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Universal precautions: Costs for protective equipment
GLOBAL PERSPECTIVES Despite tremendous advances in their treatment and prevention, infectious diseases remain a serious threat to the health of persons in all countries of the world. Persistent problems, such as tuberculosis, measles, and sexually transmitted diseases, continue to plague millions, and large-scale demographic, social, environmental, and political changes threaten to unleash new or resurgent microbial pathogens. Changes in health care delivery are often accompanied by an increased risk of nosocomial infection for patients and caregivers. Health care professionals in a wide array of settings, from small rural clinics to large urban hospitals to ministries of health, use their skills and available resources to minimize the effects of these infections. Methods may differ from one country or region to the next, but all are guided by this common goal and by fundamental principles of epidemiology. in the interest of mutual learning and improved patient care, the editors of the Journal launch this new section, called "Global Perspectives." Regardless of the country of origin, articles in this section will present work that advances the science, practice, or policy for infection prevention and control in new geographic settings. Emphasis will be given to articles that address the epidemiology of infection, particularly nosocomial infection, in areas where it may not have been previously well defined, to articles that evaluate prevention strategies in settings where conventional interventions have not been feasible or not applied consistently, and to articles about the study and control of emerging or reemerging infections of global interest. We encourage practitioners in all countries to submit their work in these areas for the benefit of the international infection prevention and control community. To initiate this section, we present an article from investigators in Thailand that evaluated the utilization and cost of universal precautions. Their findings should be interesting and useful for health care professionals and policy makers in many countries. Barbara M. Soule, RN, MPA, CIC
Global Perspectives Coeditor W. Charles Huskins, MD
Global Perspectives Coeditor
Universal precautions: Costs for protective equipment S. Danchaivijitr, MD, FRCP a T. Tangtrakool, BSc b S. Chokloikaew, MSc b V. Thamlikitkul, MD a
Bangkok, Thailand
Background: The amount and costs of protective equipment used to implement universal precautions in Thailand have not previously been studied.
Methods: A cross-sectional study was done to determine the frequency of clinical and laboratory procedures requiring universal precautions and the amount of protective equipment needed for each. Results: The study was performed in 24 government hospitals in Thailand in December 1993. Totaling 6549 beds, these hospitals had provided service to 357,391 inpatients and 3,411,122 outpatients during the previous year. The annual number of procedures performed in these hospitals was estimated at 17.5 million, with expenditures for protective equipment of $2.4 million (U.S.) per year. The average overall cost for protective equipment was U.S. $5.37 for one inpatient stay and U.S. $0.15 for one outpatient visit. The projected national expense for these barriers was U.S. $41.5 million per annum. The cost for these
From the Division of Infectious Diseases, Department of Medicine,a and Center for Nosocomial Infection Control,b Faculty of Medicine Siriraj Hospital, Mahidol, University, Bangkok, Thailand. Funded by a grant from the Bureau of University Affairs of Thailand. 44
Reprint requests: S. Danchaivijitr,MD, FRCP,Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Siriraj Hospital, 2 Prannok Rd., Bangkok 10700, Thailand. Copyright © 1997 by the Association for Professionalsin Infection Control and Epidemiology, Inc. 0196-6553/97 $5.00 + 0
t 7/46/78997
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barriers after the implementation of universal precautions was 2.5 times the cost before implementation. Conclusions: Overuse of sterile and examination gloves and gowns and underuse of heavyduty gloves, masks, aprons, goggles, and boots were discovered during the study. Appropriate use of disposable and reusable universal precautions equipment would free health care dollars for other purposes. (AJIC Am J Infect Control 1997;25:44-50)
Transmission of HIV and other blood-borne pathogens in health care settings has been well documented. 1-3 The risk of the transmission can be reduced by the use of universal precautions (UP). 4-7 In Thailand, a country with population of 60 million, the risk of the spread of these organisms is a concern both in the c o m m u n i t y and in health care settings. The prevalence of HIV 8 is as high as 0.6% among blood donors, 2.3% among pregnant women, and 2.5% to 4.0% among % 10 conscripts. Hepatitis B virus is also a threat; its carrier rates are as high as 6% to 10% among healthy people. 11 Hepatitis C has been recognized as a c o m m o n pathogen, with a prevalence rate of 5.0%. 12 Needlesticks and other injuries that predispose t o w a r d infection with b l o o d - b o r n e pathogens are c o m m o n in clinical practice. In one study, more than half of the respondents reported such injuries during the previous 6 m o n t h s ) 3 To prevent transmission of blood-borne pathogens in health care settings, the practice of UP was adopted in Thailand 14-I~ in 1991. Education on UP was provided to hospital workers by means of guidebooks, lectures, and small-group teaching. Later studies showed that fewer than half of the medical p e r s o n n e l applied UP in their practice. ~7, 18 According to the risk factors listed here, it was estimated that there were about six occupational HIV infections per year in Thailand,13 even though not a single occupational HIV infection has been reported in this country. Application of protective barriers is an important element in UR It has been a concern for the government with respect not only to the safety of patients and medical personnel b u t also to the costs for the provision of these protective barriers. This study was done to identity the costs and the amounts of protective equipment needed to perform UP in Thailand, and to identity areas where expenses might be reduced without sacrificing patient or staff safety. METHODS
A descriptive cross-sectional study was performed during two 24-hour periods (one working day and one holiday in December 1993). Twenty-
four government hospitals across Thailand were recruited by multistage random sampling. An infection control nurse in each hospital coordinated the study. This nurse trained the staff nurses in observing clinical practices so that they were not known to be observers and also in filling out the standard protocol. The n u m b e r of clinical procedures performed and the a m o u n t and types of protective equipment needed for each procedure were recorded from all 329 wards of the 24 hospitals. Protective e q u i p m e n t included gloves, gowns, masks, plastic aprons, goggles, and boots. Heavy-duty rubber gloves were r e c o m m e n d e d for handling contaminated equipment and rubber boots were r e c o m m e n d e d to protect the feet from infectious fluids (recommended in Thailand). Four sets of data were acquired. The coordinating nurse collected the first set of d a t a - - t h e total n u m b e r of beds, patients, and operations--from the records of each hospital. The second data set involved the frequencies of eight c o m m o n ward procedures and the n u m b e r of items of protective equipment used in each ward for these procedures. The procedures were observed and recorded by a trained staff nurse who was on duty in each 8-hour shift on 1 working day (Monday December 13, 1993) and one holiday (Saturday December 18, 1993). A holiday was included because elective procedures and routine laboratory tests are not usually performed during holidays. From the observed n u m b e r of procedures and the use of protective gear on the two different days, the total numbers of procedures and protective equipment for 1 year were calculated for each hospital type. For example, the numbers of procedures and protective equipment in the seven provincial hospitals directly observed on each of the two different days were applied to the entire set of 70 provincial hospitals to determine countrywide totals. The third set of data concerned 21 less commonly performed ward procedures done during a one m o n t h period. The head nurse of each ward reported the information. The fourth data set concerned the n u m b e r s of each of 26 special diagnostic and therapeutic procedures done in some departments in the previous 12 months.
