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Accidents with biologic material in health services among persons with no presumed risk
ARTICLE IN PRESS American Journal of Infection Control ■■ (2016) ■■-■■
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Brief Report
Accidents with biologic material in health services among persons with no presumed risk Thaís Arvelos Salgado RN, MSN a,b, Priscilla Santos Ferreira Ream RN, MSN a, Sheila Araújo Teles RN, PhD a, Liwcy Keller Oliveira Lopes Lima RN, MSN a, Fabiana Ribeiro Rezende RN, MSN a, Najara Queiroz Cardoso RN, MSN a, Anaclara Ferreira Veiga Tipple RN, PhD a,* a b
Postgraduate Program in Nursing, Federal University of Goias, Brazil Clinics Hospital, Federal University of Goias, Brazil
Key Words: Needlestick injuries epidemiology bloodborne pathogen hazardous waste
This study identified persons without presumed risk (PWPR) involved in accidents with blood and body fluids in 2 health care facilities between 1989 and 2012 in a state in Central Brazil. There were 181 accidents that occurred with PWPR, predominantly among women. Accidents with blood and body fluids involved needle and blood, some performed by untrained personnel. Most prematurely terminated clinical and laboratory monitoring. Accidents with blood and body fluids occur under similar circumstances to health care workers. © 2016 Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.
BACKGROUND
METHODS
During medical procedures, especially when sharps are used, accidents with blood and body fluids (BBF) can occur. Most of these cases take place in health care facilities, making health care workers (HCW) the most affected group. However, any individual who passes through the health care facility is exposed to biologic risk (eg, visitors, service providers, volunteers, administrative support professionals).1-3 A review of literature found a lack of data on accidents among this group which, although mentioned in some studies, were not the focus of investigations.1,2,4,5 Managing biologic risk to this population is challenging at all levels of service. The risk of exposure to HCWs is known and can therefore be somewhat controlled. However, when a person in the facility has no presumed risk, they may have no training in health care, not be fully aware of risk, and not be cognizant of proper pre and postexposure conduct. The objective of this study was to document the frequency and profile of accidents with persons without presumed risk (PWPR) exposed to BBF and characterize pre- and postexposure conduct.
After ethics committee approval, this study used 2 secondary sources of records from 2 leading institutions for the care of BBF exposures in a state in Central Brazil: (1) medical records of injured workers treated at a referral hospital for infectious diseases that included data from the first record (in 1989) up to December 2010, and (2) the National Mandatory Event Notification Information System considering all records up to June 2012. Probabilistic linkage of the 2 databases was completed to eliminate duplicate records. Data were processed and analyzed using SPSS Statistics 20 (IBM, Armonk, NY). The relationships between variables were analyzed using χ2 tests; P < .05 was considered significant.
* Address correspondence to Anaclara Ferreira Veiga Tipple, RN, PhD, Rua 104 número 428 Setor Sul, Goiania 74083-300, Brazil. E-mail address: [email protected] (A.F.V. Tipple). Conflicts of interest: None to report.
RESULTS Of 8,568 BBF exposure records, 181 (2.1%) involved PWPR, 90 (49.7%) completed the 3-dose hepatitis B vaccination schedule, 102 (56.4%) had no information on Hepatitis B surface antibody, 19 (10.5%) contained this information, and 13 (7.2%) indicated vaccine response. There was a higher incidence of percutaneous injuries among women, with a statistically significant difference (P = .001). Accidents involving mucosa occurred more frequent among men (P = .010). Among women, needles with lumens presented were statistically more frequent (P = .016) (Table 1).
0196-6553/© 2016 Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc. http://dx.doi.org/10.1016/j.ajic.2016.06.011
ARTICLE IN PRESS T.A. Salgado et al. / American Journal of Infection Control ■■ (2016) ■■-■■
Table 1 Comparison of profile of accidents with biologic material among persons without presumed risk, occurring in health care facilities, by sex, from 1989-June 2012, Goiania, Brazil
Profile of accidents Type of accident Percutaneous Mucous Broken skin Unbroken skin Bite Biologic material Blood Others No information* Circumstances Improper disposal of sharps Others No information* Object involved Needle with lumen Lamina-lancet Needle without lumen Glass Others No information*
Female (n = 110)
Male (n = 71)
n
%
n
%
χ2 value
P value
107 1 0 1 1
97.3 0.9 — 0.9 0.9
59 6 3 2 1
83.1 8.5 4.2 2.8 1.4
11.40 6.60 4.73 0.96 0.10
.001 .010 .030 .326 .754
59 11 40
53.6 10.0 36.4
30 13 28
42.2 18.3 39.5
3.36
.057
51 30 29
46.4 27.3 26.4
29 13 29
40.8 18.3 40.8
0.25
.51
68 9 9 3 15 6
61.8 8.2 8.2 2.7 13.6 5.5
35 6 1 3 23 3
49.3 8.5 1.4 4.2 32.4 4.2
12.26
.016
*No information available in accident records.
