Risk of exposure of surgical personnel to patients' blood during surgery at San Francisco General Hospital

Surgical glove perforation during intramedullary nailing of intertrochanteric fractures

Intramedullary nail fixation is a routine procedure for treatment of intertrochanteric fractures. Aseptic technique is vital for reducing postoperative complications, as intraoperative glove perforations increase the risk of surgical site infections. The aim of this study was to determine the incidence of surgical glove perforation during intramedullary nailing of intertrochanteric fractures and to identify surgery-specific steps at risk. A prospective series of 148 short intramedullary nail implantations was analysed. Intraoperative glove perforations and causative events were recorded. All gloves from the scrubbed surgical team were collected and examined for micro- and macroperforations. 1771 gloves were tested. A total of 341 perforations in 309 gloves were detected, resulting in an overall glove perforation rate of 17%. Surgeon experience had no influence on the overall incidence of glove perforations. Usage of the awl and insertion of the proximal locking screw resulted in 33.9% of all detected glove perforations. Perforation rate significantly increased with operative time (p = 0.003). Regular glove changing after surgery-specific risk-steps and during longer surgeries could decrease the rate of glove perforations during intramedullary nailing of intertrochanteric fractures and reduce the risk of potential septic contamination or even disease transmission for both, the surgeon, and the patient.

Surgical team member's application of personal protective equipment: an observational study

Background

Personal protective equipment (PPE) is a term used to refer to clothing or equipment that creates a barrier to protect an individual from work-place hazards, thereby protecting the worker against work-related injuries and illnesses. This study was aimed at determining the compliance of application of personal protective equipment against the standards.

Methods

One hundred surgical personnel were included in this study from 21 March 2023 to 23 April 2023. Data were collected through direct observation. The standards were directly changed into question forms with two integral checking components, "Yes", and "No". Data were entered and analyzed by statistical package of social sciences (SPSS) version 25.

Result

A total of 100 surgical personnel involved in surgical procedures were assessed for how they applied PPE. Majority of healthcare workers, 61.2%, were compliant with the communicable disease control standard on the application of PPE. The highest compliance rate was observed for the put-on gloves over the gown, while the lowest compliance rate was observed for wearing eye protection.

Conclusion and recommendation

The practice of PPE usage by surgical personnel was suboptimal. Healthcare facilities can better protect their staff and patients from the spread of infections and other hazards through PPE use protocols. Donning and doffing must always be methodical and supervised by another staff member, especially during surgical emergencies. PPE should be used in accordance with infection prevention and control guidelines and the level of risk involved in the specific procedure.

Recognition of intraoperative surgical glove perforation: a comparison by surgical role and level of training

Background:

The aim of this study was to characterize the risk of glove perforation among surgical team members performing a typical set of trauma procedures, as well as to identify the rate at which these people recognize potential perforations.

Methods:

Gloves used in orthopedic trauma room procedures were collected from all participating team members over 2 weeks and were subsequently examined for perforations. Perforation rates based on glove position, type, wearer and procedure were assessed.

Results:

Perforations were found in 5.9% of gloves; 4.3% of the perforations were found in outer gloves and 1.6% in inner gloves. Among the outer gloves, 30.7% of the perforations were recognized by the wearer at the time of perforation; none of the inner glove perforations were recognized, even when they were associated with an accompanying outer glove perforation. Significantly more perforations were identified in the gloves of attending staff than in those of other team members. Attending staff experienced more perforations than other wearers, regardless of whether they were acting as the primary surgeon or as an assistant. Perforations were more common in open reduction internal fixation and amputation procedures. For open reduction internal fixation procedures, longer operative times were associated with more frequent glove perforations.

Conclusion:

The rates of glove perforation are high in orthopedic trauma surgeries, and often these perforations are not recognized by the wearer. Attending staff are at an elevated risk of glove perforation. It is recommended that all members of the surgical team change both pairs of gloves whenever an outer glove perforation is observed.

Do surgeons use double gloves during surgery? Results of a survey

<b>Introduction:</b> The perforation of gloves during surgical procedures is quite common. A cheap and quite effective method of reducing the risk of blood-borne infections is wearing two pairs of gloves. Unfortunately, some surgeons are reluctant to it, and they report decreased dexterity and sensation. The aim of the study was to evaluate surgeons' double-gloving practices to determine the factors related to compliance. <br><b>Material and methods:</b> An anonymous, 21-question survey in Polish was sent by post to 41 surgical departments. The questions concerned: demographic data, type of surgical gloves used, allergy to latex, number of surgeries performed, frequency of using double gloves and negative impressions from using them and finally, the frequency of needlestick injuries during surgical procedures. <br><b>Results:</b> We received 179 questionnaires back. More than 62% of the surgeons believe that double gloves provide better protection than a single pair, 24% do not believe in this, and 14% have no opinion. Only 0.6% of respondents always use double gloves during surgery, 19% double glove in at least 25% of cases and 68% do it occasionally. 13% of the surgeons declared that they had never worn double gloves. During high-risk procedures, 86% of respondents wear double gloves. About half of respondents (50.3%) report discomfort while wearing double gloves; 45% - decreased dexterity; about 30% complain of numbness and tingling; and 64% - decreased sensation. <br><b>Conclusion:</b> Due to the high number of surgical glove perforations and relatively high prevalence of needlestick injuries, it is necessary to use methods that reduce the risk of transmission of pathogens. The habit of using a double pair of gloves should be implemented especially among young surgeons starting to train in their specialities. Consequently, the period of initial discomfort will be combined with the acquisition of surgical skills, which will allow for gradual acclimatization.

The Prevalence of Blood-Borne Pathogens in Maxillofacial Trauma Patients

BACKGROUND

Blood-borne pathogen infections (BPIs), caused by the human immunodeficiency virus, hepatitis C and hepatitis B viruses pose an occupational hazard to healthcare workers. Facial trauma reconstruction surgeons may be at elevated risk because of routine use of sharps, and a higher than average incidence of BPIs in the trauma patient population.

METHODS

The authors retrospectively reviewed health records of patients admitted to a level 1 trauma center with a facial fracture between January 2010 and December 2015. Patient demographics, medical history, mechanism of injury, type of fracture, and procedures performed were documented. The authors detemined the frequency of human immunodeficiency virus, hepatitis B, and hepatitis C diagnosis and utilized univariable/multivariable analyses to identify risk factors associated with infection in this population.

