rate of 36 per cent for the visor and 13 per cent for the mask. The lowest rate of contamination occurred for the visor and mask of the scrub nurse, 10 and 4 per cent respectively. For emergency procedures the duration of operation had no influence on the frequency of contamination. However, for the principal surgeon elective operations of < 2 h duration were less likely to involve contamination than those of > or = 2 h (P < 0.035). Blood contamination of visors and masks is common in vascular surgery but rarely appreciated by the surgeon. Routine eye protection should be considered in vascular surgery, in particular for emergency and prolonged elective procedures.

Prophylaxis of HIV infection following occupational exposure

OBJECTIVE

To review the risk of HIV infection following occupational exposure, the theoretical basis for chemoprophylaxis, investigative experience with chemoprophylaxis in animals and humans, and the economic aspects of postexposure chemoprophylaxis.

DATA SOURCES

English-language articles and conference proceedings pertaining to the risk of occupational HIV infection and to postexposure chemoprophylaxis.

STUDY SELECTION

Studies evaluating chemoprophylaxis of HIV infection following occupational exposure were selected for review. Abstracts reporting ongoing clinical trials were also included.

DATA EXTRACTION

In vitro studies are discussed to provide the immunologic rationale for chemoprophylaxis. Animal studies examining the efficacy of chemoprophylaxis in preventing non-HIV retroviral infection are reviewed, and their applicability to human HIV infection is critically evaluated. Human studies and case reports describing attempts at chemoprophylaxis of HIV infection following occupational exposure are discussed.

DATA SYNTHESIS

Chemoprophylaxis of HIV infection following occupational exposure has focused on the use of zidovudine (ZDV) because it was previously the only antiretroviral agent approved for treating HIV infection. Animal models of retroviral infection provide conflicting data regarding the efficacy of ZDV chemoprophylaxis, and there are important questions about the applicability of animal data to human HIV infection because of differences in natural histories of non-HIV retroviral infections, inoculum size, dosing of ZDV, and routes of infection. Human surveillance studies are thus far inadequate to determine the efficacy of ZDV prophylaxis because of the very low HIV seroconversion rates following occupational exposure. ZDV is well tolerated during short-term administration in people without HIV infection, but long-term safety is unknown. In addition, the true cost-benefit ratio of ZDV chemoprophylaxis is uncertain.

CONCLUSIONS

Current data from in vitro, animal, and human studies are inadequate to define the appropriate role of ZDV in preventing HIV infection following occupational exposure. Limited toxicity data and the high cost of treatment must be weighed against the theoretical benefits of ZDV use in this setting. The decision to employ ZDV for postexposure prophylaxis must ultimately be based on existing institutional policies, the attitude of the responsible physician regarding such practice, and/or the desires of the exposed healthcare worker after being properly informed of potential risks and benefits.