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Janice Huy, Teri Palermo and Eileen Storey of the CDC examine the prevalence of blood-borne infections. How can these be prevented in any healthcare-related profession through national guidelines, simple precautions and staff reporting?

Exposures to blood and other body fluids occur across a wide variety of occupations. Preventing these exposures is one important step in ensuring a safe working environment for healthcare providers and ancillary occupations, and complements healthcare systems' patient safety and infection control efforts. Combining strategies for achieving patient safety and healthcare worker safety ultimately lead to quality healthcare, and quality patient care is the utmost goal of healthcare delivery systems. It is equally important for healthcare personnel to be safe, and healthcare delivery systems should be aware of the practices that promote patient and worker safety.

Reducing the transmission of infections from patients to healthcare personnel and from personnel to patients is another component of a safe and healthy healthcare environment. The US Centers for Disease Control and Prevention (CDC) offers prevention strategies to accomplish this in the document, Guidelines for Infection Control in Health Care Personnel, 1998. These strategies include: immunizations for vaccine-preventable diseases, management of exposures including the use of post-exposure prophylaxis, and work restrictions for exposed or infected healthcare personnel.
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"The adoption of needleless IV delivery systems in 70% of US hospitals has almost eliminated unnecessary use of needles."

Exposure to blood-borne pathogens

Following occupational exposures to blood and body fluids, healthcare and associated personnel, are at risk of infection from blood-borne pathogens. Although healthcare workers can be exposed to more than 60 pathogens, three are of particular concern – HIV, hepatitis B (HBV) and hepatitis C (HCV) – because these are the most likely to be transmitted through percutaneous injuries and because they can cause severe illness.

The risk to healthcare personnel of exposure to blood-borne pathogens through needlesticks, cuts, or other sharps injuries (referred to as percutaneous injuries), as well as through splashes and direct contact with mucous membranes or non-intact skin, is well documented. The CDC estimates that each year 385,000 needlesticks and other sharps-related injuries are sustained by hospital-based healthcare personnel; an average of 1,000 sharps injuries per day.

The exact number of sharps injuries among all healthcare personnel cannot be determined for several reasons. There is no national surveillance system to collect this data from non-hospital-based (such as, long-term care, home healthcare, private offices) healthcare workers. In addition, not all sharps injuries are reported. Surveys of healthcare personnel indicate that 50% or more do not report their injuries.

Management, working closely with employees, has the primary responsibility for ensuring a safe working environment. Identifying where and when occupational exposures occur can provide the needed data to support changes in work practices and eliminate sharps injuries. By fostering a culture of safety within the healthcare facility, employers promote an organizational perspective of safety which covers patients, personnel and others.

Management and employees jointly commit to ensure the safety of the work environment and to be accountable for safety. A culture of safety creates a blame-free environment for reporting sharps injuries and injury hazards. Healthcare personnel who know that management will discuss problems in an open and blame-free manner are more likely to report hazards.

Occupations most affected

According to data collected by three independent surveillance systems in the US, the occupations who sustain the most sharps injuries are nurses, physicians, technicians (such as operating room technicians, phlebotomists and laboratory technicians), and support services staff, such as housekeepers.

Although sharp devices can cause injuries anywhere in the healthcare environment, the operating room, in-patient rooms, emergency room and the intensive care unit have been identified as the locations where most sharps injuries occur. Most of the exposures occurred during the use of the sharps device; however, many injuries occurred during disposal of the device, thus creating an unsafe environment for non-provider staff, such as housekeepers.

The occupational risks of exposure to blood-borne pathogens among healthcare personnel employed in non-hospital settings are not well documented. The risk of percutaneous injury in certain sub-populations of non-hospital-based healthcare personnel may approximate the risk of hospital-based healthcare personnel. For example, those employed in home care were found to be at risk for blood contact, although the rates of percutaneous injury were low. A review of published studies describing exposures to blood or surveillance of blood-borne infections among US firefighters and emergency medical technicians concluded that while there is limited data available, it appears that these occupational groups may have needlestick injury rates comparable to hospital workers.

Risk and reduction

Many types of sharp devices injure healthcare personnel. The devices most commonly involved are syringes, suture needles and scalpels. Hollowbore needles, which are more likely to transmit blood-borne disease, account for more than 50% of sharps injuries.

"The CDC estimates that each year 385,000 needlesticks and other sharps-related injuries are sustained by hospital-based healthcare personnel."

Occupational transmission of blood-borne virus infection is a relatively rare event. After a needlestick exposure to an infected patient, a healthcare worker's risk of infection depends on the pathogen involved, the immune status of the worker, the severity of the needlestick injury, and the availability and use of appropriate post-exposure prophylaxis.

The average risk of HIV transmission after a percutaneous exposure is estimated to be approximately 0.3%. Without post-exposure prophylaxis, there is a 6–30% risk that an exposed, susceptible healthcare worker will become infected with HBV after a single needlestick exposure to an HBV-infected patient. The incidence of anti-HCV seroconversion (indicating infection) averages 1.8% (range, 0% to 7%) per injury.

