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Effect of education on the use of universal precautions in a university hospital emergency department
BRIEF REPORT universal precautions
Effect of Education on the Use of Universal Precautions in a University Hospital Emergency D e p a r t m e n t Study objectives: To determine if an educational program would improve both knowledge and practice of universal precautions by nursing personnel. Design: Participants were given a 14-question test and observed for their practice of universal precautions during routine IV catheter placement or phlebotomy and trauma care before and six months after an education in-service. Setting: University hospital emergency department. Type of participants: Nursing personnel. Interventions: One-hour lecture addressing the occupational risk of human immunodeficiency virus (HIV) infection and the recommended use of universal precautions. Measurements and main results: The mean overall correct response rates to the questionnaire before and after the in-service were 70% and 73%, respectively (P - NS). The pattern of incorrect responses suggested that the perceived risks of HIV transmission are underestimated, particularly among healthy-appearing patients. For care of critical trauma patients, there were significant increases between the freqLzency rates before and after the in-service of glove and protective eyewear rise (66.7% vs 87. 7%, P < .025; 0.0% vs 17.3%, P < .05, respectively). The freq~lency rates of glove use for IV placement or phlebotomy in noncritical patients and of gown use for trauma patient care also increased (52.6% vs 65.2% and 25% vs 39.5%, respectively); however, these changes were not statistically significant. Conclusion: An intensive educational program was associated with a modest increase in the compliance of ED nursing personnel with universal precautions and had no long-term effect on their general knowledge of HIV risk. The practice of universal precautions is still far from universal in this ED. /Talan DA, Baraff LJ: Effect of education on the use of universal precautions in a university hospital emergency department. Ann Emerg Med November 1990;19.'1322-1326.]
David A Talan, MD, FACEP Larry J Baraff, MD, FACEP Los Angeles, California From the Department of Emergency Medicine, Olive View Medical Center, Sylmar, California; and the Emergency Medicine Center, UCLA Center for the Health Sciences, Los Angeles, California. Received for publication April 6, 1990. Revision received May 16, t990. Accepted for publication July 31, 1990. Address for reprints: David A Talan, MD, FACER Department of Emergency Medicine, Olive View/UCLA Medical Center, Room 2A=208, 14445 Olive View Drive, Sylmar, California 91342.
INTRODUCTION In acknowledgment of the risks of occupational exposure to human immunodeficiency virus (HIV) and other communicable agents, in 1987 the Centers for Disease Control (CDC) defined "universal precautions" and recommended that these be practiced by health care workers when caring for all patients, particularly in emergency settings. Since this time, there have been several reports of a significant prevalence of HIV-seropositive patients in various emergency department populations. ~3 One study reported that 92 of 2,275 consecutive patients (4%) at an inner-city hospital had unrecognized HIV infectionJ Despite the great potential of ED personnel for infectious exposures, we previously reported a low rate of compliance with universal precautions by these health care workers. 4 For example, gloves were worn for IV catheter placement or phlebotomy in noncritical patients by only 52.5% of providers, and other barrier precautions were infrequently worn for trauma and other critical patients. When these preliminary results demonstrating poor compliance with universal precautions were known, we decided to initiate an intensive in-
19:11 November 1990
Annals of Emergency Medicine
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UNIVERSAL PRECAUTIONS Talan & Baraff
TABLE 1. Frequency of correct responses to questionnaire regarding occupational HIV risk and universal precautions
before and after educational in-service Frequency (%) Before T
F
1. A nurse can acquire infection with the AIDS virus by contamination of his or her nonintact skin with blood from a patient who does not have AIDS. 2. Which of the following is not a "high-risk group" for AIDS? a. b. c. d. e.
41.7 83.3
After 27.3 95.5
Homosexual/bisexual males IV drug users Health care workers Prostitutes Hemophiliacs
3. The virus that causes AIDS can be transmitted by all of the following except: a. Sexual intercourse b. Blood transfusion c. Needlestick d, Touching an AIDS patient e. Factor VIII concentrate 4. A health care worker can acquire AIDS from a needlestick exposure from a healthy person,
95.8
95.5
41.7
45.5
100.0 100.0
100.0 100.0
T
F
T T
F F
5. Gloves should be worn whenever a nurse draws blood or starts an IV line. 6. GJoves, protective eyewear, and masks should be worn by all physicians who attempt endotracheal intubation.
T
F
7. Gown, gloves, mask, and protective eyewear should be worn whenever there is a possible splash and/or droplet exposure to a patient's blood.
95.8
100.0
T
F
8. tn some urban emergency departments, as many as 4% of all patients are infected with the AIDS virus.
