key: cord-0005172-f8i44vf0
authors: Wicker, Sabine; Ludwig, Ann-Marie; Gottschalk, René; Rabenau, Holger F.
title: Needlestick injuries among health care workers: Occupational hazard or avoidable hazard?
date: 2008
journal: Wien Klin Wochenschr
DOI: 10.1007/s00508-008-1011-8
sha: 45cf3c5aadfcb38d9e4146a0c81d0faff4115217
doc_id: 5172
cord_uid: f8i44vf0

OBJECTIVES: The objective of this study was to describe the mechanisms and preventability of occupational percutaneous blood exposure of healthcare workers through needlestick injuries and to discuss rational strategies for prevention. METHODS: To calculate the preventability, we surveyed in a first step the number and kind of needlestick injuries and in a second step the reasons for the injuries and the working conditions of the healthcare workers. Both data sets were collected in independent anonymous questionnaire covering occupational blood exposure among healthcare workers in a German university hospital. RESULTS: Needlestick injuries were caused through unsafe procedures, difficult working conditions and unsafe devices. On average, 50.3% (n = 492/978) of all needlestick injuries could have been avoided by the use of safety devices, whereas only 15.2% could have been prevented by organizational measures. In our study, 31.5% (n = 503/1598) of participant healthcare workers had sustained at least one needlestick injury in the past twelve months. The rate of underreporting was about 75%. After introduction of safety devices, 91.8% of the healthcare workers reported being satisfied with the anti-needlestick devices and 83.4% believed that safety devices would increase the safety of the work environment. CONCLUSIONS: Occupational exposure to blood is a common problem among healthcare workers. The introduction of safety devises is one of the main starting points for avoidance of needlestick injuries, and acceptance among healthcare workers is high. Further targets for preventive measures, such as training in safe working routines, are necessary for improvement of safe work conditions.

sundheitswesen. Eine systematische und kontinuier liche Erfassung von Nadelstichverletzungen ist unab dingbar, um riskante Praktiken und Arbeitsbedingun gen zu identifizieren. Präventive Maßnahmen, bei spielsweise die Einführung von sicheren Instrumenten sowie die Schulung sicherer Arbeitsabläufe, sollten im weiteren Zeitverlauf implementiert werden.

Objectives: The objective of this study was to describe the mechanisms and preventability of occupa tional percutaneous blood exposure of healthcare work ers through needlestick injuries and to discuss rational strategies for prevention.

Methods: To calculate the preventability, we sur veyed in a first step the number and kind of needlestick injuries and in a second step the reasons for the injuries and the working conditions of the healthcare workers. Both data sets were collected in independent anony mous questionnaire covering occupational blood expo sure among healthcare workers in a German university hospital.

Results: Needlestick injuries were caused through unsafe procedures, difficult working conditions and unsafe devices. On average, 50.3% (n = 492/978) of all needlestick injuries could have been avoided by the use of safety devices, whereas only 15.2% could have been prevented by organizational measures. In our study, 31.5% (n = 503/1598) of participant healthcare workers had sustained at least one needlestick injury in the past twelve months. The rate of underreporting was about 75%.

After introduction of safety devices, 91.8% of the healthcare workers reported being satisfied with the antineedlestick devices and 83.4% believed that safety devices would increase the safety of the work environ ment.

Conclusions: Occupational exposure to blood is a common problem among healthcare workers. The in troduction of safety devises is one of the main starting points for avoidance of needlestick injuries, and accep Introduction Needlestick injuries (NSIs) are one of the major risk fac tors in the transmission of hepatitis B virus (HBV), hep atitis C virus (HCV) and human immunodeficiency vi rus (HIV) in the healthcare environment. Worldwide, workrelated infections are responsible for about 37% of HBV infections among healthcare workers (HCWs), 39% of HCV infections and 4.4% of HIV infections [1] .

Recent experiences with SARS have demonstrated the vulnerability of HCWs to occupationally acquired infectious viral diseases. Worldwide, about 320,000 workers die of communicable diseases every year, some 5000 of them in the European Union [2] . The estimated annual death rate for HCWs from occupational events, including infection, is 17-57 per 1 million workers; over all, HCWs per million die annually from occupa tional infections. According to the Occupational Safety and Health Administration, between 1992 and 2002, 28 HCWs died in the USA from complications related to NSIs [3] . Furthermore, antiviral therapy to manage an occupational exposure to HIV has resulted in severe hepatitis requiring liver transplant [4] .