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Table 1. Recommendations for the use of protective barriers for seven common procedures before and after institution of UP Gloves t Procedure*
1. 2. 3. 4. 5. 6. 7.
Intravenous infusion Blood drawing Tracheal suction* Caring for soiled patient Wound dressing Making up beds Washing used equipment
Sterile
Examination
Heavy-duty
Mask
Apron
Goggles
0/2 0/2 0/1
0/1
0/1 NC 2/0
0/2
NO 0/1 0/1 0/1
0/1 0/2 0/2
2/0
0/1
0/1
Numbers refer to the number of items used by one health care worker before (left) and after (right) institution of UR NC, No change. *No protective barriers were recommended for injections. tNumbers refer to single gloves. *One glove worn on one hand was recommended.
Table 2. Recommendations for the use of protective barriers for 21 less common procedures before and after institution of UP Gloves* Procedure
Sterile
1. Paracentesis 2, Dressing bleeding wounds 3, Dressing wounds 4, Endotracheal intubation 5. Tracheostomy 6. Venesection 7. Respiratory support with an inflating bag 8. Cardiopulmonary resuscitation 9. Skin preparation 10. Scrubbing traumatic wounds 11. Scrubbing burn wounds 12. Gastric lavage 13. Blood exchange 14. Hemedialysis 15. Vaginal examination 16. Scrubbing for delivery 17. Delivering a baby 18. Cleaning a neonate 19. Emergency delivery of baby 20. Uterine curettage 21, Preparing a corpse
NC NC NC NC NC NC
Examination
0/2 NC
Gown
0/1 0/1 0/1
0/2 0/2 NC 2/0
NC NC 0/1 0/1 1/0
NC NC NC 0/2 0/2 NC 0/2 NC NC
Mask
NC 1/0 2/0 2/0 NC
NC 4/2
NC 0/1 0/1 NC NC 0/1 NC 0/1 NC NC
Apron
Goggles
Boots t
NC 0/1 0/1 0/2
0/1
0/2
0/1 0/2 0/1 0/1 0/1
0/1 0/1 NC 0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1
0/1 0/1 0/1 0/1
0/1
0/2
0/1 0/1
0/2
Numbers refer to the number of items used by one health care worker before (left) and after (right) institution of UP. NC, No change, *Numbers refer to single gloves, tNumbers refer to single rubber boots.
The coordinating nurse collected the details from records of the related departments. All protocols for data collection were pretested and modified before the study to ensure reliability and validity. The changes in protective barriers expected to be used in each procedure were determined from the Thai national guidelines before and after the implementation of UP (Tables 1 t h r o u g h 3). 1446 Procedures that did not need pro-
tective devices and protective devices that are not r e c o m m e n d e d for any one of the procedures are not presented in these tables. The cost of each reusable protective device in B a n g k o k in December 1993 (Table 4) was calculated as the sum of the cost of individual protective device and the recycling cost divided by the times that it could be used. The recycling cost included cleaning, packing, transportation, and sterilization for
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T a b l e 3. Recommendations for the use of protective barriers for special procedures before and after institution of UP Gloves* Procedure
Sterile
1. Dental treatment 2. Cystoscopy 3. Bronchoscopy 4. Colposcopy 5. Periteneoscopy 6. Gastroscopy 7. Proctoscopy 8. Sigmoidoscopy 9. Barium enema 10. Fistulography 11. Intravenous pyelogram 12. Cystography 13. Hysterosalpingography 14. Lymphangiography 15. Endoscopic retrograde cholangiopancreatography 16. Bronchography 17. Dacryocystography 18. T-tube cholangiography 19. Angiography 20. Embolization 21. Percutaneeus transhepatic biliary drainage 22. Peritoneal dialysis 23. Clinical chemistry 24. Blood smear, blood matching 25. Minor operation 26. Major operation
NC NC NC NC 2/0
NC NC NC NC NC NC NC NC NC NC NC 2/0 2/0 NC NC
Examination
Gown
Mask
Apron
Goggles
0/2
0/1 NC 0/2 NC NC
NC
NC NC 1/2 NC NC NC NC NC NC NC
0/1 0/1 O/2 0/1 0/1 0/1 0/1 0/1 NC 0/1
0/1 0/1 0/2 0/1 0/1 0/1 0/1 0/1 0/1 0/1
NC NC 0/1 NC NC NC NC NC NC
0/1
NC NC
NC NC NC NC NO NC NC NC NC 0/1 0/1 0/1 NC NC
0/1 0/1
0/2
0/2 NC NC NC NC 0/2
0/1 0/2 0/2
0/1 1/0 KIC
0/2 O/4
0/1
0/2 0/2
0/1 0/2 O/4
Boots were not recommended before institution of UR Two rubber boots were recommended for cystoscopy and eight rubber boots were recommended for major operations after institution of UR Numbers refer to the number of items used by one health care worker before (reft) and after (right) institution of UP. NC, No change. *Numbers refer to single gloves.