No sorology performed (n=43) Source patient known (n=67)
The circumstances of the accident were not statistically different between sexes. The most frequent involved improperly discarded sharps (n = 80; 44.2%). Some exposure incidents took place during patient care activities (n = 38; 21.0%), such as needle recapping (2.2%), injections or punctures (5.0%), assisting procedures (7.3%), and materials processing (3.3%). Postexposure prophylaxis was recommended in only 46 (40.3%) cases where the identity of the source of the BBF was not known. There was no information on the conclusion of 85 (47.0%) cases, and in 96 completed cases, most indicated premature termination of follow-up care or that follow-up care was not recommended (n = 71; 74.0%). Figure 1 shows the progression of cases where postexposure prophylaxis was indicated, according to the identification of the source patient.
DISCUSSION The frequency of 2.1% of total reports being from PWPR deserves attention because without presumed risk of exposure, there can be no assumption of training in health care. Moreover, these individuals should not be performing patient care functions that carry biologic risk and have no assumed training in proper pre- and postexposure conduct and preventive measures to mitigate the risk of exposure to biologic agents.
PEP indicated (n=4)
All sorology performed (n=5)
Anti-HIV (+) (n=3)
Only AntiHIV (n=19)
Anti-HIV (+) (n=6)
PEP indicated (n=3)
PEP indicated (n=6)
Prematurely Terminated (n=4)
Follow-up complete without soroconversion (n=3) No information (n=3) Follow-up complete without soroconversion (n=2)
Prematurely Terminated (n=1)
Prematurely Terminated (n=26) Source patient unknown (n=114)
PEP indicated (n=46)
PEP indicated, premature termination of monitoring (n=31)
2
No information (n=12) Follow-up complete without soroconversion (n=8)
* PEP: Post Exposure Prophylaxis Fig 1. Results of cases where postexposure prophylaxis was indicated, separated by serologic testing, and evolution of cases of accidents with biologic material involving persons without presumed risk, occurring in health care facilities, considering the identification of the source patient, from 1989-June 2012, Goiania, Brazil.
ARTICLE IN PRESS T.A. Salgado et al. / American Journal of Infection Control ■■ (2016) ■■-■■
There are preventive measures available for this group, such as vaccination against vaccine-preventable diseases, such as hepatitis B. Less than half of this study population (49.7%) was vaccinated against hepatitis B. The characteristics of accidents involving PWPR are similar to those involving HCWs. This implies that the commonality among these incidents is the health care environment itself, which carries inherent biologic risk and the potential for anyone in that environment to be exposed. In some cases, HCWs appear to be negligent because they are responsible for the proper disposal of the medical waste they generate (according to Brazilian law), a fundamental step in reducing environmental hazards and the incidence of accidents.3,6 It can therefore be inferred that 44.2% of the accidents with BBF with improperly discarded sharps found were completely preventable. In the hospital environment women are more affected,3,4 as found in this study, possibly because women are more present in health care facilities as patient escorts and because they are occasionally present during procedures (which, although not recommended, was identified in the study) or during patient care activities in which there may be the use of needles with lumens or other sharp objects. This is confirmed when comparing the profile of accidents between sexes, which was statistically significant: percutaneous injuries (χ2 = 11.4; P = .001) involving needles with lumens (χ2 = 12.3; P = .016) occurred more frequently among women, and accidents with mucosa occurred more frequently among men. In this study, 21.0% of accidents with BBF occurred because people were participating in activities for which they were not trained or qualified. Similar results were found in a study5 involving security services, secretaries, and receptionists of medical offices who were performing patient care activities that should have been performed by HCWs. Most of the source patients (62.7%) were unknown, consistent with the frequency of improperly disposed of sharps (44.2%), which makes postexposure prophylactic measures less obvious, unlike with health care professionals, where the source patient is known in most cases.7 Failure to report the conclusion of the case and the high rate of abandonment of follow-up care (a higher rate than that of 5.4% found
3
among nursing professionals8) suggest a failure in standards of conduct among HCWs serving these individuals and a lack of organizational structure of institutions that perform these services to proactively seek out exposed individuals for follow-up.9
CONCLUSIONS PWPR suffer accidents with BBF in health services under similar circumstances to HCWs. This group is theoretically outside of the institution’s responsibility, and an exposure can establish a care dependency and put the responsibility on the health care institution to have an administrative structure that provides postexposure support that should not depend on a prior working relationship.