Combining the results for injury and disease, the best estimate of the annual number of deaths of workers arising from occupational exposures is about two mil lion, comprising about 350,000 deaths from injury and about 1.65 million from disease [2] .

In Germany, 941 workers died from workrelated injuries and diseases in 2006 (http://de.osha.europa.eu/ statistics/statistiken/suga/suga2006/3_ueberblick.pdf).

According to the German occupational disease number BK 3101 (workrelated infectious diseases), in 2004 at least six HCWs died in Germany (www.dguv.de/ inhalt/zahlen/documents/BKDOK_2004_Original.pdf).

Between January 2000 and December 2007, the Employer's Liability Insurance Association in Hesse re ported 19 cases of probable cause of occupational infec tious diseases in HCWs at the University Hospital Frankfurt, most of them HCV infections resulting from NSIs. Distribution of reported occupational infectious disease in Germany is summarized in Fig. 1 .

Because of these high numbers for occupational disease, national and international guidelines such as the Technical Rule 250 -Biological Agents in Health Care and Welfare Facilities [5] (Technische Regeln für Biologische Arbeitsstoffe 2003) in Germany, and the Needlestick Safety and Prevention Act 2001 [6] in the USA (US Department of Labor 2001) were developed to minimize the risk of bloodborne exposure to HCWs. NSI rates declined after better compliance with infec tion control guidelines and more widespread use of safety devices [7, 8] . Safety devices have been available in the USA since the late 1990s. The implementation of such devices in Germany has failed until now because of the estimated high costs and the vague legal regula tion [9] .

The aim of this study was to evaluate the prevent ability of NSIs among HCWs in a German university hospital. In a first step we obtained the number and kind of NSI and in a second step the reasons for the in juries and the working conditions of the HCWs who sus tained NSIs. This was done to assess preventive strate gies for reducing the rate of NSIs. Identifying ways to 

Frankfurt university hospital is a 1247bed hospital with 4080 employees and 12 medical disciplines. HCWs receive individual regular training from the occupational health service and/or the supervisors in prevention of exposure to blood and other body fluids. Employees whose job involved direct contact with pati ents and contact with blood or other body fluids or sharp objects were asked to complete a questionnaire.

Data were obtained in a twostep procedure. For statistical reasons and in order to obtain data from all the medical depart ments, the number of participants was enlarged and the scope of the questionnaire was extended in the second step.

Data were obtained between April and June 2006 (anesthe sia, dermatology, gynecology, pediatrics, surgery) and between February and April 2007 (ear, nose and throat medicine, internal medicine, neurology/psychiatry, ophthalmology, pathology/fo rensic medicine, radiology) using an anonymous survey among 2085 healthcare workers: 687 (32.9%) physicians, 1205 (57.8%) nurses, 54 (2.6%) cleaners, 139 (6.7%) medical technicians and research scientists. The physicians and the laboratory personnel were informed about the study and the questionnaire by the oc cupational health service in the course of their regular meetings; the nurses and cleaners were instructed by their supervisors.

The questionnaire included a brief introduction on the po tential risk of NSIs. It also covered the incidence, reporting rate, risk factors and exposure mechanisms of NSIs, the procedure and instrument involved in the exposure, the circumstances and mechanisms that were thought to be a significant cause of the ex posure, the professional group, and the HBV vaccination status. Respondents in 2007 (n = 878) were in addition questioned on compliance and reasons for noncompliance with safety devices that had been implemented in stages in the hospital since May 2006; for example, in relation to permanent venous catheters and venous blood withdrawal.

Classifying injuries in categories enabled calculation of the numbers of reported NSIs that could have been prevented by the use of safety devices or by organizational measures. This was done in accordance with the statements of the reported NSIs. Each injury was allocated to one of the three levels of preventa bility (presumably, probably, not preventable) as described ear lier [10] . The classification process was carried out by two people who also discussed any inconsistent results.

If the responding HCWs had any further questions, they could contact the responsible occupational physician. This also applied if they had any other problems, such as sustaining an NSI or questions about vaccination status and bloodborne infec tions. The completed questionnaires were collected on the vario us wards by the occupational physician or returned anonymous ly via internal mail. Feedback was not compulsory and informed consent was obtained by the participating personnel.

Data were incorporated into a Microsoft Excel database file that was then used for the detailed analysis using standard Excel ca pabilities. 

