Curbing Sharps associated Curbing Sharps associated Infections in EDInfections in ED

Dr. Rashidi AhmadDr. Rashidi Ahmad

Medical lecturer/EmergentistMedical lecturer/Emergentist

School of Medical SciencesSchool of Medical Sciences

USM Health CampusUSM Health Campus

shidee_ahmad@yahoo.comshidee_ahmad@yahoo.com

Occupational Hazard WorkshopOccupational Hazard Workshop44thth September 2007 September 2007

““We need to create a culture of safety in the We need to create a culture of safety in the work environment to make sure that health work environment to make sure that health

care organizations promote and support care organizations promote and support sharps injury prevention.”sharps injury prevention.”

— — Julie Gerberding, M.D., M.P.H. CDC DirectorJulie Gerberding, M.D., M.P.H. CDC Director

OutlineOutline

• Facts & realitiesFacts & realities

• Risk assessment of SAIs in EDRisk assessment of SAIs in ED

• Injury preventionInjury prevention

• SuggestionsSuggestions

Sharps associated infections Sharps associated infections (SAI)(SAI)

• Bloodborne pathogenic exposures - Bloodborne pathogenic exposures - percutaneous needlestick injuries (NSIs).percutaneous needlestick injuries (NSIs).

• 600,000 - 800,000 NSIs occur each year600,000 - 800,000 NSIs occur each year

• Injections (21%), suturing (17%), drawing Injections (21%), suturing (17%), drawing blood (16%)blood (16%)

• > 50% do not report their occupational > 50% do not report their occupational sharps injuries sharps injuries (CDC facts)(CDC facts)

Perry, J., Parker, G., & Jagger, J. (2003). EPINet report: 2002 percutaneous Perry, J., Parker, G., & Jagger, J. (2003). EPINet report: 2002 percutaneous injury rates. Advances in Exposure Prevention, 6(3), 32– 36injury rates. Advances in Exposure Prevention, 6(3), 32– 36 ..

Fraction of HCV, HBV, HIV infections in HCWs Fraction of HCV, HBV, HIV infections in HCWs attributable to contaminated sharpsattributable to contaminated sharps

World Health Report. Geneva. WHO. 2001World Health Report. Geneva. WHO. 2001

Nagao et al. A long-term study of sharps injuriesNagao et al. A long-term study of sharps injuries

among health care workers in Japan. Am J Infec Control 2007;35:407-11among health care workers in Japan. Am J Infec Control 2007;35:407-11 ..

Devices involved in percutaneous injuries (n: 13,731)Devices involved in percutaneous injuries (n: 13,731)

Nagao et al. A long-term study of sharps injuriesNagao et al. A long-term study of sharps injuries

among health care workers in Japan. Am J Infec Control 2007;35:407-11.among health care workers in Japan. Am J Infec Control 2007;35:407-11.

* Recapping accounted for up to 30% * Recapping accounted for up to 30% of reported needle stick injuriesof reported needle stick injuries

Julian Gold, et al. Guidance note on Health Care Worker Safety from HIV and other Julian Gold, et al. Guidance note on Health Care Worker Safety from HIV and other Blood Borne Infections. World Bank, Washington, DC, USA, May 2004Blood Borne Infections. World Bank, Washington, DC, USA, May 2004

What is the risk of transmission What is the risk of transmission following a NSI to a following a NSI to a

positive source?positive source?

• HbeAg positiveHbeAg positive• HCV PCR (+) HCV PCR (+) • HBsAg positiveHBsAg positive• HCV positive, PCR (-)HCV positive, PCR (-)• HIV positiveHIV positive

• 30 – 40%30 – 40%• 10%10%• 2-6%2-6%• 1%1%• 0.3%0.3%

Julian Gold, et al. Guidance note on Health Care Worker Safety from HIV and Julian Gold, et al. Guidance note on Health Care Worker Safety from HIV and other Blood Borne Infections. Paper prepared for the East Asia and Pacific other Blood Borne Infections. Paper prepared for the East Asia and Pacific

Region of the World Bank. World Bank, Washington, DC, USA, May 2004Region of the World Bank. World Bank, Washington, DC, USA, May 2004

Impact of SRIsImpact of SRIs

• The evaluation and treatment of these The evaluation and treatment of these injuries and subsequent illnesses injuries and subsequent illnesses impose a heavy societal burden in terms impose a heavy societal burden in terms of:of:

