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The human immunodeficiency virus: Knowledge and precautions among anesthesiology personnel
Original Contributions The Human Immunodeficiency Virus: Knowledge and Precautions Among Anesthesiology Personnel Charles K. Stevens, MD,* Sue Wayne Mentis, MBChB, FFA,? John B. Downs, MD* Department ‘I‘ampa,
Study
of‘ Anesthesiology,
University
of South
Florida
College
of Medicine,
FL.
Objective:
To compare actual irfectious disease precau,tions with current
recommendations and to determine the influence immunodefiriency
zlirus (HIV)
ofuge, clinical
experience, humorr
knowled
education on pructices. Design: Direct clinical observations of infectious precautions and posteducation suroeys of clinical practices und gene&
and preeduccrtzon
knowledge of. the HIC’.
Setting: University teaching hospital. Participants: Forty-six anesthesiu depnrtment members completed u preedur(ltio?l .sunjey, and 24 completed a posteducation suroey. J. Clin. Anesth.
3:266-275,
1991
and Main Results:
The sur-oey showed that udeyuate precuutions Si
correlations were found between years of clinical practice und precautions used while inserting &cular catheter.sy Sign$cant positive correlation wus found ht,tween years qf clinGcalpractice nnd precautions taken while handling soiled lu~ngo-
*Resident tAssistant Professor $Professor
Measurements
were usrd during less than 50Y~ of the routine procedures.
sropes. Knowled
and Chairman
Address reprint requests to Dr. Downs at the Department of Anesthesiology, Box 59, University of South Florida College of Medicine, 1290 1 Bruce B. Downs Blvd., Tampa, FL 33612-4799, USA.
precautions were taken with patients who had proven HIV infections and those at
Received for publication June 18, 1990; revised manuscript accepted for publication December 6, 1990.
personnel. An HIV educational program precautionary measures.
high risk of infection. The posteducation survey demonstrated a significnnt increase on& in the use of gloves during routine procedures. Knowledge .score.s were only .rlightl~~improued and did not significantly reflect infection control practices.
Conclusions:
0 1991 Butterworth-Heinemann
266
,I.
Clin. Anesth.,
vol. 3, July/August
Keywords:
occupational 1991
Adequate infectious disease @cautio&
Infection; human exposure.
were not tuken by anesthesia
resulted in only u small increase in
immunodeficiency
virus
(HIV):
HIV: Knowledge, precautions, anesthesiology: Stevens et al.
Introduction
Materials and Methods
Exposure to the HIV is a risk that all anesthesiology personnel face. Risk of exposure and subsequent infection can be expected to increase considerably over the next few years. Recent statistics indicate that 1 million to 1.2 million people in the United States are infected with the HIV.’ A review of health care workers exposed to the HIV via parenteral or mucous membrane showed a 0.36% rate of seroconversion.2-4 A cooperative surveillance project conducted by the Centers for Disease Control (CDC) showed a 0.3% seroconversion rate in 1,097 health care workers with similar exposure. 5 Although exposure to infectious body fluids rarely results in seroconversion, the CDC strongly urges health care workers to adhere to its published recommendations for minimizing the risk of exposure both to health care professionals and to their patients.6 The purpose of this investigation was to determine, by questionnaire and observation, what precautions members of the Department of Anesthesiology at the University of South Florida College of Medicine were taking to prevent the transmission of the HIV to themselves and to their patients. We sought to compare the precautions being taken by members of this department with those recommended by the CDC. We wanted to determine whether precautions were influenced by various demographic factors, including age, clinical experience, general knowledge about the HIV, and previous personal or professional exposure to HIV. In addition, we wanted to determine how the precautionary practices would change in response to a routine approach to didactic teaching.
The investigation was divided into two parts, observation and questionnaire, and into two phases conducted 2 months apart. Criteria for precautions that should be used in various clinical settings were based on our interpretation of the CDC recommendations (Table l).‘j During the initial phase, we unobtrusively observed members of our department to determine their use of infection control precautions. Next, we distributed questionnaires to all department members, faculty, residents, and certified registered nurseanesthetists (CRNAs) during a weekly conference. After the questionnaires were collected, we presented an hour-long educational overview of the HIV and specific infectious disease precautions. During the second phase, 2 months later, we redistributed the questionnaire at a weekly conference to a subset of the original surveyed group who attended the educational overview. Phase 1 and 2 questionnaire responses were statistically compared using a chi-square test.
Table
1. Precautions HIV Infection
Recommended
0 bservation During the first 2 weeks of the study, we unobtrusively observed the practices and precautions of department members with both regional and general anesthetic techniques as they anesthetized patients who were scheduled for elective operations. We observed the use of gloves, masks, eye protection, and gowns during intubation and during the insertion of intravenous (IV), arterial, central, and pulmonary artery catheters. During
Various
Procedures
to Prevent
Gloves
Masks
Eye Wear
Gowns
X X
X X
X
X
X
X
X
X
X X X
X X
X X
X
X
X
X
X
X
X
X
X
Procedure
Intubation and airway manipulation IV insertion Arterial catheter insertion Handling of blood/blood products Handling of NG tubes Tracheal tube suction Clinical
Setting
During CPR Emergency department resuscitation HIV
= human
immunodeficiency
virus;
IV = intravenous;
NC
= nasogastric;
CPR =
cardiopulmonary resuscitation.
J. Clin. Anesth.,
vol. 3, July/August
1991
267
We recorded whether needles were recapped and where soiled laryngoscope blades were placed after tracheal intubat&n. All observations were made in the operating room (C)R) or staging area.
arid removing needles queried recapping. bending, from syringes. For the general knowledge section. IVY selected questions about the HIV that we felt CV~“IX appropriate for the practice of anesthesiology (TubI/, 21.
Questionnuirr The questionnaire was designed to assess infection control precautions and general knowledge of the HIV. The CDC guidelines were used to formulate questions regarding the use of gloves, masks, eye wear protection, and gowns (Table 1). The authors asked questions about the use of precautions during intubation, arterial and venous cannulation, handling of blood and blood products, handling of nasogastric tubes, tracheal suction, cardiopulmonary resuscitation, and emergency department resuscitation. Queries about masks were related to their use outside the OR, since masks are routinely worn in the OR. Respondents who wore prescription eyeglasses regularly were considered to have taken eye precautions and were asked to skip the eye wear protection questions. Specific questions concerning routine use of needles
Table
2.
Knowledge
Base
Section
During the first phase of the investigation, we presented an educational overview at a weekly conference, after the questionnaire had been completed, and showed a 20-minute videotape about the care of’ patients with HIV-positive antibodies or acquired immunodeficiency syndrome (AIDS).7 Afterward, the correct answers for the questions from the general knowledge section of the questionnaire were reviewed. We distributed our interpretation of the CDC guidelines for recommended precautions (Table 1). A member of the Infectious Disease Department of The -I‘ampa General Hospital distributed literature about hospital policy concerning HIV exposure and workmen’s compensation. A period of questions and answers concluded the session.
of‘ the Questionnaire Correct Phase 1 (n = 46)
Estimated incidence in the general population of the U.S. in 1988 infected with the HIV? A: 1 to 2 million Projected incidence of‘ AIDS in the general population of the U.S. by 1991? A: YOO,OOO 3. ‘l‘he % of’ total reported cases of AIDS occurring in women with no known risk factors? A: 2.2 % 4. Incidence of seroconversion after needle stick or ~~LICOUSmenr-
brdne exposure to HIV infected blood? A:
268
J. Clin.
Anesth.,
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1991
Responses Phase 2 (n = 24)
15(33%)
8(33%)
8(17%)
5(21%)
10(!22%)
24(52%)
15(33%)
7(29%)
14(58%)
4(17%/c)
HIV: Knowledge, precautions, anesthesiology: Stevens et al. Table 2.
