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Needlestick injuries among medical students
‘Journal
of Hospital
Infection
(1993)
23, 31 S-320
Letters
to the Editor
Sir, Needlestick
injuries
among
medical
students
We read with interest the article by Choudhury and Cleator’ on needlestick injuries among medical students. In January 1992 we surveyed the 30 medical students in their first clinical year at Southmead Hospital (using a questionnaire administered at individual interview). We wished to find out about the difficulties students experienced with venepuncture, their incidence of inoculation risk injuries, knowledge of reporting systems for such incidents, and their hepatitis B vaccination status. At the time of interview the students had been taking blood for about 12 risk incidents occurred to 11 weeks. During this time, 12 inoculation students, none of which was associated with ‘high inoculation risk’ patients. Nine incidents were caused by needles, three of which were suture needles, and three students described incidents where mucous membranes or broken skin were contaminated by a patient’s blood or body fluids. Eight incidents occurred during venepuncture and four during surgery. Most of the injuries were self-inflicted, but one needlestick injury was caused by the needle being left protruding from a sharps bin and two students described being pricked by another person’s suture needle during surgery. Only two of the 12 incidents (16.6%) were reported, a similar rate to that reported by Choudhury and Cleator.’ Five of the students were unaware that they should have reported any incidents, two did not know to whom to report and many felt that as the incident involved a patient of low inoculation risk, reporting was unnecessary. Two students did not wish to report because they thought it would reflect poorly on their clinical skills. Before their first clinical attachment 27 of the 30 students attended an introductory course during which there was a demonstration of venepuncture using the Vacutainer system and they had an opportunity to practise on each other, although not all were individually supervised. Only 11 of the 30 students (36%) were supervised when taking blood from patients for the first time. While the Vacutainer system was used in the initial demonstration the majority of students admitted using a conventional needle and syringe system as well. The latter is necessary for collecting blood cultures, but students felt it was also useful if their patients had ‘difficult veins’. However, only 16/ 30 (.53%), had conventional needle and 0195-6701i93/040315+06
$08.00/O
0 1993 The Hospml
315
Infectmn
Society
316
Letters
to the Editor
syringe techniques demonstrated and only 9/30 (30%) had been directly supervised. In order to re-use the Vacutainer needle mount, students were resheathing needles and although the majority did so with a safe single-handed approach, some (20%) d escribed unsafe methods, such as using both hands. It had been assumed that the needle mounts were changed daily but 56% of students had not changed them at all during the 12 weeks they had been at the hospital while 30% said they would clean the needle mounts if they were visibly contaminated with blood rather than discard them. Hospital policy is that students should not take blood from known high-inoculation-risk patients, yet 14/30 said they would do so and four based this answer on their previous experience. It was also worrying that a number of students were not clear about which groups of patients fell into the hospital’s inoculation risk categories. To deal with these areas of concern and the finding that 40% of students felt inadequately prepared for taking blood and 30% wanted more individual supervision, we have arranged that students arriving at Southmead for clinical attachments will receive further training sessions and supervision. Many needlestick injuries occur during re-sheathing2A and although Choudhury and Cleator’ did not show a significant difference in injury rates between those resheathing and not resheathing, we have recommended the single use of Vacutainer needle mounts to remove the need to resheath. ‘Winged butterfly’ sets have been made available on our wards which can be used with the Vacutainer system to avoid the use of the conventional needle and syringe for patients with difficult veins and the hazard involved with injecting blood into vacuum tubes. Once more we have emphasized that students not take blood from known inexperienced should high-inoculation-risk patients and the importance of reporting inoculation incidents has been stressed. In addition an accident book has been introduced as Choudhury and Cleator’ recommended. The recent introduction of phlebotomists to our hospital will reduce greatly the number of blood samples taken by students because, apart from safety, repeated venepuncture is not felt to be a useful educational experience. In addition the University of Bristol has introduced the policy that medical students must have a full hepatitis B vaccination course for their clinical attachments and we were encouraged to find that 21 out of 30 students (70%) had been vaccinated and were known to be immune. Only one student had made no attempt to start his vaccination course during the 12 weeks at Southmead. However, of the 11 students who had had inoculation risk incidents, five had not completed their vaccination course. In conclusion our study has again shown that medical students are indeed vulnerable to inoculation risk injuries as they are inexperienced and may be responsible for taking large numbers of blood samples. As infection control specialists we must ensure that students receive adequate instruction and close supervision for initial venepunctures and that they are aware of the correct course of action if a needlestick injury occurs. We hope to follow
Letters
317
to the Editor
new groups of students in the future to try to assess the impact of the additional training and other changes that we have made in reducing their chances of sustaiming inoculation injuries. B. V. D. A.
