Prevalence of nonreporting behavior of sharps injuries in Taiwanese health care workers Judith S.-C. Shiao, MHSa Mary-Louise McLaws, PhDb Kun-Yen Huang, MD, PhDc Wen-Chen Ko, MDd Yueliang Leon Guo, MD, PhDe Taiwan, Republic of China, and New South Wales, Australia Background: Health care workers (HCWs) were surveyed to identify factors associated with nonreporting behavior of sharps injuries (SIs) in Taiwan. Methods: We surveyed 10,469 full-time medical, nursing, technical, and supporting personnel employed at 16 randomly selected hospitals from 132 available accredited teaching hospitals in Taiwan. Information about the most recent injury and reporting behavior after an SI were collected from July 1996 to June 1997 by using a pretested structured questionnaire. Eleven categories, including an open-ended option, were provided for participants to explain their nonreporting behavior. Results: Questionnaires were completed by 82.6% (8645) of our sample, of whom 87.3% reported to have experienced a recent SI. A used item was the most commonly (P < .001) involved item in an SI, and SIs with a used item were significantly more likely (odds ratio 3.6; CI 95%, 3.03-4.26; P < .001) to be reported compared with an SI that involved unused items. A total of 81.8% of injuries were not reported, with job category significantly affecting reporting behavior (P < .001). Medical staff had the highest nonreporting rate (85.2%). Although attendees of a prevention program were statistically more likely (P < .001) to report an injury compared with nonattendees, the level of reporting in both groups was not encouraging (21.3% and 17.2%, respectively). All reasons given for nonreporting were disconcerting, but none more so than the use of subjective assessment of risk by 21.7% of HCWs who did not report their injuries. Other reasons for not reporting SIs included that the item was unused (34%) and that the HCW was too busy to report the SI (14.9%), unaware of reporting requirements (14.4%), or immune to hepatitis B virus (12.4%). Conclusions: With 82% of SIs in Taiwanese HCWs going unreported, the expected national incidence will be seriously underestimated and impact the appropriateness of prevention programs. The very low rate of reporting suggests that the current reporting system requires simplification. Because most injuries involved used items, the reporting systems also should include a more responsive management component. The results also suggest that the current prevention programs, currently provided by the general nursing department, require expert content knowledge in infection control if nonreporting and SIs are to be reduced. (AJIC Am J Infect Control 1999;27:254-7)
Since the first reported case of occupationally acquired HIV infection through a needlestick injury in 1984,1 awareness and practice of infection control in From the China Junior College of Medical Technologya; New South Wales Hospital Infection, Epidemiology and Surveillance Unit, School of Health Services Management, Faculty of Medicine, The University of New South Walesb; Microbiology and Immunology, National Cheng Kung University Medical Collegec; Internal Medicine, National Cheng Kung University Medical Colleged; and Environmental and Occupational Health, National Cheng Kung University Medical College.e Supported by the Center for Occupational Health; jointly sponsored by National Cheng Kung University Medical College and the Ministry of Health, Taiwan, Republic of China. Reprint requests: Professor Yueliang Leon Guo, Environmental and Occupational Health, National Cheng Kung University Medical College, 138 Sheng Li Road, Tainan, 70428, TAIWAN, ROC. Copyright © 1999 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/99/$8.00 + 0
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health care settings has increased.2,3 However, despite recommendations aimed at reducing needlestick/ sharps injuries (SIs) in recent years,4-7 these injuries are by far the most common cause of accidental exposure to and transmission of bloodborne infectious diseases in health care workers (HCWs).5-8 Reporting of an SI is imperative because penetrative and splash injuries can be potentially life threatening and require HCWs to have vital assessments of their risk of acquiring HIV, hepatitis B, and hepatitis C.4,6,8 Nonreporting also has the potential to leave the infection control practitioner (ICP) educator unaware of endemic risk behavior associated with the handling and disposing of the sharps.9 Nonreporting of SIs differs throughout groups of HCWs, and despite special warnings commonly given to high-risk HCWs in emergency departments, nurses have staggeringly higher nonreporting behavior compared with physicians (66% and 12%, respectively).10-12 Fortunately, the prevalence of nonreporting behavior has been demonstrated to improve with the introduction of postexposure follow-up protocols.13
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Validity and reliability
Nonreporting of SIs may be potentially fatal for HCWs because bloodborne diseases are becoming endemic in Taiwan. Hepatitis C virus antibodies have been isolated in 2.5% of the general population, and hepatitis B is already endemic at a level of 15% to 20%.14,15 The prevalence of HIV infection in Taiwan is well on its way to becoming endemic, with 1491 cases reported since the establishment of HIV surveillance in the 1980s.16 The endemic level of hepatitis B and C infections indicates that infection control in Taiwan needs to address sharps prevention programs. The overall risk of needlestick and sharps injuries in HCWs in Taiwan has been published elsewhere.17 We further investigated the factors associated with nonreporting behavior and key occupational safety issues that ICPs should target.
