Splash and splatter risk often underestimated

The risk of infection from exposure to a patient's bodily fluids gained great attention over the past 20 years, spurred by the risk of exposure to HIV, and that heightened awareness has led to improvements in needlestick prevention. But another route of exposure to bodily fluids has not received adequate attention, say some experts.

Splashes and splatters can transmit disease effectively, but many institutions do not adequately protect against this risk, says Susan Y. Parnell, RN, MSN, MPH, CIC, director of employee health clinical services at the University of Texas Health Science Center in Houston.

"These exposures are grossly underreported," she says. "The risk of HIV and hepatitis B transmission through this route is lower than with a needlestick, but it is still a very significant risk."

Parnell advises risk managers to review their work practice control policies to determine if it adequately addresses splash and splatter risk by requiring protective equipment and protective measures when contact with blood and bodily fluids is "reasonably anticipated," as required by the federal Occupational Safety and Health Administration.

But what does "reasonably anticipated" mean? The work practice control policy should define those circumstances for your own organization, so that the frontline worker is not left to guess about each situation, Parnell says. The definitions will vary for each institution, based on variables such as the type of patients treated, procedures performed, and patient volume. A trauma center may need to expect a splash and splatter risk with every patient, whereas a radiology department may not. Facilities treating the mentally ill and criminals may need to expect a higher likelihood of willful exposure through spitting, for instance.

"The next step is a product review. We're all pretty focused on sharps containers and related items, but we need to review the containers for body fluids also to make sure they have tight fitting lids to prevent spills and splash exposures," Parnell says. "Then you need to review your personal protective equipment. That is where you can gain the most ground in preventing exposures through splash and splatter."

Sizing of gear is crucial

Step one with personal protective equipment is to make sure it actually is available to clinicians. Parnell says the risk manager should ensure that all units have an adequate supply of the gear that can prevent bodily fluid exposure — protective glasses and goggles, face shields, hair covers, sleeve covers, long gowns, and gloves. And remember, it's not enough to just have a supply of these items. They have to fit the user, and that may mean keeping a variety of sizes.

"Many, many splashes occur because small nurses are wearing gloves that are too big for them, so they don't have a good grip. They lose control of a container or tubing and someone gets splashed," Parnell explains. "I used to see that a lot when I did acute care hospital employee health."

The work control policy also should specify what equipment is appropriate for different procedures and situations. Parnell says a risk manager, working closely with the employee health director, can have great influence in improving policies and procedures to prevent splash and splatter exposure. Get involved with the acquisition of protective equipment also, she suggests. Bring in the frontline employees, and let them review the products you're considering in a "product review fair." This can show employees that you are not simply buying the lowest bid products and that you want them to have the most effective supplies.

"A lot of what they say won't be new to you, but somebody's going to say something novel, point out a problem that you hadn't realized, or why one product is better than another for your facility. You really need to hear from those frontline nurses," she says. "We can't always buy the most expensive option, but if what they're saying ties directly to the injuries we're seeing in our data, the added cost can be justified, because injuries cost money."

Involving the staff also can reveal other issues that need to be addressed by the risk manager. For instance, Parnell says you may ask nurses to review protective equipment options, and one mentions that "My manager says we use too many of those, so she won't keep them on the unit." That's a managerial problem that must be addressed.

Staff may minimize risk

Educating staff about the risk from splash and splatter may be more challenging than talking about needlesticks, Parnell says. The risk from needlesticks has been ingrained in health care workers now, and people can more easily grasp how they could be infected by a needle actually puncturing the skin.

"Being splashed with some fluid is not as clearly an entry to the body, but bloodborne pathogens can cause infection if the circumstances are right," Parnell says. "It takes a little convincing sometimes to show people that this is a real health risk and not just a matter of avoiding something unpleasant on your face."

Splash and splatter exposures typically occur in the emergency department, the intensive care unit, and the operating room, says Connie Steed, MSN, RN, CIC, director of infection prevention at Greenville (SC) Hospital System University Medical Center in Greenville. Staff in those areas are at greater risk and should more routinely use the protective equipment that can prevent exposure.

"But we've seen splashes and splatters even in physician practices where they were doing a Pap smear or a cervical exam and didn't realize that there was a lot of secretions in that area," she says. "We've had people splattered in the eye with cervical secretions, believe it or not. That's not as common as some of the other scenarios, but these exposures can happen when people are not expecting it."

Steed says employees should be wearing facial protection any time they are performing high-risk procedures, such as intubations, suctioning with an open suction-type catheter, irrigating wounds with a lot of drainage or secretions, or any procedure such as a bronchosopy that generates aerosols.

Facial protection is the key to reducing exposure, Steed says, but statistics for personal protective equipment usage consistently show that facial protection has the lowest rate of compliance.

"People just don't think splatter is going to happen, so they don't put on the protection. In our OR, we purchased eye protection that goes along with masks they wear, and now it is expected practice in our organization for them to use that eye protection all the time."

Bloodborne pathogen exposure to the eyes decreased to almost zero after Greenville Hospital System required the use of eye protection in the OR, she says. Making the use of such equipment mandatory is the most effective strategy, Steed says, but is only practical in the highest-risk areas. In other settings, providers usually must give the employee some leeway to decide when face shields or other equipment are needed, and unfortunately, they opt to forgo the protection too often.

Analyzing your exposure data can reveal which areas, procedures, and staff are most at risk of exposure from splash and splatter, pointing the risk manager in the right direction when making policy and urging better compliance.

"We saw that we were having a lot of exposure or potential for splattering in the ER during trauma care, so we educated them about that fact, and now we have made it routine for them to wear facial protection with those cases," Steed says. "Where you can make it routine, expected practice rather than leaving it to the individual to decide on a case-by-case basis, you'll always get better results."


For more information on splashes and splatters, contact:

• Alicia Mares, RN, CRNI, Clinical Marketing Manager, BD Medical — Medical Surgical Systems, Franklin Lakes, NJ. Telephone: (801) 565-2815. E-mail: alicia_mares@bd.com.

• Susan Y. Parnell, RN, MSN, MPH, CIC, Director of Employee Health Clinical Services, University of Texas Health Science Center, Houston. Telephone: (713) 500-3255. E-mail: susan.y.parnell@uth.tmc.edu.

• Connie Steed, MSN, RN, CIC, Director of Infection Prevention, Greenville (SC) Hospital System University Medical Center. Telephone:(864) 455-6267. E-mail: csteed@ghs.org.