83.3
81.8
12.5
22.7
87.5
77.3
33.3 25.0
50.0 22.7
95.8 75.0
100.0 90.9
70.0
72.9
9. The risk of infection with the AIDS virus after a needlestick exposure from an AIDS patient is: a. 1/100,000 b. 1/10,000 c. 1/1,000 d. 1/200 e. 1/50 T F 10. The AIDS virus can be inactivated by soaking instruments in a 1/10 dilution of household bleach. T F 11. Gloves should be worn for all contact with AIDS patients. 12. Health care workers with open sores on their hands can work in the emergency department if: a. They wear gloves at all times b. They do not get blood on their hands c. They do not care for AIDS patients d. They do not care if they get AIDS e. They do not engage in direct patient care T F 13. All used needles should immediately be placed in puncture-resistant containers. 14. Another name for the AIDS virus is: a. HBV b. HBIG c. HIV d. HTLV-1 e. Retrovirus Mean score Correct answers are in bold type.
138/1323
Annals of Emergency Medicine
19:11 November 1990
TABLE 2. Frequency of ED personnel compliance with universal precaution policies before and
after education in-service program Before Patient Procedure
Precautions
Noncritical IV/phlebotomy
Gloves
After
%
N/Obs*
%
N/Obs
P
52.6
51/97
65.2
75/115
NS (.7)
71.81 32/81 0/81 14/81
< .025 NS (.2) NS < .05
Critical trauma IV/phlebotomy and patient handling
Gloves 66.7 16/24 87.7 Gowns 25.0 6/24 39.5 Masks 0.0 0/24 0.0 Eyewear 0.0 0/24 17.3 *N/Obs, number of times barrier precaution used/number of patient encounter observations.
service educational program for our ED nursing personnel. We hypothesized t h a t this educational effort would increase both knowledge of HIV occupational risk and compliance with universal precautions. We report the results for pre-educational and posteducational testing and observation of ED nursing practices.
METHODS The study was conducted at the UCLA Emergency Medicine Center, a Level 1 trauma center with approxi m a t e l y 40,000 p a t i e n t visits per year. Subsequent to publication of the u n i v e r s a l p r e c a u t i o n s by the CDC, the written policies for care of all ED p a t i e n t s were a m e n d e d to state that gloves must be worn by all health care workers performing IV catheter p l a c e m e n t or p h l e b o t o m y and that gloves, gown, mask, and protective eyewear must be worn by all health care workers before any contact with patients treated in the resuscitation suite (ie, critical trauma and cardiac arrest patients). Immediately before and six months after an educational in-service, full-time ED nursing personnel were given a 14-item questionnaire designed to test their knowledge of HIV occupational risk and universal precautions (Table 1). To d o c u m e n t the f r e q u e n c y of compliance with universal precautions, n u r s i n g practices were observed before and after the educational in-service. One research assistant was present to observe these practices during a convenience sample of hours, weighted to preferentially include evenings and weekends. The research assistant was also conducting a separate ongoing study of trauma patients, and health care 19:11 November 1990
workers were informed that her purpose was to collect data regarding these patients. During the hours of the study, the research assistant attended the resuscitation of critical trauma patients triaged to the resuscitation suite and observed ED health care w o r k e r s starting IV lines or drawing blood in the other ED patients. Included in the study were only nursing personnel who performed IV catheter placem e n t or phlebotomy in all ED patients and, in trauma patients cared for in the resuscitation suite, IV catheter placement or phlebotomy, moving or s t a b i l i z i n g the p a t i e n t , or closed-chest compression. The before and after in-service observational periods were March 3, through May 18, 1988, and January 21, through July 11, 1989, respectively. Between September 15, and September 20, 1988, three separate onehour educational in-service lectures were given by one of the authors during different shift changes of fulltime ED nursing personnel. The material discussed included the means by which HIV can be transmitted, risk factors for HIV infection, HIV seroprevalence in ED populations, docu m e n t e d , o c c u p a t i o n a l l y acquired HIV i n f e c t i o n a m o n g h e a l t h care workers, universal precautions policies, and r e s u l t s of our p r e v i o u s study demonstrating the poor compliance with universal precautions. 4 The frequency of use of universal precautions for various procedures and the f r e q u e n c y of c o r r e c t responses to the individual questionnaire questions before and after the e d u c a t i o n a l in-service were compared by the Xz method. The overall correct response rates to the questionnaire before and after the in-serAnnals of Emergency Medicine
vice were compared using the twosided Student's t test. Statistical significance was defined as a P value < .05.
RESULTS T w e n t y - f o u r of 30 f u l l - t i m e ED nursing personnel (80%) participated in the in-service lecture and took the pretest, whereas 22 nursing personnel (73%) took the post-test. There was no significant difference in the mean correct response rates to any of the individual questions or to the entire questionnaire before and after the in-service instruction (Table 1). A m o n g n o n c r i t i c a l patients, ED nursing personnel were observed during performance of 97 IV catheter placements or phlebotomies in 81 patients before the educational in-service and during 115 of these procedures in 112 patients after this instruction. A m o n g critical t r a u m a patients, ED nursing personnel were observed during performance of 24 IV catheter placements, phlebotomies, or patient-handling procedures (chest compression or moving or stabilizing the patient) on ten patients before the educational in-service and during performance of 81 IV catheter placements, phlebotomies, or patient-handling procedures among 32 of these patients after the in-service instruction. The frequency of compliance with universal precautions for noncritical patients and critical trauma patients is given (Table 2). The frequency of glove and p r o t e c t i v e eyewear use among critical t r a u m a patients increased significantly between the before and after in-service periods. The use of gloves for IV catheter placement or phlebotomy in noncritical p a t i e n t s and the use of gowns in 1324/139
UNIVERSAL PRECAUTIONS Talan & Baraff
t r a u m a patients also increased; however, these changes did n o t reach statistical significance (P = .07 and .2, respectively).