-- economic costeconomic cost

-- worker anxiety and distressworker anxiety and distress

-- future morbidity & mortalityfuture morbidity & mortality

Work locations where blood & fluid exposures Work locations where blood & fluid exposures occurred (n: 16,855)occurred (n: 16,855)

Hazards among EDHCWs Hazards among EDHCWs

• Skin, mucous membranes, RS damages - Skin, mucous membranes, RS damages - cleaning, disinfecting, and sterilizing agents cleaning, disinfecting, and sterilizing agents

• Exposure to radiation. Exposure to radiation. • Sharp objects injuries & infectionsSharp objects injuries & infections• Musculoskeletal problems - handling of Musculoskeletal problems - handling of

heavy patients, continuous work while heavy patients, continuous work while standing standing

• Stress & burnout - shift & ON duty, Stress & burnout - shift & ON duty, psychological & organizational factorspsychological & organizational factors

• Sick patients in the ER present a risk of Sick patients in the ER present a risk of infection from body fluidsinfection from body fluids

• Violence patientsViolence patients

Why EDHCWs are at risk of Why EDHCWs are at risk of sharp-associated infections?sharp-associated infections?

• Johns Hopkins Hospital in Baltimore (1998)Johns Hopkins Hospital in Baltimore (1998)

• 5% of all adults presenting to the ED were 5% of all adults presenting to the ED were seropositive for HBV, 18% for HCV, and 6% seropositive for HBV, 18% for HCV, and 6% for HIVfor HIV

• 24% of ED patients were infected with 24% of ED patients were infected with either HIV, HBV, or HCV.either HIV, HBV, or HCV.

GD Kelen, GB Green and RH Purcell GD Kelen, GB Green and RH Purcell et al.et al., Hepatitis B and hepatitis C in emergency , Hepatitis B and hepatitis C in emergency

department patients, department patients, N Engl J MedN Engl J Med 326326 (1992), pp. 1399–1404 (1992), pp. 1399–1404

Cont…Cont…

• HIV seroprevalence studies of ED patients have HIV seroprevalence studies of ED patients have found infection rates up to 18% among patients found infection rates up to 18% among patients with penetrating trauma in inner-city EDs with penetrating trauma in inner-city EDs

• In addition, nonemergency health care workers In addition, nonemergency health care workers are frequently referred to hospital EDs for are frequently referred to hospital EDs for immediate treatment of occupational exposuresimmediate treatment of occupational exposures. .

J Jui, P Stevens and K Hedberg J Jui, P Stevens and K Hedberg et al.et al., HIV seroprevalence in ED patients:, HIV seroprevalence in ED patients: Portland, Oregon, 1988-1991, Portland, Oregon, 1988-1991, Acad Emerg MedAcad Emerg Med 22 (1995), pp. 773–783. (1995), pp. 773–783.

GD Kelen, GB Green and RH Purcell et al., Hepatitis B and hepatitis C in ED patients, N Engl J Med 326 (1992), pp. 1399–1404

Risk of HIV infection among EDHCWsRisk of HIV infection among EDHCWs

• R Marcus R Marcus et al.et al., Risk of HIV infection among , Risk of HIV infection among ED workers, ED workers, Am J MedAm J Med 94 (1993), pp. 363–370 94 (1993), pp. 363–370

• 8-month study in 3 pairs of inner-city and 8-month study in 3 pairs of inner-city and suburban hospital EDs in high AIDS incidence suburban hospital EDs in high AIDS incidence areas in the United Statesareas in the United States

• HIV seroprevalence:HIV seroprevalence:- 4.1 to 8.9 per 100 patient visits in the 3 inner-- 4.1 to 8.9 per 100 patient visits in the 3 inner-city Edscity Eds- 6.1 in 1 suburban ED- 6.1 in 1 suburban ED- 0.2 & 0.7 in other 2 suburban EDs.- 0.2 & 0.7 in other 2 suburban EDs.

• 69% of HIV patients was unknown to ED staff. 69% of HIV patients was unknown to ED staff.

