Analysis of sharp-edged medical-object injuries at a medical center in Taiwan

How to develop a standard operating procedure for sorting unfixed cells

Written standard operating procedures (SOPs) are an important tool to assure that recurring tasks in a laboratory are performed in a consistent manner. When the procedure covered in the SOP involves a high-risk activity such as sorting unfixed cells using a jet-in-air sorter, safety elements are critical components of the document. The details on sort sample handling, sorter set-up, validation, operation, troubleshooting, and maintenance, personal protective equipment (PPE), and operator training, outlined in the SOP are to be based on careful risk assessment of the procedure. This review provides background information on the hazards associated with sorting of unfixed cells and the process used to arrive at the appropriate combination of facility design, instrument placement, safety equipment, and practices to be followed.

Prevalence of injuries and reporting of accidents among health care workers at the University Hospital of the West Indies

OBJECTIVES

This study investigated the knowledge, awareness and practices of health care workers towards universal precautions at the University Hospital of the West Indies. The study also examined the prevalence of injuries experienced by health care workers, as well as incidence of accidents and compliance with post-exposure prophylaxis.

MATERIALS AND METHODS

A cross sectional survey was conducted in September and October 2007. A 28-item self-administered questionnaire was provided to two hundred health care workers including medical doctors, medical technologists, nurses and porters to assess knowledge and practices regarding universal precautions, prevalence of injuries and incidence of accidents.

RESULTS

Almost two-thirds (62.3%) of the respondents were aware of policies and procedures for reporting accidents while one-third (33.2%) were unsure. All nurses were aware of policies and procedures for reporting accidents, followed by medical doctors (88%) and medical technologists (61.2%). The majority (81.5%) of the respondents experienced splashes from bodily fluid. Over three-quarters of medical doctors (78%) and two-thirds of nurses (64%) reported having experienced needle stick injuries, while the incidence among medical technologists was remarkably lower (26%). The majority of the respondents (59%) experienced low accident incidence while just over one-tenth (14%) reported high incidence. Eighty four respondents reported needle stick injuries; just under two-thirds (59.5%) of this group received post-exposure treatment.

CONCLUSIONS

The study found that majority of health care workers were aware of policies and procedures for reporting accidents. Splashes from body fluids, needle stick injuries and cuts from other objects were quite prevalent among health care workers. There is a need for monitoring systems which would provide accurate information on the magnitude of needle stick injuries and trends over time, potential risk factors, emerging new problems, and the effectiveness of interventions at The University Hospital of the West Indies and other hospitals in Jamaica.

The effectiveness of a training program on reducing needlestick injuries/sharp object injuries among soon graduate vocational nursing school students in southern Taiwan

Needlestick/sharp injuries (NSIs/SIs) are a serious threat to medical/nursing students in hospital internships. Education for preventing NSIs/SIs is important for healthcare workers but is rarely conducted and evaluated among vocational school nursing students. We conducted an educational intervention for such students after their internship rotations before graduation. This program consisted of a lecture to the students after the internship training and a self-study brochure for them to study before their graduation. This study used the pre-test questionnaires completed by all students and the post-test questionnaires completed by 107 graduates after work experience as licensed nurses to assess the effectiveness of the intervention. After educational intervention, the incidence of NSIs/SIs decreased significantly from 50.5% pre-test to 25.2% post-test, and the report rate increased from 37.0% to 55.6%, respectively. In conclusion, this intervention significantly reduced the incidence of NSIs/SIs and increased the report rate of such events.

Poor knowledge--predictor of nonadherence to universal precautions for blood borne pathogens at first level care facilities in Pakistan

Background

We conducted an assessment of knowledge about blood borne pathogens (BBP) and use of universal precautions at first level care facilities (FLCF) in two districts of Pakistan.

Methods

We conducted a cross-sectional survey and selected three different types of FLCFs ; public, general practitioners and unqualified practitioners through stratified random sampling technique. At each facility, we interviewed a prescriber, a dispenser, and a housekeeper for knowledge of BBPs transmission and preventive practices, risk perception, and use of universal precautions. We performed multiple linear regression to assess the effect of knowledge score (11 items) on the practice of universal precautions score (4 items- use of gloves, gown, needle recapping, and HBV vaccination).

Results

We interviewed 239 subjects. Most of the participants 128 (53%) were recruited from general practitioners clinics and 166 (69.5%) of them were dispensers. Mean (SD) knowledge score was 3.8 (2.3) with median of 4. MBBS prescribers had the highest knowledge score while the housekeepers had the lowest. Mean universal precautions use score was 2.7 ± 2.1. Knowledge about mode of transmission and the work experience alone, significantly predicted universal precaution use in multiple linear regression model (adR² = 0.093).

Conclusion

Knowledge about mode of transmission of blood borne pathogens is very low. Use of universal precautions can improve with increase in knowledge.