sterile items. Costs were estimated by head nurses and heads of the laundry and central supply departments. The only exception, to the rule of reusability was examination gloves; only disposable gloves were used because of their low cost. All data were processed centrally at Siriraj Hospital in Bangkok. Costs are presented in U.S. dollars. RESULTS
This study was performed in 24 randomly selected government hospitals in Thailand. These included one of the nine university hospitals, two of the 19 regional hospitals, seven of the 70 provincial hospitals, and 14 of the 650 district hospitals. The last are small hospitals providing primary medical care. The total number of hospital beds in Thailand at the time of the study investigation was about 90,000. This study involved 6549 beds, or 7.28% of the total. The bed occupancy in Thai hospitals is greater than 90% at any time of the year. The 24 hospitals studied provid-
T a b l e 4, Cost for one single use of protective item Item
Cost
Recycling cost"
No. items used
Cost per use
0.27 0.03 0.24 10.0 0.32 0.96 4.00 1.20
0.04 -0.02 0.09 0.004 0.04 0.02 0.01
2 -120 60 45 60 30 120
0.16 0.03 0.01 0.26 0.01 0.06 0.15 0.02
Gloves* Sterile
Examination t Heavy-duty Gown Mask Apron Goggles Boots*
All figures in U.S. dollars. Recycling cost was estimated by ward, laundry, and supply departments. *Cost per one glove and one boot. tOnly disposables were used.
ed medical service to 357,391 inpatients and 3,441,122 outpatients per year. The numbers of eight c o m m o n ward procedures and of barriers used were recorded for one working day and one holiday. In Thailand, there are 248 working days
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Table 5. Number of procedures performed and protective equipment used in 1 year in 24 Thai hospitals (in thousands) Type of procedure
No. of procedures Gloves used* Sterile Examination Heavy-duty Gown used Mask used Apron used Goggles used Boots used*
Common
Less common
Special
Total
11,078
2847
3566
17,491
6,155 8,257 686 450 1,112 807 87 123
3203 2131 23 217 823 481 185 114
1548 611 37 310 307 156 119 89
10,906 10,998 747 974 2,242 1,443 392 326
Table 6. Numbers of equipment that should have been used before and after institution of UP in 24 Thai hospitals (in thousands) Barriers
Before UP
After UP
Gloves* Sterile Examination Heavy-duty Gown Mask Apron Goggles Boots* Total
4,647 8,962 -520 921 1,579 --16,683
8,132 9,752 4,436 734 6,821 6,319 5,046 565 41,805
*Numbers refer to single gloves and boots.
*Numbers refer to single gloves and boots.
and 117 holidays in 1 year. The total n u m b e r s of procedures and barriers for 1 year were calculated from the recorded n u m b e r of procedures and barriers on two different days. The estimated n u m b e r Of procedures and required amounts of protective equipment for the 1-year period in these 24 hospitals are shown in Table 5. The numbers of each type of barrier or protective equipment that should be used according to recommendations used in Thailand before and after the implementation of UP and the actual n u m b e r s observed to be used are presented in Table 6. More protective barriers were required after UE Heavy-duty gloves, goggles, and boots were used only after the institution of UR The recommended n u m b e r s of masks, aprons, sterile gloves, gowns, and examination gloves after UP were 7.4, 4.0, 1.8, 1.4, and 1.1 times, respectively, the numbers r e c o m m e n d e d before UE The cost for protective barrier garb after UP is estimated at 2.5 times that before UP was implemented (Table 7). Overuse of sterile gloves, gowns, and examination gloves by 34%, 24.8%, and 11.5%, respectively, was observed. In contrast, goggles, heavy-duty gloves, aprons, masks, and boots were grossly under used, as little as 7.8%, 17.0%, 23.0%, 32.9%, and 56.5%, respectively, of levels r e c o m m e n d e d in the guidebooks. The cost of the protective attire actually observed was 81.1% of that expected if the UP guidelines had been vigorously followed. 141~ Ideal implementation of UP would have cost U.S. $3.01 million per year for these 24 hospitals (Table 7). The b r e a k d o w n of costs for the barriers for an average inpatient hospitalization and an average outpatient visit are compared in Table 8. On aver-
age, U.S. $5.37 was used for one inpatient visit. The m e a n duration of admission was 7 days; the average cost was therefore U.S. $0.77 per inpatient day. One outpatient visit required U.S. $0.15 for r e c o m m e n d e d barriers. DISCUSSION
HIV, hepatitis B virus, and hepatitis C infections are incurable at present, and every measure must be used to prevent these diseases. Because health care workers are at particular risk for acquiring these and other blood-borne infections, guidelines on UP must be adhered to strictly. Appropriate use of protective equipment is an essential part of UR Even though guidelines on the use of protective devices are available, 4-7,14-1~.19problems often arise in practice from both lack of adequate supplies and improper application. ~8-2°Because no studies have been published on the a m o u n t of protective barriers required in hospitals outside the United States and Europe, there are no guides for the allocation of budget or for the control of the use of these protective barriers in such hospitals. This study was performed in 24 government hospitals representing all the types of hospitals in Thailand. The estimated requirements for the n u m b e r of protective devices used was determined by the types and frequencies of the procedures performed in each hospital during the cross-sectional survey. The numbers of procedures performed and protective devices actually used (Table 5) showed that over 17 million procedures of all types were done in the 24 hospitals in 1 year. Seven c o m m o n procedures done in wards (Table 1) accounted for almost two thirds of these procedures. Twenty-one less c o m m o n procedures
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Table 7. Total estimated costs for protective equipment
Table 8. Costs for protective equipment according to
in 1 year in 24 Thai hospitals (in thousands of U.S. dollars)
UP for one inpatient and one outpatient (in U.S. dollars)
Barriers
Gloves* Sterile Examination Heavy-duty Gown Mask Apron Goggles Boots* Total
Per unit
0.16 0.03 0.01 0.26 0.01 0.06 0.15 0.04
Before UP
725 247 -133 10 92 --1207
After UP
1269 269 53 188 76 366 773 23 3017
Inpatient stay*
Outpatient visit
1,763,483.80 357,391.00 4.94 0.43 5.37
303,801.50 441,122.00 0.09 0.06 0.15
Observed
1701 304 9 250 25 84 60 13 2445
*Numbers refer to single gloves and boots.
