An 'Academic Detailing' Intervention To Decrease Exposure to HIV Infection among Health-care Workers

This intervention aimed to decrease health-care workers' experience of automatic pilot (mindless functioning) when performing high risk procedures. An academic detailing visit resulted in a significant increase in compliance with safety guidelines and a decreased incidence of other unsafe practices among 80 health care workers of two hospital units. The effects of mindlessness on health behaviour may be far reaching and the model described in this paper can be used to develop appropriate interventions.

Compliance with universal precautions among physicians

This study characterized and assessed self-reported levels of compliance with universal precautions (UP) among hospital-based physicians, and determined significant factors associated with both compliance and noncompliance. The physicians (n = 322) were a subgroup of a larger study population of hospital-based health care workers recruited from three geographically distinct locations (n = 1746), and were surveyed using a detailed confidential questionnaire that assessed personal, work-related, and organizational factors. Compliance with UP was measured through 11 items that examined how often physicians followed specific recommended work practices. Compliance was found to vary among the 11 items: they were high for certain activities (eg, glove use, 94%; disposal of sharps, 92%) and low for others (eg, wearing protective clothing, 55%; not recapping needles, 56%). Compliance with all items was low (31% to 38%). Stepwise logistic regression revealed that noncompliant physicians were likely to be age 37 or older, to report high work stress, and to perceive a conflict of interest between providing patient care and protecting themselves. Compliant physicians were more likely to be knowledgeable and to have been trained in universal precautions, to perceive protective measures as being effective, and to perceive an organizational commitment to safety.

The college student, the dentist, and the North Carolina senator: risk analysis and risk management of HIV transmission from health care worker to patient

The risk of acquiring human immunodeficiency virus (HIV) infection from a health care worker is 2,000 times less than that of dying from a car accident. It is 700 times less probable than perishing from being struck by lightning or suffering a fatal fall. Despite the rarity of this occurrence, reduction of the risk of health-care-worker-to-patient HIV transmission in the workplace has been the focus of congressional, federal, state, and local agencies. If all HIV transmission from health care workers to patients were prevented using current guidelines and legislation, the epidemic of AIDS would be reduced by 0.0006%. Current efforts to prevent HIV transmission from health care workers to patients are the result of incomplete risk analysis and management. In a society of limiting resources and of cherished freedoms, sanctions imposed on health care workers to prevent HIV transmission to patients may benefit no one.

Postexposure prophylaxis for occupational exposures to hepatitis B, hepatitis C, and human immunodeficiency virus

Bloodborne pathogens are becoming increasingly prevalent in, and therefore contributing increasing levels of risk to, the health-care work-place environment. This problem is magnified in the blood-intense operating room and obstetric environments. Whereas we will never be able to eliminate such risks entirely from the health-care workplace, a multifaceted approach to the management of these risks throughout the hospital environment and particularly in risk-intense environments will likely create a safer milieu and climate. Such an improved environment will clearly be necessary as we continue to strive to provide optimal care for all patients, irrespective of their bloodborne infection status.

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.

Laboratory-associated infections and biosafety

An estimated 500,000 laboratory workers in the United States are at risk of exposure to infectious agents that cause disease ranging from inapparent to life-threatening infections, but the precise risk to a given worker unknown. The emergence of human immunodeficiency virus and hantavirus, the continuing problem of hepatitis B virus, and the reemergence of Mycobacterium tuberculosis have renewed interest in biosafety for the employees of laboratories and health care facilities. This review examines the history, the causes, and the methods for prevention of laboratory-associated infections. The initial step in a biosafety program is the assessment of risk to the employee. Risk assessment guidelines include the pathogenicity of the infectious agent, the method of transmission, worker-related risk factors, the source and route of infection, and the design of the laboratory facility. Strategies for the prevention and management of laboratory-associated infections are based on the containment of the infectious agent by physical separation from the laboratory worker and the environment, employee education about the occupational risks, and availability of an employee health program. Adherence to the biosafety guidelines mandated or proposed by various governmental and accrediting agencies reduces the risk of an occupational exposure to infectious agents handled in the workplace.