DISCUSSION The e s t i m a t e d risk of seroeonversion from a needlestick exposure f r o m a n H I V - i n f e c t e d p a t i e n t is 0.4%; and there have been only isol a t e d cases of m u c o s a l s p l a s h - t y p e t r a n s m i s s i o n . 5 H o w e v e r , it a p p e a r s that in c e r t a i n l o c a t i o n s there is a significant p r e v a l e n c e of HIV-infected patients in ED p o p u l a t i o n s P -3 In o n e i n n e r - c i t y U S ED, H I V ser o p o s i t i v i t y was noted in 4% of patients n o t k n o w n to have HIV infection 1 and a m o n g 10.4% of t r a u m a patients. 6 Previous studies have e s t a b l i s h e d t h a t ED p e r s o n n e l are among those at highest risk of occup a t i o n a l l y acquired hepatitis B virus infection.7, 8 T h e n e e d for strict adherence to universal precautions appears to be p a r t i c u l a r l y i m p o r t a n t in the ED setting. Previously, we e x a m i n e d c o m p l i ance w i t h universal precautions at an u r b a n u n i v e r s i t y h o s p i t a l and were s u r p r i s e d to f i n d p o o r c o m p l i a n c e w i t h t h e s e p o l i c i e s . 4 For e x a m p l e , gloves were w o r n by p h y s i c i a n s or n u r s i n g p e r s o n n e l for IV c a t h e t e r p l a c e m e n t or p h l e b o t o m i e s d u r i n g only 52.5% and 75% of observations i n v o l v i n g n o n c r i t i c a l p a t i e n t s and critical t r a u m a patients, respectively. Among trauma patients, gowns, masks, or eyewear were worn during only 27%, 2%, and 19% of encounters, respectively. Once these preliminary results were known, we discont i n u e d the s t u d y to i n s t i t u t e and test the effects of an e d u c a t i o n a l in-service designed to i m p r o v e knowledge about occupational HIV risk and compliance with universal precautions. The educational in-service was an interactional lecture in w h i c h the basic p r i n c i p l e s of HIV t r a n s m i s s i o n , o c c u p a t i o n a l r i s k , a n d p o l i c i e s of u n i v e r s a l p r e c a u t i o n s were covered in detail. We t h o u g h t t h a t this session w o u l d be p a r t i c u l a r l y effective b e c a u s e w e c o n f r o n t e d the n u r s i n g personnel w i t h the results of our previous study, which demonstrated their poor c o m p l i a n c e w i t h the practice of universal precautions. Despite these efforts, we could not d e m o n s t r a t e long-term i m p r o v e m e n t in t h e c o g n i t i v e u n d e r s t a n d i n g of 140/1325
these p r i n c i p l e s based on a 14-item q u e s t i o n n a i r e . A n a l y z i n g t h e questions separately revealed a near-100% correct r e s p o n s e rate on the before and after in-service tests for all questions except 1, 4, 9, 11, and 12 (Table 1). A l t h o u g h m o s t nursing personnel incorrectly indicated that gloves should be w o r n for all contact w i t h AIDS p a t i e n t s (question 11), they app a r e n t l y did n o t u n d e r s t a n d that a patient m a y appear h e a l t h y and n o t have AIDS p e r se, y e t be p o t e n t i a l l y infectious w i t h HIV (questions 1 and 4). M o s t nursing personnel underestim a t e d the risk of HIV t r a n s m i s s i o n from a n e e d l e s t i c k exposure from an AIDS p a t i e n t (question 9; 67% and 64% chose answers a, b, or c in the before and after tests, respectively). T h e y also m o s t often incorrectly indicated t h a t h e a l t h care workers w i t h open sores could care for patients if they wore gloves at all times (question 12). In general, there appeared to be an u n d e r e s t i m a t i o n of t h e r i s k of HIV transmission from a patient not k n o w n or p e r c e i v e d to have AIDS. These represent the vast m a j o r i t y of patients in the ED; even a m o n g HIVinfected patients, it is e s t i m a t e d that there are a p p r o x i m a t e l y ten healthyappearing i n d i v i d u a l s for every one p a t i e n t w i t h AIDS. T h i s m i s u n d e r standing m a y explain the i n c o m p l e t e a d h e r e n c e to u n i v e r s a l p r e c a u t i o n s policies. The educational in-service was associated with modest improvement in the observed compliance w i t h universal