RESULTS

In total, 4608 consecutive patients were included. Infections were found in 4.8% (n = 219) of patients (human immunodeficiency virus 1.6%, hepatitis C 3.3%, hepatitis B 0.8%). 76.3% of BPI patients in this cohort were identified by medical history, while 23.7% were diagnosed by serology following initiation of care. 39.0% of all patients received surgical treatment during initial hospitalization, of whom 4.3% had a diagnosed BPI. History of intravenous drug use (odds ratio [OR] 6.79, P < 0.001), assault-related injury (OR 1.61, P = 0.003), positive toxicology screen (OR 1.56, P = 0.004), and male gender (OR 1.53, P = 0.037) were significantly associated with a BPI diagnosis.

CONCLUSION

Patients presenting with facial fractures commonly harbor a BPI. The benefit of early diagnosis and risk to surgical staff may justify routine screening for BPI in high risk facial trauma patients (male, assault-related injury, and history of intravenous drug use).

Personal protective equipment and evidence-based advice for surgical departments during COVID-19

BACKGROUND

Inconsistencies regarding the use of appropriate personal protective equipment (PPE) have raised concerns for the safety of surgical staff during the coronavirus disease 2019 (COVID-19) pandemic. This rapid review synthesizes the literature and includes input from clinical experts to provide evidence-based guidance for surgical services.

METHODS

The rapid review comprised of targeted searches in PubMed and grey literature. Pertinent findings were discussed by a working group of clinical experts, and consensus recommendations, consistent with Australian and New Zealand Government guidelines, were formulated.

RESULTS

There was a paucity of high-quality primary studies specifically investigating appropriate surgical PPE for healthcare workers treating patients possibly infected with COVID-19. SARS-CoV-2 is capable of aerosol, droplet and fomite transmission, making it essential to augment standard infection control measures with appropriate PPE, especially during surgical emergencies and aerosol-generating procedures. All biological material should be treated a potential source of SARS-COV-2. Staff must have formal training in the use of PPE and should be supervised by a colleague during donning and doffing. Patients with suspected or confirmed COVID-19 should wear a surgical mask during transfer to and from theatre. Potential solutions exist in the literature to extend the use of surgical P2/N95 respirators in situations of limited supply.

CONCLUSION

PPE is advised for all high-risk procedures and when a patient's COVID-19 status is unknown. Surgical departments should facilitate staggered rostering, remote meeting attendance, and self-isolation of symptomatic staff. Vulnerable surgical staff should be identified and excluded from operations with a high risk of COVID-19 infection.

Safe surgery during the coronavirus disease 2019 crisis

BACKGROUND

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has created a global pandemic. Surgical care has been impacted, with concerns raised around surgical safety, especially in terms of laparoscopic versus open surgery. Due to potential aerosol transmission of SARS-CoV-2, precautions during aerosol-generating procedures and production of surgical plume are paramount for the safety of surgical teams.

METHODS

A rapid review methodology was used with evidence sourced from PubMed, Departments of Health, surgical colleges and other health authorities. From this, a working group of expert surgeons developed recommendations for surgical safety in the current environment.

RESULTS

Pre-operative testing of surgical patients with reverse transcription-polymerase chain reaction does not guarantee lack of infectivity due to a demonstrated false-negative rate of up to 30%. All bodily tissues and fluids should therefore be treated as a potential source of COVID-19 infection during operative management. Caution must be taken, especially when using an energy source that produces surgical plumes, and an appropriate capture device should also be used. Limiting the use of such devices or using lower energy devices is desirable. To reduce perceived risks association with desufflation of pneumoperitoneum during laparoscopic surgery, an appropriate suction irrigator system, attached to a high-efficiency particulate air filter, should be used. Additionally, appropriate use of personal protective equipment by the surgical team is necessary during high-risk aerosol-generating procedures.

CONCLUSIONS

As a result of the rapid review, evidence-based guidance has been produced to support safe surgical practice.

Occupational exposure during emergency department thoracotomy: A prospective, multi-institution study

BACKGROUND

Occupational exposure is an important consideration during emergency department thoracotomy (EDT). While human immunodeficiency virus/hepatitis prevalence in trauma patients (0-16.8%) and occupational exposure rates during operative trauma procedures (1.9-18.0%) have been reported, exposure risk during EDT is unknown. We hypothesized that occupational exposure risk during EDT would be greater than other operative trauma procedures.

METHODS

A prospective, observational study at 16 US trauma centers was performed (2015-2016). All bedside EDT resuscitation providers were surveyed with a standardized data collection tool and risk factors analyzed with respect to the primary end point, EDT occupational exposure (percutaneous injury, mucous membrane, open wound, or eye splash). Provider and patient variables and outcomes were evaluated with single and multivariable logistic regression analyses.

RESULTS

One thousand three hundred sixty participants (23% attending, 59% trainee, 11% nurse, 7% other) were surveyed after 305 EDTs (gunshot wound, 68%; prehospital cardiopulmonary resuscitation, 57%; emergency department signs of life, 37%), of which 15 patients survived (13 neurologically intact) their hospitalization. Overall, 22 occupational exposures were documented, resulting in an exposure rate of 7.2% (95% confidence interval [CI], 4.7-10.5%) per EDT and 1.6% (95% CI, 1.0-2.4%) per participant. No differences in trauma center level, number of participants, or hours worked were identified. Providers with exposures were primarily trainees (68%) with percutaneous injuries (86%) during the thoracotomy (73%). Full precautions were utilized in only 46% of exposed providers, while multiple variable logistic regression determined that each personal protective equipment item utilized during EDT correlated with a 34% decreased risk of occupational exposure (odds ratio, 0.66; 95% CI, 0.48-0.91; p = 0.010).

CONCLUSIONS

Our results suggest that the risk of occupational exposure should not deter providers from performing EDT. Despite the small risk of viral transmission, our data revealed practices that may place health care providers at unnecessary risk of occupational exposure. Regardless of the lifesaving nature of the procedure, improved universal precaution compliance with personal protective equipment is paramount and would further minimize occupational exposure risks during EDT.

LEVEL OF EVIDENCE

Therapeutic/care management study, level III.