L. E. S. P.
Department of Medical Microbiology, Southmead Health Services NHS Trust, Westbury-on- Trym, Bristol, UK
Kirkpatrick Ricketts Reeves MacGowan
References 1. Choudhury vaccination
RP, Cleator SJ. An examination of needlestick injury rates, uptake and instruction on ‘sharps’ technique among medical
hepatitis students.
B J
Hasp Infect 1992; 22: 143-148. 2. Jagger J, Hunt EH, Brand-Elnaggar J, Pearson RD. Rates of needlestick injury caused by various devices in a university hospital. N Eng J’ Med 1988; 319: 284-288. 3. Kennedy DA. Needlestick injuries: mechanisms and control. J Hasp Infect 1988; 12: 315-322. 4. Gompertz S. Needlestick injuries in medical students. J Sot Occup Med 1990; 40: 19-20.
Sir, Hepatitis
B surface
antibody
responses
following
accelerated
vaccination
Until all health care workers have been vaccinated against hepatitis B virus, unimmunised staff will need post-exposure prophylaxis following parenteral or mucosal exposure to infected blood or secretions. When the source patient is hepatitis B surface antigen positive, hepatitis B immune and vaccine are given. ’ However, in view of the limited globulin (HBIG) supply of HBIG, an accelerated course of vaccine (doses given at O-24 h, 2 or 4 weeks, 6 or 8 weeks, and 12 months) is recommended for exposures of unknown source l-4 where the risk of infection is much lower and the use of HBIG is probably not cost-effective.’ We report the surface (‘protective’) antibody responses in a group of health care workers given accelerated vaccination following unidentified source exposures. Exposed health care workers were vaccinated with recombinant hepatitis B vaccine (20 pg intramuscularly in the deltoid muscle; Smith, Kline and French) at O-24 h, 2 weeks, 6 weeks, and 12 months. Clotted blood samples were collected at 0 weeks, 8 weeks (or 12 or more weeks if an S-week specimen was not collected), and immediately before the 12-month dose of vaccine. These specimens were tested for hepatitis B surface antibody (HBsAb) by passive haemagglutination (PHA; Fujirebio Inc., Tokyo, limit5 10-50 IU 1-1) detection and/or enzyme-linked Japan; immunosorbent assay (ELISA, Biokit, Barcelona, Spain, result considered positive if the specimen OD exceeded the OD for a 10 IU 1-l control).
of Hospital
Infection
(1993)
23, 31 S-320
Letters
to the Editor
Sir, Needlestick
injuries
among
medical
students
We read with interest the article by Choudhury and Cleator’ on needlestick injuries among medical students. In January 1992 we surveyed the 30 medical students in their first clinical year at Southmead Hospital (using a questionnaire administered at individual interview). We wished to find out about the difficulties students experienced with venepuncture, their incidence of inoculation risk injuries, knowledge of reporting systems for such incidents, and their hepatitis B vaccination status. At the time of interview the students had been taking blood for about 12 risk incidents occurred to 11 weeks. During this time, 12 inoculation students, none of which was associated with ‘high inoculation risk’ patients. Nine incidents were caused by needles, three of which were suture needles, and three students described incidents where mucous membranes or broken skin were contaminated by a patient’s blood or body fluids. Eight incidents occurred during venepuncture and four during surgery. Most of the injuries were self-inflicted, but one needlestick injury was caused by the needle being left protruding from a sharps bin and two students described being pricked by another person’s suture needle during surgery. Only two of the 12 incidents (16.6%) were reported, a similar rate to that reported by Choudhury and Cleator.’ Five of the students were unaware that they should have reported any incidents, two did not know to whom to report and many felt that as the incident involved a patient of low inoculation risk, reporting was unnecessary. Two students did not wish to report because they thought it would reflect poorly on their clinical skills. Before their first clinical attachment 27 of the 30 students attended an introductory course during which there was a demonstration of venepuncture using the Vacutainer system and they had an opportunity to practise on each other, although not all were individually supervised. Only 11 of the 30 students (36%) were supervised when taking blood from patients for the first time. While the Vacutainer system was used in the initial demonstration the majority of students admitted using a conventional needle and syringe system as well. The latter is necessary for collecting blood cultures, but students felt it was also useful if their patients had ‘difficult veins’. However, only 16/ 30 (.53%), had conventional needle and 0195-6701i93/040315+06
$08.00/O
0 1993 The Hospml
315
Infectmn
Society
316
Letters
to the Editor