precautions policies. During the care of t r a u m a patients, the frequency of glove and protective eyewear use increased significantly compared w i t h that before the in-service. T h e frequency of glove use for noncritical p a t i e n t s and use of gowns for c a r e of t r a u m a p a t i e n t s a l s o i n creased; however, these changes were not s t a t i s t i c a l l y significant. To t h e b e s t of o u r k n o w l e d g e , there has b e e n o n l y one s t u d y t h a t e x a m i n e d t h e use of u n i v e r s a l precautions in the ED. 9 C o n s i s t e n t w i t h o u r findings, a d h e r e n c e to s i m i l a r policies in critical patients in an inner-city ED, m e a s u r e d only after an e d u c a t i o n a l program, was poor. For m i n o r procedures comparable to activities performed by our nursing personnel, adherence to precaution policies was 62.9% for c r i t i c a l t r a u m a Annals of Emergency Medicine
p a t i e n t s . L a c k of t i m e a n d i n t e r f e r e n c e w i t h p e r f o r m a n c e of p r o cedures were cited as reasons for the l a c k of p r e c a u t i o n s . T h e a u t h o r s noted that universal precautions were m o r e l i k e l y to be used for patients w i t h k n o w n HIV infection. Our educational program m a y have been causally related to the improvem e n t in the use of these precautions by e m p h a s i z i n g the p o l i c i e s of universal precautions. However, the imp r o v e m e n t of t h e s e p r a c t i c e s w a s m o d e s t and m a y well have been due to such other factors u n r e l a t e d to our testing and lectures as increased fam i l i a r i t y w i t h and acceptance of the use of barrier precautions before performing various procedures. (We have n o t observed a change in the approxim a t e 1% p r e v a l e n c e of ED p a t i e n t s w i t h k n o w n HIV infection.) Finally, our questionnaire m a y n o t have been a valid m e a s u r e of u n d e r s t a n d i n g of these issues.
CONCLUSION A l t h o u g h we were heartened to see an i m p r o v e m e n t in the use of barrier precautions after our educational program, we suspect that the practice of universal precautions will n o t be universal until there is a better understanding of the p o t e n t i a l for any p a t i e n t to be infectious. F u t u r e research should further e x a m i n e the attitudes that m a y influence the decision to follow these precautions.
REFERENCES 1. Kelen GD, Fritz S, Qaquish B, et al: Unrecognized human immunodeficiency virus infection in emergency department patients. N EngI J Med 1988~318:1645-16501 2. Baker JL, Kelen GD, Sivertson KT, et al: Unsuspected human immunodeficiency virus in critically ill emergency patients. JAMA 1987; 257:2609-2611. 3. Risi GI~, Gaumer RH, Weeks 8, et al: Human immunodeficiency virus: Risk of exposure among health care workers in a southern urban hospital. South Med J 1989~82:1079-1082. 4. Baraff LJ, Talan DA: Compliance with universal precautions in a mliversity hospital emergency department. Ann Emerg Med 1989;18: 654-657. 5. Centers for Disease Control: Public health service statement on management of occupa tional exposure to human immunodeficiency virus, including considerations regarding zidovudine post-exposure use. MMWR 1990;39: 1-14. 6. Kelen GD, Fritz S, Qaquish B, et al: Substantial increase in human immunodeficiency virus (HIV-1) infection in critically ill emergency patients: 1986 and 1987 compared. Ann Emerg Med 1989;18:378-382. 7. Dienstag JL, Ryna DM: Occupational exposure to hepatitis B virus in hospital personnel: 19:11 November1990
Infection or i m m u n i z a t i o n ? A m J Epidemiol 1982;115:26-39.
personnel: Prevalence of serologic markers and need for i m m u n i z a t i o n . A m J Med 1982;75: 269-272.
8. Kunches LM, Craven DE, Wener BG, et al: Hepatitis B exposure in emergency medicine
9. Kelen GD, DiGioranna T, Bisson L, et al: Hu-
man immunodeficiency virus infection in emergency department patients: Epidemiology, clinical p r e s e n t a t i o n s , and risk to h e a l t h care workers: The Johns Hopkins experience. JAMA 1989;262:516~522.
ERRATUM The figure in "Manpower Needs statistics. The correct information
in Academic Emergency appears below.
