A QUALITY IMPROVEMENT EFFORT

A STUDY ON ASSESSMENT OF SHARPS INJURIES AND ITS

MANAGEMENT AMONG HEALTH CARE

WORKERS WITHIN THE MINISTRY OF HEALTH MALAYSIA

 DR NOORHAIDA UJANGMEDICAL OFFICER(RESEARCH)

QUALITY HEALTHCARE DIVISIONINSTITUTE FOR HEALTH SYSTEM

RESEARCH18 APRIL 2010

BackgroundBackground3,168 cases of needle stick injuries

among HCW reported from 2002 to 2006 (Occupational Health Unit, Ministry of Health)

The indicator for NIA is the Incidence of NSI among HCW and the standard is 0

Highest SIQ for NIA indicators were reported from Perak, Johor, Selangor and Sarawak

Currently follow up information of NSI cases unknown

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OBJECTIVESOBJECTIVES

General objective 

To assess the management of sharps injuries among healthcare workers.

 Specific objectives 

1. To determine the existing sharps injuries management protocol in hospitals.

 2. To identify the proportion of sharps

injury cases which have been reported with incomplete follow up.

 3. To identify the reason/s for incomplete

follow up of sharps injuries.

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MethodologyMethodology• Phase 1

– Cross sectional survey of sharps injuries in all hospitals in the four identified states (Perak, Selangor, Sarawak and Johor)

– Postal survey sent to 55 hospital directors– Data collected on hospital protocol and

numbers of sharps injuries

• Phase 2 – Two states (Johor and Perak) with highest

incidence of the sharps injuries. – Self-administered questionnaire on Post

Exposure experience and follow-up assessment to all the HCWs who had sustained sharps injuries in the year 2006

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FINDINGS – Phase 1FINDINGS – Phase 1Results from 41 hospitals

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Incidence Rate of Needle stick Injury among HCW in the MOH (per 1000 HCW)-2006

Malaysia : 3.7/1000 HCW 5.2/1000HCW

•

To determine the existing sharps injuries To determine the existing sharps injuries management protocol in hospital.management protocol in hospital.

1) All 41 hospitals studied have a protocol 1) All 41 hospitals studied have a protocol on NSI management. on NSI management.

2)2) Units responsible for managing sharp Units responsible for managing sharp injuriesinjuries

Office hours After office hours

Infection control unit (73.8%)

Emergency unit (21.4%)

Emergency unit (54.8%)Respective

departments(35.7%)

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Currently there is no standardized Currently there is no standardized protocol as indicated by the protocol as indicated by the following findingsfollowing findingsStorage of drugs: 57.1% of Post

Exposure Prophylactic (PEP) drugs for immediate use were kept in the Pharmacy.

88.1% records of all the sharps injuries were kept in the Infection Control Unit.

The infection control nurse/sister were responsible for compilation and analysis of data (88.1%). 9

Injury rate Total

<1% 1% to <2%

2% to <3%

3% to <4% 4% or more

Type of Hospital

State 0 (0%) 2 (66.7%) 1 (33.3%)

0 (0%) 0 (0%) 3 (100%)

Major Specialist

0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (100%) 1 (100%)

District with Specialist

5 (41.7%) 4 (33.3%) 0 (0%) 2 (16.7%) 1 (8.3%) 12 (100%)

District without Specialist

10 (62.5%)

2 (12.5%) 1 (6.3%) 1 (6.3%) 2 (12.5%) 16 (100%)

Institute 3 (100%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 3 (100%)

Total 18 (51.4%)

8 (22.9%) 2 (5.7%) 3 (8.6%) 4 (11.4%) 35(100%)

Sharps Injury Rate = No. of HCW with sharps injury/ Total no of HCW

To identify the proportion of sharps injury cases To identify the proportion of sharps injury cases which have been reported with incomplete which have been reported with incomplete follow up.follow up.

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Type of

Hospital

Follow up rates

< 50% > 50% Total

State 2(66.7%) 1(33.3%) 3 (100%)

Major

Specialist

0 (0%) 1(100%) 1 (100%)

District with

Specialist

3(30%) 7(70%) 10 (100%)

District without

Specialist

4(30.8%) 9(69.2%) 13 (100%)

Institute 0 (0%) 1(100%) 1 (100%)

Total 9(32.1%) 19(67.9%) 28 (100%)

Regularity of presentation of Regularity of presentation of analysed data to the hospital analysed data to the hospital managementmanagement

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Regularity Numbers Percentage

Monthly 3 7.1

3 monthly 9 21.5

4 monthly 11 26.2

6 monthly 10 23.8

Yearly 4 9.5

Never 5 11.9

Type of Hospital

Annually Six monthly

Four monthly

Three monthly

Monthly Total

State 0 (0%) 1 (33.3%) 0 (0%) 2 (66.7%)

0 (0%) 3 (100%)

Major Specialist

0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (100%)

1 (100%)

District with Specialist

2 (18.2%)

0 (0%) 3 (27.3%) 5 (45.5%)

1 (9.1%)

11 (100%)

District without Specialist

0 (0%) 9 (60%) 4 (26.7%) 1 (6.7%)

1 (6.7%)

15 (100%)

Institute 1 (25%) 0 (0%) 2 (50%) 1 (25%) 0 (0%) 4 (100%)

Total 3 (8.8%) 10 (29.4%)

9 (26.5%) 9 (26.5%)

3 (8.8%)

34 (100%)

Summary of Phase 1 findings :There are protocols in all hospitals

however not standardized- Different units managing sharps injuries- Different areas of storage of PEP drugs- Different areas of storage of sharps injuries

records- Different person responsible for compilation

and analysis of dataPoor follow up ratesNo standardization in regularity of

presentation of analyzed data to hospital management

Findings – Phase 2Findings – Phase 2Self-administered questionnaire to HCWs

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Sharps injuries in year 2006Sharps injuries in year 2006