Awareness, Concerns, and Protection Strategies Against Bloodborne Viruses Among Surgeons

BACKGROUND

Surgeons are at high risk of contracting infectious viruses such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) through exposure to patients' blood. The purpose of this study was to assess the surgeons' awareness of contracting bloodborne viruses.  Methods: A cross-sectional study with a questionnaire distributed to 241 surgeons at King Abdulaziz Medical City - Riyadh (KAMC-R) during the period June 2017 through January 2018. Descriptive statistics were used to analyze data collected using Stata®, v14 (StataCorp LLC, College Station, Texas, USA). Categorical variables were analyzed using Pearson chi-square test. P-value of < 0.05 was considered significant.

RESULTS

A total of 241 surgeons answered the questionnaire, 179 (74.3%) surgeons were male and 62 (25.7%) were female. The mean age ± standard deviation (SD) of male surgeons was 35.8 ± 11.0 years while for females was 33.3 ± 9.1 years. The majority of our cohort were vaccinated for HBV (96% in males and 97% in females). Two-thirds of the study cohort did not know the conversion rate post-needlestick injury by HIV, HBV, and HCV. Two-thirds of the study cohort think there is a need for HIV screening before surgery. Mixed answers were received from the cohort when asked about their concern regarding contracting HIV infection from their patients; only one-third of the surgeons were extremely concerned. When asked about the risk of needlestick injury during treating patients positive for HBV, the majority of the surgeons said no. However, a significant difference between the female and male surgeons was found in which 12 of the 62 female surgeons answered yes (19.4%) compared to 11 of the 179 male surgeons (6.1%) (p = 0.002).

CONCLUSION

The majority of our surgeons are vaccinated for HBV. However, female surgeons appear to be at higher risk of needlestick injury from HBV patients. This requires further investigation into the reasons for such high incidents. More education is needed about bloodborne viruses.

Glove Perforation in Orthopaedics: Probability of Tearing Gloves During High-Risk Events in Trauma Surgery

OBJECTIVE

To assess the risk of glove perforation during common maneuvers or events in trauma-related orthopaedic surgical procedures.

METHODS

Four investigators executed 6 high-risk maneuvers in a simulated laboratory setting. Alternative techniques were also performed for most maneuvers. Glove integrity was examined by 2 standard methods of fluid leak testing. The rates of perforation were compared between techniques using χ and Fisher exact tests.

RESULTS

Investigators were only able to identify 14.3% of perforations. Cleaning drill bit flutes by hand had the highest overall tear rate (85%). Catching a glove along the guide wire when passing a cannulated drill bit resulted in a 50% perforation rate. Catching a glove around a rotating drill shaft had a tear rate of 40%. Palpating the end of a flexible nail cut with a wire cutter had a significantly higher perforation rate than a nail cut with a proprietary, nail-specific tool (35% vs. 5%, P = 0.022). Blind digital fracture reduction had a tear rate that was not statistically different than directly visualizing the reduction (20% vs. 15%, P = 0.5). Inserting screws while stabilizing the threads with one's fingers resulted in a perforation rate of 15%.

CONCLUSIONS

Orthopaedic surgeons should be aware that microperforation of surgical gloves often goes undetected and should consider modifying or using alternative techniques when performing certain surgical maneuvers. The results of this study can be used by orthopaedic and surgical first assist training programs to promote safe surgical practice.

Prevention of Cardiac Implantable Electronic Device Infections: Single Operator Technique with Use of Povidone-Iodine, Double Gloving, Meticulous Aseptic/Antiseptic Measures and Antibiotic Prophylaxis

BACKGROUND

Cardiac implantable electronic device (CIED) implantation is complicated by infection still at a worrisome rate of 2-5%. Since early on during device implantation procedures, we have adopted an infection-preventive technique which has hitherto resulted in effective prevention of infections. Herein we present our results of applying this technique by a single operator in a prospective series of 762 consecutive patients undergoing device implantation.

METHODS

A meticulous search for and treatment of active, occult, or smoldering infection was undertaken preoperatively. An aseptic/antiseptic technique was used for implantation of each device. Skin preparation is thorough with initial cleansing performed with alcohol followed by povidone-iodine 10% solution, which is also used in the wound and inside the pocket. In addition, we routinely use double gloving, and IV antibiotic prophylaxis 1 hour before and for 48 hours afterwards followed by oral antibiotic for 2-3 days after discharge. The skin is closed with absorbable sutures. The study includes 382 patients having a new pacemaker (n = 333) or battery change, system upgrade or lead revision (n = 49), and 380 patients having a new implantable cardioverter-defibrillator (ICD) (n = 296) or device replacement/upgrade/lead revision (n = 84).

RESULTS

The pacemaker group, aged 70.2 ± 16.5 years, includes 18% VVI, 49% DDD, 29% VDD, and 4% cardiac resynchronization therapy (CRT) devices. The ICD group, aged 61.3 ± 13.0 years, with a mean ejection fraction of 36 ± 13%, includes 325 ICD and 55 CRT implants. Over 26.6 ± 33.4 months for the pacemaker group and 36.6 ± 38.3 months for the ICD group, infection occurred in one patient in each group (0.26%) having a device replacement.

CONCLUSION

A consistent and strict approach of aseptic/antiseptic technique with the use of double gloving and povidone-iodine solution within the pocket plus a 4-day regimen of antibiotic prophylaxis minimizes infections in CIED implants.

Is there a benefit for health care workers in testing HIV, HCV and HBV in routine before elective arthroplasty?

INTRODUCTION

Occupational infection of clinical health care workers with blood-borne viruses (BBVs) like human immunodeficiency virus (HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV) is a current and often emotionally discussed issue. HCV and especially HIV are still stigmatized. The consequence is a broad and maybe irrational fear of professional health care workers being infected occupationally. Therefore, we assessed preoperative screening to: (1) answer whether this can detect not previously diagnosed blood-borne virus infections to a great extent, (2) calculate a cost-benefit ratio to find out, if the screening's potential ability to prevent occupational transmission of BBVs to health care workers faces unjustifiable high costs.

HYPOTHESIS

Preoperative routine screening is limited suitable for enhancement of detecting fomites compared to interview the patient.