International Society for Analytical Cytology biosafety standard for sorting of unfixed cells

BACKGROUND

Cell sorting of viable biological specimens has become very prevalent in laboratories involved in basic and clinical research. As these samples can contain infectious agents, precautions to protect instrument operators and the environment from hazards arising from the use of sorters are paramount. To this end the International Society of Analytical Cytology (ISAC) took a lead in establishing biosafety guidelines for sorting of unfixed cells (Schmid et al., Cytometry 1997;28:99-117). During the time period these recommendations have been available, they have become recognized worldwide as the standard practices and safety precautions for laboratories performing viable cell sorting experiments. However, the field of cytometry has progressed since 1997, and the document requires an update.

METHODS

Initially, suggestions about the document format and content were discussed among members of the ISAC Biosafety Committee and were incorporated into a draft version that was sent to all committee members for review. Comments were collected, carefully considered, and incorporated as appropriate into a draft document that was posted on the ISAC web site to invite comments from the flow cytometry community at large. The revised document was then submitted to ISAC Council for review. Simultaneously, further comments were sought from newly-appointed ISAC Biosafety committee members.

RESULTS

This safety standard for performing viable cell sorting experiments was recently generated. The document contains background information on the biohazard potential of sorting and the hazard classification of infectious agents as well as recommendations on (1) sample handling, (2) operator training and personal protection, (3) laboratory design, (4) cell sorter set-up, maintenance, and decontamination, and (5) testing the instrument for the efficiency of aerosol containment.

CONCLUSIONS

This standard constitutes an updated and expanded revision of the 1997 biosafety guideline document. It is intended to provide laboratories involved in cell sorting with safety practices that take into account the enhanced hazard potential of high-speed sorting. Most importantly, it states that droplet-based sorting of infectious or hazardous biological material requires a higher level of containment than the one recommended for the risk group classification of the pathogen. The document also provides information on safety features of novel instrumentation, new options for personal protective equipment, and recently developed methods for testing the efficiency of aerosol containment.

Postexposure prophylaxis after sexual exposure to HIV

Increasing numbers of international, national and state/provincial health organizations in the developed and developing world recommend postexposure prophylaxis (PEP) following potential sexual exposure to HIV. The evidence for these policies is extrapolated from occupational healthcare worker, perinatal prophylaxis and animal studies. There is no direct evidence of PEP efficacy after sexual exposures. Studies addressing potential increases in risk behavior, toxicities and cost–effectiveness are encouraging. Considerations for offering PEP include the timing and characteristics of the exposure and the HIV status of the source and exposed individuals. PEP includes 28 days of a combination antiretroviral drug regimen containing two or more drugs and associated laboratory testing, counseling and referrals. PEP service delivery challenges include ensuring adequate access to services, optimizing PEP adherence and facilitating follow-up HIV testing and counseling. Men who have sex with men, sexual assault survivors, children and adolescents, and individuals in resource-limited settings present unique needs and challenges.

Multiple needle-stick injuries with risk of human immunodeficiency virus exposure in a primary school

Twenty children received needle-stick injuries with a risk of exposure to human immunodeficiency virus type 1 during an incident in a primary school playground. All were counseled and offered human immunodeficiency virus postexposure prophylaxis. All 20 children started postexposure prophylaxis, and 19 attended for follow-up testing 3 months later. More than one-half of the children completed the full 4-week course of treatment. None of the 19 children tested seroconverted after the incident.

Infection Control: Old Problems and New Challenges

Infection control faces radical changes at the beginning of the third millennium. The first part of this review focuses on problems not yet solved, such as 1) surveillance systems, which should be active and extremely flexible; 2) infection outbreaks in hospitals and strategies to avoid them; 3) hand washing and alternatives such as rapid hand antisepsis; 4) water and food in the hospital as potential reservoirs of nosocomial pathogens; 5) upgrading of infection control programs to turn them into systems to improve the quality of care; 6) fatal Gram-negative bacteremias in hospitals from developing countries, which can be avoided with better standards of care; 7) the elemental role of the microbiology laboratory in the prevention and control of infections; 8) the unprecedented crisis due to the emergence of specific multi-resistant pathogens; 9) the risks for healthcare workers, such as tuberculosis, hepatitis, HIV, SARS, and hemorrhagic fevers; and 10) the need for the consistent application of guidelines. The second part of this review focuses on new challenges for infection control, such as 1) the ever-growing number of immunocompromised patients and basic control measures to avoid opportunistic infections; 2) the concerns about the capacity of the public health systems to deal with terrorist acts; 3) the practice of high-risk procedures in facilities lacking trained personnel, efficient laboratories, and protective items; and 4) gene therapy and its potential infectious complications. Consideration is given to the asymmetric development of infection control globally.

Needlestick/sharps injuries among vocational school nursing students in southern Taiwan

BACKGROUND

Although most needlestick/sharps injuries (NSIs/SIs) research focuses on health care workers (HCWs), students in hospital internships are also at risk. Investigations that examined NSIsS/SIs in student populations generally studied medical rather than nursing students (NSs). In 1999, approximately 17,000 Taiwanese nursing graduates were exposed to the hazard of NSIs/SIs. We examined the frequency and mechanism of NSIs/SIs among vocational school NSs in southern Taiwan.

