HIV seroprevalence in emergency department patients: Portland, Oregon, 1988-1991

Pharmacologic management of HIV/STD exposure

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

The occupational hazards of emergency physicians

Emergency physicians are exposed to a variety of occupational hazards. Among these are infectious diseases, such the human immunodeficiency virus, hepatitis B and C viruses, and tuberculosis. Hepatitis G virus is transmissible but may not be a cause of illness. The likelihood of being exposed to these agents appears to be higher in the ED than other medical settings but estimates of the prevalence of these diseases in the ED vary, depending on the patient population served. Estimates of risk for contracting these infections are reviewed. Measures to prevent these exposures can reduce risk, but compliance is low, particularly for those involving changes in the behavior of emergency physicians (such as not recapping needles). Latex allergy is a hazard of health care workers. Its prevalence is reported to be quite high, but these findings are difficult to interpret in the absence of a universally accepted definition of the condition. Its prevalence in emergency physicians is not known. Other noninfectious hazards include workplace violence and exposure to nitrous oxide. The health effects of rotating shift work may put emergency physicians at increased risk of coronary artery disease and impaired reproductive health. Emotional stress is another hazard of emergency physicians, and may lead to burnout.

Emergency department management of blood and body fluid exposures

Exposure to blood and body fluids that may be contaminated with infectious agents is a common occupational hazard for health care workers. Health care workers in the emergency department or out-of-hospital setting are at especially high risk for exposure to blood or body fluids. Nonemergency health care workers are frequently referred to hospital EDs for immediate treatment of occupation exposures. A series of recommendations by the Centers for Disease Control and Prevention evolved over the past decade, and changes are expected to continue. This state-of the-art article reviews current recommendations for management of persons exposed to blood or body fluids and discusses the scientific basis for recommendations regarding hepatitis B virus, hepatitis C virus, and HIV.

Reducing the rate of paramedic needlesticks in emergency medical services: the role of self-capping intravenous catheters

OBJECTIVE

To determine whether the frequency of unintentional needlesticks can be reduced by replacing conventional i.v. catheters with self-capping ones.

METHODS

Retrospective cohort, historically controlled study, conducted in an emergency medical services advanced life support (ALS) service. The ALS service annually transports 12,000 patients, for whom i.v. therapy is attempted in about 65% of cases. The needlestick rate per 1,000 patients receiving attempts at i.v. access was examined during the 2 10-month periods, before and after introduction of a self-capping i.v. catheter.

RESULTS

For the 2 periods, the percentage of patients for whom i.v. access was attempted remained constant at 65%. The success rate for i.v. access was statistically unchanged from 88% to 90% (p > 0.5, power = 0.995). During the period prior to use of the new catheter, 44 injuries were reported overall. Of these, 15 were due to unintentional needlesticks, 11 associated with contaminated needles. Following the system-wide introduction of the new catheter, only 1 of 31 reported injuries was due to needlestick (uncontaminated). The extrapolated annual incidence of contaminated needlesticks decreased from 169 (95% CI; 85, 253) to 0 (95% CI; 0, 46) per 100,000 i.v.attempts. The extrapolated incidence for all needlesticks decreased from 231 (95% CI; 132, 330) to 15 (95% CI; 0, 40) per 100,000 i.v. attempts. The absolute number of needlesticks and the proportion of injuries due to needlesticks decreased significantly (p < 0.005).

CONCLUSION

The use of i.v. catheters with self-capping needles was associated with a significant reduction in the absolute number of inadvertent needlesticks as well as the proportion of injuries due to needlesticks among ALS providers. The use of self-capping i.v. catheters was feasible and did not appear to be a deterrent to initiating i.v. therapy in the out-of-hospital environment.