MATERIALS AND METHODS

Retrospective cohort study of preoperative screening for HIV, HBV and HCV (HBsAg, anti-HCV and HIV-Ab/Ag-Combination) for every patient who was admitted to the traumatologic department for elective arthroplasty between 01/01/1997 and 31/12/2008.

RESULTS

Among the 1534 patients who underwent elective prosthetic surgery [total hip (879) and knee arthroplasty (508), followed by shoulder, elbow and upper ankle joint], 693 (45.2%) patients were male and 841 (54.8) female. Mean age was 64.2±13.8 years. Screening tests were available for 1373 patients (89.5%). Among all screened patients, we found 21 HCV, 10 HBV and 1 HIV infections. 5 HBV (0.5%) and 7 HCV infections (0.7%) were unknown before. Every newly detected infectious patient occasions screening costs about 7250€. Considering this data, the risk of HCV transmission from an index patient with unknown status of infectiousness to health care worker after percutaneous contact to blood is 0.08 ‰ and of HIV transmission is 0.00054 ‰ in our study population.

DISCUSSION

Routine preoperative screening for BBVs of patients undergoing elective arthroplasty, who were asked for HBV, HCV and HIV, should be reconsidered and is, in times of sparse funds, overpriced.

LEVEL OF EVIDENCE

IV.

Risk factors for and circumstances of needlestick and sharps injuries of doctors in operating rooms: A study focusing on surgeries using general anesthesia at Kurume University Hospital, Japan

Healthcare workers are exposed to serious infectious diseases via needlestick and sharps injuries. The operating room is a particularly important environment in which the risk for needlestick injuries is increased for surgical doctors. According to national surveillance studies, the proportion of needlestick and sharps injuries in operating rooms has been increasing for unknown reasons. In this study, we examined risk factors for and circumstances of injuries in operating rooms by combining and analyzing incidence reports and electronic records of every surgery in Kurume University Hospital (Kurume, Japan). The annual injury rate (reflecting the reporting rate) rose continuously from fiscal years 2007-2012. We conducted analyses focusing on surgeries that used general anesthesia, which accounted for 88.1% of the injuries. An analysis of the time of injury found that the number of injuries increased toward the end of the surgical procedure. A comparative analysis of surgeries by doctors who had experienced injury revealed risk for the injury increased when a procedure ended after 20:00. In addition, a comparative analysis of doctors with and without injury experience who had similar level of operating time per year revealed that the number of working years was not lower in the injured doctors. Although the data analyzed in this study were confined to one university hospital, our approach and these results will form a basis on which to consider more effective measures to prevent injury in operating rooms.

Surgical Procedure Characteristics and Risk of Sharps-Related Blood and Body Fluid Exposure

OBJECTIVE To use a unique multicomponent administrative data set assembled at a large academic teaching hospital to examine the risk of percutaneous blood and body fluid (BBF) exposures occurring in operating rooms. DESIGN A 10-year retrospective cohort design. SETTING A single large academic teaching hospital. PARTICIPANTS All surgical procedures (n=333,073) performed in 2001-2010 as well as 2,113 reported BBF exposures were analyzed. METHODS Crude exposure rates were calculated; Poisson regression was used to analyze risk factors and account for procedure duration. BBF exposures involving suture needles were examined separately from those involving other device types to examine possible differences in risk factors. RESULTS The overall rate of reported BBF exposures was 6.3 per 1,000 surgical procedures (2.9 per 1,000 surgical hours). BBF exposure rates increased with estimated patient blood loss (17.7 exposures per 1,000 procedures with 501-1,000 cc blood loss and 26.4 exposures per 1,000 procedures with >1,000 cc blood loss), number of personnel working in the surgical field during the procedure (34.4 exposures per 1,000 procedures having ≥15 personnel ever in the field), and procedure duration (14.3 exposures per 1,000 procedures lasting 4 to <6 hours, 27.1 exposures per 1,000 procedures lasting ≥6 hours). Regression results showed associations were generally stronger for suture needle-related exposures. CONCLUSIONS Results largely support other studies found in the literature. However, additional research should investigate differences in risk factors for BBF exposures associated with suture needles and those associated with all other device types. Infect. Control Hosp. Epidemiol. 2015;37(1):80-87.

Gastrointestinal surgery and the acquired immune deficiency syndrome

Acquired immune-deficiency syndrome (AIDS) is becoming an increasing problem to the surgeon. The impact of HIV/AIDS on surgical practice include the undoubted risk to which the surgeon will expose him or herself, the atypical conditions that may be encountered and the outcome and long term benefit of the surgical treatment in view of disease progression. The two factors most associated with surgical outcome and poor wound healing were AIDS and poor performance status (ASA score). This article questions whether gastrointestinal surgical procedures can be safe and effective therapeutic measures in HIV/AIDS patients and if surgical outcome is worthy of the surgeon's ethical responsibility to treat. As HIV/AIDS patients are not a homogeneous group, with careful patient selection, emergency laparotomy for peritonitis confers worthwhile palliation. However, aggressive surgical intervention must be undertaken with caution and adequate peri-operative care is required. Symptomatic improvement of anorectal pathology may make delayed wound healing an acceptable complication. Alternatives to surgery can be contemplated for diagnosis, prophylaxis or palliation.

Blood and Body Fluid Exposures Among Surgeons: A Survey of Attitudes and Perceptions Five Years Following Universal Precautions

A mail survey of surgeons at our medical center 5 years following adoption of Universal Precautions revealed that 29% estimated having ≥1 potentially serious blood or body fluid exposures (BBEs) per month. Failure to report BBEs (usually needlesticks) to the employee health department was common, and the majority of surgeons in practice for ≥10 years never reported such exposures. The most commonly cited reason for not reporting BBEs was perceived low risk of acquiring bloodborne infections.

Surveillance of Occupational Blood and Body Fluid Exposures Among French Healthcare Workers in 2004

Objective.

To estimate the incidence rate of reported occupational blood and body fluid exposures among French healthcare workers (HCWs).

Design.

Prospective national follow-up of HCWs from January 1 to December 31, 2004.

Setting.

University hospitals, hospitals, clinics, local medical centers, and specialized psychiatric centers were included in the study on a voluntary basis.

Participants.

At participating medical centers, every reported blood and body fluid exposure was documented by the occupational practitioner in charge of the exposed HCW by use of an anonymous, standardized questionnaire.