Medicine"
[July 1990;19:797-801] contained
incorrect
Physician Specialty Supply 1980, 85 - 87 Active Society Members US Practicing Physicians 1980 1985 1986 1987
Active Nonsociety Members US Practicing Physicians
Active Total US Practicing Physicians
Certified
Noncertified
Certified
Noncertified
Certified
Noncertified
248 1,493 2,158 2,801
10,203 11,187 11,191 11,400
0 1,360 1,811 2,570
2,230 3,216 3,220 3,430
248 2,853 3,969 5,371
12,433 14,403 14,411 14,830
19:11 November1990
Annals of Emergency Medicine
1326/141
Effect of Education on the Use of Universal Precautions in a University Hospital Emergency D e p a r t m e n t Study objectives: To determine if an educational program would improve both knowledge and practice of universal precautions by nursing personnel. Design: Participants were given a 14-question test and observed for their practice of universal precautions during routine IV catheter placement or phlebotomy and trauma care before and six months after an education in-service. Setting: University hospital emergency department. Type of participants: Nursing personnel. Interventions: One-hour lecture addressing the occupational risk of human immunodeficiency virus (HIV) infection and the recommended use of universal precautions. Measurements and main results: The mean overall correct response rates to the questionnaire before and after the in-service were 70% and 73%, respectively (P - NS). The pattern of incorrect responses suggested that the perceived risks of HIV transmission are underestimated, particularly among healthy-appearing patients. For care of critical trauma patients, there were significant increases between the freqLzency rates before and after the in-service of glove and protective eyewear rise (66.7% vs 87. 7%, P < .025; 0.0% vs 17.3%, P < .05, respectively). The freq~lency rates of glove use for IV placement or phlebotomy in noncritical patients and of gown use for trauma patient care also increased (52.6% vs 65.2% and 25% vs 39.5%, respectively); however, these changes were not statistically significant. Conclusion: An intensive educational program was associated with a modest increase in the compliance of ED nursing personnel with universal precautions and had no long-term effect on their general knowledge of HIV risk. The practice of universal precautions is still far from universal in this ED. /Talan DA, Baraff LJ: Effect of education on the use of universal precautions in a university hospital emergency department. Ann Emerg Med November 1990;19.'1322-1326.]
David A Talan, MD, FACEP Larry J Baraff, MD, FACEP Los Angeles, California From the Department of Emergency Medicine, Olive View Medical Center, Sylmar, California; and the Emergency Medicine Center, UCLA Center for the Health Sciences, Los Angeles, California. Received for publication April 6, 1990. Revision received May 16, t990. Accepted for publication July 31, 1990. Address for reprints: David A Talan, MD, FACER Department of Emergency Medicine, Olive View/UCLA Medical Center, Room 2A=208, 14445 Olive View Drive, Sylmar, California 91342.
INTRODUCTION In acknowledgment of the risks of occupational exposure to human immunodeficiency virus (HIV) and other communicable agents, in 1987 the Centers for Disease Control (CDC) defined "universal precautions" and recommended that these be practiced by health care workers when caring for all patients, particularly in emergency settings. Since this time, there have been several reports of a significant prevalence of HIV-seropositive patients in various emergency department populations. ~3 One study reported that 92 of 2,275 consecutive patients (4%) at an inner-city hospital had unrecognized HIV infectionJ Despite the great potential of ED personnel for infectious exposures, we previously reported a low rate of compliance with universal precautions by these health care workers. 4 For example, gloves were worn for IV catheter placement or phlebotomy in noncritical patients by only 52.5% of providers, and other barrier precautions were infrequently worn for trauma and other critical patients. When these preliminary results demonstrating poor compliance with universal precautions were known, we decided to initiate an intensive in-
19:11 November 1990
Annals of Emergency Medicine
1322/137
UNIVERSAL PRECAUTIONS Talan & Baraff
TABLE 1. Frequency of correct responses to questionnaire regarding occupational HIV risk and universal precautions
before and after educational in-service Frequency (%) Before T
F
1. A nurse can acquire infection with the AIDS virus by contamination of his or her nonintact skin with blood from a patient who does not have AIDS. 2. Which of the following is not a "high-risk group" for AIDS? a. b. c. d. e.
41.7 83.3
After 27.3 95.5
Homosexual/bisexual males IV drug users Health care workers Prostitutes Hemophiliacs
3. The virus that causes AIDS can be transmitted by all of the following except: a. Sexual intercourse b. Blood transfusion c. Needlestick d, Touching an AIDS patient e. Factor VIII concentrate 4. A health care worker can acquire AIDS from a needlestick exposure from a healthy person,
95.8
95.5
41.7
45.5
100.0 100.0
100.0 100.0
T
F
T T
F F
5. Gloves should be worn whenever a nurse draws blood or starts an IV line. 6. GJoves, protective eyewear, and masks should be worn by all physicians who attempt endotracheal intubation.
T
F
7. Gown, gloves, mask, and protective eyewear should be worn whenever there is a possible splash and/or droplet exposure to a patient's blood.
95.8
100.0
T
F
8. tn some urban emergency departments, as many as 4% of all patients are infected with the AIDS virus.