syringe techniques demonstrated and only 9/30 (30%) had been directly supervised. In order to re-use the Vacutainer needle mount, students were resheathing needles and although the majority did so with a safe single-handed approach, some (20%) d escribed unsafe methods, such as using both hands. It had been assumed that the needle mounts were changed daily but 56% of students had not changed them at all during the 12 weeks they had been at the hospital while 30% said they would clean the needle mounts if they were visibly contaminated with blood rather than discard them. Hospital policy is that students should not take blood from known high-inoculation-risk patients, yet 14/30 said they would do so and four based this answer on their previous experience. It was also worrying that a number of students were not clear about which groups of patients fell into the hospital’s inoculation risk categories. To deal with these areas of concern and the finding that 40% of students felt inadequately prepared for taking blood and 30% wanted more individual supervision, we have arranged that students arriving at Southmead for clinical attachments will receive further training sessions and supervision. Many needlestick injuries occur during re-sheathing2A and although Choudhury and Cleator’ did not show a significant difference in injury rates between those resheathing and not resheathing, we have recommended the single use of Vacutainer needle mounts to remove the need to resheath. ‘Winged butterfly’ sets have been made available on our wards which can be used with the Vacutainer system to avoid the use of the conventional needle and syringe for patients with difficult veins and the hazard involved with injecting blood into vacuum tubes. Once more we have emphasized that students not take blood from known inexperienced should high-inoculation-risk patients and the importance of reporting inoculation incidents has been stressed. In addition an accident book has been introduced as Choudhury and Cleator’ recommended. The recent introduction of phlebotomists to our hospital will reduce greatly the number of blood samples taken by students because, apart from safety, repeated venepuncture is not felt to be a useful educational experience. In addition the University of Bristol has introduced the policy that medical students must have a full hepatitis B vaccination course for their clinical attachments and we were encouraged to find that 21 out of 30 students (70%) had been vaccinated and were known to be immune. Only one student had made no attempt to start his vaccination course during the 12 weeks at Southmead. However, of the 11 students who had had inoculation risk incidents, five had not completed their vaccination course. In conclusion our study has again shown that medical students are indeed vulnerable to inoculation risk injuries as they are inexperienced and may be responsible for taking large numbers of blood samples. As infection control specialists we must ensure that students receive adequate instruction and close supervision for initial venepunctures and that they are aware of the correct course of action if a needlestick injury occurs. We hope to follow
Letters
317
to the Editor
new groups of students in the future to try to assess the impact of the additional training and other changes that we have made in reducing their chances of sustaiming inoculation injuries. B. V. D. A.
L. E. S. P.
Department of Medical Microbiology, Southmead Health Services NHS Trust, Westbury-on- Trym, Bristol, UK
Kirkpatrick Ricketts Reeves MacGowan
References 1. Choudhury vaccination
RP, Cleator SJ. An examination of needlestick injury rates, uptake and instruction on ‘sharps’ technique among medical
hepatitis students.
B J
Hasp Infect 1992; 22: 143-148. 2. Jagger J, Hunt EH, Brand-Elnaggar J, Pearson RD. Rates of needlestick injury caused by various devices in a university hospital. N Eng J’ Med 1988; 319: 284-288. 3. Kennedy DA. Needlestick injuries: mechanisms and control. J Hasp Infect 1988; 12: 315-322. 4. Gompertz S. Needlestick injuries in medical students. J Sot Occup Med 1990; 40: 19-20.
Sir, Hepatitis
B surface
antibody
responses
following
accelerated
vaccination
Until all health care workers have been vaccinated against hepatitis B virus, unimmunised staff will need post-exposure prophylaxis following parenteral or mucosal exposure to infected blood or secretions. When the source patient is hepatitis B surface antigen positive, hepatitis B immune and vaccine are given. ’ However, in view of the limited globulin (HBIG) supply of HBIG, an accelerated course of vaccine (doses given at O-24 h, 2 or 4 weeks, 6 or 8 weeks, and 12 months) is recommended for exposures of unknown source l-4 where the risk of infection is much lower and the use of HBIG is probably not cost-effective.’ We report the surface (‘protective’) antibody responses in a group of health care workers given accelerated vaccination following unidentified source exposures. Exposed health care workers were vaccinated with recombinant hepatitis B vaccine (20 pg intramuscularly in the deltoid muscle; Smith, Kline and French) at O-24 h, 2 weeks, 6 weeks, and 12 months. Clotted blood samples were collected at 0 weeks, 8 weeks (or 12 or more weeks if an S-week specimen was not collected), and immediately before the 12-month dose of vaccine. These specimens were tested for hepatitis B surface antibody (HBsAb) by passive haemagglutination (PHA; Fujirebio Inc., Tokyo, limit5 10-50 IU 1-1) detection and/or enzyme-linked Japan; immunosorbent assay (ELISA, Biokit, Barcelona, Spain, result considered positive if the specimen OD exceeded the OD for a 10 IU 1-l control).