Continued Correct
6. Survival of the HIV on dried material at room temperature? A: days 7. Risk of HIV transmission (in Tampa) with a blood transfusion? A: l/200,000 a. After a needle stick or mucous membrane exposure, is the HIV or HBV more infectious? A: HBV 9. From which of the following body fluids has the HIV been isolated? A: breast milk urine CSF tears stool saliva 10. From which of the above (9) body fluids has there been a report of infection? A: breast milk No reported infection? A: urine CSF tears stool saliva 11. Which of the following destroys the HIV? A: alcohol hydrogen peroxide boiling water ethylene oxide household bleach 12. Which are the groups at high risk for becoming HIV Positive? A: blood transfusion prior to 1985 bisexuals hemophiliacs male homosexuals IV drug abusers Not high risk? A: female homosexuals heterosexuals
Responses
Phase 1 (n = 46)
Phase 2 (n = 24)
4(9%)
3(13%)
9(20%)
6(25%)
34(74%)
23(96%)
31(67%) 31(67%) 31(67%) 33(72%) 34(74%) 38(83%)
20(83%) 22(92%) 22(92%) 2 1(88%) 20(83%) 24( 100%)
18(39%)
9(380/o)
17(37%) 20(43%) 19(41%) 15(33%) 12(26%)
12(50%) 10(42%) 16(67%) 11(46%) 10(42%)
22(48%) 24(52%) 29(63%) 29(63%) 38(83%)
10(42%) 10(42%) 7(29%) 8(33%) 3( 13%)
34(74%) 43(93%) 44(96%) 44(96%) 44(96%)
23(96%) 24( 100%) 24( 100%) 24( 100%) 24( 100%)
20(43%)
16(67%)
27(59%)
20(83%)
HIV = human immunodeficiency virus; A = answer; AIDS = acquired immunodeficiency syndrome; HBV = hepatitis B virus; CSF = cerebrospinal fluid; IV = intravenous.
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1991
269
Analysis of Questionnaires The questions were answered on a five-point frequency scale, from Never to Alwt~y.,. Questions that pertained to eyeglasses were excluded so that responses would not be artificially inflated. However, for the following categories, the wearing of prescription eyeglasses was considered an eye precaution. We placed respondents into one of three groups-A& quote, Inadequatr, or Excessixje-according to their indicated practices. Answers were rated Adequate if department members always used a precaution from our recommended guidelines; Inadequate if the response was often, occasionally, seldom, or never; and Excessive if respondents used more precautionns than those recommended. Individual response groups were then analyzed for each procedure and clinical setting. The strength of association between these responses and demographic variables was quantified with Spearman’s coefficient of rank correlation. A value of p 9 0.05 was considered significant. The demographic data were categorized according to the level and type of medical education: faculty, resident, and CRNA (Table ?). The demographic variables included clinical experience, HIV knowledge, academic position, and existence of HIV seroconversion in a friend or colleague. We compared the precautions taken with different patient groups (routine, potentially infectious, high risk, and HIV positive) and specifically analyzed the responses for correlations between the demographic variables and the precautions taken.
Results
Table
3.
Demographic Data (in years) Phase 1 (XI = 46)
Phase 2 (n = 24)
Faculty (11 = 18) .4F
40.1
‘%v Experience
30.9 1.4
It 9.0 7.7 * 6.1
Experience Resiclenrs (n = 21) CRNAs (n = 7) Age
* 3.2 + 1.04
33.9 -+ 6. 1 4.1 -c 2.7 30.8 k 3.4 1.2 -+ 1.2
44.1 * 11.0
38.5 -t 5.0
Experience
15.7
lr x.7
11.5
+ 9.2
Total (I1 = 46) A!V Experience
36.6 6.3
k 9.0 k 7.2
32.9 4.8
k 5.1 f 4.0
Note:
Allvalues are
2
SD.
CKNAs = certified registered nurse-anesthetists
dling blood or blood products, and the most precautions with intubation or airway manipulation. Precautions during insertion of IV and arterial catheters were not separately queried; however, only 26% of the practitioners stated that they wore gloves when they performed either procedure. When placing central venous and pulmonary artery catheters, practitioners wore gloves 80% of the time and masks 100Y~ of the time. During procedures in the OR, respondents said that they wore gloves but not eye wear or gowns. The reported frequency and number of precautions increased during cardiopulmonary resuscitation (CPR) and during emergency department resuscitation; nevertheless, all precautionary measures were inadequate during CPR and in the emergency department.
Observation We the the ary
recorded data from 74 direct observations during initial phase of the investigation. We observed that surveyed group never used adequate precautionpractices in any procedure they performed (Table 4). Face masks were used more often in the OR than in the staging area because of hospital policy.
Preeducation
Questionnaire
The results of the questionnaire also showed that department members never took adequate precautions with any procedure. Practitioners stated that they used the fewest precautionary measures during IV and arterial catheter insertion, more precautions when han270
J. Clin. Anesth., vol. 3, July/August 1991
General Knowledge Analysis of the general knowledge section of the questionnaire demonstrated a low knowledge level regarding the HIV. The question that was answered incorrectly most often concerned the survival time of the HIV on dried material at room temperature. Most respondents indicated a survival time of seconds 01 minutes rather than days. Residents received 60% of the highest correct scores and only 20% of the lowest scores. We found a negative correlation between general knowledge about the HIV and the precautions used with IV and arterial catheter insertions (masks, r= -0.37, p < 0.01; gowns, r = -0.35,p < 0.02), emergency department resuscitation (masks, r = -0.38, p < O.Ol), and tracheal suction (masks, Y =
HIV: Knowledge, precautions, anesthesiology: Stevens et al.
Table 4.
Observed
Precautions
All Recommended Precautions Used
Precaution
Precautions Used
Gloves Masks Eye wear Gowns*
15(52%) 28(97%) 13(45%) O(O%)
6(21%)
Gloves Masks Eye wear* Gowns*
6(22%) 16(59%) 8(30%) O(O%)
4(15%)
Arterial catheter insertion (n = 12)
Gloves Masks Eye wear Gowns
4(33%) 6(50%) 4(33%) O(O%)
O(O%)
CVPiPAFC
Gloves Masks Eye wear Gowns
6( 100%) 6( 100%) 1(17%) 2(33%)
O(O%)
Procedure Intubation
(n = 29)
IV insertion
(n = 27)
(n = 6)
Note: Those who wore prescription glasses were considered to wear protection. Those who used all the recommended precautions for that specific procedure are listed in the third column. IV = intravenous; *Nonrecommended
-0.33,
p < 0.02).