83.3
81.8
12.5
22.7
87.5
77.3
33.3 25.0
50.0 22.7
95.8 75.0
100.0 90.9
70.0
72.9
9. The risk of infection with the AIDS virus after a needlestick exposure from an AIDS patient is: a. 1/100,000 b. 1/10,000 c. 1/1,000 d. 1/200 e. 1/50 T F 10. The AIDS virus can be inactivated by soaking instruments in a 1/10 dilution of household bleach. T F 11. Gloves should be worn for all contact with AIDS patients. 12. Health care workers with open sores on their hands can work in the emergency department if: a. They wear gloves at all times b. They do not get blood on their hands c. They do not care for AIDS patients d. They do not care if they get AIDS e. They do not engage in direct patient care T F 13. All used needles should immediately be placed in puncture-resistant containers. 14. Another name for the AIDS virus is: a. HBV b. HBIG c. HIV d. HTLV-1 e. Retrovirus Mean score Correct answers are in bold type.
138/1323
Annals of Emergency Medicine
19:11 November 1990
TABLE 2. Frequency of ED personnel compliance with universal precaution policies before and
after education in-service program Before Patient Procedure
Precautions
Noncritical IV/phlebotomy
Gloves
After
%
N/Obs*
%
N/Obs
P
52.6
51/97
65.2
75/115
NS (.7)
71.81 32/81 0/81 14/81
< .025 NS (.2) NS < .05
Critical trauma IV/phlebotomy and patient handling
Gloves 66.7 16/24 87.7 Gowns 25.0 6/24 39.5 Masks 0.0 0/24 0.0 Eyewear 0.0 0/24 17.3 *N/Obs, number of times barrier precaution used/number of patient encounter observations.
service educational program for our ED nursing personnel. We hypothesized t h a t this educational effort would increase both knowledge of HIV occupational risk and compliance with universal precautions. We report the results for pre-educational and posteducational testing and observation of ED nursing practices.
METHODS The study was conducted at the UCLA Emergency Medicine Center, a Level 1 trauma center with approxi m a t e l y 40,000 p a t i e n t visits per year. Subsequent to publication of the u n i v e r s a l p r e c a u t i o n s by the CDC, the written policies for care of all ED p a t i e n t s were a m e n d e d to state that gloves must be worn by all health care workers performing IV catheter p l a c e m e n t or p h l e b o t o m y and that gloves, gown, mask, and protective eyewear must be worn by all health care workers before any contact with patients treated in the resuscitation suite (ie, critical trauma and cardiac arrest patients). Immediately before and six months after an educational in-service, full-time ED nursing personnel were given a 14-item questionnaire designed to test their knowledge of HIV occupational risk and universal precautions (Table 1). To d o c u m e n t the f r e q u e n c y of compliance with universal precautions, n u r s i n g practices were observed before and after the educational in-service. One research assistant was present to observe these practices during a convenience sample of hours, weighted to preferentially include evenings and weekends. The research assistant was also conducting a separate ongoing study of trauma patients, and health care 19:11 November 1990
workers were informed that her purpose was to collect data regarding these patients. During the hours of the study, the research assistant attended the resuscitation of critical trauma patients triaged to the resuscitation suite and observed ED health care w o r k e r s starting IV lines or drawing blood in the other ED patients. Included in the study were only nursing personnel who performed IV catheter placem e n t or phlebotomy in all ED patients and, in trauma patients cared for in the resuscitation suite, IV catheter placement or phlebotomy, moving or s t a b i l i z i n g the p a t i e n t , or closed-chest compression. The before and after in-service observational periods were March 3, through May 18, 1988, and January 21, through July 11, 1989, respectively. Between September 15, and September 20, 1988, three separate onehour educational in-service lectures were given by one of the authors during different shift changes of fulltime ED nursing personnel. The material discussed included the means by which HIV can be transmitted, risk factors for HIV infection, HIV seroprevalence in ED populations, docu m e n t e d , o c c u p a t i o n a l l y acquired HIV i n f e c t i o n a m o n g h e a l t h care workers, universal precautions policies, and r e s u l t s of our p r e v i o u s study demonstrating the poor compliance with universal precautions. 4 The frequency of use of universal precautions for various procedures and the f r e q u e n c y of c o r r e c t responses to the individual questionnaire questions before and after the e d u c a t i o n a l in-service were compared by the Xz method. The overall correct response rates to the questionnaire before and after the in-serAnnals of Emergency Medicine
vice were compared using the twosided Student's t test. Statistical significance was defined as a P value < .05.
RESULTS T w e n t y - f o u r of 30 f u l l - t i m e ED nursing personnel (80%) participated in the in-service lecture and took the pretest, whereas 22 nursing personnel (73%) took the post-test. There was no significant difference in the mean correct response rates to any of the individual questions or to the entire questionnaire before and after the in-service instruction (Table 1). A m o n g n o n c r i t i c a l patients, ED nursing personnel were observed during performance of 97 IV catheter placements or phlebotomies in 81 patients before the educational in-service and during 115 of these procedures in 112 patients after this instruction. A m o n g critical t r a u m a patients, ED nursing personnel were observed during performance of 24 IV catheter placements, phlebotomies, or patient-handling procedures (chest compression or moving or stabilizing the patient) on ten patients before the educational in-service and during performance of 81 IV catheter placements, phlebotomies, or patient-handling procedures among 32 of these patients after the in-service instruction. The frequency of compliance with universal precautions for noncritical patients and critical trauma patients is given (Table 2). The frequency of glove and p r o t e c t i v e eyewear use among critical t r a u m a patients increased significantly between the before and after in-service periods. The use of gloves for IV catheter placement or phlebotomy in noncritical p a t i e n t s and the use of gowns in 1324/139
UNIVERSAL PRECAUTIONS Talan & Baraff
t r a u m a patients also increased; however, these changes did n o t reach statistical significance (P = .07 and .2, respectively).