Managing occupational risks in the dental office: HIV and the dental professional

Despite universal precautions, work behavior modifications and technological advances, health care workers continue to experience occupational exposures to HIV and other bloodborne pathogens. Although the risk for infection is low when compared with other bloodborne pathogens, 39 documented cases of HIV seroconversion have been recorded. Recent attention has focused on secondary prevention of HIV infection through post-exposure chemoprophylaxis.

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.

Managing occupational exposures to HIV-1 in the healthcare workplace

Managing occupational exposures to human immunodeficiency virus type 1 (HIV-1) in the healthcare workplace remains both controversial and complex. Healthcare workers' perceptions of risk for occupational transmission of HIV-1, their knowledge of risk-reduction strategies, and their perceptions about appropriate postexposure management are all derived from an intricate interplay of scientific, political, social, and emotional sources. Following an occupational exposure to blood or blood-containing body fluids, a healthcare worker's immediate emotional response may be extreme gut-wrenching anxiety, with perceptions often biased by ignorance, uncertainty, and fear. The healthcare worker's postinjury emotional and psychological stress can be extraordinary; postinjury therapy, of necessity, must integrate medical, physical, psychological, and psychosocial aspects of care. Clinical decisions regarding HIV-1 injury management, therefore, are based not only on available scientific and medical information but also on measured actions designed to manage and presumably to diminish the profound anxiety almost invariably associated with an occupational exposure to HIV-1. In stark contrast to this common and extreme emotional reaction, the likelihood of disease transmission from such occupational exposures is relatively small.

In this article, we will discuss a series of questions and issues typically encountered when a healthcare worker sustains an occupational exposure to HIV-1.

Mandatory HIV testing for healthcare workers: is it ethical?

The AIDS epidemic has caused hysteria among the public and concern to many healthcare workers in the past 12 years. Currently, legislation exists for mandatory AIDS testing in some populations. The questions remain: Should healthcare workers be routinely tested? If so, is mandatory testing ethical? The author explores the incidence and prevalence of AIDS among healthcare workers, discusses why mandatory testing for healthcare workers is an issue, and examines the legal and ethical principles involved in mandatory testing.

Does knowledge of human immunodeficiency virus infection decrease the frequency of occupational exposure to blood?

Implementation of universal precautions is advocated to prevent exposure to human immunodeficiency virus (HIV) and other bloodborne pathogens. Critics of this approach argue that additional benefit can be derived by identifying and labeling patients known to be infected. Knowledge of HIV infection status could result in a reduced exposure rate by two mechanisms: (a) by motivating improved compliance with universal precautions, or (b) by allowing changes in procedure or technique not feasible for all patients. Compliance with universal precautions may reduce the frequency of some types of exposure but has not been associated with a reduction in the frequency of needlestick exposures in several studies. Despite the perception by some health care workers that awareness of HIV status will result in improved safety, no objective data have demonstrated a direct benefit from testing or identifying infected patients. Health care workers who recognize the presence of occupational HIV risk are apt to be motivated to practice universal infection control precautions and experience little additional benefit from testing individual patients. Health care workers in low prevalence areas may experience less incentive to comply routinely with universal precautions and selectively may be motivated when HIV infection is diagnosed in individual patients. However, routine testing in areas of low HIV prevalence is not likely to be cost effective. Until further research clarifies the efficacy and costs of universal precautions or HIV testing, infection control standards should maximize local autonomy in developing rational policies consistent with institutional needs.

Epidemiology of hospital sharps injuries: a 14-year prospective study in the pre-AIDS and AIDS eras