(Table 2) and procedures done in special units (Table 3) comprised 16% and 20% of the total, respectively. These procedures require a greater n u m b e r of devices per procedure. The cost for the barriers in these 24 hospitals was about U.S. $2.4 million per a n n u m (Table 7). Sterile gloves were the most costly item, amounting to nearly 70% of the total cost. Examination gloves and gowns accounted for 12% and 10% of the expenditure respectively. The study found disparities between the recommended usage of protective devices under UP guidelines and actual practice (Table 7). 17' is, 21 The overuse of sterile and examination gloves and of gowns cost U.S. $0.54 million, or 22% of the total cost. Goggles were the least frequently used protective barrier, followed by heavy-duty gloves, aprons, masks, and boots. If these five barriers had been used as recommended, the total expense would have been U.S. $1.3 million per year in these 24 hospitals, about 12 times the a m o u n t required before the i m p l e m e n t a t i o n of UP. Underuse of protective equipment predisposes both personnel and patients toward infection, whereas overuse increases expenses. The cost of barriers after the application of UP was 2.5 times that before implementation (Table 7). Resterilized gloves contributed to 30% of the increase in cost. As shown in Table 8, an average of U.S. $4.94 was needed for protective barriers for each inpatient hospitalization for an average 7-day stay. The average expense for UP barriers per inpatient per day was U.S. $0.71. One outpatient visit cost U.S. $0.09 for protective equipment. In addition, special units on average required an additional U.S. $0.06 for barriers for one outpatient visit or one inpatient-day. The total costs for one inpatient
Cost in related dept. Number of patients Cost per patient Costs in special units Total cost per patient
*Average length of stay was 7 days; divide by 7 to get inpatient-day cost.
hospitalization and one outpatient visit were therefore U.S. $5.37 and U.S. $0.15, respectively. Our administrators can n o w set and audit budgets for these items on the basis of these figures. The annual expenditure for these items was U.S. $41.5 million for Thailand, about one eighth of the a m o u n t required in the United States. 2°,22,23 Both overuse and underuse of these items were discovered. These findings reflect the fact that the existing education on UP for hospital workers is not effective and must be modified. A proper education program, set jointly by medical schools and the Ministry of Public Health, is urgently needed. Because of differences in resources and h u m a n behavior, programs based on the results of studies in the organizations concerned are more practical.17, 18,21 Regular internal and external audits can help to improve compliance with UP guidelines. It is r e c o m m e n d e d that studies on the costs of protective barriers and compliance to UP guidelines be performed in places where UP has already been applied. Results from studies in individual institutions or countries are valuable for allocation of budget and for controlling the use of protective equipment. Proper UP practice, even if costly, is essential for the safety of patients and medical personnel. 24 We thank all hospital directors and nurses who took part in this study. References
1. Ricketts M, Deschamps L. Reported seroconversions to h u m a n immunodeficiency virus among workers worldwide: a review. Can J Infect Control 1992;7:85-90. 2. Centers for Disease Control and Prevention. Surveillance for occupationally acquired H W infection--United States 1988-1992. MMWR 1992;41:823-5. 3. Centers for Disease Control and Prevention. Update: transmission of HIV infection during an invasive dental proced u r e - F l o r i d a . MMWR 1991 ;40:21-7. 4. Centers for Disease Control and Prevention. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987;36:2S-18S. 5. Centers for Disease Control and Prevention. Update: universal precautions for prevention of transmission of
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6.
7.
8.
9.
10.
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12.
Danchaivijitr human immunodeficiency virus hepatitis B virus and other bloodborne pathogens in health-care settings. MMWR 1988;37:377-88. Centers for Disease Control and Prevention. Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis B virus for health-care and public-safety workers. MMWR 1989;38:1-37. World Health Organization. Report of a WHO consultation on the prevention of human immunodeficiency virus and hepatitis B virus transmission in the health-care setting. WHO/GPADIR/915. Geneva: World Health Organization, 1991. Division of Epidemiology, Ministry of Public Health, Thailand. Weekly epidemiological surveillance report, Ministry of Public Health, Thailand. 1995;26(13)$157-62. Mason CJ, Markowitz LE, Kitsiripornchai S, et al. Decline prevalence of HIV-1 infection in young Thai men. AIDS 1995;9:1061-5. Kitsiripornchai S, Jugsudee A, Mason CJ, Markowitz LE, Chanbancherd P, Torugsa K, et al. HIV-1 infection in young men entering the Royal Thai Army: trends and demographic risk factors [abstract 13201]. Presented at: Third International Conference on AIDS in Asia and Pacific, the Fifth National AIDS Seminar in Thailand. Bangkok: September 1995. Punyagupta S, Olson LC, Harinasuta U, Akarawong K, Varawidhya W. The epidemiology of hepatitis B antigen in high prevalence area. Am J Epidemiol 1973;97:349-54. Luengrojanakul P, Tanwandee T, Manasatit S, Sattawatthamrong Y, Chainuvuti T. Prevalence of hepatitis B and hepatitis C virus in Thailand [abstract]. Presented at: Ninth Biennial Scientific Meeting, Asian Pacific Association for the Study of the Liver. Kuala Lumpur, Malaysia: Asian Pacific Association for the Study of the Liver, 1994:213.
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13. Danchaivijitr S, Kachintom K, Sangkard K. Needlesticks and cuts with sharp objects in Siriraj Hospital 1992. J Med Assoc Thai 1995;78(Suppl 2):108S-1 IS. 14. Danchaivijitr S. Universal precautions. Bangkok: Fair Print, 1991. 15. Ruekgnam S. Universal precautions. Bangkok: Veterans Press, 1992. 16. Danchaivijitr S, Wararak A. Universal precautions, first revision. Bangkok: Veterans Press, 1993. 17. Danchaivijitr S, Chokloikaew S, Suttisanon L, et al. Universal precautions: knowledge, compliance and attitudes of doctors and nurses in Thailand. J Med Assoc Thai 1995;78(Suppl 2):113S-7S. 18. Picheansathian W. Compliance with universal precautions by emergency room nurses at Maharaj Nakorn Chiang Mai Hospital. J Med Assoc Thai 1995;78(Suppl 2):118S-22S. 19. Miller CH, Palenik CJ. Protective barriers. In: Miller CH, Palenik CJ, editors. Infection control and management of hazardous materials for the dental team. St Louis: Mosby, 1994:116-31. 20. Jackson MM. The economics of needlestick injuries. Lab Notes 1994;5:3-7. 21. Courington KR, Patterson SL, Howard RJ. Universal precautions and not universally followed. Arch Surg 1991;126:93-6. 22. Doebbling BN, Wenzel RR The direct costs of universal precautions in a teaching hospital. JAMA 1990;264:2083-7. 23. US Department of Labor, Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens: final rule, 29 CFR part 1910:1030. Federal Register 1991;(56):64003-182. 24. McPherson DC, Jackson MM. The costs of safety precautions to reduce risk of exposure to bloodborne pathogen. In: McClosky JC, Grace HK, editors. Current issues in nursing. 4th ed. St Louis: Mosby, 1994:515-21.