Results.

A total of 375 medical centers (15% of French medical centers, accounting for 29% of hospital beds) reported 13,041 blood and body fluid exposures; of these, 9,396 (72.0%) were needlestick injuries. Blood and body fluid exposures were avoidable in 39.1% of cases (5,091 of 13,020), and 52.2% of percutaneous injuries (4,986 of 9,552) were avoidable (5.9% due to needle recapping). Of 10,656 percutaneous injuries, 22.6% occurred during an injection, 17.9% during blood sampling, and 16.6% during surgery. Of 2,065 splashes, 22.6% occurred during nursing activities, 19.1% during surgery, 14.1% during placement or removal of an intravenous line, and 12.0% during manipulation of a tracheotomy tube. The incidence rates of exposures were 8.9 per 100 hospital beds (95% confidence interval [CI], 8.7-9.0 exposures), 2.2 per 100 full-time—equivalent physicians (95% CI, 2.4-2.6 exposures), and 7.0 per 100 full-time—equivalent nurses (95% CI, 6.8-7.2 exposures). Human immunodeficiency virus serological status was unknown for 2,789 (21.4%) of 13,041 patients who were the source of the blood and body fluid exposures.

Conclusion.

National surveillance networks for blood and body fluid exposures help to better document their characteristics and risk factors and can enhance prevention at participating medical centers.

Occupational Exposures and the Prevalence of Blood-Borne Pathogens in a Deployed Setting Data from a US Military Trauma Center in Afghanistan

Objective.

Occupational exposures to blood and other bodily fluids occur in approximately 5 per 100 persons every year in US hospitals. Since the provision of health care in the deployed environment poses unique challenges to hospital personnel, it is important to characterize the rates of occupational exposures and understand the prevalence of blood-borne pathogens (BBPs) in host nations.

Methods.

A retrospective review of public health and laboratory records at a US military trauma center in Afghanistan from October 1, 2010, to March 31, 2012.

Results.

A total of 65 occupational exposures were reported, including 47 (72%) percutaneous and 18 (28%) mucocutaneous, with a yearly rate of 8.6 exposures per 100 persons. During 6-month deployment cycles, the majority of exposures (46.2%) occurred in the first 2 months after arrival in Afghanistan. Physicians reported the most exposures (26%), and the operating room (48%) was the most common hospital location. The prevalence of hepatitis B and hepatitis C among local national source patients (n= 59 ) was 8.9% and 2.3%, respectively, with no cases of HIV or syphilis detected. In contrast, there were no BBPs detected in coalition source (n= 12) or exposed (n = 57) patients.

Conclusions.

The characteristics of occupational exposures in this deployed environment were comparable to those of US-based hospitals. Standard practices used to reduce occupational exposures, such as use of personal protective equipment and safety devices, should continue to be prioritized in the deployed setting. Although BBP rates are not well defined in Afghanistan, our results were consistent with those of prior epidemiologic studies.

Risk of Sharp Device–Related Blood and Body Fluid Exposure in Operating Rooms

Objective.

The risk of percutaneous blood and body fluid (BBF) exposures in operating rooms was analyzed with regard to various properties of surgical procedures.

Design.

Retrospective cohort study.

Setting.

A single university hospital.

Methods.

All surgical procedures performed during the period 2001–2002 (n = 60,583) were included in the analysis. Administrative data were linked to allow examination of 389 BBF exposures. Stratified exposure rates were calculated; Poisson regression was used to analyze risk factors. Risk of percutaneous BBF exposure was examined separately for events involving suture needles and events involving other device types.

Results.

Operating room personnel reported 6.4 BBF exposures per 1,000 surgical procedures (2.6 exposures per 1,000 surgical hours). Exposure rates increased with an increase in estimated blood loss (17.5 exposures per 1,000 procedures with 501–1,000 cc blood loss and 22.5 exposures per 1,000 procedures with >1,000 cc blood loss), increased number of personnel ever working in the surgical field (20.5 exposures per 1,000 procedures with 15 or more personnel ever in the field), and increased surgical procedure duration (13.7 exposures per 1,000 procedures that lasted 4–6 hours, 24.0 exposures per 1,000 procedures that lasted 6 hours or more). Associations were generally stronger for suture needle–related exposures.

Conclusions.

Our results support the need for prevention programs that are targeted to mitigate the risks for BBF exposure posed by high blood loss during surgery (eg, use of blunt suture needles and a neutral zone for passing surgical equipment) and prolonged duration of surgery (eg, double gloving to defend against the risk of glove perforation associated with long surgery). Further investigation is needed to understand the risks posed by lengthy surgical procedures.

Costs of Management of Occupational Exposures to Blood and Body Fluids

Objective.

To determine the cost of management of occupational exposures to blood and body fluids.

Design.

A convenience sample of 4 healthcare facilities provided information on the cost of management of occupational exposures that varied in type, severity, and exposure source infection status. Detailed information was collected on time spent reporting, managing, and following up the exposures; salaries (including benefits) for representative staff who sustained and who managed exposures; and costs (not charges) for laboratory testing of exposure sources and exposed healthcare personnel, as well as any postexposure prophylaxis taken by the exposed personnel. Resources used were stratified by the phase of exposure management: exposure reporting, initial management, and follow-up. Data for 31 exposure scenarios were analyzed. Costs were given in 2003 US dollars.

Setting.

The 4 facilities providing data were a 600-bed public hospital, a 244-bed Veterans Affairs medical center, a 437-bed rural tertiary care hospital, and a 3,500-bed healthcare system.

Results.

The overall range of costs to manage reported exposures was $71-$4,838. Mean total costs varied greatly by the infection status of the source patient. The overall mean cost for exposures to human immunodeficiency virus (HIV)-infected source patients (n = 19, including those coinfected with hepatitis B or C virus) was $2,456 (range, $907-$4,838), whereas the overall mean cost for exposures to source patients with unknown or negative infection status (n = 8) was $376 (range, $71-$860). Lastly, the overall mean cost of management of reported exposures for source patients infected with hepatitis C virus (n = 4) was $650 (range, $186-$856).

Conclusions.

Management of occupational exposures to blood and body fluids is costly, the best way to avoid these costs is by prevention of exposures.

