Needlestick Injuries among Support Staff in Hospitals - Dissertation Example

? Research proprosal: Needle Stick Injuries Among Support and Ancillary Staff in National Hospitals of the Under the guidance of University Aims and objectives To estimate the incidence of needle stick injuries among support and ancillary staff in a national hospital and to ascertain causes for the injuries, so that appropriate preventive measures can be developed. Background information Needle stick injuries are a common source of health hazards to health care workers like doctors, nurses, attendants and technicians and also to non-health workers like ancillary and support staff (NHS, 2008). These injuries pose a risk for development of various infectious diseases to the injured threatening their employment, health morbidity and mortality. Despite these injuries being common, they are often under reported and in many places, both health care and non-health care workers are unaware of safety methods to prevent these infections. Globally, needle stick injuries are the most common cause of blood-borne infections among health care workers (Wilburn and Eijekamans, 2004). More than 35 million people worldwide constitute health care work force and they represent 12 percent of the working population in the world (Wilburn and Eijekamans, 2004). It is estimated that people working with them as non-health workers are even more in numbers (NHS, 2008). While health care workers are exposed to several biological hazards including blood-borne pathogens and airborne pathogens directly, non-health workers too are at risk of exposure. In addition to pathogens, both health and non-health workers are also exposed hazardous chemicals like sterilizing agents and disinfectants which increase the risk of development of dermatitis, asthma, carcinogens, reproductive toxins, etc (Wilburn and Eijekamans, 2004). According to the Health Protection Agency report (2008), the most common type of exposure that has been reported among health care workers is the percutaneous injury which accounts for 45 percent of exposures. These exposures contributed to significant seroconversion for HCV, HIV and other diseases. The HIV seroconversion rates reported were high, 0.8 percent. In the NHS, needle stick injury continues to be the most commonly reported adverse incident among healthcare workers, which are a potential source for transmission of various diseases like Hepatitis B and C and human immunodeficiency virus. These injuries are also a potential source of transmission of prion-related diseases. The risk of transmission of hepatitis C with needle stick injuries is 3 percent, for hepatitis B is 30 percent and for HIV is 0.3 percent (Elmiyeh et al, 2004). The transmission from the patient to the healthcare worker through the injury depends on the viral load of the patient and also on the amount of blood that passes from the patient to the healthcare worker. Other infections which are transmissible through needle stick injuries are malaria, syphilis and herpes (Wilburn and Eijekamans, 2004). Management of needle stick injuries should follow state, national and international protocols. From various studies, especially the study by Thomson and Murray (2009), it is evident that only 3 percent of those who suffered from needle stick injuries followed any policy, be it either reporting or prevention of disease. The first aid for contaminated sharps injury must be encourage bleeding and washing with soap and water. The type of injury and the status of the patient must be discussed with local public health consultant immediately who will conduct an urgent preliminary risk assessment. In case there is risk of HIV infection, post exposure prophylaxis must be initiated as soon as possible, ideally within one hour. This is estimated to reduce the risk of transmission bu 80 percent. Post exposure prophylaxis must initiated much before the reports of the donor are available. Post exposure prophylaxis is a 28-day treatment with triple combination of antiretroviral drugs. it is associated with significant complications and needs follow up (Knott, 2010). In case, the source is known to have HBsAg positive, hepatits B immunoglobulin must be given within 72 hours (Knott, 2010). Exposed persons must be advised to practice safe sex for 3 months and not to donate any blood or blood products during that period (Knott, 2010). Suitable investigations must be performed for the injured worker after 3 months. Liver function tests must be done after 3-6 months. Female workers must do tests to rule out pregnancy (Knott, 2010). Needle stick injuries can be prevented by washing hands before and after contact patients with soap and water, by changing gloves between patients, by wearing water proof dressing as and when required: especially when wounds and skin lesions exist, by avoiding sharps as much as possible, by avoiding wearing open foot wear, by cleaning up blood spillage promptly, by performing preemployment occupational health assessment for identification of damaged skin like for eczema and by following safe procedures for disposal of waste (Knott, 2010). According to NHS (2008), 20 percent of needle stick injuries occur among ancillary and support staff. However, there is not much evidence in this regard in the literature review. Hence this prospective study aims to ascertain the incidence and