The questionnaire was completed by 1598 of 2085 HCWs (76.6%): 549 (79.9%) physicians, 811 (67.3%) nurses, 46 (85.2%) cleaners, 69 medical technicians and 123 who did not specify their professional group (Table 1) . Over all, 58.8% of the participants were female, 38.4% male and 2.8% did not provide the information.

The questionnaire response rate varied from 82.2% in surgery to 66.7% in gynecology. In total, 31.5% (n = 503/1598) of respondents had sustained at least one NSI in the past 12 months. The number of reported NSIs varied widely across disciplines, ranging from 46.9% (n = 91/194) among medical staff in surgery to 18.7% (n = 53/283) among HCWs in pediatrics. The number of NSIs per person and year also varied significantly, from one injury to 55. The highest rate was reported by sur geons. Of all occupational groups, physicians had the Risk of NSI varied by procedure: blood withdrawal and sewing caused most of the injuries. The majority of Table 2 .

Most of the NSIs occurred during routine activi ties (80.8%) but a few happened in emergency situations (13.4%). Stress (39.6%) and fatigue/lapses in concentra tion (39.4%) were the most common reasons for NSI. Ex tended working hours and night shifts were associated with 16.4% and 22.1%, respectively, of percutaneous in juries.

Regarding the rate of preventability of NSI, an av erage of 50.3% (n = 492/978) of all NSIs could have been avoided by the introduction of safety devices and a fur ther 24% (n = 235/978) might have been avoided, but 25.7% (n = 251/978) could not have been prevented. However, the rate of NSI that could have been avoided varied widely across the different medical disciplines. Only 15.2% (n = 149/978) of NSIs could have been pre vented by organizational measures such as training in safe working routines and improvement of the disposal of used needles. The preventability of NSI across medi cal disciplines is summarized in Table 3 .

Within occupational groups, only 20.4% of injured physicians reported the NSI to a consultant in emer gency medicine, compared with 40.0% of nurses (Fig. 2) . Reasons for a lack of reporting were: little or no percep tion of risk by the employee (15.3%), selfcare for NSI (7.2%), patients did not pose an infectious threat (10.2%), too busy (29.0%) and dissatisfaction with waiting times and followup procedures (28.9%).

On analyzing the working conditions of the HCWs, it was evident that twothirds of the physicians had di rect contact with infectious patients. Overall, around 90% of the HCWs were satisfied with the introduction of safer devices and believed that they would increase the safety of the working environment (Table 4 ).

NSIs are associated with several bloodborne infections, such as HBV, HCV and HIV [11, 12] ; however, most NSIs wkw 15-16/2008 Needlestick injuries among HCWs original article 490 do not result in disease and rarer yet are those that lead to fatal infection. Thus, rate of NSI, although meaning ful, may not accurately reflect the outcomes of greatest interest: disease and death. Further complicating this problem, the latent period from initial infection to dis ease may be measured in years or decades. For example, a HCW may sustain an NSI, become infected with HIV, and not develop clinical symptoms for several years. In the interval, the HCW may have changed jobs several times, making linkage of the exposure to the disease difficult [3] .

For the healthcare provider, complete surveillance of exposure is necessary for identification of highrisk activities and environments in order to define new tar gets for preventive measures and to monitor the success or failure of these measures. The true number of NSIs sustained by HCWs is still unclear, primarily due to un derreporting [13, 14] . HCWs must be made aware of the importance of reporting NSIs so that they receive the appropriate medical treatment. In our study, only 28.7% of injured HCWs reported all NSIs and had seen a physi cian after the incident. Other studies have examined the problem of underreporting: Panlilio et al. found an underreporting rate of 57% [15] . Our results illustrate the importance of targeting prevention measures at specific groups, such as physicians, that would other wise not be identified by routine reporting mechanisms. Physicians in particular often fail to report NSIs, as con firmed in a number of studies [16] . Previous studies have shown that selfassessment of low risk and selfcare for NSIs are reasons for underreporting by physicians [17] . In our study, reasons for not reporting an NSI included little or no perception of risk by the employee (15.3%), being too busy (29.0%) and dissatisfaction with long waiting times and followup procedures (28.9%). HCWs who do not report injuries because they are too busy create a challenge for preventive measures and must be made aware of the longterm risks of possible serocon version as opposed to simply the shortterm impact on their work load. Dissatisfaction with followup proce dures is an important criticism. Standardizing the post exposure procedures might help, as well as minimizing waiting times, so that staff can report injuries even if they are busy. All staff should report injuries and should do so quickly. Delays in reporting may subsequently de lay interventions; for example, administration of anti retrovirals or other medical treatments that may lessen the risk of acquiring a bloodborne infection [17] .