Frequency and comparison of proportions for reporting behavior between usage status of items involved in SIs, job category, and attendance at a prevention program were performed by the JMP statistical package (SAS Institute Inc, Cary, NC, 1984-94). The χ2 and the Fisher exact test were calculated with significance set at P = .05.
METHODS
RESULTS
Study population
Sample and reporting behavior
Methods of subject recruitment have been reported elsewhere in detail.17 The target population included 10,469 full-time medical, nursing, technical, and supporting personnel employed at 16 randomly selected hospitals from all 132 available accredited teaching hospitals in Taiwan. Hospitals were randomly selected from 4 strata based on the number of HCWs employed and not geographical location. Four hospitals were randomly selected from the hospitals with more than 1000 HCWs, 5 from hospitals with 500 to 999 HCWs, 3 from hospitals with 200 to 499 HCWs, and 4 from hospitals with 1 to 199 HCWs. Randomly selected hospitals represented the 4 different geographical areas of Taiwan: 8 were from 68 northern regional hospitals, 3 from 26 central regional hospitals, 3 from 32 southern regional hospitals, and 2 from 6 hospitals along the East Coast.
Completed questionnaires were returned by 82.6% (8645 of 10,469) of the HCWs from the study hospitals. The response rates of each stratum was 76.6% for hospitals with more than 1000 employees, 85.7% for hospitals with 500 to 999 HCWs, 89.0% for hospitals with 200 to 499 HCWs, and 79.0% for hospitals with 1 to 199 HCWs. At least one SI was experienced by 87.3% (7550 of 8645) of the study group, of whom 81.7% (6169 of 7550) failed to report the injury to the infection control department. Sharps injuries involving a used item were reported more often compared with injuries involving an unused item (odds ratio 3.6; CI 95%, 3.04-4.26; P < .001). Job category significantly affected the HCWs’ reporting behaviors (P < .001), with the prevalence of nonreporting in all staff ranging from 74.6% to 85.2%. Medical staff failed to report 85.2% of their injuries (CI 95%, 83.2%-87.2%), nurses 81.7% (CI 95%, 79.6%83.8%), technicians 81.5% (CI 95%, 79.9%-83.7%) and supporting personnel 74.6% (CI 95%, 70.4%-78.8%). The rate of reporting SIs was influenced by the size of the hospital (P = .05), with HCWs from smaller hospitals less likely to report compared with HCWs from larger hospitals. Duration of employment was not significantly (P = .35) associated with reporting behavior.
Questionnaire interview Written notification and visits to the hospitals were made before the survey. Names of currently employed HCWs were provided by using the employment records. Every participant was asked to complete a structured selfadministered pretested questionnaire. A face-to-face interview was used to collect data for supporting personnel with literacy problems. Questions included the frequency of SIs in the past 12 months, information about all episodes of SIs, including the sites, items involved, usage status of the stuck item, whether the incident was officially reported and, if not, reasons for nonreporting. Serologic status for hepatitis B in HCWs and their past attendance at an SI prevention program were included in the questionnaire. Content of individual prevention programs was not measured in the questionnaire; however, each hospital covered issues that related to needle-handling techniques and reporting pathways for SIs.