Scarcity of protective items against HIV and other bloodborne infections in 13 low- and middle-income countries

OBJECTIVE

To assess protection of surgical healthcare workers against HIV and other bloodborne infections in low- and middle-income countries (LMICs).

METHODS

Literature review based on recent studies assessing baseline surgical capacity in LMICs using the WHO Situational Analysis of Access to Emergency and Essential Surgical Care, the Surgeons OverSeas (SOS) Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) survey and the Harvard Humanitarian Initiative survey tools. The availability of protective eyewear, sterile gloves and sterilisers was assessed.

RESULTS

Thirteen individual country studies with relevant data were identified documenting items from 399 hospitals. The countries included Afghanistan, Bolivia, Gambia, Ghana, Liberia, Mongolia, Nigeria, Sierra Leone, Solomon Islands, Somalia, Sri Lanka, Tanzania and Zambia. Overall, only 29% (79/270) of hospitals always had eye protection. Sterilisers were only available at 64% (244/383) of facilities. Sterile gloves were the most available item, available at 75% of facilities (256/340).

CONCLUSION

Surgical healthcare worker protection for bloodborne infections continues to be deficient in LMICs. Improved documentation of these items should be incorporated into future surgical capacity studies. Policy makers and clinicians should work together to secure resources and interventions that will protect this vital workforce.

Study of Glove Perforation during Hip Replacement Arthroplasty: Its Frequency, Location, and Timing

Objective. The aim of the study was to evaluate the location, timing, and frequency of glove perforation during hip replacement arthroplasty. Methods. Gloves worn by surgical team members in 19 primary hip replacement arthroplasties were assessed. The study was of a single gloving system. All the used gloves were collected at the end of the surgery and assessed visually and by using water inflation technique. Relevant data were collected at the time of surgery. Results. A total of one hundred and ninety-one surgical gloves were evaluated. Twenty-three glove perforations were noted in nineteen of the operations. Of these perforations 14 belonged to gloves worn by surgeon and first assistant (60.1%). Glove perforation in thumb, index finger, and palm was more common. More perforation occurred in the gloves worn in nondominant hand (52%) but was insignificant. Conclusion. Glove perforation in surgeries such as total hip arthroplasty is not uncommon. In this study of single gloving system glove perforation rate was 12.04%, whereas literature reports of glove perforation rate as low as 3.3% in elective orthopedic surgeries with double gloving system. As such emphasis should be given to wear double pair of gloves wherever this practice is uncommon.

How often are major blood-borne pathogens found in eye patients? A serosurvey at an eye hospital in Southern China

BACKGROUND

The hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV) and treponema pallidum (TP) are blood-borne pathogens. They can lead to nosocomial and occupational infections in health care settings. We aimed to identify the prevalence of and risk factors associated with HBV, HCV, HIV and TP infections among patients with eye diseases at a tertiary eye hospital in Southern China.

METHODS

From July 2011 to June 2012, a total of 26,386 blood units were collected from eye patients, including inpatients and the day surgery patients at Zhongshan Ophthalmic Center, one of the biggest eye hospitals in China. Based on the primary diagnoses from this period, the subjects were classified into different ocular disease groups. All blood samples were tested for HBsAg, anti-HCV, anti-HIV and anti-TP.

RESULT

The overall prevalence of HBV, HCV, TP and HIV was 9.79%, 0.99%, 2.43% and 0.11%, respectively. The prevalence of HBsAg was much lower among patients younger than 20 years compared to other age groups. In addition, the risk of HBsAg was associated with the male gender, ocular trauma and glaucoma. The prevalence of TP increased with age and the prevalence among patients older than 30 was higher than that in patients younger than 20 years.

CONCLUSIONS

The prevalence of HBV, HCV, HIV and TP in patients with eye diseases was identified. This information can be utilised to strengthen the health education and implementation of universal safety precautions to prevent the spread of blood-borne pathogens in health care settings.

The comparison of sharps injuries reported by doctors versus nurses from surgical wards in the context of the prevalence of HBV, HCV and HIV infections

The aim of the study was to evaluate the nature and frequency of sharps injuries among doctors and nurses from the same surgical/gynecological wards and the prevalence of HBV/HCV/HIV infection.

MATERIAL AND METHODS

An anonymous cross-sectional sero-survey, with ELISA system used to detect anti-HBc, anti-HCV, anti-HIV, was conducted among 89 doctors and 414 nurses from 16 randomly selected hospitals in West Pomerania, Poland, between January-June 2009.

RESULTS

During the preceding 12 months, 82% doctors and 44.4% nurses (p<0.0001) had sustained at least one sharps injury; 12.3% doctors vs 2.2% nurses (p<0.003) sustained more than 10 injuries. The multivariable regression model revealed that being a doctor was associated with a greater odds (OR 4.2) of being injured with sharps. Sixty nine percent of nurses sustained a hollow-bore needle injury vs 8.9% doctors; p<0.001. Anti-HBc were found in 16.4% of doctors and 11.2% of nurses, p>0.28; anti-HCV - in 1.1% of doctors vs 1.4% of nurses, p>0.79; no anti-HIV positive cases were found. The analysis of potential risk factors for contracting a HBV revealed that for both job categories only length of employment was associated with an increased odds of being infected.

CONCLUSIONS

Although the prevalence of HBV/HCV infection between doctors and nurses does not differ significantly, modifiable risk factors for contracting a BBI such as frequency and nature of sharps injuries may differ, which call for tailoring preventive measures to specific job categories. Long lasting exposure to injury events should be taken into consideration while assessing the risk for accuiring an occupational infection with HBV, HCV or HIV.