9,793 procedures9,793 procedures

Blood contact Blood contact 379 (3.9%)379 (3.9%)

SkinSkin362 (95%) 362 (95%)

Mucus membraneMucus membrane

11 (3%) 11 (3%)

PercutaneousPercutaneous

6 (2%)6 (2%)

• Ungloved HCWs: Overall procedure-Ungloved HCWs: Overall procedure-adjusted skin BC rates were 11.2 BCs per adjusted skin BC rates were 11.2 BCs per 100 procedures & 1.3 for gloved EDHCWs100 procedures & 1.3 for gloved EDHCWs

• RR = 8.8; 95% CI = 7.3 to 10.3RR = 8.8; 95% CI = 7.3 to 10.3• In high HIV seroprevalence EDs: 1 in every In high HIV seroprevalence EDs: 1 in every

40 full-time ED physicians or nurses can 40 full-time ED physicians or nurses can expect an HIV-positive percutaneous BC expect an HIV-positive percutaneous BC annuallyannually

• In low HIV seroprevalence EDs:1 in every In low HIV seroprevalence EDs:1 in every 575. 575.

ResultsResults

Risk factors for HIV infection in healthcare workers after percutaneous Risk factors for HIV infection in healthcare workers after percutaneous exposure exposure

Risk factor Risk factor Adjusted odds ratio* Adjusted odds ratio* 95% confidence interval 95% confidence interval

Deep injury Deep injury 16.1 16.1 6.1-44.6 6.1-44.6

Visible blood on device Visible blood on device 5.2 5.2 1.8-17.7 1.8-17.7

Needle placed directly in Needle placed directly in artery or vein artery or vein 5.1 5.1 1.9-14.8 1.9-14.8

End-stage disease in End-stage disease in patient patient 6.4 6.4 2.2-18.9 2.2-18.9

Postexposure zidovudine Postexposure zidovudine use use 0.2 0.2 0.1-0.6 0.1-0.6

*All significant at *All significant at PP<0.01. <0.01. Adapted from Centers for Disease Control and Prevention (30).Adapted from Centers for Disease Control and Prevention (30).

Prevalence of HBV markers in Prevalence of HBV markers in emergency physicians.emergency physicians.

• Kenneth V et al. Kenneth V et al. Annals of Emergency Annals of Emergency MedicineMedicine, , Volume 14, Issue 2Volume 14, Issue 2, , February February 19851985, , Pages 119-122Pages 119-122

• American College of EmergencyAmerican College of Emergency Physicians (ACEP)Physicians (ACEP)

• Physicians already vaccinated against Physicians already vaccinated against hepatitis B were excluded. hepatitis B were excluded.

• 58%: community EP (30 and 39 y.o) who 58%: community EP (30 and 39 y.o) who had > 6 years in ED had > 6 years in ED

Results & conclusionResults & conclusion

• 94% of EPs indicated no prior history of 94% of EPs indicated no prior history of hepatitishepatitis

• Yet: 13.1% had serologic markers for Yet: 13.1% had serologic markers for HBV. HBV.

• Including the 10 physicians with both Including the 10 physicians with both HBV markers and history of hepatitis, the HBV markers and history of hepatitis, the overall prevalence for markers in this overall prevalence for markers in this study was 15.5%study was 15.5%

• This prevalence was 5 X greater than This prevalence was 5 X greater than general population.general population.

• EPs should be considered a high-risk EPs should be considered a high-risk group for HBV infection. group for HBV infection.

The management of sharps in the The management of sharps in the Emergency Department: Is it safe?Emergency Department: Is it safe?

• Steven T. Moss. Journal of EM (1994); Vol 12; Steven T. Moss. Journal of EM (1994); Vol 12; issue 6: 745-52issue 6: 745-52

• Cross sectional – observational studyCross sectional – observational study

• ED of the University of California-San Diego ED of the University of California-San Diego Medical CenterMedical Center

• Management of sharps by physicians, nurses, Management of sharps by physicians, nurses, technicians, studentstechnicians, students

• 418 eligible participants418 eligible participants

Excess risk to the user, Excess risk to the user, another person, or bothanother person, or both

[28% of 418][28% of 418]

Excess risk to the userExcess risk to the user[27%] [27%]

Excess risk to another personExcess risk to another person[12%][12%]

* Of the 418 observed sharp utilizations, none * Of the 418 observed sharp utilizations, none resulted in a puncture woundresulted in a puncture wound

• 64% were disposed of uncapped.64% were disposed of uncapped.

• 4 sharps (1%) were inadvertently thrown in the 4 sharps (1%) were inadvertently thrown in the trash.trash.

• Excess Risk: Physicians > technicians & students Excess Risk: Physicians > technicians & students

• In IV drug abusers with unknown HIV status, 29% In IV drug abusers with unknown HIV status, 29% ((nn = 28) sharps were handled with excess risk to = 28) sharps were handled with excess risk to the user, another person, or both.the user, another person, or both.