Global Perspectives Coeditor W. Charles Huskins, MD
Global Perspectives Coeditor
Universal precautions: Costs for protective equipment S. Danchaivijitr, MD, FRCP a T. Tangtrakool, BSc b S. Chokloikaew, MSc b V. Thamlikitkul, MD a
Bangkok, Thailand
Background: The amount and costs of protective equipment used to implement universal precautions in Thailand have not previously been studied.
Methods: A cross-sectional study was done to determine the frequency of clinical and laboratory procedures requiring universal precautions and the amount of protective equipment needed for each. Results: The study was performed in 24 government hospitals in Thailand in December 1993. Totaling 6549 beds, these hospitals had provided service to 357,391 inpatients and 3,411,122 outpatients during the previous year. The annual number of procedures performed in these hospitals was estimated at 17.5 million, with expenditures for protective equipment of $2.4 million (U.S.) per year. The average overall cost for protective equipment was U.S. $5.37 for one inpatient stay and U.S. $0.15 for one outpatient visit. The projected national expense for these barriers was U.S. $41.5 million per annum. The cost for these
From the Division of Infectious Diseases, Department of Medicine,a and Center for Nosocomial Infection Control,b Faculty of Medicine Siriraj Hospital, Mahidol, University, Bangkok, Thailand. Funded by a grant from the Bureau of University Affairs of Thailand. 44
Reprint requests: S. Danchaivijitr,MD, FRCP,Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Siriraj Hospital, 2 Prannok Rd., Bangkok 10700, Thailand. Copyright © 1997 by the Association for Professionalsin Infection Control and Epidemiology, Inc. 0196-6553/97 $5.00 + 0
t 7/46/78997
AJIC
Danchaivijitr
Volume 25, Number 1
45
barriers after the implementation of universal precautions was 2.5 times the cost before implementation. Conclusions: Overuse of sterile and examination gloves and gowns and underuse of heavyduty gloves, masks, aprons, goggles, and boots were discovered during the study. Appropriate use of disposable and reusable universal precautions equipment would free health care dollars for other purposes. (AJIC Am J Infect Control 1997;25:44-50)
Transmission of HIV and other blood-borne pathogens in health care settings has been well documented. 1-3 The risk of the transmission can be reduced by the use of universal precautions (UP). 4-7 In Thailand, a country with population of 60 million, the risk of the spread of these organisms is a concern both in the c o m m u n i t y and in health care settings. The prevalence of HIV 8 is as high as 0.6% among blood donors, 2.3% among pregnant women, and 2.5% to 4.0% among % 10 conscripts. Hepatitis B virus is also a threat; its carrier rates are as high as 6% to 10% among healthy people. 11 Hepatitis C has been recognized as a c o m m o n pathogen, with a prevalence rate of 5.0%. 12 Needlesticks and other injuries that predispose t o w a r d infection with b l o o d - b o r n e pathogens are c o m m o n in clinical practice. In one study, more than half of the respondents reported such injuries during the previous 6 m o n t h s ) 3 To prevent transmission of blood-borne pathogens in health care settings, the practice of UP was adopted in Thailand 14-I~ in 1991. Education on UP was provided to hospital workers by means of guidebooks, lectures, and small-group teaching. Later studies showed that fewer than half of the medical p e r s o n n e l applied UP in their practice. ~7, 18 According to the risk factors listed here, it was estimated that there were about six occupational HIV infections per year in Thailand,13 even though not a single occupational HIV infection has been reported in this country. Application of protective barriers is an important element in UR It has been a concern for the government with respect not only to the safety of patients and medical personnel b u t also to the costs for the provision of these protective barriers. This study was done to identity the costs and the amounts of protective equipment needed to perform UP in Thailand, and to identity areas where expenses might be reduced without sacrificing patient or staff safety. METHODS
A descriptive cross-sectional study was performed during two 24-hour periods (one working day and one holiday in December 1993). Twenty-
four government hospitals across Thailand were recruited by multistage random sampling. An infection control nurse in each hospital coordinated the study. This nurse trained the staff nurses in observing clinical practices so that they were not known to be observers and also in filling out the standard protocol. The n u m b e r of clinical procedures performed and the a m o u n t and types of protective equipment needed for each procedure were recorded from all 329 wards of the 24 hospitals. Protective e q u i p m e n t included gloves, gowns, masks, plastic aprons, goggles, and boots. Heavy-duty rubber gloves were r e c o m m e n d e d for handling contaminated equipment and rubber boots were r e c o m m e n d e d to protect the feet from infectious fluids (recommended in Thailand). Four sets of data were acquired. The coordinating nurse collected the first set of d a t a - - t h e total n u m b e r of beds, patients, and operations--from the records of each hospital. The second data set involved the frequencies of eight c o m m o n ward procedures and the n u m b e r of items of protective equipment used in each ward for these procedures. The procedures were observed and recorded by a trained staff nurse who was on duty in each 8-hour shift on 1 working day (Monday December 13, 1993) and one holiday (Saturday December 18, 1993). A holiday was included because elective procedures and routine laboratory tests are not usually performed during holidays. From the observed n u m b e r of procedures and the use of protective gear on the two different days, the total numbers of procedures and protective equipment for 1 year were calculated for each hospital type. For example, the numbers of procedures and protective equipment in the seven provincial hospitals directly observed on each of the two different days were applied to the entire set of 70 provincial hospitals to determine countrywide totals. The third set of data concerned 21 less commonly performed ward procedures done during a one m o n t h period. The head nurse of each ward reported the information. The fourth data set concerned the n u m b e r s of each of 26 special diagnostic and therapeutic procedures done in some departments in the previous 12 months.