causes of needlestick injuries among ancillary and support staff in a national hospital. Literature review There is uncertain information about the prevalence of the diseases among hospital population and health care workers and non-health workers (Elmiyeh et al, 2004). According to a study by Elmiyeh et al (2004), 38 percent of health care workers had atleast one needle stick injury in the past one year and 74 percent has such injury atleast one time during their career. Of these, only 50 percent had notified needle stick injuries, despite the fact that more than 80 percent were aware of the fact that needle stick injuries need to be notified. According to Roy et al (cited in Elmiyeh et al, 2004), there is under estimation of institutional needle injuries by atleast 50 percent because of under reporting due to own risk assessment by doctors, time constraints and workload pressures. It is also yet unclear as to whether the advent of safer needle devices has decreased the risk of needle injury among health care workers. Mandatory post-exposure testing of health care professionals is very simple on theoretical grounds (NHS, 2000). However; it presents with ethical, legal and moral dilemmas and with risk of loss of gainful employment for those who have been diagnosed with infection. Globally, health care workers contribute to 2 million needle stick injuries per year that result in infections with HIV, hepatitis B and hepatitis C (Wilburn and Eijekamans, 2004). According to WHO, the global burden of infections subsequent to exposure through occupation is about 40 percent for hepatitis B and C infections and 2.5 percent for HIV infections. The WHO further informs that 90 percent of such infections occur in the developing countries and 90 percent of reports come from developed countries. While 70 percent of the world's health care workers live in sub-saharan Africa, only 4 percent of the reported cases in the world come from this region. Most researchers opine that the estimates by the WHO are actually low (Wilburn and Eijekamans, 2004). Injection safety surveys in different parts of the world have provided different estimates with regard to needle stick injuries, but mainly among health care workers and not among ancillary or support staff. In the Asian, African and Eastern Mediterranean regions, the estimates have been four needle stick injuries per healthcare worker per year. In Vietnam, 66 percent of nursing staff and 38 percent of physicians report needle stick injury in the past 9 months. In South Africa, 91 percent of doctors reported needle stick injuries in the previous one year, 55 percent of which from HIV positive patients (Wilburn and Eijekamans, 2004). Ng and Hassim (2006) conducted a cross sectional study among Emergency department healthcare workers at 2 teaching hospitals in Malaysia. From this study, it was evident that the prevalence of needle stick injuries in emergency departments is 31.6 to 52.9 percent, the greatest risk was faced by medical assistants. According to the NHS (2009; cited in Knott, 2010), injuries related to needle stick and sharps account for more than 400,000 injuries to NHS staff every year. The NHS (2009, cited in Knott, 2009) summaries that "the average risk following percutaneous exposure to HIV-infected blood in healthcare settings is about 3 per 1,000 injuries, less than 1:1000 following mucocutaneous exposure and has never been recorded following contact of HIV blood with intact skin." In a study by Thompson and Murray (2009) in which surgeons from district general hospital were evaluated, 44 percent of surgeons admitted to having needle stick injury. According to a study by Mehta et al (2009), 45 percent of those who reported needle stick injuries were nurses, 33 percent were attendants, 11 percent were doctors and 11 percent technicians. Of the 380 health workers who reported needle stick injuries, 23, 15 and 12 were positive for HBsAg, HIV and HCV. Analysis of sources of needle stick injuries revealed that of the 380 reported cases, 254 injuries were from known sources of injury and the rest were from unknown sources like garbage bags. The most common immediate action following injury was washing hands with soap and water, encouraging bleeding and reporting the incident to emergency. Those who suffered needle stick injuries from patients with hepatitis B positive patients took hepatitis B booster immunisation. Those who were Anti-HBs negative took a full course of hepatitis b vaccination. All the staff who sustained injury from HIV positive patients received immediate antiretroviral therapy in the form of AZT 600mg per day for six weeks. The most common causes of needle stick injuries include two handed needle recapping and unsafe disposal and collection of waste of sharps (Wilburn and Eijekamans, 2004). In the study by Mehta et al (2005), most of the needle stick injuries occurred during intravenous line insertion, followed by drawing samples for blood collection, then surgical blade injury and lastly recapping of needles. Determinants of needle stick injuries include lack of proper awareness with regard to the possible hazards, lack of appropriate training of the health care workers, overuse of needles, injections and unnecessary sharp instruments, lack of adequate supplies of sharp instruments like disposable syringes, sharps disposable containers and safer needle