• Of 24 sharps used on known HIV-infected Of 24 sharps used on known HIV-infected patients, there were no practices observed that patients, there were no practices observed that subjected either the user or another person to subjected either the user or another person to excess risk. excess risk.

ResultsResults

EDHCWs and compliance to EDHCWs and compliance to universal precautionsuniversal precautions

• ED, UCLA Medical Center and Olive View-ED, UCLA Medical Center and Olive View-UCLA Medical Center, Los Angeles UCLA Medical Center, Los Angeles

• Barrier precaution policies adapted from Barrier precaution policies adapted from the CDC “Recommendations for the CDC “Recommendations for Prevention of HIV Transmission in Health-Prevention of HIV Transmission in Health-Care Settings.” Care Settings.”

• 169 HCW encounters with 97 patients were 169 HCW encounters with 97 patients were observed. observed.

169 HCWs169 HCWs

IV catheter placement (35) IV catheter placement (35) Phlebotomy (66).Phlebotomy (66).

ETI (98) ETI (98) PE (8) PE (8)

Use of needles (22)Use of needles (22)Patient handling (17)Patient handling (17)

Foley catheter Foley catheter placement (3) placement (3)

101 HCWs101 HCWs(Non critical)(Non critical)

68 HCWs68 HCWs

(Critical)(Critical)

101 HCWs101 HCWs

(Non critical)(Non critical)

Wearing GloveWearing Glove

(52.5%)(52.5%)

Wearing GloveWearing Glove

Needle use (64%)Needle use (64%)PE (72%)PE (72%)ETI (88%)ETI (88%)

Physical handling of patients (76%)Physical handling of patients (76%)Foley catheter placement (100%).Foley catheter placement (100%).

68 HCWs68 HCWs

(Critical)(Critical)

• In critical patients:In critical patients:-- Gowns (28%)Gowns (28%)-- Masks (1%)Masks (1%)-- Protective eyewear (18%) Protective eyewear (18%)

• Universal precautions compliance among Universal precautions compliance among

EDHCWs are poor.EDHCWs are poor.

LJ Baraff and DA Talan, Compliance with universal precautions in a universityLJ Baraff and DA Talan, Compliance with universal precautions in a university

hospital emergency department, hospital emergency department, Ann Emerg MedAnn Emerg Med 1818 (1989), pp. 654–657 (1989), pp. 654–657

Results and conclusionResults and conclusion

Summary on SAIs in EDSummary on SAIs in ED

• ED has multiple hazards including SRIED has multiple hazards including SRI• EDHCWs are at risk due to patient volume EDHCWs are at risk due to patient volume

overload, many activities @ procedures overload, many activities @ procedures that exposed them to body fluid & bloodthat exposed them to body fluid & blood

• About 25% of ED patients are high risk About 25% of ED patients are high risk patientspatients

• EDHCWs have excess risk of behaviorsEDHCWs have excess risk of behaviors• EDHCWs are not compliance to universal EDHCWs are not compliance to universal

precautionsprecautions• EPs are high risk personalEPs are high risk personal

Injury Prevention: Injury Prevention: The Three E’sThe Three E’s

• EducationEducation

• EnforcementEnforcement

• EngineeringEngineering

Christoffel T., and Gallagher S., Christoffel T., and Gallagher S., Injury Prevention and Public HealthInjury Prevention and Public Health, Gaithers, , Gaithers, Gaithersburg, Maryland: Aspen Publishers, 1999, 30-32,139-200Gaithersburg, Maryland: Aspen Publishers, 1999, 30-32,139-200

The Three E’s:The Three E’s: Education Education

• Aim is to provide EDHCWs with Aim is to provide EDHCWs with information on how to avoid SAIsinformation on how to avoid SAIs

• Alter attitudes about risk reductionAlter attitudes about risk reduction• Modify behaviors by educating EDHCWs Modify behaviors by educating EDHCWs

about why they must adopt behaviorabout why they must adopt behavior• Altering social norms about risk of injuryAltering social norms about risk of injury• Promoting societal policy change for Promoting societal policy change for

safer environmentsafer environment

Rushing, distracted, angry & multiple passes are Rushing, distracted, angry & multiple passes are significant risk behavior to SRIssignificant risk behavior to SRIs

Behavior ModificationBehavior Modification

The Three E’s: The Three E’s: EnforcementEnforcement

• Enforcement is usually more effective Enforcement is usually more effective than educationthan education