References 1. Tipple AFV, Silva EAC, Teles AS, Mendonça KM, Souza ACS, Melo DS. [Accident with biological material at the prehospital mobile care: reality for health and non-healthcare] workers] [in Portuguese]. Rev Bras Enferm 2013;66:378-84. 2. Julio RS, Filardi MBS, Marziale MHP. [Work accidents with biological material occurred in municipalities of Minas Gerais] [in Portuguese]. Rev Bras Enferm 2014;67:119-26. 3. Ream PSF, Tipple AFV, Salgado TA, Souza ACS, Souza SMB, Galdino-Júnior H, et al. Hospital housekeepers: victims of ineffective hospital waste management. Arch Environ Occup Health 2015;doi:10.1080/19338244.2015.1089827. 4. Santos SS, Costa NA, Mascarenhas MDM. [Characterization of occupational exposures to biological material among hospital workers—Teresina, Piauí State, Brazil, 2007 to 2011] [in Portuguese]. Epidemiol Serv Saúde 2013;22:165-70. 5. Dias MAC, Machado AA, Santos BMO. [Occupational injury involving exposure to biological fluids: a portrait of reality] [in Portuguese]. Medicina (Ribeirão Preto) 2012;45:12-22. 6. Alves SB, Souza ACS, Tipple AFV, Rezende KC, Resende FR, Rodrigues EG, et al. The reality of waste management in primary health care units in Brazil. Waste Manag Res 2014;32(Suppl):40-7. 7. Valim MD, Marziale MHP. [Evaluating occupational exposure to biological material in health services] [in Portuguese]. Texto Contexto Enferm 2011;20:138-46. 8. Garbaccio JL, Regis WCB, Silva RMC, Estevão WG. Occupational accidents with the nursing team involved in hospital care. Cogitare Enfermagem 2015;20:14551. 9. Centers for Disease Control and Prevention. Updated U.S. Public Health Service Guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Surveill Summ 2001;50:1-42.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Brief Report
Accidents with biologic material in health services among persons with no presumed risk Thaís Arvelos Salgado RN, MSN a,b, Priscilla Santos Ferreira Ream RN, MSN a, Sheila Araújo Teles RN, PhD a, Liwcy Keller Oliveira Lopes Lima RN, MSN a, Fabiana Ribeiro Rezende RN, MSN a, Najara Queiroz Cardoso RN, MSN a, Anaclara Ferreira Veiga Tipple RN, PhD a,* a b
Postgraduate Program in Nursing, Federal University of Goias, Brazil Clinics Hospital, Federal University of Goias, Brazil
Key Words: Needlestick injuries epidemiology bloodborne pathogen hazardous waste
This study identified persons without presumed risk (PWPR) involved in accidents with blood and body fluids in 2 health care facilities between 1989 and 2012 in a state in Central Brazil. There were 181 accidents that occurred with PWPR, predominantly among women. Accidents with blood and body fluids involved needle and blood, some performed by untrained personnel. Most prematurely terminated clinical and laboratory monitoring. Accidents with blood and body fluids occur under similar circumstances to health care workers. © 2016 Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.
BACKGROUND
METHODS
During medical procedures, especially when sharps are used, accidents with blood and body fluids (BBF) can occur. Most of these cases take place in health care facilities, making health care workers (HCW) the most affected group. However, any individual who passes through the health care facility is exposed to biologic risk (eg, visitors, service providers, volunteers, administrative support professionals).1-3 A review of literature found a lack of data on accidents among this group which, although mentioned in some studies, were not the focus of investigations.1,2,4,5 Managing biologic risk to this population is challenging at all levels of service. The risk of exposure to HCWs is known and can therefore be somewhat controlled. However, when a person in the facility has no presumed risk, they may have no training in health care, not be fully aware of risk, and not be cognizant of proper pre and postexposure conduct. The objective of this study was to document the frequency and profile of accidents with persons without presumed risk (PWPR) exposed to BBF and characterize pre- and postexposure conduct.