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Hospital No.of cases Identified

No.of Respondents

Hospital Sultanah Aminah (Hsa), Johor

47 36 ( 77%)

Hospital Raja Permaisuri Tuanku Bainun (Hrptb), Ipoh

35 25 (71%)

Total 82 61

Frequency of sharps injury by Frequency of sharps injury by occupationoccupationType of occupation Number %

Staff nurse 18 29.5

House officer 13 21.3

Medical Officer 7 11.5

Student Nurse 7 11.5

Attendant 6 9.8

Support staff service 4 6.6

Specialist/Consultants 3 4.9

Midwife 1 1.6

Medical Assistant 1 1.6

Clinical Lab worker 1 1.6

Total 61 100

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Frequency of Immediate Care Received Frequency of Immediate Care Received By LocationBy Location

Location Number %

Emergency Unit 17 27.9

Infection Control 16 26.2

Medical Clinic 10 16.4

Occupational Health

Clinic

7 11.5

Others 7 11.5

Outpatient Unit 2 3.3

None 2 3.3

Total 61 100 18

Post-exposure experiencePost-exposure experience21.3%(13) felt they were not

given sufficient information to make a decision about post exposure treatment◦46.1%(6) – doctors◦23.1%(3) – nurses◦15.4%(2) – attendants

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Follow up assessmentFollow up assessmentOf the 41 who were asked to come for follow up,

11(26.8%) did not complete their follow up

Occupation Freq Percent

Medical Officer 3 27.3

House Officer 2 18.2

Attendant 2 18.2

Consultant/specialist 1 9.1

Staff Nurse 1 9.1

Midwife 1 9.1

Student Nurse 1 9.1

Total 11 100.0%

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Reasons for not completing Reasons for not completing follow upfollow up

Reason n %

Stigma 0 0

Forgot 4 36.4

Too Busy 4 36.4

Was transferred to different health

facility

0 0

Did not think it is important 1 0.1

Scared/Worried 0 0

Continue follow up in another facility 0 0

Did not like the management given 0 0

Medical examination done elsewhere 4 36.4

Others 4 36.4

Total 17 100% 21

Interpretation of findingsThe study has identified the following

weaknesses in the protocols:- No standardization in management of

cases- No specific department identified to

handle sharps injuries cases- Inadequate follow up rates- Irregularity in presentation of data to

hospital management- Insufficient post exposure information

given to the injured personnel- Injured staff not giving adequate

importance to follow up

RecommendationsRecommendations

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RecommendationsRecommendationsSharps injuries management protocol has been

developed by the Occupational Health Unit which should be used by all MOH hospitals

Dedicated staff to handle sharps injury cases have been outlined out in the protocol

Specific department indentified for managing cases has been identified in the protocol

Documented Reminder System to improve follow-up compliance to be developed

Sharps Injury Surveillance Manual

Guidelines On Occupational Exposures to HIV, HBV and HCV, And Recommendations For Post Exposure Prophylaxis

Guidelines On Management of HCW Guidelines On Management of HCW Infected with HIV,HBV and HCVInfected with HIV,HBV and HCV

RecommendationsRecommendationsRegular presentation of data on sharps

injuries to hospital management to ensure proper and effective management

Reporting of analyzed data to the State Infection Control Committee as per the protocol

More commitment from top level management

- Ministry : Evaluation- State : Monitoring- Institution : Adhering to protocol

RecommendationsRecommendationsReview of Quality Assurance Indicator

‘Incidence of Needle Stick Injury Among Health Care Workers In Ministry of Health’ to include all sharps injuries ; to be taken up by the Quality Unit, Public Health Department

Use of safety needles in facilities

A new Sharps Injuries Surveillance (SIS) has been introduced in 2007. Study on effectiveness of this system need to be conducted.

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LimitationUnderreportingThis has resulted in incomplete

data thus reducing the actual number of injuries as well as the proportions of workers affected and subsequently the management and follow up of the cases

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• Follow up rates for sharps injuries in health care workers is poor - Dedicated staff and documented reminder system will help in improving the follow up rates.

No standardized management protocol on sharps injuries - Occupational Health Unit, Ministry of Health has developed guidelines on management of health care workers exposed to sharps injuries and infected with blood borne diseases. - Adherence to this new guidelines is important to prevent and manage sharps injuries in the country.

Conclusion

ACTION PLANACTION PLAN

ACTION PLAN STRATEGY KEY CONSIDERATIONS

To have a standardised sharps injuries management protocol.

Guidelines already developed in 2007Sharps Injury SurveillanceGuideline on management of HCW

commitment from Physician and Hospital Directors needed

To improve affected workers clinical management and follow through

To establish a reminder system.Example : Develop a tag for sharps injuries cases

A dedicated personnel to determine the improvement

Commitment from Hospital Directors needed

Placement of OHU in state hospitals

ACTION PLANACTION PLAN

ACTION PLAN STRATEGY KEY CONSIDERATIONS

Present data on sharps injuries on regular basis to local management for immediate action

Department in-charge to present to hospital directors four monthly

A letter from QA Steering committee to inform hospital directors to provide feedback to OHU MOH on the remedial action

To review of current QA indicator:incidence of needle stick injury to number of sharps injuries

To propose HCW should cover all personnel working at MOH facilitiesNSI to sharps surveillance

Committee to support

THANK YOU FOR YOUR ATTENTION

If you don’t have time to solve problems,How come you always have time to do it wrong again.(Unknown)

Thank youThank you

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