Literature review

Beekman SE, Vaughn TE, McCoy KD, et al. Hospital bloodborne pathogens programs: Program characteristics and blood and body fluid exposure rates. Infect Control Hosp Epidemiol 2001; 22:73-81.

Training in standard precautions is inadequate for new employees and physicians in more than one-quarter of hospitals, and exposure rates of health care workers remains "unacceptably high," conclude researchers at the University of Iowa in Iowa City.

In a survey of 153 hospitals in Iowa and Virginia, researchers found that 29% offered training in standard precautions only once or twice a year. The U.S. Occupational Safety and Health Administra-tion (OSHA) requires employees to be trained when they are assigned to exposure-prone tasks. Only 27% of physicians receive the training because they are not employees of the hospitals, the study found.

Blood and fluid exposures are still a common occurrence, the researchers found. Overall, 106 hospitals reported a percutaneous exposure rate of 5.3 per 100 hospital employees per year.

The survey was conducted in 1996 and 1997, some five years after OSHA’s bloodborne patho-gens standard required health care facilities to take measures to reduce exposures but before the recent state laws, federal Needlestick Safety and Prevention Act, and revised OSHA standard added tougher mandates for safety devices. Most of the facilities included in the survey are community hospitals. The use of safety devices varied by type of device and size of facility, the survey showed. About half of the hospitals (75 of 140 reporting) used a needleless IV system, and 35% (49 of 140) used safety devices for phlebotomy or IV access. Larger facilities were more likely to use the safer systems.

The annual percutaneous injury rates per 100 workers ranged from 1.0 for housekeeping staff to 10.8 for operating room and emergency department technicians, for a mean of 5.3. "Despite the apparent trend to slightly lower injury rates, these rates still are unacceptably high," the researchers stated. Even more troubling, 11% of hospitals surveyed did not have clinicians available to provide postexposure care during all working hours.

"Health care workers clearly remain at risk for [injury]," the researchers concluded. "More attention needs to be directed not only to effective approaches for employee training and behavioral modification but also to needlestick-prevention devices."

In an accompanying editorial, David K. Henderson, MD, deputy director for clinical care at the Warren G. Magnuson Clinical Center of the National Institutes of Health in Bethesda, MD, called several of the study’s findings "disquieting. "That several of these institutions invest little or nothing in training for staff with respect to occupational risks and postexposure management is disturbing, perhaps even frightening," he wrote. "The fact that that one of every eight of the responding hospitals does not offer continuous occupational medicine support for employees sustaining occupational exposures is even more problematic."

Safer devices, coupled with systematic analysis of all exposures and broad efforts to improve adherence to standard precautions, can help reduce exposures, says Henderson. Some issues raised by the University of Iowa study lead to simple solutions. Henderson suggests linking physician credentialing with training and tapping into the National Postexposure Hotline — (888) 448-4911 — for expertise on postexposure prophylaxis. (For more information on the hotline, see Hospital Employee Health, January 2001.)

Hospitals need to commit resources to reduce exposures, Henderson wrote. "Their article underscores the importance of having the institutional administration to be cognizant of, intimately involved with, and aggressively supportive of organizational programs designed to reduce occupational exposures," he stated.