There are several strategies to prevent occupational transmission of blood-borne pathogens. HBV vaccine largely prevents infection and has accounted for the more than 95% decline in occupational HBV among healthcare personnel. Post-exposure prophylaxis can be given for HBV and HIV exposure. Currently, there are no vaccines to prevent HIV or HCV infection, nor recommended post-exposure prophylaxis for HCV exposure.

Therefore, strategies that focus on the prevention of sharps injuries and other blood and body fluid exposures are essential in preventing occupational transmission of these and other blood-borne pathogens to healthcare workers.

In 1981, McCormick and Maki were the first to recommend a series of sharps injury prevention strategies. The CDC released recommendations for Universal Precautions which included guidance on sharps injury prevention in 1987. Several reports on needlestick prevention published between 1987 and 1991 focused on the appropriate design and convenient placement of puncture-resistant sharps disposal containers and the education of healthcare personnel on the dangers of recapping, bending and breaking used needles. Standard Precautions, first introduced in 1996, combined Universal Precautions and Body Substance Isolation, and focused heavily on the use of barrier precautions and work-practice controls.

In 1991, the US Occupational Safety and Health Administration (OSHA) first issued its Bloodborne Pathogens Standard. In 1999, NIOSH issued an alert, Preventing Needlestick Injuries in Health Care Settings, which described the risk of needlestick injuries and recommended prevention strategies. Due to strong pressure by nurses groups and representatives of other healthcare personnel, in 2000, in the US, the Needlestick Safety and Prevention Act was signed into law and directed OSHA to revise the Bloodborne Pathogens Standard.

The requirement for using engineering controls to prevent percutaneous injuries was strengthened and soliciting input from frontline healthcare workers in the identification, evaluation and selection of engineering and work practice controls by employers was required.

While these changes have been in effect since 2001, and 21 states have enacted injury prevention laws that reflect the federal OSHA standard, sharps incidents continue to occur. Contributing to the continuing occurrence of sharps injuries include lack of adoption of safety engineered devices, lack of availability of safety engineered devices for the full range of products, design shortcomings and lack of activation of safety features.

Healthcare organizations have adopted the hierarchy of control prevention model to prioritize prevention interventions. In the hierarchy for sharps injury prevention, the first priority is to eliminate and reduce the use of needles and other sharps where possible. For example, the wide adoption of needleless IV delivery systems in an estimated 70% of US hospitals has almost eliminated unnecessary use of needles to access IVs. These systems do not require (and in some instances do not permit) needle access. Next is to isolate the hazard, thereby protecting an otherwise exposed sharp, through the use of an engineering control. Engineering controls include sharps disposal containers and needles and other sharps devices with an integrated engineered sharps injury prevention feature.

When the above strategies are not available or will not provide total protection, the focus shifts to work-practice controls and personal protective equipment. Attempts to reduce exposures to potentially infectious blood and body fluids through the modification of work practices have been limited. Personal protective equipment (gloves, gowns) provides a barrier to shield skin and mucous membranes from contact with blood and other potentially infectious body fluids. While most protective equipment is easily penetrated by needles, the quantity of blood carried by the needle is reduced if a percutaneous injury occurs through gloves.

Injury-prevention strategies

Although strategies introduced a decade or more ago to reduce the incidence of sharps injuries remain important today, given the incidence of needlesticks and other sharps injuries, additional interventions are clearly needed. These interventions include: surveillance, education and training of healthcare workers, human and organizational factors associated with sharps injuries, and development and implementation of devices with engineered sharps injury prevention features.

"Although strategies introduced a decade or more ago to reduce the incidence of sharps injuries remain important, additional interventions are clearly needed."

Surveillance of sharps injuries and other blood and body fluid exposures is necessary for monitoring of injury and exposure trends, identifying emerging problems, and targeting and evaluating the impact of prevention measures. Consideration should be given for developing a national reporting system that systematically collects sharps injury data from both hospital- and non-hospital-based personnel.

Educating healthcare workers about the risks associated with blood-borne pathogen exposures and methods to limit these exposures, including the importance of reporting all injuries, remain crucial to sharps injury prevention efforts. Standardized tools and methods for conducting training are needed, as well as specialized education for occupational groups who are at high risk for blood-borne pathogen exposure.

Work practice and engineering controls have been the cornerstone of sharps injury prevention efforts for nearly two decades. The implementation of work practice controls (universal precautions/standard precautions) and engineering controls (devices with engineered sharps injury prevention features) in healthcare settings has reduced, but not eliminated, sharps injuries. Adherence to these strategies is less than optimal and research is needed to address barriers to compliance.

A wide variety of sharps with engineered safety features have been developed, and the efficacy of injury protection for some of these devices has been demonstrated. Additional research is needed to assess the degree to which safety devices are used and the continuing development and improvement of safety engineered device.

Healthcare delivery systems intent on providing quality patient care also advocate for work practices that support worker safety. Implementing strategies to prevent occupational transmission of blood-borne pathogens can reduce the direct costs and emotional toll that is associated with disease transmission and can help create an organisation-wide culture of safety.

Research material has been referenced in this text. For full details please contact the editor, andrewtunnicliffe@spgmedia.com

Tags: healthcare, needles, needlesticks, niosh, osha, safety, syringes

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