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Table 1. Recommendations for the use of protective barriers for seven common procedures before and after institution of UP Gloves t Procedure*
1. 2. 3. 4. 5. 6. 7.
Intravenous infusion Blood drawing Tracheal suction* Caring for soiled patient Wound dressing Making up beds Washing used equipment
Sterile
Examination
Heavy-duty
Mask
Apron
Goggles
0/2 0/2 0/1
0/1
0/1 NC 2/0
0/2
NO 0/1 0/1 0/1
0/1 0/2 0/2
2/0
0/1
0/1
Numbers refer to the number of items used by one health care worker before (left) and after (right) institution of UR NC, No change. *No protective barriers were recommended for injections. tNumbers refer to single gloves. *One glove worn on one hand was recommended.
Table 2. Recommendations for the use of protective barriers for 21 less common procedures before and after institution of UP Gloves* Procedure
Sterile
1. Paracentesis 2, Dressing bleeding wounds 3, Dressing wounds 4, Endotracheal intubation 5. Tracheostomy 6. Venesection 7. Respiratory support with an inflating bag 8. Cardiopulmonary resuscitation 9. Skin preparation 10. Scrubbing traumatic wounds 11. Scrubbing burn wounds 12. Gastric lavage 13. Blood exchange 14. Hemedialysis 15. Vaginal examination 16. Scrubbing for delivery 17. Delivering a baby 18. Cleaning a neonate 19. Emergency delivery of baby 20. Uterine curettage 21, Preparing a corpse
NC NC NC NC NC NC
Examination
0/2 NC
Gown
0/1 0/1 0/1
0/2 0/2 NC 2/0
NC NC 0/1 0/1 1/0
NC NC NC 0/2 0/2 NC 0/2 NC NC
Mask
NC 1/0 2/0 2/0 NC
NC 4/2
NC 0/1 0/1 NC NC 0/1 NC 0/1 NC NC
Apron
Goggles
Boots t
NC 0/1 0/1 0/2
0/1
0/2
0/1 0/2 0/1 0/1 0/1
0/1 0/1 NC 0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1
0/1 0/1 0/1 0/1
0/1
0/2
0/1 0/1
0/2
Numbers refer to the number of items used by one health care worker before (left) and after (right) institution of UP. NC, No change, *Numbers refer to single gloves, tNumbers refer to single rubber boots.
The coordinating nurse collected the details from records of the related departments. All protocols for data collection were pretested and modified before the study to ensure reliability and validity. The changes in protective barriers expected to be used in each procedure were determined from the Thai national guidelines before and after the implementation of UP (Tables 1 t h r o u g h 3). 1446 Procedures that did not need pro-
tective devices and protective devices that are not r e c o m m e n d e d for any one of the procedures are not presented in these tables. The cost of each reusable protective device in B a n g k o k in December 1993 (Table 4) was calculated as the sum of the cost of individual protective device and the recycling cost divided by the times that it could be used. The recycling cost included cleaning, packing, transportation, and sterilization for
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T a b l e 3. Recommendations for the use of protective barriers for special procedures before and after institution of UP Gloves* Procedure
Sterile
1. Dental treatment 2. Cystoscopy 3. Bronchoscopy 4. Colposcopy 5. Periteneoscopy 6. Gastroscopy 7. Proctoscopy 8. Sigmoidoscopy 9. Barium enema 10. Fistulography 11. Intravenous pyelogram 12. Cystography 13. Hysterosalpingography 14. Lymphangiography 15. Endoscopic retrograde cholangiopancreatography 16. Bronchography 17. Dacryocystography 18. T-tube cholangiography 19. Angiography 20. Embolization 21. Percutaneeus transhepatic biliary drainage 22. Peritoneal dialysis 23. Clinical chemistry 24. Blood smear, blood matching 25. Minor operation 26. Major operation
NC NC NC NC 2/0
NC NC NC NC NC NC NC NC NC NC NC 2/0 2/0 NC NC
Examination
Gown
Mask
Apron
Goggles
0/2
0/1 NC 0/2 NC NC
NC
NC NC 1/2 NC NC NC NC NC NC NC
0/1 0/1 O/2 0/1 0/1 0/1 0/1 0/1 NC 0/1
0/1 0/1 0/2 0/1 0/1 0/1 0/1 0/1 0/1 0/1
NC NC 0/1 NC NC NC NC NC NC
0/1
NC NC
NC NC NC NC NO NC NC NC NC 0/1 0/1 0/1 NC NC
0/1 0/1
0/2
0/2 NC NC NC NC 0/2
0/1 0/2 0/2
0/1 1/0 KIC
0/2 O/4
0/1
0/2 0/2
0/1 0/2 O/4
Boots were not recommended before institution of UR Two rubber boots were recommended for cystoscopy and eight rubber boots were recommended for major operations after institution of UR Numbers refer to the number of items used by one health care worker before (reft) and after (right) institution of UP. NC, No change. *Numbers refer to single gloves.
sterile items. Costs were estimated by head nurses and heads of the laundry and central supply departments. The only exception, to the rule of reusability was examination gloves; only disposable gloves were used because of their low cost. All data were processed centrally at Siriraj Hospital in Bangkok. Costs are presented in U.S. dollars. RESULTS
This study was performed in 24 randomly selected government hospitals in Thailand. These included one of the nine university hospitals, two of the 19 regional hospitals, seven of the 70 provincial hospitals, and 14 of the 650 district hospitals. The last are small hospitals providing primary medical care. The total number of hospital beds in Thailand at the time of the study investigation was about 90,000. This study involved 6549 beds, or 7.28% of the total. The bed occupancy in Thai hospitals is greater than 90% at any time of the year. The 24 hospitals studied provid-
T a b l e 4, Cost for one single use of protective item Item
Cost
Recycling cost"
No. items used
Cost per use
0.27 0.03 0.24 10.0 0.32 0.96 4.00 1.20
0.04 -0.02 0.09 0.004 0.04 0.02 0.01
2 -120 60 45 60 30 120
0.16 0.03 0.01 0.26 0.01 0.06 0.15 0.02
Gloves* Sterile
Examination t Heavy-duty Gown Mask Apron Goggles Boots*
All figures in U.S. dollars. Recycling cost was estimated by ward, laundry, and supply departments. *Cost per one glove and one boot. tOnly disposables were used.