HIV knowledge
Posteducation
No correlation and precautions
CVPiPAFC
= central venous pressure/pulmonary
artery flow catheter.
precaution.
was found between taken during CPR.
Questionnaire
Twenty-four department members, a subset of the original group, responded to the survey two months after the HIV educational effort. The demographic characteristics of the two groups were similar (Table ?). Tables 5 and 6 list the changes in precautions after the HIV education. The use of gloves (p < 0.05) increased for a procedure and during CPR and emergency department resuscitation. However, we found no increase in any of the other recommended precautions. Answers to the general knowledge questions showed an increased awareness of the high-risk groups and potentially infectious body fluids.
Demographic Data Examination of demographic variables showed that the largest group of respondents was residents (n = 21), the next largest, faculty (n = 18), and the smallest, CRNAs (n = 7). The oldest members of the group
(mean age 44 years) were CRNAs, and they had the most clinical experience (15.7 years). Residents were the youngest members (mean age 30.9 years) and had the least clinical experience (1.7 years). All three groups expressed concerns about potential exposure to the HIV, but residents expressed the greatest concern. Faculty members and residents reported a total of eight friends or colleagues with positive HIV serology or HIV infection. We found statistically significant positive correlations between years of clinical practice and precautions taken when inserting IV or arterial catheters (goggles, r = 0.462,~ < 0.01; gowns, r = 0.431,p < 0.005). We found a positive correlation between clinical experience and precautions used in handling soiled laryngoscopes (r = 0.3 1, p < 0.04) and ensuring clean laryngoscope blades (T = 0.39, p < 0.01). A significant negative correlation was noted between age and precautions during IV and arterial line insertion and during emergency department resuscitation for specific age-groups. Members aged 30 years or younger used gloves more frequently when inserting IV and arterial catheters (r = 0.63, p < 0.01) and during emergency department resuscitation (r = 0.72, p < 0.005). In contrast, as age increased, the use of gloves when placing IV and arterial catheters decreased (r = - 0.32,
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1991
271
Original Cant?-ihuliow Table
5.
Sur\q
Kesul~s:
(:onqdiance
with
Keco~runer~ied
Phase 1 (n = 46)
Precaution Procedure Intubationiairway manipulation
Precxurioms Phase 2 (n = 24)
Gloves
‘LO(43%)
Masks Eye wear Gowns*
15(33’ic)
9(38%)
18(397c) 1(2%)
lO(42%.) O(O7c)
IV/A-line insertion
Gloves Masks Eye wear Gowns
12(26YL) 4(9S) 18(39%) O(O%‘)
10(42’?) 2(8S) Y(38S) O(f)%‘)
Handling of blood/blood products
Gloves Masks* Eye wear* Gowns*
21(46%) 9(20%) 9(20%) l(2S’)
15(630/u) 5(21%)) 10(42%a)t O(O%,)
During CPR
Gloves Masks Eye wear Gowns
22(48%) 10(22%) 20(43%) l(2S)
20(83%)i
Emergency department resuscitation
Gloves Masks Eye wear Gowns
26(57%) 1 l(24S) 21(46%) 2(4R)
2 1(H8%)1 7(29%) 12(50%) O(OYG)
Clinical
Note:
17(71%:)t
Setting
In phase
IV/A-line
1, 18 wore prescription
= intravenous
*Nonrecommended
or arterial
glasses.
In phase
6(25%) Y(38S) O(OS)
2, 9 wore prescription
line; CPK = cardiopulmonary
glasses.
resuscitation.
precautions.
tp < 0.05
p < 0.03). The knowledge or precautions of those members who had a friend or colleague with HIV positive serology did not differ from the average of the study group.
44% responded that they never, seldom, or only occasionally ensured that the laryngoscope handle was clean.
Needle Precautions Patient Groups When precautions taken with different patient groups were examined, we found that precautions increased as the potential risk of disease increased (Table 6).
Laryngoscope Precautions After intubation in the OR, we observed that the laryngoscope blade was sometimes replaced in its original protective package and then placed on the anesthesia machine. However, 39% of the time (17 of 44 cases), the soiled laryngoscope was placed unprotected on the anesthesia machine, the surface of which was not cleaned between cases. In the questionnaire, 272
J. Clin. Anesth., vol. 3, July/August 1991
A large proportion of the surveyed department members reported that they recapped needles (36 of 46) and removed needles from disposable syringes (22 of 46). During our observations, we recorded needle recapping in 99% of needle usage (79 of 80 cases). The frequency reported on the questionnaire was less. Only one of the practitioners routinely bent needles.
Discussion We found that members of the department failed to take adequate precautions during more than half of the routine procedures they performed. They used slightly more precautions in clinical settings outside the OR. The failure to use recommended precautions
HIV: Knowledge, precautions, anesthesiology: Stevens et al. Table 6. Survey Results: Various Patient Groups
Compliance
with Recommended
Precautions
in
Phase 1 (n = 46)
Phase 2 (n = 24)
Routine cases Gloves Masks Eye wear Gowns
17(37%) 12(26%) 18(39%) 2(4%)
12(50%) 8(33%) 10(42%) O(O%)
Infectious cases Gloves Masks Eye wear Gowns
35(76%) 21(46%) 24(52%) 4(9%)
20(83%) 14(58%) 13(54%) 2(8%)
High-risk cases Gloves Masks Eye wear Gowns
39(85%) 19(41%) 26(57%) 8(17%)
23(96%) 11(46%) 14(58%) 4(17%)
HIV-positive Gloves Masks Eye wear Gowns
42(91%) 30(65%) 36(78%) 20(43%)
24(100%) 17(71%) 23(96%)* 9(38%)
cases
Note: In phase 1, 18 wore prescription HIV
= human
immunodeficiency
glasses. In phase 2, 9 wore prescription
glasses.
virus.
*p < 0.05.