• Most injury prevention laws at state Most injury prevention laws at state levellevel

• Laws can have varied focus:Laws can have varied focus:– individual behaviorsindividual behaviors– engineering of environmentengineering of environment– consumer products designconsumer products design

Mandating compliance with UP is Mandating compliance with UP is more effective than just a guidelinemore effective than just a guideline

• 7 months following the introduction of an 7 months following the introduction of an institutional policy mandating compliance with institutional policy mandating compliance with universal precautions (UPs)universal precautions (UPs)

• 127 HCWs performing 1421 interventions on 155 127 HCWs performing 1421 interventions on 155 critically ill and injured patients in an emergency critically ill and injured patients in an emergency department setting in July 1989.department setting in July 1989.

• Results were compared with a similar study Results were compared with a similar study undertaken exactly 1 year previously when UPs undertaken exactly 1 year previously when UPs were considered as guidelines only. were considered as guidelines only.

Kelen P, et al. Substantial improvement in compliance with universal precautionsKelen P, et al. Substantial improvement in compliance with universal precautionsin an emergency department following institution of policy.(1991) in an emergency department following institution of policy.(1991) Archives of Internal Archives of Internal

MedicineMedicine, 151 (10), pp. 2051-2056, 151 (10), pp. 2051-2056

• Adherence to Ups: intervention of profuse bleeding Adherence to Ups: intervention of profuse bleeding patients – improved from 19.5% to 55.7%; patients – improved from 19.5% to 55.7%; performance of major procedure – improved from performance of major procedure – improved from 16.7% to 54.5%16.7% to 54.5%

• Overall adherence to Ups: improved from 44.0% to Overall adherence to Ups: improved from 44.0% to 72.7% 72.7%

• Compliance for EDHCWs: improved from 47.9% to Compliance for EDHCWs: improved from 47.9% to 81.0%.81.0%.

Kelen P, et al. Substantial improvement in compliance with universal precautionsKelen P, et al. Substantial improvement in compliance with universal precautionsin an emergency department following institution of policy.(1991) in an emergency department following institution of policy.(1991) Archives of Internal Archives of Internal

MedicineMedicine, 151 (10), pp. 2051-2056, 151 (10), pp. 2051-2056

ResultsResults

The Three E’s: The Three E’s: EngineeringEngineering

• Use modifications in environment Use modifications in environment to reduce SAIS risks by providing to reduce SAIS risks by providing passive protectionpassive protection

Blunt needleBlunt needle

Needleless intravenous -Needleless intravenous -line access line access

Needless access systemNeedless access system

It has been well demonstrated that these devices can reduce It has been well demonstrated that these devices can reduce intravenous-connection-related percutaneous injuries by 50% intravenous-connection-related percutaneous injuries by 50% to 60% while maintaining user satisfaction to 60% while maintaining user satisfaction

Lawrence LW, Delclos GL, Felknor SA, et al. The effectiveness Lawrence LW, Delclos GL, Felknor SA, et al. The effectiveness of a needleless intravenous connection system: of a needleless intravenous connection system:

an assessment by injury rate and user satisfaction. an assessment by injury rate and user satisfaction. Infect Control Hosp Epidemiol 1997;18(3):175-82 Infect Control Hosp Epidemiol 1997;18(3):175-82

ConclusionsConclusions

Preventive measuresPreventive measures

• VaccinationsVaccinations• Personal protective gearPersonal protective gear• Mandating UPsMandating UPs• Education and trainingEducation and training• Safety devicesSafety devices• SupervisionSupervision• Convenience, non stress working Convenience, non stress working

environmentenvironment• Policies & proceduresPolicies & procedures

General factors for SAIs preventionGeneral factors for SAIs prevention

• Population development factorPopulation development factor

• Social need factorSocial need factor

• Policy maker factorPolicy maker factor

• Economic development factorEconomic development factor

SummarySummary

• SAIs in ED is REALSAIs in ED is REAL• In ED HUSM context: paramedics are the In ED HUSM context: paramedics are the

high risk group not the EPshigh risk group not the EPs• Unsure of the prevalence of HCV, HBV & Unsure of the prevalence of HCV, HBV &

HIV at EDHUSMHIV at EDHUSM• SAIs is a disease; it is not an accident; it SAIs is a disease; it is not an accident; it

is preventableis preventable• Time for proper Haddon Matrix analysis Time for proper Haddon Matrix analysis

in EDin ED• Strategies: 3EStrategies: 3E

Thank youThank you

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