Bloodborne pathogen exposures to healthcare workers were higher than expected and not declining in incidence rates, according to the latest results from the Exposure Study of Occupational Practice (EXPO-STOP)1.

The ongoing study of members of the Association of Occupational Health Professionals in Healthcare (AOHP) ascertains blood exposures (BE) to healthcare workers via percutaneous sharps injuries (SI) or mucocutaneous (MC) exposure such as a splash to the eyes.

A 16-item electronic survey was distributed to AOHP members to ascertain BE incidence and denominator data for their hospitals. Participants were asked to report the annual number of SI and MC exposures for all staff. The annual SIs were reported separately for surgical procedures, for nurses, and for doctors. The denominator metrics included 100 occupied beds (OB), full-time equivalent (FTE) staff, FTE nursing staff, and adjusted patient days (APD).

Responses from 84 hospitals in 28 states were included in the analysis. In 2013, 7,158 BEs were reported and in 2014, 6,954 BEs were reported. In both years, 73% of BEs were SIs and 27% were MC exposures. The SI incidence rates in 2013 were: 33.0/100 OB; 2.6/100 FTE; and 0.54/1,000 APD. In 2014, the SI incidence rates were: 33.3/100 OB; 2.7/100 FTE; and 0.56/1,000 APD.

There was a time beginning in the 1980s when healthcare workers were literally at risk of death if they seroconverted for HIV following a needlestick. Awareness of the risk of exposures led to the federal Needlestick Safety and Prevention Act in 2000. With implementation of the act, there was a drop off in blood exposures, which are now beginning to edge back up as a certain level of complacency sets in.

“It did drop right after that legislation took place, but over the years since then it has continued to creep up,” says Linda Good, PhD, RN, co-author of the study and director of Employee Occupational Health Services for Scripps Health in La Jolla, CA. “I think a lot of people saw the initial drop and said, ‘Good, we took care of that problem.’ But the takeaway from this study is that legislating this is not enough to take care of it. It’s something that needs continued attention.”

For one thing, hepatitis C virus — the most common chronic bloodborne infection in the country — threatens healthcare workers with severe liver problems if infected. Then there is the threat of Zika and whatever follows it as a novel bloodborne pathogen. The effectiveness of post-exposure prophylaxis for HIV — and the development of antiretroviral drugs that drive virus counts to levels that are scarcely detectable — may have contributed to a sense of complacency.

“That was one of the things that motivated the AOHP to commission this study,” Good says. “We were concerned that there might be an assumption out there that this problem had been solved. This is an ongoing issue and it won’t just go away without sustained focused attention.”

Even if the cold calculus of potential infection and exposure outcomes has shifted to somewhat safer footing, armchair analysts should walk a mile in a nurse’s shoes before dismissing the emotional trauma that follows a needlestick. A study that looked at this issue concluded that “enduring psychiatric illness” can result from needlesticks, but swift delivery of source-patient test results may reduce duration of depression and anxiety.2

Among the case vignettes are this one, summarized as follows:

“A 36-year-old healthcare worker in an emergency department was emptying a clinic bin. She was replacing a bag when a needle, which had been incorrectly disposed of, pierced her leg. She was immediately shocked and worried and tried to make it bleed. She talked to the doctor on duty and he tried to reassure her that they had not had any knowingly infected patients in, but she was not reassured. She was worried that she had been exposed to an infectious disease such as HIV or hepatitis or another disorder and underwent a course of injections over the next week, which gave her diarrhea. The injections then moved to monthly. She also had to have regular blood tests to check on whether she had seroconverted and was suffering from hepatitis B or C or HIV. She received the all-clear from blood tests approximately 6 months later. Her anxiety gradually subsided thereafter.”

As part of the EXPO-STOP study, Good interviewed some of the sites that had successfully driven needlesticks and exposures down and kept them there.

“The hospitals that have been very successful are not complacent about this at all,” she says. “They have a goal of achieving zero, so they don’t consider any bloodborne pathogens exposure as acceptable. That’s kind of remarkable. So anytime it happens, they really drill down with the employee that has been injured, their manager, and they investigate any unsafe practices. They look for a root cause rather than make an assumption about it.”

“Effective reduction strategies in the low-incidence hospitals included prevention through education, data-driven communication, immediate root cause investigation of all exposures, adoption of safer safety engineered devices, engagement of staff on all levels, and acceptance by staff that safety is their responsibility,” the authors reported.

For example, one hospital picked up a trend that blood draws interrupted by visitors or other healthcare workers could be at higher risk of resulting in a needlestick. As a result, they placed a sign or symbol on the door indicating a procedure was in progress and developed a script to explain and alert the patient to the moment of needle puncture.

“Sometimes it’s just something very simple — low-tech interventions — [which were possible] because they paid attention to what was causing their exposures,” Good says. “Another hallmark of sharps-safety hospitals is that they hold everyone responsible. They don’t say it’s employee health’s job to cut down on needlestick injuries. It’s everyone’s job.”

Another example cited from a low-exposure hospital was a team of safety advocates, which includes members from front-line staff, employee health, department directors, and hospital administration. The group meets regularly for breakfast and to discuss injury rates and identify key problems.

REFERENCES

  1. Brown C, Dally M, Grimmond T, et al. Exposure Study of Occupational Practice (EXPO-STOP): An update of a national survey of sharps injuries and mucocutaneous blood exposures among healthcare workers in U.S. hospitals. AOHP Jrl 2016:36(1):37-42.
  2. Green B, Grifiths EC. Psychiatric consequences of needlestick injury. Occup Med 2013;63(3):183-188.