is a finding of health
similar care
to those
workers
who
reported routinely
in a recent cared
study
for AIDS
AIDS related complex (ARC) patients.H Our interpretation of the CDC precautions was based on the recommendations for protection against splashes of blood or body fluids (Table I). With these guidelines in mind, we included wearing gowns where a “splash” of blood or body fluids might occur. During intubation, the patient sometimes coughs and expels airway secretions and blood toward the endoscopist. Such incidents occur more frequently during intubations on the wards, where general anesthesia is less likely to be provided. Suctioning of the tracheal tube frequently generates splashing of airway secretions and blood, particularly at the termination of general anesthesia when the patient is coughing and straining on the tracheal tube. During the insertion of an arterial line, the clothing of a practitioner is often soiled with blood, especially with a less experienced practitioner. In this case, gowns seem appropriate. During CPR and emergency department resuscitation, the placement of an airway and the insertion of lines often expose team members to oral and airway secretions, regurgitated fluids, and blood. Frequently, the resuscitation team is exposed to a large amount of body
and
fluids, especially with trauma victims. Caring for these patients in a less controlled environment creates the greatest potential for exposure and warrants the use of all recommended precautions. The data show that department members took fewer precautions with procedures that involved more risk of infection than with those involving less risk. They exercised greater caution during tracheal intubation than during IV or arterial catheter insertion and with handling blood products. This difference may reflect habit and the group’s limited knowledge about the transmission and infection rate of the HIV. Practitioners who received their training before the onset of the AIDS epidemic may have developed casual attitudes toward infectious disease precautions. If so, as role models for residents and nurses, they may be perpetuating inadequate precautions. The format of the general knowledge section of the questionnaire may account for the low score on the HIV knowledge questions. About half the questions required knowledge of a specific nature regarding the HIV. More of the general questions were answered correctly. The fact that residents received the highest scores on the knowlege base section may be because their medical education occurred after
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273
198 1, during a period of intensive investigation, publication, and education concerning AIDS.” ‘l‘he negative correlation observed between general knowledge and precautions for IV and arterial catheter insertion and emergency department resuscitation suggests that the less practitioners knew about the disease, the more precautions they used. However, this conclusion is suspect because we did not see the anticipated increase in precautions with intubation and handling of blood and blood products and, more important, during CPR in the groups that demonstrated the least knowledge. All personnel took the most precautions while intubating patients. Direct observation showed that practitioners took more precautions while actually intubating patients than they reported on the questionnaires. Since intubations are performed in the OR under controlled conditions and with supplies nearby, practitioners may be more inclined to use them. In addition, time is less crucial during routine intubation, when supplies can be assembled prior to the procedure. The observations and questionnaire separated vascular lines into three groups: IV, arterial, and central venous/pulmonary artery catheters. Despite the greater risk associated with the placement of arterial catheters, fewer precautions were taken with them than during venous cannulation. As the age of the practitioner increased, the routine use of gloves decreased. The infrequent use of gloves may be linked to a perception of failure to cannulate because of loss of tactile feedback when gloves are worn during the insertion of peripheral intravascular catheters. The increased number of precautions taken when placing central venous and pulmonary artery catheters may be attributed to the invasive nature of the line placement and the requirement for a sterile field, compared with the lack of such a requirement during peripheral catheter placement. All practitioners took more precautions, and took them more often, during CPR and in the emergency department than in other settings. We found no difference between the number of precautions taken during CPR and the number taken in the emergency department. ‘rhe younger practitioners used gloves most frequently during IV and arterial line insertion and during emergency department resuscitation. The chaotic, less controlled environment of CPR increases the risk of potential exposure. That fact and the availability and access to material and protective clothing on the code cart may influence practitioners to use more precautions. In addition, the practitioners’ lack of familiarity with the patients’ medical history and HIV status may motivate them to use more precautions. 274
J. Clin. Anesth., vol. 3, July/August 1991
F$Tedid not find consistent or predictable rela~iotrships betbveen age, clinical experience, general kno\+ledge, previous personal or protessional exposure lo HIV. and precautionary measures. Conseqnenrly, wt. were not able to characterize a group that took the most precautions or to determine which groups \voutd benefit from concentrated efforts to improve (x)111pliance \yith recommended precautions. Practitioners seemed to take precautions when the risk was above a11 undetermined level. This trend ill the use of precautions is disturbing, especially in vieb+ of the rapidly increasing rate of’ HIV infection. ‘l‘his study showed that the use of laryngoscopes and needles requires special consideration in preventing the spread of the HIV. ‘l‘he practice of placing the laryngoscope on the anesthesia cart after intubation is a major concern because items on the cart, and the machine itself, may become contaminated, and cross-infection may result. The practice of resheathing needles also is alarming, since a study of health care workers who were exposed to the HIV demonstrated that 81.3% were exposed by a parenteral exposure--i.r., by a needle or sharp object. I” ‘I‘his practice occurred in the current study despite conveniently located containers for proper disposal. ‘I-he CDC recommends that needles not be recapped, deliberately bent or broken by hand, removed from disposable syringes, or otherwlse manipulated manually.’ Anesthesia practitioners routinely recap needles that have been used to give an IV injection through an IV administration port. The needle does not come into direct contact with the patient or with blood under these circumstances, so if a needle stick were to occur, the risk of exposure would be expected to be less. The routine use of stopcocks would eliminate the unnecessary risk associated with recurrent needle capping. ‘l-he limited increase of precautions after HIV education may indicate that anesthesia personnel do not view the HIV as a personal threat. The results also indicate that education alone may not be the solution for decreasing the risk of exposure to the HIV. The establishment and enforcement of precautionary rules may be required. The CDC recommends that all hospital anesthesiology departments establish and enforce rules for HIV precautions.’ Guidelines similar to those used in this study could be used to determine the adequacy of existing ‘precautionary measures and the need for stronger measures. The CDC: guidelines state, “Medical history and examination cannot reliably identify all patients infected with the HIV or other blood borne pathogens.“” Therefore, the CDC recommends that health care personnel take precau-
HIV: Knowledge, precautions, anesthesiology: Stevens et al.
tionary measures with all patients to minimize the risk of HIV exposure. Participants in our study were not taking adequate precautions to protect themselves and their patients from exposure to the HIV. General knowledge about the HIV was limited. An educational program about the HIV resulted in only a small increase in precautionary measures. Precautionary guidelines, as recommended by the CDC, should be provided for all hospital anesthesiology departments. Perhaps health care institutions and professionals would benefit from the establishment and enforcement of rules for precautionary measures to prevent the spread of the HIV among their personnel and patients.
3.
4.
5.
6.
7.
Acknowledgments We thank Jukka Rasanen, MD, PhD, and Davey Volkhardt for editorial assistance.
8.
References 9. Centers for Disease Control: Estimates of HIV prevalence and projected AIDS cases: summary of a workshop, October 31-November 1, 1990. MMWR 1990;39: 110-g. Henderson D, Saah A, Zak B, et al: Risk of nosocomial infection with human T-cell lymphotropic virus type III/lymphadenopathy-associated virus in a large cohort
10.
of intensively exposed health care workers. Ann Intern Med 1986;104:644-7. Marcus R: Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus. N Engl J Med 1988;319:111823. Stock SR, Gafni A, Bloch RF: Universal precautions to prevent HIV transmission to health care workers: an economic analysis. Can Med AssocJ 1990; 142:937-46. Centers for Disease Control: Update: human immunodeficiency virus infections in health care workers exposed to blood of infected patients. MMWR 1987;36:285-9. Centers for Disease Control: Recommendations for prevention of HIV transmission in health care settings. MMWR 1987;36(Suppl 2):3-7. Mills J, Lute J, Gerberding J: Recommendations for precautions to be taken when caring for HIV and HBV patients. Videotape. University of California, San Francisco. Gerberding J, Bryant-LeBlanc C, Nelson K, et al: Risk of transmitting the human immunodeficiency virus, cytomegalovirus, and hepatitis B virus to health care workers exposed to patients with AIDS and AIDSrelated conditions. J Infect Dis 1987; 156: l-8. Allen J: Heterosexual transmission of human immunodeficiency virus (HIV) in the United States. Bull NY Acad Med 1988;64:464-79. Centers for Disease Control: Update: acquired immunodeficiency syndrome and human immunodefiamong health-care workers. ciency virus infection MMWR 1988;37:229-38.