After ethics committee approval, this study used 2 secondary sources of records from 2 leading institutions for the care of BBF exposures in a state in Central Brazil: (1) medical records of injured workers treated at a referral hospital for infectious diseases that included data from the first record (in 1989) up to December 2010, and (2) the National Mandatory Event Notification Information System considering all records up to June 2012. Probabilistic linkage of the 2 databases was completed to eliminate duplicate records. Data were processed and analyzed using SPSS Statistics 20 (IBM, Armonk, NY). The relationships between variables were analyzed using χ2 tests; P < .05 was considered significant.
* Address correspondence to Anaclara Ferreira Veiga Tipple, RN, PhD, Rua 104 número 428 Setor Sul, Goiania 74083-300, Brazil. E-mail address: [email protected] (A.F.V. Tipple). Conflicts of interest: None to report.
RESULTS Of 8,568 BBF exposure records, 181 (2.1%) involved PWPR, 90 (49.7%) completed the 3-dose hepatitis B vaccination schedule, 102 (56.4%) had no information on Hepatitis B surface antibody, 19 (10.5%) contained this information, and 13 (7.2%) indicated vaccine response. There was a higher incidence of percutaneous injuries among women, with a statistically significant difference (P = .001). Accidents involving mucosa occurred more frequent among men (P = .010). Among women, needles with lumens presented were statistically more frequent (P = .016) (Table 1).
0196-6553/© 2016 Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc. http://dx.doi.org/10.1016/j.ajic.2016.06.011
ARTICLE IN PRESS T.A. Salgado et al. / American Journal of Infection Control ■■ (2016) ■■-■■
Table 1 Comparison of profile of accidents with biologic material among persons without presumed risk, occurring in health care facilities, by sex, from 1989-June 2012, Goiania, Brazil
Profile of accidents Type of accident Percutaneous Mucous Broken skin Unbroken skin Bite Biologic material Blood Others No information* Circumstances Improper disposal of sharps Others No information* Object involved Needle with lumen Lamina-lancet Needle without lumen Glass Others No information*
Female (n = 110)
Male (n = 71)
n
%
n
%
χ2 value
P value
107 1 0 1 1
97.3 0.9 — 0.9 0.9
59 6 3 2 1
83.1 8.5 4.2 2.8 1.4
11.40 6.60 4.73 0.96 0.10
.001 .010 .030 .326 .754
59 11 40
53.6 10.0 36.4
30 13 28
42.2 18.3 39.5
3.36
.057
51 30 29
46.4 27.3 26.4
29 13 29
40.8 18.3 40.8
0.25
.51
68 9 9 3 15 6
61.8 8.2 8.2 2.7 13.6 5.5
35 6 1 3 23 3
49.3 8.5 1.4 4.2 32.4 4.2
12.26
.016
*No information available in accident records.
No sorology performed (n=43) Source patient known (n=67)
The circumstances of the accident were not statistically different between sexes. The most frequent involved improperly discarded sharps (n = 80; 44.2%). Some exposure incidents took place during patient care activities (n = 38; 21.0%), such as needle recapping (2.2%), injections or punctures (5.0%), assisting procedures (7.3%), and materials processing (3.3%). Postexposure prophylaxis was recommended in only 46 (40.3%) cases where the identity of the source of the BBF was not known. There was no information on the conclusion of 85 (47.0%) cases, and in 96 completed cases, most indicated premature termination of follow-up care or that follow-up care was not recommended (n = 71; 74.0%). Figure 1 shows the progression of cases where postexposure prophylaxis was indicated, according to the identification of the source patient.
DISCUSSION The frequency of 2.1% of total reports being from PWPR deserves attention because without presumed risk of exposure, there can be no assumption of training in health care. Moreover, these individuals should not be performing patient care functions that carry biologic risk and have no assumed training in proper pre- and postexposure conduct and preventive measures to mitigate the risk of exposure to biologic agents.
PEP indicated (n=4)
All sorology performed (n=5)
Anti-HIV (+) (n=3)
Only AntiHIV (n=19)
Anti-HIV (+) (n=6)
PEP indicated (n=3)
PEP indicated (n=6)
Prematurely Terminated (n=4)
Follow-up complete without soroconversion (n=3) No information (n=3) Follow-up complete without soroconversion (n=2)
Prematurely Terminated (n=1)
Prematurely Terminated (n=26) Source patient unknown (n=114)
PEP indicated (n=46)
PEP indicated, premature termination of monitoring (n=31)
2
No information (n=12) Follow-up complete without soroconversion (n=8)
* PEP: Post Exposure Prophylaxis Fig 1. Results of cases where postexposure prophylaxis was indicated, separated by serologic testing, and evolution of cases of accidents with biologic material involving persons without presumed risk, occurring in health care facilities, considering the identification of the source patient, from 1989-June 2012, Goiania, Brazil.