Unexpected injury of the orthopaedic surgeon: a case report of a hammer splinter

Sharps injuries have become one of the most important occupational injuries and they are common during surgery, with rates between 1.7 and 6.9% of all surgical procedures. This case report, however, revealed an extremely rare and unexpected condition, which could not be prevented by the reasonable safety precautions against injury. Closed reduction and closed intramedullary fixation was planned for the patient with humeral shaft fracture. While advancing the nail by hammering a piece of metal detached. A short time following the commencement of the procedure, the surgeon who was performing the operation felt a sudden severe pain in the neck. A radio-opaque intensity in the cervical region was detected on X-rays. There was a piece of metal from the hammer. The risk encountered in the present case comprises a condition, the prevention of which is probably impossible with the frequently utilized preventive measures against injuries. For this reason, the operating room team and in particular, the surgeon, should be careful about possible expected injuries, as well as the unexpected ones. Sharps injuries continue to be a serious concern for all healthcare workers. In some studies however, reporting of sharps injuries by healthcare workers remains a problem with reporting levels cited as low as 15% and as high as 90% (Kerr H-L, Stewart N Ann R Coll Surg Engl 91:430-432, [6]). Guo et al. pointed out the most recent sharps injuries at work, and syringe needles was by far the most important items causing injuries, followed by glass products, suture needles, and intravenous catheters.

Risk of surgical glove perforation in oral and maxillofacial surgery

Oral and maxillofacial surgery, which involves several sharp instruments and fixation materials, is consistently at a high risk for cross-contamination due to perforated gloves, but it is unclear how often such perforations occur. This study aimed to address this issue. The frequency of the perforation of surgical gloves (n=1436) in 150 oral and maxillofacial surgeries including orthognathic surgery (n=45) was assessed by the hydroinsufflation technique. Orthognathic surgery had the highest perforation rate in at least 1 glove in 1 operation (91.1%), followed by cleft lip and palate surgery (55.0%), excision of oral soft tumour (54.5%) and dental implantation (50.0%). The perforation rate in scrub nurses was 63.4%, followed by 44.4% in surgeons and first assistants, and 16.3% in second assistants. The odds ratio for the perforation rate in orthognathic surgery versus other surgeries was 16.0 (95% confidence interval: 5.3-48.0). The protection rate offered by double gloving in orthognathic surgery was 95.2%. These results suggest that, regardless of the surgical duration and blood loss in all fields of surgery, orthognathic surgery must be categorized in the highest risk group for glove perforation, following gynaecological and open lung surgery, due to the involvement of sharp objects.

Scarcity of healthcare worker protection in eight low- and middle-income countries: surgery and the risk of HIV and other bloodborne pathogens

OBJECTIVE

In view of the substantial incidence of bloodborne diseases and risk to surgical healthcare workers in low- and middle-income countries (LMICs), we evaluated the availability of eye protection, aprons, sterile gloves, sterilizers and suction pumps.

METHODS

Review of studies using the WHO Tool for the Situational Analysis of Access to Emergency and Essential Surgical Care.

RESULTS

Eight papers documented data from 164 hospitals: Afghanistan (17), Gambia (18), Ghana (17), Liberia (16), Mongolia (44), Sierra Leone (12), Solomon Islands (9) and Sri Lanka (31). No country had a 100% supply of any item. Eye protection was available in only one hospital in Sri Lanka (4%) and most abundant in Liberia (56%). The availability of sterile gloves ranged from 24% in Afghanistan to 94% in Ghana.

CONCLUSION

Substantial deficiencies of basic protective supplies exist in low- and middle-income countries.

Surgeons' and residents' double-gloving practices at 2 teaching hospitals in Ontario

BACKGROUND

Surgeons and residents are at increased risk of exposure to blood-borne pathogens owing to percutaneous injury (PI) and contamination. One method known to reduce risk is double-gloving (DG) during surgery.

METHODS

All surgeons and residents affiliated with the University of Western Ontario (UWO) and McMaster University in 2005 were asked to participate in a Web-based survey. The survey asked respondents their specialty, the number of operations they participated in per week, their age and sex, the proportion of surgeries in which they double-gloved (DG in ≥75% surgeries was considered to be routine), and the average number of PIs they sustained per year and whether or not they reported them to an employee health service.

RESULTS

In total, 155 of 331 (47%) eligible surgeons and residents responded; response rates for UWO and McMaster surgeons were 50% and 39%, respectively, and for UWO and McMaster residents, they were 52% and 47%, respectively. A total of 43% of surgeons and residents reported routine DG; 50% from McMaster and 36% from UWO. Using logistic regression to simultaneously adjust for participant characteristics, we confirmed that DG was more frequent at McMaster than at UWO, with an odds ratio of 3.32 (95% confidence interval 1.35-8.17). Surgeons and residents reported an average of 3.3 surgical PIs per year (2.2 among McMaster participants and 4.5 among UWO participants). Of the 77% who reported at least 1 injury/year, 67% stated that they had not reported it to an employee health service.

CONCLUSION

Percutaneous injuries occur frequently during surgery, yet routine DG, an effective means of reducing risk, was carried out by less than half of the surgeons and residents participating in this study. This highlights the need for a more concerted and broad-based approach to increase the use of a measure that is effective, inexpensive and easily carried out.

Needlestick an sharps injuries among theatre care professionals

Health care professionals are exposed to blood and other body fluids in the course of their work: (Al-Benna et al 2008). The World Health Organisation (2003) estimates that 9% of the 35 million healthcare professionals worldwide will experience percutaneous exposure to bloodborne pathogens each year (WHO 2003). In the U.K. about 100,000 sharps injuries occur in NHS hospitals each year (Trim & Elliott 2003). This is 17% of all accidents involving NHS staff (NAO 2003). Four percent of NHS staff sustain from 1 to 6.2 sharps injuries each year. These injuries occur mainly in clinical areas such as wards and theatres, but also in non-clinical areas due to accidental handling of inappropriately discarded sharps (Trim & Elliott 2003, Waterson 2004). Percutaneous injuries involving hollowbore needles remain the most commonly reported occupational exposures in the healthcare setting (HPA 2010). Consequently, workers are at risk of infection with bloodborne viruses including human immunodeficiency virus, hepatitis B virus, hepatitis C virus and bacterial infections (Al-Benna et al 2008).