J. Clin. Anesth.,
vol. 3, July/August
1991
275
Study
of‘ Anesthesiology,
University
of South
Florida
College
of Medicine,
FL.
Objective:
To compare actual irfectious disease precau,tions with current
recommendations and to determine the influence immunodefiriency
zlirus (HIV)
ofuge, clinical
experience, humorr
knowled
education on pructices. Design: Direct clinical observations of infectious precautions and posteducation suroeys of clinical practices und gene&
and preeduccrtzon
knowledge of. the HIC’.
Setting: University teaching hospital. Participants: Forty-six anesthesiu depnrtment members completed u preedur(ltio?l .sunjey, and 24 completed a posteducation suroey. J. Clin. Anesth.
3:266-275,
1991
and Main Results:
The sur-oey showed that udeyuate precuutions Si
correlations were found between years of clinical practice und precautions used while inserting &cular catheter.sy Sign$cant positive correlation wus found ht,tween years qf clinGcalpractice nnd precautions taken while handling soiled lu~ngo-
*Resident tAssistant Professor $Professor
Measurements
were usrd during less than 50Y~ of the routine procedures.
sropes. Knowled
and Chairman
Address reprint requests to Dr. Downs at the Department of Anesthesiology, Box 59, University of South Florida College of Medicine, 1290 1 Bruce B. Downs Blvd., Tampa, FL 33612-4799, USA.
precautions were taken with patients who had proven HIV infections and those at
Received for publication June 18, 1990; revised manuscript accepted for publication December 6, 1990.
personnel. An HIV educational program precautionary measures.
high risk of infection. The posteducation survey demonstrated a significnnt increase on& in the use of gloves during routine procedures. Knowledge .score.s were only .rlightl~~improued and did not significantly reflect infection control practices.
Conclusions:
0 1991 Butterworth-Heinemann
266
,I.
Clin. Anesth.,
vol. 3, July/August
Keywords:
occupational 1991
Adequate infectious disease @cautio&
Infection; human exposure.
were not tuken by anesthesia
resulted in only u small increase in
immunodeficiency
virus
(HIV):
HIV: Knowledge, precautions, anesthesiology: Stevens et al.
Introduction
Materials and Methods
Exposure to the HIV is a risk that all anesthesiology personnel face. Risk of exposure and subsequent infection can be expected to increase considerably over the next few years. Recent statistics indicate that 1 million to 1.2 million people in the United States are infected with the HIV.’ A review of health care workers exposed to the HIV via parenteral or mucous membrane showed a 0.36% rate of seroconversion.2-4 A cooperative surveillance project conducted by the Centers for Disease Control (CDC) showed a 0.3% seroconversion rate in 1,097 health care workers with similar exposure. 5 Although exposure to infectious body fluids rarely results in seroconversion, the CDC strongly urges health care workers to adhere to its published recommendations for minimizing the risk of exposure both to health care professionals and to their patients.6 The purpose of this investigation was to determine, by questionnaire and observation, what precautions members of the Department of Anesthesiology at the University of South Florida College of Medicine were taking to prevent the transmission of the HIV to themselves and to their patients. We sought to compare the precautions being taken by members of this department with those recommended by the CDC. We wanted to determine whether precautions were influenced by various demographic factors, including age, clinical experience, general knowledge about the HIV, and previous personal or professional exposure to HIV. In addition, we wanted to determine how the precautionary practices would change in response to a routine approach to didactic teaching.
The investigation was divided into two parts, observation and questionnaire, and into two phases conducted 2 months apart. Criteria for precautions that should be used in various clinical settings were based on our interpretation of the CDC recommendations (Table l).‘j During the initial phase, we unobtrusively observed members of our department to determine their use of infection control precautions. Next, we distributed questionnaires to all department members, faculty, residents, and certified registered nurseanesthetists (CRNAs) during a weekly conference. After the questionnaires were collected, we presented an hour-long educational overview of the HIV and specific infectious disease precautions. During the second phase, 2 months later, we redistributed the questionnaire at a weekly conference to a subset of the original surveyed group who attended the educational overview. Phase 1 and 2 questionnaire responses were statistically compared using a chi-square test.
Table
1. Precautions HIV Infection
Recommended
0 bservation During the first 2 weeks of the study, we unobtrusively observed the practices and precautions of department members with both regional and general anesthetic techniques as they anesthetized patients who were scheduled for elective operations. We observed the use of gloves, masks, eye protection, and gowns during intubation and during the insertion of intravenous (IV), arterial, central, and pulmonary artery catheters. During
Various
Procedures
to Prevent
Gloves
Masks
Eye Wear
Gowns
X X
X X
X
X
X
X
X
X
X X X
X X
X X
X
X
X
X
X
X
X
X
X
Procedure
Intubation and airway manipulation IV insertion Arterial catheter insertion Handling of blood/blood products Handling of NG tubes Tracheal tube suction Clinical
Setting
During CPR Emergency department resuscitation HIV
= human
immunodeficiency
virus;
IV = intravenous;
NC
= nasogastric;
CPR =
cardiopulmonary resuscitation.
J. Clin. Anesth.,
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1991
267
We recorded whether needles were recapped and where soiled laryngoscope blades were placed after tracheal intubat&n. All observations were made in the operating room (C)R) or staging area.
arid removing needles queried recapping. bending, from syringes. For the general knowledge section. IVY selected questions about the HIV that we felt CV~“IX appropriate for the practice of anesthesiology (TubI/, 21.
Questionnuirr The questionnaire was designed to assess infection control precautions and general knowledge of the HIV. The CDC guidelines were used to formulate questions regarding the use of gloves, masks, eye wear protection, and gowns (Table 1). The authors asked questions about the use of precautions during intubation, arterial and venous cannulation, handling of blood and blood products, handling of nasogastric tubes, tracheal suction, cardiopulmonary resuscitation, and emergency department resuscitation. Queries about masks were related to their use outside the OR, since masks are routinely worn in the OR. Respondents who wore prescription eyeglasses regularly were considered to have taken eye precautions and were asked to skip the eye wear protection questions. Specific questions concerning routine use of needles
Table
2.
Knowledge
Base
Section
During the first phase of the investigation, we presented an educational overview at a weekly conference, after the questionnaire had been completed, and showed a 20-minute videotape about the care of’ patients with HIV-positive antibodies or acquired immunodeficiency syndrome (AIDS).7 Afterward, the correct answers for the questions from the general knowledge section of the questionnaire were reviewed. We distributed our interpretation of the CDC guidelines for recommended precautions (Table 1). A member of the Infectious Disease Department of The -I‘ampa General Hospital distributed literature about hospital policy concerning HIV exposure and workmen’s compensation. A period of questions and answers concluded the session.
of‘ the Questionnaire Correct Phase 1 (n = 46)
Estimated incidence in the general population of the U.S. in 1988 infected with the HIV? A: 1 to 2 million Projected incidence of‘ AIDS in the general population of the U.S. by 1991? A: YOO,OOO 3. ‘l‘he % of’ total reported cases of AIDS occurring in women with no known risk factors? A: 2.2 % 4. Incidence of seroconversion after needle stick or ~~LICOUSmenr-
brdne exposure to HIV infected blood? A:
268
J. Clin.
Anesth.,
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1991
Responses Phase 2 (n = 24)
15(33%)
8(33%)
8(17%)
5(21%)
10(!22%)
24(52%)
15(33%)
7(29%)
14(58%)
4(17%/c)
HIV: Knowledge, precautions, anesthesiology: Stevens et al. Table 2.