Validity of the questionnaire was ensured through focus-discussion groups with representatives from each of the HCWs groups and experts in occupational and public health safety. A high level (r = 0.902) of test-retest reliability was identified. Data analysis
Items involved in SIs Syringe needles were by far the most common (52.0%) items involved in SIs, followed by suture needles (7.2%) and intravenous catheter stylets (4.6%) (Table 1). Items other than syringes and needles, such as glass and scalpel blades, were involved in 11.4% of injuries. Significantly (P < .001) more used items were involved in injuries compared with items that were unused or had unknown usage status. Used items accounted for 54.9% (4141 of 7550) of all injuries, of which 72.8% (3014 of
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Table 1. Nonreporting rate of the most recent episode of SI by item Nonreport % (n)
Needles Syringe needle Suture needle Intravenous catheter stylet Insulin needle/hypodermic needle Air-induction needle/needles of the intravenous kit Phlebotomy needle Butterfly needle Blood glucose lancet Tapping needle† Central venous pressure introducer needle Sharps Glass item Scalpel blade Others % (Total n)
Report % (n)
Total % (Total n)
81.0 (3178) 85.1 (463) 63.4 (218) 76.1 (153) 88.3 (159) 59.9 (97) 71.1 (106) 73.3 (96) 58.3 (42) 64.7 (22)
19.0 (746) 14.9 (81) 36.6 (126) 23.9 (48) 11.7 (21) 40.1 (65) 28.9 (43) 26.7 (35) 41.7 (30) 35.3 (12)
52.0 (3924) 7.2 (544) 4.6 (344) 2.7 (201) 2.4 (180) 2.2 (162) 2.0 (149) 1.7 (131) 1.0 (72) 0.5 (34)
92.6 (653) 83.8 (134) 94.9 (536) 81.8 (6179)
7.4 (52) 16.3 (26) 5.1 (2.9) 18.2 (1371)
9.3 (705) 2.1 (160) 7.5 (565) 100 (7550)
P < .001. †Collection of bursa fluid/cerebral spinal fluid/amniotic fluid.
4141) were not reported. Of the 33.4% (2518 of 7550) of injuries involving unused items, the majority (93.3%, 2350 of 2518) were not reported. Items of unknown usage accounted for 11.8% (891 of 7550) of injuries, of which 91.5% (815 of 891) were not reported. The high level of nonreporting in the study group was not completely explained by attendance at an SI prevention program. Significantly (P = .0001) more nonattendees failed to report an injury compared with attendees, yet the level of nonreporting by both groups was high (82.8% and 78.7%, respectively) (Table 2). Reasons for nonreporting behavior Reasons for nonreporting were provided by 98.6% (6081 of 6169) of the respondents who had not reported their most recent injury (Table 3). A common reason (34%) for nonreporting was that the object involved was “unused in a patient.” This reason was more commonly (41.7%, P < .001) given by nurses than by other staff. An additional 14.9% of nonreporting behavior was a result of being “too busy,” and 14.4% were “unaware of the reporting requirement or mechanism.” This latter reason was commonly given by supporting staff (32.6%), technicians (25.4%), and medical officers (21.2%), and infrequently (9.4%) by nurses. Having immunity to hepatitis B was given as a reason for nonreporting by 12.4% of staff and was given by more medical, nursing, and technical staff compared with supporting staff (P < .001). DISCUSSION Our survey has revealed several important findings about nonreporting behavior in Taiwanese HCWs. These findings include missed opportunities for postexposure prophylaxis for injuries involved with used items, lack of
Table 2. Nonreporting rate of HCWs versus SI prevention education attendance
SI prevention Yes No % (Total n)
Nonreport % (n)
Report % (n)
78.7 (1735) 82.8 (2819) 81.2 (4554)
21.3 (469) 17.2 (584) 18.8 (1053)
Total % (Total n)
39.3 (2204) 60.7 (3403) 100 (5607)*
*Missing values not included. †P = .001.