ARTICLE IN PRESS T.A. Salgado et al. / American Journal of Infection Control ■■ (2016) ■■-■■
There are preventive measures available for this group, such as vaccination against vaccine-preventable diseases, such as hepatitis B. Less than half of this study population (49.7%) was vaccinated against hepatitis B. The characteristics of accidents involving PWPR are similar to those involving HCWs. This implies that the commonality among these incidents is the health care environment itself, which carries inherent biologic risk and the potential for anyone in that environment to be exposed. In some cases, HCWs appear to be negligent because they are responsible for the proper disposal of the medical waste they generate (according to Brazilian law), a fundamental step in reducing environmental hazards and the incidence of accidents.3,6 It can therefore be inferred that 44.2% of the accidents with BBF with improperly discarded sharps found were completely preventable. In the hospital environment women are more affected,3,4 as found in this study, possibly because women are more present in health care facilities as patient escorts and because they are occasionally present during procedures (which, although not recommended, was identified in the study) or during patient care activities in which there may be the use of needles with lumens or other sharp objects. This is confirmed when comparing the profile of accidents between sexes, which was statistically significant: percutaneous injuries (χ2 = 11.4; P = .001) involving needles with lumens (χ2 = 12.3; P = .016) occurred more frequently among women, and accidents with mucosa occurred more frequently among men. In this study, 21.0% of accidents with BBF occurred because people were participating in activities for which they were not trained or qualified. Similar results were found in a study5 involving security services, secretaries, and receptionists of medical offices who were performing patient care activities that should have been performed by HCWs. Most of the source patients (62.7%) were unknown, consistent with the frequency of improperly disposed of sharps (44.2%), which makes postexposure prophylactic measures less obvious, unlike with health care professionals, where the source patient is known in most cases.7 Failure to report the conclusion of the case and the high rate of abandonment of follow-up care (a higher rate than that of 5.4% found
3
among nursing professionals8) suggest a failure in standards of conduct among HCWs serving these individuals and a lack of organizational structure of institutions that perform these services to proactively seek out exposed individuals for follow-up.9
CONCLUSIONS PWPR suffer accidents with BBF in health services under similar circumstances to HCWs. This group is theoretically outside of the institution’s responsibility, and an exposure can establish a care dependency and put the responsibility on the health care institution to have an administrative structure that provides postexposure support that should not depend on a prior working relationship.
References 1. Tipple AFV, Silva EAC, Teles AS, Mendonça KM, Souza ACS, Melo DS. [Accident with biological material at the prehospital mobile care: reality for health and non-healthcare] workers] [in Portuguese]. Rev Bras Enferm 2013;66:378-84. 2. Julio RS, Filardi MBS, Marziale MHP. [Work accidents with biological material occurred in municipalities of Minas Gerais] [in Portuguese]. Rev Bras Enferm 2014;67:119-26. 3. Ream PSF, Tipple AFV, Salgado TA, Souza ACS, Souza SMB, Galdino-Júnior H, et al. Hospital housekeepers: victims of ineffective hospital waste management. Arch Environ Occup Health 2015;doi:10.1080/19338244.2015.1089827. 4. Santos SS, Costa NA, Mascarenhas MDM. [Characterization of occupational exposures to biological material among hospital workers—Teresina, Piauí State, Brazil, 2007 to 2011] [in Portuguese]. Epidemiol Serv Saúde 2013;22:165-70. 5. Dias MAC, Machado AA, Santos BMO. [Occupational injury involving exposure to biological fluids: a portrait of reality] [in Portuguese]. Medicina (Ribeirão Preto) 2012;45:12-22. 6. Alves SB, Souza ACS, Tipple AFV, Rezende KC, Resende FR, Rodrigues EG, et al. The reality of waste management in primary health care units in Brazil. Waste Manag Res 2014;32(Suppl):40-7. 7. Valim MD, Marziale MHP. [Evaluating occupational exposure to biological material in health services] [in Portuguese]. Texto Contexto Enferm 2011;20:138-46. 8. Garbaccio JL, Regis WCB, Silva RMC, Estevão WG. Occupational accidents with the nursing team involved in hospital care. Cogitare Enfermagem 2015;20:14551. 9. Centers for Disease Control and Prevention. Updated U.S. Public Health Service Guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Surveill Summ 2001;50:1-42.