Continued Correct
6. Survival of the HIV on dried material at room temperature? A: days 7. Risk of HIV transmission (in Tampa) with a blood transfusion? A: l/200,000 a. After a needle stick or mucous membrane exposure, is the HIV or HBV more infectious? A: HBV 9. From which of the following body fluids has the HIV been isolated? A: breast milk urine CSF tears stool saliva 10. From which of the above (9) body fluids has there been a report of infection? A: breast milk No reported infection? A: urine CSF tears stool saliva 11. Which of the following destroys the HIV? A: alcohol hydrogen peroxide boiling water ethylene oxide household bleach 12. Which are the groups at high risk for becoming HIV Positive? A: blood transfusion prior to 1985 bisexuals hemophiliacs male homosexuals IV drug abusers Not high risk? A: female homosexuals heterosexuals
Responses
Phase 1 (n = 46)
Phase 2 (n = 24)
4(9%)
3(13%)
9(20%)
6(25%)
34(74%)
23(96%)
31(67%) 31(67%) 31(67%) 33(72%) 34(74%) 38(83%)
20(83%) 22(92%) 22(92%) 2 1(88%) 20(83%) 24( 100%)
18(39%)
9(380/o)
17(37%) 20(43%) 19(41%) 15(33%) 12(26%)
12(50%) 10(42%) 16(67%) 11(46%) 10(42%)
22(48%) 24(52%) 29(63%) 29(63%) 38(83%)
10(42%) 10(42%) 7(29%) 8(33%) 3( 13%)
34(74%) 43(93%) 44(96%) 44(96%) 44(96%)
23(96%) 24( 100%) 24( 100%) 24( 100%) 24( 100%)
20(43%)
16(67%)
27(59%)
20(83%)
HIV = human immunodeficiency virus; A = answer; AIDS = acquired immunodeficiency syndrome; HBV = hepatitis B virus; CSF = cerebrospinal fluid; IV = intravenous.
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1991
269
Analysis of Questionnaires The questions were answered on a five-point frequency scale, from Never to Alwt~y.,. Questions that pertained to eyeglasses were excluded so that responses would not be artificially inflated. However, for the following categories, the wearing of prescription eyeglasses was considered an eye precaution. We placed respondents into one of three groups-A& quote, Inadequatr, or Excessixje-according to their indicated practices. Answers were rated Adequate if department members always used a precaution from our recommended guidelines; Inadequate if the response was often, occasionally, seldom, or never; and Excessive if respondents used more precautionns than those recommended. Individual response groups were then analyzed for each procedure and clinical setting. The strength of association between these responses and demographic variables was quantified with Spearman’s coefficient of rank correlation. A value of p 9 0.05 was considered significant. The demographic data were categorized according to the level and type of medical education: faculty, resident, and CRNA (Table ?). The demographic variables included clinical experience, HIV knowledge, academic position, and existence of HIV seroconversion in a friend or colleague. We compared the precautions taken with different patient groups (routine, potentially infectious, high risk, and HIV positive) and specifically analyzed the responses for correlations between the demographic variables and the precautions taken.
Results
Table
3.
Demographic Data (in years) Phase 1 (XI = 46)
Phase 2 (n = 24)
Faculty (11 = 18) .4F
40.1
‘%v Experience
30.9 1.4
It 9.0 7.7 * 6.1
Experience Resiclenrs (n = 21) CRNAs (n = 7) Age
* 3.2 + 1.04
33.9 -+ 6. 1 4.1 -c 2.7 30.8 k 3.4 1.2 -+ 1.2
44.1 * 11.0
38.5 -t 5.0
Experience
15.7
lr x.7
11.5
+ 9.2
Total (I1 = 46) A!V Experience
36.6 6.3
k 9.0 k 7.2
32.9 4.8
k 5.1 f 4.0
Note:
Allvalues are
2
SD.
CKNAs = certified registered nurse-anesthetists
dling blood or blood products, and the most precautions with intubation or airway manipulation. Precautions during insertion of IV and arterial catheters were not separately queried; however, only 26% of the practitioners stated that they wore gloves when they performed either procedure. When placing central venous and pulmonary artery catheters, practitioners wore gloves 80% of the time and masks 100Y~ of the time. During procedures in the OR, respondents said that they wore gloves but not eye wear or gowns. The reported frequency and number of precautions increased during cardiopulmonary resuscitation (CPR) and during emergency department resuscitation; nevertheless, all precautionary measures were inadequate during CPR and in the emergency department.
Observation We the the ary
recorded data from 74 direct observations during initial phase of the investigation. We observed that surveyed group never used adequate precautionpractices in any procedure they performed (Table 4). Face masks were used more often in the OR than in the staging area because of hospital policy.
Preeducation
Questionnaire
The results of the questionnaire also showed that department members never took adequate precautions with any procedure. Practitioners stated that they used the fewest precautionary measures during IV and arterial catheter insertion, more precautions when han270
J. Clin. Anesth., vol. 3, July/August 1991
General Knowledge Analysis of the general knowledge section of the questionnaire demonstrated a low knowledge level regarding the HIV. The question that was answered incorrectly most often concerned the survival time of the HIV on dried material at room temperature. Most respondents indicated a survival time of seconds 01 minutes rather than days. Residents received 60% of the highest correct scores and only 20% of the lowest scores. We found a negative correlation between general knowledge about the HIV and the precautions used with IV and arterial catheter insertions (masks, r= -0.37, p < 0.01; gowns, r = -0.35,p < 0.02), emergency department resuscitation (masks, r = -0.38, p < O.Ol), and tracheal suction (masks, Y =
HIV: Knowledge, precautions, anesthesiology: Stevens et al.
Table 4.
Observed
Precautions
All Recommended Precautions Used
Precaution
Precautions Used
Gloves Masks Eye wear Gowns*
15(52%) 28(97%) 13(45%) O(O%)
6(21%)
Gloves Masks Eye wear* Gowns*
6(22%) 16(59%) 8(30%) O(O%)
4(15%)
Arterial catheter insertion (n = 12)
Gloves Masks Eye wear Gowns
4(33%) 6(50%) 4(33%) O(O%)
O(O%)
CVPiPAFC
Gloves Masks Eye wear Gowns
6( 100%) 6( 100%) 1(17%) 2(33%)
O(O%)
Procedure Intubation
(n = 29)
IV insertion
(n = 27)
(n = 6)
Note: Those who wore prescription glasses were considered to wear protection. Those who used all the recommended precautions for that specific procedure are listed in the third column. IV = intravenous; *Nonrecommended
-0.33,
p < 0.02).