DISCUSSION The e s t i m a t e d risk of seroeonversion from a needlestick exposure f r o m a n H I V - i n f e c t e d p a t i e n t is 0.4%; and there have been only isol a t e d cases of m u c o s a l s p l a s h - t y p e t r a n s m i s s i o n . 5 H o w e v e r , it a p p e a r s that in c e r t a i n l o c a t i o n s there is a significant p r e v a l e n c e of HIV-infected patients in ED p o p u l a t i o n s P -3 In o n e i n n e r - c i t y U S ED, H I V ser o p o s i t i v i t y was noted in 4% of patients n o t k n o w n to have HIV infection 1 and a m o n g 10.4% of t r a u m a patients. 6 Previous studies have e s t a b l i s h e d t h a t ED p e r s o n n e l are among those at highest risk of occup a t i o n a l l y acquired hepatitis B virus infection.7, 8 T h e n e e d for strict adherence to universal precautions appears to be p a r t i c u l a r l y i m p o r t a n t in the ED setting. Previously, we e x a m i n e d c o m p l i ance w i t h universal precautions at an u r b a n u n i v e r s i t y h o s p i t a l and were s u r p r i s e d to f i n d p o o r c o m p l i a n c e w i t h t h e s e p o l i c i e s . 4 For e x a m p l e , gloves were w o r n by p h y s i c i a n s or n u r s i n g p e r s o n n e l for IV c a t h e t e r p l a c e m e n t or p h l e b o t o m i e s d u r i n g only 52.5% and 75% of observations i n v o l v i n g n o n c r i t i c a l p a t i e n t s and critical t r a u m a patients, respectively. Among trauma patients, gowns, masks, or eyewear were worn during only 27%, 2%, and 19% of encounters, respectively. Once these preliminary results were known, we discont i n u e d the s t u d y to i n s t i t u t e and test the effects of an e d u c a t i o n a l in-service designed to i m p r o v e knowledge about occupational HIV risk and compliance with universal precautions. The educational in-service was an interactional lecture in w h i c h the basic p r i n c i p l e s of HIV t r a n s m i s s i o n , o c c u p a t i o n a l r i s k , a n d p o l i c i e s of u n i v e r s a l p r e c a u t i o n s were covered in detail. We t h o u g h t t h a t this session w o u l d be p a r t i c u l a r l y effective b e c a u s e w e c o n f r o n t e d the n u r s i n g personnel w i t h the results of our previous study, which demonstrated their poor c o m p l i a n c e w i t h the practice of universal precautions. Despite these efforts, we could not d e m o n s t r a t e long-term i m p r o v e m e n t in t h e c o g n i t i v e u n d e r s t a n d i n g of 140/1325
these p r i n c i p l e s based on a 14-item q u e s t i o n n a i r e . A n a l y z i n g t h e questions separately revealed a near-100% correct r e s p o n s e rate on the before and after in-service tests for all questions except 1, 4, 9, 11, and 12 (Table 1). A l t h o u g h m o s t nursing personnel incorrectly indicated that gloves should be w o r n for all contact w i t h AIDS p a t i e n t s (question 11), they app a r e n t l y did n o t u n d e r s t a n d that a patient m a y appear h e a l t h y and n o t have AIDS p e r se, y e t be p o t e n t i a l l y infectious w i t h HIV (questions 1 and 4). M o s t nursing personnel underestim a t e d the risk of HIV t r a n s m i s s i o n from a n e e d l e s t i c k exposure from an AIDS p a t i e n t (question 9; 67% and 64% chose answers a, b, or c in the before and after tests, respectively). T h e y also m o s t often incorrectly indicated t h a t h e a l t h care workers w i t h open sores could care for patients if they wore gloves at all times (question 12). In general, there appeared to be an u n d e r e s t i m a t i o n of t h e r i s k of HIV transmission from a patient not k n o w n or p e r c e i v e d to have AIDS. These represent the vast m a j o r i t y of patients in the ED; even a m o n g HIVinfected patients, it is e s t i m a t e d that there are a p p r o x i m a t e l y ten healthyappearing i n d i v i d u a l s for every one p a t i e n t w i t h AIDS. T h i s m i s u n d e r standing m a y explain the i n c o m p l e t e a d h e r e n c e to u n i v e r s a l p r e c a u t i o n s policies. The educational in-service was associated with modest improvement in the observed compliance w i t h universal precautions policies. During the care of t r a u m a patients, the frequency of glove and protective eyewear use increased significantly compared w i t h that before the in-service. T h e frequency of glove use for noncritical p a t i e n t s and use of gowns