devices, lack of access to sharps containers after administering injections, failure to use sharps containers immediately after injection, inadequate staffing, recapping of needles after use and passing of used sharp instrument from one hand to another (Wilburn and Eijekamans, 2004). Factors which increase the risk of transmission of HIV infection from the patient to the health care worker include presence of deep wound, presence of visible blood over the needle, presence of blood in the needle that was hollow bore, use of device that has accessed vein or artery and high-viral-load status of the patient. When taken together, these factors increase the risk of transmission of HIV infection from the contaminated sharp by atleast 5 percent (Wilburn and Eijekamans, 2004). One major contributing factor in the developing countries is increased handling of syringes which are contaminated (Wilburn and Eijekamans, 2004). According to HPA (2008), in addition to these, terminal HIV-related illness is also an important high risk factor for developing infection subsequent to injury. There is very little evidence among non-health workers. According to a retrospective study by O'Leary and Green (2003), males, cleaners and police officers are at particular risk of needle stick injuries and the most common mechanism of injury was exposure to syringes that were discarded. While 36 percent were work-related, 20 percent were non-accidental. Blenkharn and Odd (2008) opined that the main cause for sharp injuries among ancillary and support workers is deficiencies in glove selection and use and also in hand hygiene. The researchers reported that due to discomfort associated with ballistic-puncture-resistant gloves, these workers preferred thin-walled nitrile gloves which provide no resistance to penetrating injury. They estimated that sharp injuries occurred in 1 per 29 000 man hours and these injuries were mainly related to hypodermic needles from improperly closed or overfilled sharps boxes or from sharps incorrectly discarded into thin-walled plastic sacks intended only for soft wastes. Materials and methods The study will be conducted in a national hospital over one year period. All workers, both health-related and support staff will be educated to report needle stick and sharp injuries. Data pertaining to the type of occupation, cause of injury and source of injury will be recorded and based on data analysis the incidence and causes of needle stick injuries will be ascertained. Study design Prospective study Results Appropriate statistical software will be used for data analysis and results will be deduced from that. Conclusion Injury by sharp needles and instruments that are contaminated is a major occupational hazard to health care workers and non-health care workers. Needle stick injuries continue to be the most commonly reported adverse incident among healthcare workers, which are a potential source for transmission of various diseases like Hepatitis B and C and human immunodeficiency virus. There is under estimation of institutional needle injuries by atleast 50 percent because of under-reporting. The risk of transmission of hepatitis C with needle stick injuries is 3 percent, for hepatitis B is 30 percent and for HIV is 0.3 percent. However, there is not much data available about the incidence of needle stick injuries among ancillary and support staff. The main responsibility for protection against contraction of legal viral pathogens vests with workers who must handle sharp objects carefully and adhere to the hospital guidelines in their disposal. In this regard, the employer of the hospital also has a role to provide and environment that is safe and also educate all employees about the risk of viral transmission through sharp instrument injuries and about protocols which help in the prevention of needle injuries and safe disposal of needles. References Blenkharn, J.I., Odd, C. (2008). Sharps injuries in healthcare waste handlers. Ann Occup Hyg., 52(4), 281-6. Elmiyeh, B., Whitaker, S., James, M.J., et al. (2004). Needle-stick injuries in the National Health Service: a culture of silence. J R Soc Med., 97(7), 326–327. Health Protection Agency. (2008). Eye of the Needle. Surveillance of significant Occupational Exposure to bloodborne Viruses in Healthcare Workers. Knott, L. (2010). Needle stick injury. Retrieved from http://www.patient.co.uk/doctor/Needle-Stick-Injury.htm. Mehta, A., Rodrigues, C., Ghag, S., et al. (2009). Needlestick injuries in a tertiary care centre in Mumbai, India Journal of Hospital Infection, 60, Issue 4, Pages 368-373. NHS. (2000). Needle stick injuries: sharpen your awareness. Retrieved from http://www.sehd.scot.nhs.uk/publications/nisa/nisa-04.htm Ng, Y.W., and Hassim, I.N. (2006). Needlestick Injury Among Medical Personnel in Accident and Emergency Department of Two Teaching Hospitals. Med J Malaysia, 62(1), 9-12. O'Leary, F.M., and Green, T.C. (2003). Community acquired needlestick injuries in non-health care workers presenting to an urban emergency department. Emerg Med (Fremantle), 15(5-6), 434-40. Thomas, W.J., Murray, J.R. (2009). The incidence and reporting rates of needle-stick injury amongst UK surgeons. Ann R Coll Surg Engl., 91(1), 12-7. Wilburn, S.Q., Eljkemans, G. (2004). Preventing needle stick injuries among health care owrkers: A WHO-ICN collaboration. IJOEH, 10(4), 451- 456. Read More