HIV knowledge
Posteducation
No correlation and precautions
CVPiPAFC
= central venous pressure/pulmonary
artery flow catheter.
precaution.
was found between taken during CPR.
Questionnaire
Twenty-four department members, a subset of the original group, responded to the survey two months after the HIV educational effort. The demographic characteristics of the two groups were similar (Table ?). Tables 5 and 6 list the changes in precautions after the HIV education. The use of gloves (p < 0.05) increased for a procedure and during CPR and emergency department resuscitation. However, we found no increase in any of the other recommended precautions. Answers to the general knowledge questions showed an increased awareness of the high-risk groups and potentially infectious body fluids.
Demographic Data Examination of demographic variables showed that the largest group of respondents was residents (n = 21), the next largest, faculty (n = 18), and the smallest, CRNAs (n = 7). The oldest members of the group
(mean age 44 years) were CRNAs, and they had the most clinical experience (15.7 years). Residents were the youngest members (mean age 30.9 years) and had the least clinical experience (1.7 years). All three groups expressed concerns about potential exposure to the HIV, but residents expressed the greatest concern. Faculty members and residents reported a total of eight friends or colleagues with positive HIV serology or HIV infection. We found statistically significant positive correlations between years of clinical practice and precautions taken when inserting IV or arterial catheters (goggles, r = 0.462,~ < 0.01; gowns, r = 0.431,p < 0.005). We found a positive correlation between clinical experience and precautions used in handling soiled laryngoscopes (r = 0.3 1, p < 0.04) and ensuring clean laryngoscope blades (T = 0.39, p < 0.01). A significant negative correlation was noted between age and precautions during IV and arterial line insertion and during emergency department resuscitation for specific age-groups. Members aged 30 years or younger used gloves more frequently when inserting IV and arterial catheters (r = 0.63, p < 0.01) and during emergency department resuscitation (r = 0.72, p < 0.005). In contrast, as age increased, the use of gloves when placing IV and arterial catheters decreased (r = - 0.32,
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1991
271
Original Cant?-ihuliow Table
5.
Sur\q
Kesul~s:
(:onqdiance
with
Keco~runer~ied
Phase 1 (n = 46)
Precaution Procedure Intubationiairway manipulation
Precxurioms Phase 2 (n = 24)
Gloves
‘LO(43%)
Masks Eye wear Gowns*
15(33’ic)
9(38%)
18(397c) 1(2%)
lO(42%.) O(O7c)
IV/A-line insertion
Gloves Masks Eye wear Gowns
12(26YL) 4(9S) 18(39%) O(O%‘)
10(42’?) 2(8S) Y(38S) O(f)%‘)
Handling of blood/blood products
Gloves Masks* Eye wear* Gowns*
21(46%) 9(20%) 9(20%) l(2S’)
15(630/u) 5(21%)) 10(42%a)t O(O%,)
During CPR
Gloves Masks Eye wear Gowns
22(48%) 10(22%) 20(43%) l(2S)
20(83%)i
Emergency department resuscitation
Gloves Masks Eye wear Gowns
26(57%) 1 l(24S) 21(46%) 2(4R)
2 1(H8%)1 7(29%) 12(50%) O(OYG)
Clinical
Note:
17(71%:)t
Setting
In phase
IV/A-line
1, 18 wore prescription
= intravenous
*Nonrecommended
or arterial
glasses.
In phase
6(25%) Y(38S) O(OS)
2, 9 wore prescription
line; CPK = cardiopulmonary
glasses.
resuscitation.
precautions.
tp < 0.05
p < 0.03). The knowledge or precautions of those members who had a friend or colleague with HIV positive serology did not differ from the average of the study group.
44% responded that they never, seldom, or only occasionally ensured that the laryngoscope handle was clean.
Needle Precautions Patient Groups When precautions taken with different patient groups were examined, we found that precautions increased as the potential risk of disease increased (Table 6).
Laryngoscope Precautions After intubation in the OR, we observed that the laryngoscope blade was sometimes replaced in its original protective package and then placed on the anesthesia machine. However, 39% of the time (17 of 44 cases), the soiled laryngoscope was placed unprotected on the anesthesia machine, the surface of which was not cleaned between cases. In the questionnaire, 272
J. Clin. Anesth., vol. 3, July/August 1991
A large proportion of the surveyed department members reported that they recapped needles (36 of 46) and removed needles from disposable syringes (22 of 46). During our observations, we recorded needle recapping in 99% of needle usage (79 of 80 cases). The frequency reported on the questionnaire was less. Only one of the practitioners routinely bent needles.
Discussion We found that members of the department failed to take adequate precautions during more than half of the routine procedures they performed. They used slightly more precautions in clinical settings outside the OR. The failure to use recommended precautions
HIV: Knowledge, precautions, anesthesiology: Stevens et al. Table 6. Survey Results: Various Patient Groups
Compliance
with Recommended
Precautions
in
Phase 1 (n = 46)
Phase 2 (n = 24)
Routine cases Gloves Masks Eye wear Gowns
17(37%) 12(26%) 18(39%) 2(4%)
12(50%) 8(33%) 10(42%) O(O%)
Infectious cases Gloves Masks Eye wear Gowns
35(76%) 21(46%) 24(52%) 4(9%)
20(83%) 14(58%) 13(54%) 2(8%)
High-risk cases Gloves Masks Eye wear Gowns
39(85%) 19(41%) 26(57%) 8(17%)
23(96%) 11(46%) 14(58%) 4(17%)
HIV-positive Gloves Masks Eye wear Gowns
42(91%) 30(65%) 36(78%) 20(43%)
24(100%) 17(71%) 23(96%)* 9(38%)
cases
Note: In phase 1, 18 wore prescription HIV
= human
immunodeficiency
glasses. In phase 2, 9 wore prescription
glasses.
virus.
*p < 0.05.