The 978 NSIs described in this study reflect both unsafe working procedures and difficult working condi tions. However, the impact of each of these factors varied with the instruments and procedures involved and also with the specialty. Our data indicate that a change in rou tines and an increase in technical interventions are nec essary to reduce the incidence of NSI in the different spe cialist areas. Preventive measures should be introduced in all specialties. The use of cutresistant gloves may re duce NSIs; for example, from bone fragments during pal pation. Double gloving lowers the risk of innerglove per forations [18] . The implementation of safety devices has provided HCWs with new ways of reducing NSIs. Health care providers should evaluate the efficacy and usability of these safety devices, as well as their acceptability by employees. In our study, approximately 90% of the HCWs were satisfied with the introduction of safer devices. Ear lier studies have shown similar results [19] .

The use of safety devices is considerably lower in Germany than in the USA and this may be the reason for the higher injury rate in Germany: 500,000 NSIs among 750,000 HCWs in Germany [20] versus 100,000 to 1 million NSIs among 6 million HCWs in the USA [3, 15] . Wider availability of safer technologies, together with the introduction and stronger enforcement of occupa tional safety and health regulations, would probably lower NSI rates [21] . Despite this, unsafe devices are still in use and safer alternatives do not exist in some areas of work; for example, in some parts of pathology.

Safer devices are not consistently protective and are often only effective if used correctly. A study by the Centers for Disease Control and Prevention identified that over 5% of all NSIs were sustained while using a safety device, highlighting that these devices do not provide complete protection [22] . Injuries that occur de spite the use of a safety device may be due to failure of activation or an inherent risk in the activation proce dures. However, we agree with Vaughn et al that safety devices would probably not completely eradicate NSI [23] . Other organizational factors, such as workload and management support, continue to be important areas for improvement.

A study from the Work and Health Research Cen ter in Baltimore demonstrated that working 13 or more hours per day, noonday shifts, or weekends and having less than 10 hours off were significant factors in the oc currence of NSI [24] .

A study by Harvard medical school found that fa tigue and lapses in concentration were the two most common factors (31% and 64% of injuries, respectively) [25] . Percutaneous injuries were more frequent during extended shifts than in regular working hours, and in juries were more frequent during the night than the day (1.48/1000 opportunities versus 0.7/1000 opportunities, respectively) [24, 25] . Long work hours and sleep depri vation among medical trainees resulted in a 3fold in crease in the risk of NSI [26] . In our study, stress (39.6%) and fatigue/lapses in concentration (39.4%) were the most common factors in NSI. Inexperience was a rela tively rare cause of NSI (4.6%).

Our study has some limitations: individuals who had suffered NSI may not have responded to the ques tionnaire, and when calculating injury rates we used reported sharps injuries as total sharps injuries.

Nevertheless, our data demonstrate the need to improve, and to evaluate the impact of prevention mea sures and to implement prevention strategies. It is clear that HCWs need to receive more training to make their work environment safer.

Because the costs of NSI are high, not just eco nomically but psychologically and physically, preven tive measures are paramount. A change in working con ditions and the wider use of safety devices could further reduce NSI [24] .

The prevention of percutaneous injuries is vital, because they are one of the commonest injuries among HCWs and the most efficient mechanism of transmis sion of bloodborne pathogens. The 4.3 million persons employed in the health care setting in Germany merit better protection for their health and greater recognition for their contribution. We propose that national organizations assume respon sibility for accurately tracking occupationally acquired infections [3] . A worldwide surveillance system of oc cupationally acquired infections and deaths would de termine the magnitude of the problem and could lead to future interventions.

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The authors wish to thank Mrs. Sarah Althaus for her editorial support.

Roles played by each author: Sabine Wicker: author of the publication. Also provided analysis and interpretation of data, responsible for study design. Ann-Marie Ludwig: data collecting, data analysis. René Gottschalk: statisti cal analysis, scientific supervision. Holger F. Rabenau: coauthor of the publication. Also contributed analysis and interpretation of data, responsible for study design.We herewith confirm that there are no potential conflicts of interest or any sources of funding.