ed medical service to 357,391 inpatients and 3,441,122 outpatients per year. The numbers of eight c o m m o n ward procedures and of barriers used were recorded for one working day and one holiday. In Thailand, there are 248 working days
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Table 5. Number of procedures performed and protective equipment used in 1 year in 24 Thai hospitals (in thousands) Type of procedure
No. of procedures Gloves used* Sterile Examination Heavy-duty Gown used Mask used Apron used Goggles used Boots used*
Common
Less common
Special
Total
11,078
2847
3566
17,491
6,155 8,257 686 450 1,112 807 87 123
3203 2131 23 217 823 481 185 114
1548 611 37 310 307 156 119 89
10,906 10,998 747 974 2,242 1,443 392 326
Table 6. Numbers of equipment that should have been used before and after institution of UP in 24 Thai hospitals (in thousands) Barriers
Before UP
After UP
Gloves* Sterile Examination Heavy-duty Gown Mask Apron Goggles Boots* Total
4,647 8,962 -520 921 1,579 --16,683
8,132 9,752 4,436 734 6,821 6,319 5,046 565 41,805
*Numbers refer to single gloves and boots.
*Numbers refer to single gloves and boots.
and 117 holidays in 1 year. The total n u m b e r s of procedures and barriers for 1 year were calculated from the recorded n u m b e r of procedures and barriers on two different days. The estimated n u m b e r Of procedures and required amounts of protective equipment for the 1-year period in these 24 hospitals are shown in Table 5. The numbers of each type of barrier or protective equipment that should be used according to recommendations used in Thailand before and after the implementation of UP and the actual n u m b e r s observed to be used are presented in Table 6. More protective barriers were required after UE Heavy-duty gloves, goggles, and boots were used only after the institution of UR The recommended n u m b e r s of masks, aprons, sterile gloves, gowns, and examination gloves after UP were 7.4, 4.0, 1.8, 1.4, and 1.1 times, respectively, the numbers r e c o m m e n d e d before UE The cost for protective barrier garb after UP is estimated at 2.5 times that before UP was implemented (Table 7). Overuse of sterile gloves, gowns, and examination gloves by 34%, 24.8%, and 11.5%, respectively, was observed. In contrast, goggles, heavy-duty gloves, aprons, masks, and boots were grossly under used, as little as 7.8%, 17.0%, 23.0%, 32.9%, and 56.5%, respectively, of levels r e c o m m e n d e d in the guidebooks. The cost of the protective attire actually observed was 81.1% of that expected if the UP guidelines had been vigorously followed. 141~ Ideal implementation of UP would have cost U.S. $3.01 million per year for these 24 hospitals (Table 7). The b r e a k d o w n of costs for the barriers for an average inpatient hospitalization and an average outpatient visit are compared in Table 8. On aver-
age, U.S. $5.37 was used for one inpatient visit. The m e a n duration of admission was 7 days; the average cost was therefore U.S. $0.77 per inpatient day. One outpatient visit required U.S. $0.15 for r e c o m m e n d e d barriers. DISCUSSION
HIV, hepatitis B virus, and hepatitis C infections are incurable at present, and every measure must be used to prevent these diseases. Because health care workers are at particular risk for acquiring these and other blood-borne infections, guidelines on UP must be adhered to strictly. Appropriate use of protective equipment is an essential part of UR Even though guidelines on the use of protective devices are available, 4-7,14-1~.19problems often arise in practice from both lack of adequate supplies and improper application. ~8-2°Because no studies have been published on the a m o u n t of protective barriers required in hospitals outside the United States and Europe, there are no guides for the allocation of budget or for the control of the use of these protective barriers in such hospitals. This study was performed in 24 government hospitals representing all the types of hospitals in Thailand. The estimated requirements for the n u m b e r of protective devices used was determined by the types and frequencies of the procedures performed in each hospital during the cross-sectional survey. The numbers of procedures performed and protective devices actually used (Table 5) showed that over 17 million procedures of all types were done in the 24 hospitals in 1 year. Seven c o m m o n procedures done in wards (Table 1) accounted for almost two thirds of these procedures. Twenty-one less c o m m o n procedures
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Table 7. Total estimated costs for protective equipment
Table 8. Costs for protective equipment according to
in 1 year in 24 Thai hospitals (in thousands of U.S. dollars)
UP for one inpatient and one outpatient (in U.S. dollars)
Barriers
Gloves* Sterile Examination Heavy-duty Gown Mask Apron Goggles Boots* Total
Per unit
0.16 0.03 0.01 0.26 0.01 0.06 0.15 0.04
Before UP
725 247 -133 10 92 --1207
After UP
1269 269 53 188 76 366 773 23 3017
Inpatient stay*
Outpatient visit
1,763,483.80 357,391.00 4.94 0.43 5.37
303,801.50 441,122.00 0.09 0.06 0.15
Observed
1701 304 9 250 25 84 60 13 2445
*Numbers refer to single gloves and boots.