is a finding of health
similar care
to those
workers
who
reported routinely
in a recent cared
study
for AIDS
AIDS related complex (ARC) patients.H Our interpretation of the CDC precautions was based on the recommendations for protection against splashes of blood or body fluids (Table I). With these guidelines in mind, we included wearing gowns where a “splash” of blood or body fluids might occur. During intubation, the patient sometimes coughs and expels airway secretions and blood toward the endoscopist. Such incidents occur more frequently during intubations on the wards, where general anesthesia is less likely to be provided. Suctioning of the tracheal tube frequently generates splashing of airway secretions and blood, particularly at the termination of general anesthesia when the patient is coughing and straining on the tracheal tube. During the insertion of an arterial line, the clothing of a practitioner is often soiled with blood, especially with a less experienced practitioner. In this case, gowns seem appropriate. During CPR and emergency department resuscitation, the placement of an airway and the insertion of lines often expose team members to oral and airway secretions, regurgitated fluids, and blood. Frequently, the resuscitation team is exposed to a large amount of body
and
fluids, especially with trauma victims. Caring for these patients in a less controlled environment creates the greatest potential for exposure and warrants the use of all recommended precautions. The data show that department members took fewer precautions with procedures that involved more risk of infection than with those involving less risk. They exercised greater caution during tracheal intubation than during IV or arterial catheter insertion and with handling blood products. This difference may reflect habit and the group’s limited knowledge about the transmission and infection rate of the HIV. Practitioners who received their training before the onset of the AIDS epidemic may have developed casual attitudes toward infectious disease precautions. If so, as role models for residents and nurses, they may be perpetuating inadequate precautions. The format of the general knowledge section of the questionnaire may account for the low score on the HIV knowledge questions. About half the questions required knowledge of a specific nature regarding the HIV. More of the general questions were answered correctly. The fact that residents received the highest scores on the knowlege base section may be because their medical education occurred after
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273
198 1, during a period of intensive investigation, publication, and education concerning AIDS.” ‘l‘he negative correlation observed between general knowledge and precautions for IV and arterial catheter insertion and emergency department resuscitation suggests that the less practitioners knew about the disease, the more precautions they used. However, this conclusion is suspect because we did not see the anticipated increase in precautions with intubation and handling of blood and blood products and, more important, during CPR in the groups that demonstrated the least knowledge. All personnel took the most precautions while intubating patients. Direct observation showed that practitioners took more precautions while actually intubating patients than they reported on the questionnaires. Since intubations are performed in the OR under controlled conditions and with supplies nearby, practitioners may be more inclined to use them. In addition, time is less crucial during routine intubation, when supplies can be assembled prior to the procedure. The observations and questionnaire separated vascular lines into three groups: IV, arterial, and central venous/pulmonary artery catheters. Despite the greater risk associated with the placement of arterial catheters, fewer precautions were taken with them than during venous cannulation. As the age of the practitioner increased, the routine use of gloves decreased. The infrequent use of gloves may be linked to a perception of failure to cannulate because of loss of tactile feedback when gloves are worn during the insertion of peripheral intravascular catheters. The increased number of precautions taken when placing central venous and pulmonary artery catheters may be attributed to the invasive nature of the line placement and the requirement for a sterile field, compared with the lack of such a requirement during peripheral catheter placement. All practitioners took more precautions, and took them more often, during CPR and in the emergency department than in other settings. We found no difference between the number of precautions taken during CPR and the number taken in the emergency department. ‘rhe younger practitioners used gloves most frequently during IV and arterial line insertion and during emergency department resuscitation. The chaotic, less controlled environment of CPR increases the risk of potential exposure. That fact and the availability and access to material and protective clothing on the code cart may influence practitioners to use more precautions. In addition, the practitioners’ lack of familiarity with the patients’ medical history and HIV status may motivate them to use more precautions. 274
J. Clin. Anesth., vol. 3, July/August 1991
F$Tedid not find consistent or predictable rela~iotrships betbveen age, clinical experience, general kno\+ledge, previous personal or protessional exposure lo HIV. and precautionary measures. Conseqnenrly, wt. were not able to characterize a group that took the most precautions or to determine which groups \voutd benefit from concentrated efforts to improve (x)111pliance \yith recommended precautions. Practitioners seemed to take precautions when the risk was above a11 undetermined level. This trend ill the use of precautions is disturbing, especially in vieb+ of the rapidly increasing rate of’ HIV infection. ‘l‘his study showed that the use of laryngoscopes and needles requires special consideration in preventing the spread of the HIV. ‘l‘he practice of placing the laryngoscope on the anesthesia cart after intubation is a major concern because items on the cart, and the machine itself, may become contaminated, and cross-infection may result. The practice of resheathing needles also is alarming, since a study of health care workers who were exposed to the HIV demonstrated that 81.3% were exposed by a parenteral exposure--i.r., by a needle or sharp object. I” ‘I‘his practice occurred in the current study despite conveniently located containers for proper disposal. ‘I-he CDC recommends that needles not be recapped, deliberately bent or broken by hand, removed from disposable syringes, or otherwlse manipulated manually.’ Anesthesia practitioners routinely recap needles that have been used to give an IV injection through an IV administration port. The needle does not come into direct contact with the patient or with blood under these circumstances, so if a needle stick were to occur, the risk of exposure would be expected to be less. The routine use of stopcocks would eliminate the unnecessary risk associated with recurrent needle capping. ‘l-he limited increase of precautions after HIV education may indicate that anesthesia personnel do not view the HIV as a personal threat. The results also indicate that education alone may not be the solution for decreasing the risk of exposure to the HIV. The establishment and enforcement of precautionary rules may be required. The CDC recommends that all hospital anesthesiology departments establish and enforce rules for HIV precautions.’ Guidelines similar to those used in this study could be used to determine the adequacy of existing ‘precautionary measures and the need for stronger measures. The CDC: guidelines state, “Medical history and examination cannot reliably identify all patients infected with the HIV or other blood borne pathogens.“” Therefore, the CDC recommends that health care personnel take precau-
HIV: Knowledge, precautions, anesthesiology: Stevens et al.
tionary measures with all patients to minimize the risk of HIV exposure. Participants in our study were not taking adequate precautions to protect themselves and their patients from exposure to the HIV. General knowledge about the HIV was limited. An educational program about the HIV resulted in only a small increase in precautionary measures. Precautionary guidelines, as recommended by the CDC, should be provided for all hospital anesthesiology departments. Perhaps health care institutions and professionals would benefit from the establishment and enforcement of rules for precautionary measures to prevent the spread of the HIV among their personnel and patients.
3.
4.
5.
6.
7.
Acknowledgments We thank Jukka Rasanen, MD, PhD, and Davey Volkhardt for editorial assistance.
8.
References 9. Centers for Disease Control: Estimates of HIV prevalence and projected AIDS cases: summary of a workshop, October 31-November 1, 1990. MMWR 1990;39: 110-g. Henderson D, Saah A, Zak B, et al: Risk of nosocomial infection with human T-cell lymphotropic virus type III/lymphadenopathy-associated virus in a large cohort
10.
of intensively exposed health care workers. Ann Intern Med 1986;104:644-7. Marcus R: Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus. N Engl J Med 1988;319:111823. Stock SR, Gafni A, Bloch RF: Universal precautions to prevent HIV transmission to health care workers: an economic analysis. Can Med AssocJ 1990; 142:937-46. Centers for Disease Control: Update: human immunodeficiency virus infections in health care workers exposed to blood of infected patients. MMWR 1987;36:285-9. Centers for Disease Control: Recommendations for prevention of HIV transmission in health care settings. MMWR 1987;36(Suppl 2):3-7. Mills J, Lute J, Gerberding J: Recommendations for precautions to be taken when caring for HIV and HBV patients. Videotape. University of California, San Francisco. Gerberding J, Bryant-LeBlanc C, Nelson K, et al: Risk of transmitting the human immunodeficiency virus, cytomegalovirus, and hepatitis B virus to health care workers exposed to patients with AIDS and AIDSrelated conditions. J Infect Dis 1987; 156: l-8. Allen J: Heterosexual transmission of human immunodeficiency virus (HIV) in the United States. Bull NY Acad Med 1988;64:464-79. Centers for Disease Control: Update: acquired immunodeficiency syndrome and human immunodefiamong health-care workers. ciency virus infection MMWR 1988;37:229-38.
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1991
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