METHODS

Between July and December of 1999, within 1 week after the NSs completed their internship training, one of the researchers, who was a teacher in this vocational school, asked them to fill out questionnaires.

RESULTS

Five hundred twenty-seven of 550 (92.6%) questionnaires were considered valid. Two hundred sixty-four of 527 (50.1%) responders sustained one or more NSIs/SIs. Ninety-six of 527 (18.2%) responders suffered contaminated NSIs/SIs. The average number of NSIs/SIs per student was 8.0 times/year (4.9 times/student/year for NSIs and 3.1 times/student/year for SIs). NSIs/SIs rates for NSs in 10-week and 4-week internships were significantly different ( P = .039): 53.3% versus 43.7%, respectively. The NSIs/SIs frequencies were influenced by length of internship: 7.3 times/student/year in 10-week internship and 11.7 times/student/year in 4-week internship. Logistic regression analysis indicated that length of internship rotation was statistically significant with respect to contaminated NSIs/SIs (OR = 1.682; 95% CI: 1.005-2.81; P = .048).

CONCLUSIONS

The NSIs/SIs frequencies of NSs were higher than those for HCWs. We found that frequency of NSIs/SIs for vocational school NSs is above average. Whether the young age of these NSs put them at greater risk for NSIs/SIs warrants further inquiry.

Biosafety concerns for shared flow cytometry core facilities

Many researchers who need flow cytometry for their projects have neither sufficient funds nor the work volume to justify the purchase of an analytic cytometer or cell sorter. In shared flow cytometry facilities, costs for instrument purchases, cytometer maintenance, and personnel are pooled to provide economic services for a multitude of users when they are required. Owing to the diverse nature of the samples that are submitted to core facilities, the biohazard potential of the samples can vary dramatically. For the safety of facility personnel and users, it is critical that information about hazards contained in the samples be transmitted to instrument operators before flow cytometry experiments are started. During 1999 the former Biosafety Committee of the International Society for Analytical Cytology formulated a framework biosafety questionnaire for shared facilities designed to request information about the hazard potential of experimental samples from investigators who wish to use the facility. In this report we review safety issues that are pertinent to flow cytometry core facilities by discussing the individual components of this biosafety questionnaire.

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.

Tolerability of postexposure antiretroviral prophylaxis for occupational exposures to HIV

A substantial body of evidence provides support (but not definitive proof of efficacy) for the use of antiretroviral agents as postexposure prophylaxis for occupational exposures to HIV in the healthcare workplace. Despite the lack of definitive evidence of the efficacy of these agents in this setting, over the past decade this intervention has become the standard of care for healthcare workers who sustain occupational exposures to HIV. Administration of these agents--even for a relatively short 28-day postexposure course--is often fraught with difficulty. All of the agents currently used for postexposure prophylaxis regimens have substantial adverse effects, and significant adverse effects occur in more than two-thirds of individuals electing prophylaxis. This manuscript reiterates current US Federal Government guidelines for the administration of postexposure prophylaxis, specifically noting that zidovudine plus lamivudine (with or without a protease inhibitor) remains the recommended regimen. The paper summarises the significant toxicities associated with nucleoside reverse transcriptase inhibitors (primarily nausea, vomiting, diarrhoea and bone marrow suppression), non-nucleoside reverse transcriptase inhibitors (rash, fever, gastrointestinal symptoms and hepatitis, including hepatic decompensation necessitating liver transplantation) and protease inhibitors (nausea, vomiting, diarrhoea, abdominal pain, hyperglycaemia, hyperlipidaemia, headache and anorexia). As a class, the antiretroviral agents have an extraordinary number of drug interactions. The non-nucleoside reverse transcriptase inhibitors and the protease inhibitors are metabolised through the cytochrome P450 pathway, and the effects of concomitant administration of protease inhibitors with other agents in the same class are discussed, as well as the effects of concomitant administration of protease inhibitors with non-nucleoside agents. The potential for numerous and medically risky drug interactions emphasises the importance of planning antiretroviral prophylaxis in consultation with practitioners or clinical pharmacists who are skilled in the use of these agents and knowledgeable about the potential for significant drug interactions that could either reduce the benefit of prophylaxis or increase the potential for toxicity. Another common problem encountered by individuals managing postexposure prophylaxis programmes relates to the administration of chemoprophylaxis to a pregnant healthcare worker who has sustained an occupational exposure to HIV. We address what is known about the potential for toxicity and emphasise the recently published warning concerning the deaths of pregnant women and their offspring from lactic acidosis while receiving regimens containing stavudine and didanosine.

Infection control in developing countries

Infection control activities in developing countries have increased substantially during the last decade, particularly in certain regions of the world. Pressure to improve hospital care cost-effectiveness, the emergence of highly resistant microorganisms, the perception of healthcare worker occupational hazards, and public claims for improved health assistance quality have been important factors responsible for this development. A major challenge for infection control personnel in developing countries is to sustain this development.