(Table 2) and procedures done in special units (Table 3) comprised 16% and 20% of the total, respectively. These procedures require a greater n u m b e r of devices per procedure. The cost for the barriers in these 24 hospitals was about U.S. $2.4 million per a n n u m (Table 7). Sterile gloves were the most costly item, amounting to nearly 70% of the total cost. Examination gloves and gowns accounted for 12% and 10% of the expenditure respectively. The study found disparities between the recommended usage of protective devices under UP guidelines and actual practice (Table 7). 17' is, 21 The overuse of sterile and examination gloves and of gowns cost U.S. $0.54 million, or 22% of the total cost. Goggles were the least frequently used protective barrier, followed by heavy-duty gloves, aprons, masks, and boots. If these five barriers had been used as recommended, the total expense would have been U.S. $1.3 million per year in these 24 hospitals, about 12 times the a m o u n t required before the i m p l e m e n t a t i o n of UP. Underuse of protective equipment predisposes both personnel and patients toward infection, whereas overuse increases expenses. The cost of barriers after the application of UP was 2.5 times that before implementation (Table 7). Resterilized gloves contributed to 30% of the increase in cost. As shown in Table 8, an average of U.S. $4.94 was needed for protective barriers for each inpatient hospitalization for an average 7-day stay. The average expense for UP barriers per inpatient per day was U.S. $0.71. One outpatient visit cost U.S. $0.09 for protective equipment. In addition, special units on average required an additional U.S. $0.06 for barriers for one outpatient visit or one inpatient-day. The total costs for one inpatient
Cost in related dept. Number of patients Cost per patient Costs in special units Total cost per patient
*Average length of stay was 7 days; divide by 7 to get inpatient-day cost.
hospitalization and one outpatient visit were therefore U.S. $5.37 and U.S. $0.15, respectively. Our administrators can n o w set and audit budgets for these items on the basis of these figures. The annual expenditure for these items was U.S. $41.5 million for Thailand, about one eighth of the a m o u n t required in the United States. 2°,22,23 Both overuse and underuse of these items were discovered. These findings reflect the fact that the existing education on UP for hospital workers is not effective and must be modified. A proper education program, set jointly by medical schools and the Ministry of Public Health, is urgently needed. Because of differences in resources and h u m a n behavior, programs based on the results of studies in the organizations concerned are more practical.17, 18,21 Regular internal and external audits can help to improve compliance with UP guidelines. It is r e c o m m e n d e d that studies on the costs of protective barriers and compliance to UP guidelines be performed in places where UP has already been applied. Results from studies in individual institutions or countries are valuable for allocation of budget and for controlling the use of protective equipment. Proper UP practice, even if costly, is essential for the safety of patients and medical personnel. 24 We thank all hospital directors and nurses who took part in this study. References
1. Ricketts M, Deschamps L. Reported seroconversions to h u m a n immunodeficiency virus among workers worldwide: a review. Can J Infect Control 1992;7:85-90. 2. Centers for Disease Control and Prevention. Surveillance for occupationally acquired H W infection--United States 1988-1992. MMWR 1992;41:823-5. 3. Centers for Disease Control and Prevention. Update: transmission of HIV infection during an invasive dental proced u r e - F l o r i d a . MMWR 1991 ;40:21-7. 4. Centers for Disease Control and Prevention. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987;36:2S-18S. 5. Centers for Disease Control and Prevention. Update: universal precautions for prevention of transmission of
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Danchaivijitr human immunodeficiency virus hepatitis B virus and other bloodborne pathogens in health-care settings. MMWR 1988;37:377-88. Centers for Disease Control and Prevention. Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis B virus for health-care and public-safety workers. MMWR 1989;38:1-37. World Health Organization. Report of a WHO consultation on the prevention of human immunodeficiency virus and hepatitis B virus transmission in the health-care setting. WHO/GPADIR/915. Geneva: World Health Organization, 1991. Division of Epidemiology, Ministry of Public Health, Thailand. Weekly epidemiological surveillance report, Ministry of Public Health, Thailand. 1995;26(13)$157-62. Mason CJ, Markowitz LE, Kitsiripornchai S, et al. Decline prevalence of HIV-1 infection in young Thai men. AIDS 1995;9:1061-5. Kitsiripornchai S, Jugsudee A, Mason CJ, Markowitz LE, Chanbancherd P, Torugsa K, et al. HIV-1 infection in young men entering the Royal Thai Army: trends and demographic risk factors [abstract 13201]. Presented at: Third International Conference on AIDS in Asia and Pacific, the Fifth National AIDS Seminar in Thailand. Bangkok: September 1995. Punyagupta S, Olson LC, Harinasuta U, Akarawong K, Varawidhya W. The epidemiology of hepatitis B antigen in high prevalence area. Am J Epidemiol 1973;97:349-54. Luengrojanakul P, Tanwandee T, Manasatit S, Sattawatthamrong Y, Chainuvuti T. Prevalence of hepatitis B and hepatitis C virus in Thailand [abstract]. Presented at: Ninth Biennial Scientific Meeting, Asian Pacific Association for the Study of the Liver. Kuala Lumpur, Malaysia: Asian Pacific Association for the Study of the Liver, 1994:213.
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13. Danchaivijitr S, Kachintom K, Sangkard K. Needlesticks and cuts with sharp objects in Siriraj Hospital 1992. J Med Assoc Thai 1995;78(Suppl 2):108S-1 IS. 14. Danchaivijitr S. Universal precautions. Bangkok: Fair Print, 1991. 15. Ruekgnam S. Universal precautions. Bangkok: Veterans Press, 1992. 16. Danchaivijitr S, Wararak A. Universal precautions, first revision. Bangkok: Veterans Press, 1993. 17. Danchaivijitr S, Chokloikaew S, Suttisanon L, et al. Universal precautions: knowledge, compliance and attitudes of doctors and nurses in Thailand. J Med Assoc Thai 1995;78(Suppl 2):113S-7S. 18. Picheansathian W. Compliance with universal precautions by emergency room nurses at Maharaj Nakorn Chiang Mai Hospital. J Med Assoc Thai 1995;78(Suppl 2):118S-22S. 19. Miller CH, Palenik CJ. Protective barriers. In: Miller CH, Palenik CJ, editors. Infection control and management of hazardous materials for the dental team. St Louis: Mosby, 1994:116-31. 20. Jackson MM. The economics of needlestick injuries. Lab Notes 1994;5:3-7. 21. Courington KR, Patterson SL, Howard RJ. Universal precautions and not universally followed. Arch Surg 1991;126:93-6. 22. Doebbling BN, Wenzel RR The direct costs of universal precautions in a teaching hospital. JAMA 1990;264:2083-7. 23. US Department of Labor, Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens: final rule, 29 CFR part 1910:1030. Federal Register 1991;(56):64003-182. 24. McPherson DC, Jackson MM. The costs of safety precautions to reduce risk of exposure to bloodborne pathogen. In: McClosky JC, Grace HK, editors. Current issues in nursing. 4th ed. St Louis: Mosby, 1994:515-21.