SHEA guideline for management of healthcare workers who are infected with hepatitis B virus, hepatitis C virus, and/or human immunodeficiency virus

This guideline provides the updated recommendations of the Society for Healthcare Epidemiology of America (SHEA) regarding the management of healthcare providers who are infected with hepatitis B virus (HBV), hepatitis C virus (HCV), and/or the human immunodeficiency virus (HIV). For the reasons cited in the guideline, SHEA continues to recommend that, although some aspects of the approach to and administrative management of each of these infectious syndromes in healthcare providers are similar, separate management strategies for healthcare workers who are infected with these unrelated viruses remain appropriate. As we did in both prior iterations of this document, SHEA emphasizes the use of appropriate infection control procedures to minimize exposure of patients or providers to blood, emphasizes that transfers of blood from patients to providers and from providers to patients should be avoided, and recommends that infected healthcare providers should not be totally prohibited from participating in patient-care activities solely on the basis of a bloodborne pathogen infection. The types of procedures assessed by the panel as associated with an increased risk for provider-to-patient transmission of these pathogens are discussed in detail. For each pathogen, recommendations are graduated according to the relative viral load level of the infected provider (Tables 1 and 2). However, SHEA emphasizes that, because of the complexity of these cases, each such case will be slightly different from the next, and each should be independently considered in context.

Infection control guidelines for prevention of health care-associated transmission of hepatitis B and C viruses

Viral hepatitis was first identified as an occupational hazard for health care workers more than 60 years ago. For the past few decades, hepatitis B has been one of the most significant occupational infectious risks for health care providers. With the increasing prevalence of hepatitis C infections around the world, occupational transmission of this flavivirus from infected patients to their providers has also become a significant concern. Several factors influence the risk for occupational blood-borne hepatitis infection among health care providers, among them: the prevalence of infection among the population served, the infection status of the patients to whom workers are exposed (ie, the source patient's circulating viral burden), the types and frequencies of parenteral and mucosal exposures to blood and blood-containing body fluids, and whether the patient or provider has been immunized with the hepatitis B vaccine. This article reviews patient-to-provider, patient-to-patient, and provider-to-patient transmission of hepatitis B and C in the health care setting. Current prevention strategies, precautions, and guidelines are discussed.

Is use of the hands-free technique during surgery, a safe work practice, associated with safety climate?

BACKGROUND

A better safety climate has been linked to better compliance with safety behaviors. This study assessed whether "management support," the most commonly measured safety climate dimension, was associated with greater use of the hands-free technique (HFT), a work practice recommended for use during surgery to prevent exposure to blood and body fluids.

METHODS

Questionnaires from operating room nurses participating in a test retest reliability study and in training sessions for an intervention study, from 9 hospitals in 3 Canadian provinces, were analyzed.

RESULTS

Response rates in the hospitals varied from 61% to 97%. Four hundred forty-two operating room nurses responded; 16% reported using the HFT approximately 75% or more of the time in surgery, and 39% had received HFT training. Management support and HFT training were each associated with increased HFT use: odds ratio (OR), 6.63; 95% confidence interval (CI): 1.89-23.30 and OR, 6.36; 95% CI: 1.97-20.51, respectively. When training occurred in a context of management support, HFT use was further increased: OR, 9.12; 95% CI: 2.71-30.72.

CONCLUSION

Consistent with previous research linking management support for health and safety to uptake of safety practices, management support and HFT training acted synergistically to increase HFT use most of the time in surgery.

Sharps injury reporting amongst surgeons

INTRODUCTION

The aim of this study was to evaluate the level of sharps injury reporting amongst surgeons.

SUBJECTS AND METHODS

A total of 164 surgeons completed a questionnaire on the reporting of sharps injuries, on the reasons for not reporting and their practise of universal precautions.

RESULTS

Out of 164 surgeons, only 25.8% had reported all their injuries, 22.5% had reported some and 51.7% had reported none. The top three reasons for not reporting their injuries included perception of low risk of transmission, not being concerned and no time. Of the respondents, 15.9% practised all three universal precautions of double-gloving, face shields and hands-free technique.

CONCLUSIONS

We showed that despite local trust adherence to Department of Health policy, sharps injury reporting rates are inadequate. Further investment into healthcare worker education as well as a facilitation of the process of reporting may be necessary to improve reporting rates.

Accidental exposures to blood and body fluid in the operation room and the issue of underreporting

A retrospective review of all exposure injuries affecting members of the operative care line at a single university hospital between January 2000 and December 2007 was performed. A questionnaire survey on current status of adherence to barrier precautions was also completed by 164 staff members. Of 136 exposure injuries, 87 (64.0%) were in surgeons, and 49 (36.0%) were in scrub nurses. Surgeons were most commonly injured during suturing (49, 56%), followed by "handing over sharps" (7, 8%), whereas scrub nurses were most commonly injured during "counting and sorting of sharps" (15, 41%), followed by "handing over sharps," and "splash." The questionnaire survey revealed that compliance with goggles, face shields, and double gloving was poor, and only 9% of respondents routinely used the hands-free technique. Only 22% of staff who had experienced exposure injuries reported every incident. Because circumstances of exposure injuries in operating rooms differ by profession, appropriate preventive measures should address individual situations. To reduce exposure injuries in the operating room, further efforts are required including education, mentoring, and competency training for operation personnel.

Hands-free technique in the operating room: reduction in body fluid exposure and the value of a training video

OBJECTIVES

This study sought to determine if (1) using a hands-free technique (HFT)--whereby no two surgical team members touch the same sharp item simultaneously--> or = 75% of the time reduced the rate of percutaneous injury, glove tear, and contamination (incidents); and (2) if a video-based intervention increased HFT use to > or = 75%, immediately and over time.

METHODS

During three and four periods, in three intervention and three control hospitals, respectively, nurses recorded incidents, percentage of HFT use, and other information in 10,596 surgeries. The video was shown in intervention hospitals between Periods 1 and 2, and in control hospitals between Periods 3 and 4. HFT, considered used when > or = 75% passes were done hands-free, was practiced in 35% of all surgeries. We applied logistic regression to (1) estimate the rate reduction for incidents in surgeries when the HFT was used and not used, while adjusting for potential risk factors, and (2) estimate HFT use of about 75% and 100%, in intervention compared with control hospitals, in Period 2 compared with Period 1, and Period 3 compared with Period 2.

RESULTS

A total of 202 incidents (49 injuries, 125 glove tears, and 28 contaminations) were reported. Adjusted for differences in surgical type, length, emergency status, blood loss, time of day, and number of personnel present for > or = 75% of the surgery, the HFT-associated reduction in rate was 35%. An increase in use of HFT of > or = 75% was significantly greater in intervention hospitals, during the first post-intervention period, and was sustained five months later.

CONCLUSION

The use of HFT and the HFT video were both found to be effective.