for c a r e of t r a u m a p a t i e n t s a l s o i n creased; however, these changes were not s t a t i s t i c a l l y significant. To t h e b e s t of o u r k n o w l e d g e , there has b e e n o n l y one s t u d y t h a t e x a m i n e d t h e use of u n i v e r s a l precautions in the ED. 9 C o n s i s t e n t w i t h o u r findings, a d h e r e n c e to s i m i l a r policies in critical patients in an inner-city ED, m e a s u r e d only after an e d u c a t i o n a l program, was poor. For m i n o r procedures comparable to activities performed by our nursing personnel, adherence to precaution policies was 62.9% for c r i t i c a l t r a u m a Annals of Emergency Medicine
p a t i e n t s . L a c k of t i m e a n d i n t e r f e r e n c e w i t h p e r f o r m a n c e of p r o cedures were cited as reasons for the l a c k of p r e c a u t i o n s . T h e a u t h o r s noted that universal precautions were m o r e l i k e l y to be used for patients w i t h k n o w n HIV infection. Our educational program m a y have been causally related to the improvem e n t in the use of these precautions by e m p h a s i z i n g the p o l i c i e s of universal precautions. However, the imp r o v e m e n t of t h e s e p r a c t i c e s w a s m o d e s t and m a y well have been due to such other factors u n r e l a t e d to our testing and lectures as increased fam i l i a r i t y w i t h and acceptance of the use of barrier precautions before performing various procedures. (We have n o t observed a change in the approxim a t e 1% p r e v a l e n c e of ED p a t i e n t s w i t h k n o w n HIV infection.) Finally, our questionnaire m a y n o t have been a valid m e a s u r e of u n d e r s t a n d i n g of these issues.
CONCLUSION A l t h o u g h we were heartened to see an i m p r o v e m e n t in the use of barrier precautions after our educational program, we suspect that the practice of universal precautions will n o t be universal until there is a better understanding of the p o t e n t i a l for any p a t i e n t to be infectious. F u t u r e research should further e x a m i n e the attitudes that m a y influence the decision to follow these precautions.
REFERENCES 1. Kelen GD, Fritz S, Qaquish B, et al: Unrecognized human immunodeficiency virus infection in emergency department patients. N EngI J Med 1988~318:1645-16501 2. Baker JL, Kelen GD, Sivertson KT, et al: Unsuspected human immunodeficiency virus in critically ill emergency patients. JAMA 1987; 257:2609-2611. 3. Risi GI~, Gaumer RH, Weeks 8, et al: Human immunodeficiency virus: Risk of exposure among health care workers in a southern urban hospital. South Med J 1989~82:1079-1082. 4. Baraff LJ, Talan DA: Compliance with universal precautions in a mliversity hospital emergency department. Ann Emerg Med 1989;18: 654-657. 5. Centers for Disease Control: Public health service statement on management of occupa tional exposure to human immunodeficiency virus, including considerations regarding zidovudine post-exposure use. MMWR 1990;39: 1-14. 6. Kelen GD, Fritz S, Qaquish B, et al: Substantial increase in human immunodeficiency virus (HIV-1) infection in critically ill emergency patients: 1986 and 1987 compared. Ann Emerg Med 1989;18:378-382. 7. Dienstag JL, Ryna DM: Occupational exposure to hepatitis B virus in hospital personnel: 19:11 November1990
Infection or i m m u n i z a t i o n ? A m J Epidemiol 1982;115:26-39.
personnel: Prevalence of serologic markers and need for i m m u n i z a t i o n . A m J Med 1982;75: 269-272.
8. Kunches LM, Craven DE, Wener BG, et al: Hepatitis B exposure in emergency medicine
9. Kelen GD, DiGioranna T, Bisson L, et al: Hu-
man immunodeficiency virus infection in emergency department patients: Epidemiology, clinical p r e s e n t a t i o n s , and risk to h e a l t h care workers: The Johns Hopkins experience. JAMA 1989;262:516~522.
ERRATUM The figure in "Manpower Needs statistics. The correct information
in Academic Emergency appears below.
Medicine"
[July 1990;19:797-801] contained
incorrect
Physician Specialty Supply 1980, 85 - 87 Active Society Members US Practicing Physicians 1980 1985 1986 1987
Active Nonsociety Members US Practicing Physicians
Active Total US Practicing Physicians
Certified
Noncertified
Certified
Noncertified
Certified
Noncertified
248 1,493 2,158 2,801
10,203 11,187 11,191 11,400
0 1,360 1,811 2,570
2,230 3,216 3,220 3,430
248 2,853 3,969 5,371
12,433 14,403 14,411 14,830
19:11 November1990
Annals of Emergency Medicine
1326/141