The world pandemic of acquired immunodeficiency syndrome (AIDS) has focused enormous attention on the problem of accidental sharps injuries sustained by health care workers (HCWs) and the risk of occupationally acquired infection by human immunodeficiency virus (HIV). At the 1980 Conference, we reported a 4-year epidemiologic study (1975-1979) of sharps injuries in HCWs at our hospital. Using the same reporting system and analyses, we now report the epidemiology of sharps injuries in our center during the current AIDS era (1987-1988) and assess trends over the 14-year period. Despite greatly increased institutional efforts to prevent sharps injuries, the annual incidence has increased more than threefold (60.4 to 187.0/1,000 HCWs), reflecting better reporting and increased exposure. Reported injuries by house officers have increased ninefold. Adjusting for inflation, the direct costs of sharps injuries has increased sevenfold ($5,354 to $37,271/year). Environmental service HCWs (305.8 sharps injuries per 1,000 employees) now have the highest incidence in our center, followed by nursing personnel (196.5/1,000) and laboratory personnel (169.9/1,000), but as in 1975-1979, two thirds of all injuries occur in nursing personnel. Although phlebotomy team members have a very low risk per procedure (1/26,871 draws), their annual incidence is extraordinarily high, 407.0/1,000. Injuries continue to occur mainly during disposal of waste, linen, or used procedure trays (19.7% of all injuries), administration of parenteral injections or infusion therapy (15.7%), surgery (16.0%), blood drawing (13.3%), or recapping of used needles (10.1%). Making disposal units available at every bedside has reduced injuries from needle disposal two-fold since 1975-1979. With consistent application of a stringent postexposure protocol, and wide acceptance of the hepatitis B vaccine, we have had no sharps injury-related infections during the past 3 years. These data indicate the increasing risk, complexity and cost of sharps injuries in HCWs and the need for more innovative--ideally, technology-based--approaches to prevention. Certain groups of HCWs are at very high risk. Comprehensive postexposure protocols that are uniformly applied can provide substantial protection to exposed HCWs.

Postexposure chemoprophylaxis for occupational exposure to human immunodeficiency virus type 1: current status and prospects for the future

Occupational exposures to the human immunodeficiency virus (HIV) continue to occur in the health care setting. Each such exposure is associated with risk for occupational infection. Although occupational HIV infections have been uncommon in health care workers, the occurrence of even one such infection is traumatic for the health care worker and his or her institution. To attempt to prevent infection following occupational exposures, some institutions and investigators have elected to offer postexposure chemoprophylaxis with zidovudine. Unfortunately, data describing the use of nucleoside analogues in animals and humans as antiviral chemoprophylaxis are quite limited and data simply do not exist that definitely support or refute their use in this setting. One can mount an equally reasonable argument for or against the use of these agents in this setting in 1990. This article reviews the available data regarding postexposure chemoprophylaxis, summarizes the clinical experience with zidovudine use for postexposure chemoprophylaxis to date, and evaluates prospects for additional chemoprophylaxis options in the future.

Reducing occupational risk of HIV infection

At San Francisco General Hospital and many other institutions in areas of high HIV prevalence, a policy of body substance isolation has proved easier to implement than the CDC's across-the-board recommendations. Prevention of needle-stick injury and use of barrier methods of infection control are emphasized. Preoperative HIV testing is addressed.

Procedure-related rate of contact of intensive care unit personnel with patient body fluids

We prospectively recorded the frequency with which ICU personnel came in contact with body fluids in order to provide an empirical basis for the recommendation of relevant protective precautions. ICU personnel completed a questionnaire when performing a range of 29 standardized procedures. The rate of contact with body fluid was: manual ventilation (55%); catheterization of peripheral vein (36%); insertion of central venous catheter (69%); arterial puncture (18%); tracheal intubation (76%); tracheal extubation (87%); suction from mouth, pharynx or trachea (82%); drawing of blood sample (52%); establishing or discontinuing blood transfusion (50%); establishing or discontinuing infusion (20%); changing of wound dressing (52%). We suggest that the contact rates observed should be used in combination with a universal precautions policy, in order to identify procedures that are likely to involve contact with body fluid. By using gloves 95% of contacts to body fluid would have been prevented.

HIV infection in healthcare workers. How great is the risk? What can be done before and after exposure?

Healthcare workers know that there is a risk of HIV infection through exposure to AIDS patients. In both hospital and office settings, physicians have the opportunity to set standards and promote education about the degree of risk, effective precautions, and postexposure testing, prophylaxis, and treatment. Drs Henry and Thurn share the latest findings and offer policy recommendations based on their own experience.