awareness of formal reporting mechanisms, and subjective measurement of postexposure risk. More than half (62.0%) of all nonreported SIs occurred with items either used or of unknown usage, yet the majority of the staff did not benefit from any formal assessment of risk and prophylaxis. This nonreporting behavior also impacts the development of SI prevention programs, which may require more content knowledge and expertise in infection control. Nonreporting behavior results in a missed opportunity by the infection control department to gain an insight into the factors associated with injuries after SIs, even injuries involved with clean items, such as the existence of potentially hazardous working practices and environments. It has been frequently suggested that needlestick prevention and intervention programs alter SI-related behaviors.9,18,19 Although attendance at a prevention program was found to have a statistically significant (P < .001) impact on HCWs’ reporting behavior, the actual level of behavioral impact was minimal, with only a 4.1% improvement in reporting by HCWs exposed to a prevention program. This result should cast grave doubts about the simplicity of the existing reporting mechanisms and also may be in response to the lack of a prompt postexposure management process.
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Table 3. Reasons for nonreporting rate in the most recent sharps injuries in the 4 groups of HCWs MD % (n = 1013)
Object was never used on a patient 17.9 (185) Too busy 20.8 (215) Unaware of reporting requirement or mechanism 21.2 (219) I had either hepatitis B antigen or antibody 11.9 (123) The patient in whom the sharp object was used 11.5 (119) did not have infectious diseases of concern I had been stuck too many times 10.0 (103) I thought I should not be so unfortunate as to 5.7 (59) contract any disease My colleagues suggested that I should be OK 0.6 (6) and did not have to worry I reported when I was stuck in the past 0.5 (5) Total % (n) 100 (1034)
Supporting personnel %
Total %
(n = 3963)
Nurse % Technical personnel % (n = 292)
(n = 813)
(Total n)
41.7 (1645) 12.4 (491) 9.4 (370) 13.1 (518) 10.3 (405)
25.6 (188) 15.7 (115) 25.4 (186) 11.3 (83) 6.4 (47)
6.2 (16) 27.1 (70) 32.6 (84) 6.6 (17) 1.6 (4)
34.1 (2034) 14.9 (891) 14.4 (859) 12.4 (741) 9.6 (575)
5.2 (204) 5.7 (225)
7.4 (54) 6.4 (43)
5.0 (21) 8.2 (34)
5.7 (382) 5.3 (361)
1.4 (54)
1.4 (10)
0.5 (2)
1.1 (72)
0.8 (33) 100 (3954)
1.0 (7) 100 (733)
2.4 (10) 100 (258)
.008 (55) 100 (6081)*
*Missing values not included. †P = .0001.
An easy to follow postexposure protocol would greatly assist reporting rates, and, as a consequence, a more effective SI prevention strategy would be formulated. More than 29% of the obstacles to reporting are a perception of lack of time or a lack of knowledge about the reporting mechanism. An initial approach may be the introduction of a computerized anonymous reporting program available in all departments and a 24-hour hot line telephone service to the infectious disease department. This approach would allow staff to report all injuries during work time without leaving their work site. The most disconcerting obstacle to reporting was the use of subjective assessment of an injury. The practice of subjective assessments by HCWs has greatly inhibited their reporting incentive and should be addressed during a prevention program. In conclusion, our results have identified the most important barrier to improved occupational health— that of underreporting of SIs—and sheds light about the importance of involving the expertise of infection control. As a resultant bonus, improved reporting of SIs would serve the interest of patients through vaccination and counseling of HCWs who sustain an SI. We are grateful to the participants and administrators of the 16 surveyed hospitals in Taiwan.
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