Indian Journal of Medical Sciences Medknow Publications on behalf of Indian Journal of Medical Sciences Trust ISSN: 0019-5359 EISSN: 1998-3654 Vol. 64, Num. 12, 2010, pp. 540-551

Indian Journal of Medical Sciences, Vol. 64, No. 12, December, 2010, pp. 540-551

Original Article

The epinet data of four Indian hospitals on incidence of exposure of healthcare workers to blood and body fluid: A multicentric prospective analysis

Murali Chakravarthy¹, Sanjeev Singh², Anita Arora³, Sharmila Sengupta³, Nita Munshi⁴

¹ Department of Anesthesia, Critical care and Pain relief, Wockhardt Forits Hospitals, Bangalore, Karnataka - 560 076, India
² Medical Superintendent, Department of Microbiology and Hospital Infection Control Committee, Amrita Institute of Medical Sciences, Cochin, India
³ Department of Microbiology and Hospital Infection Control Committee, Escorts Hospital, New Delhi, India
⁴ Department of Pathology and Microbiology and Infection Control, Ruby Hall Clinic, Pune, India

Correspondence Address:
Murali Chakravarthy
Fortis Hospitals, Bangalore, Karnataka - 560 076
India
mailchakravarthy@gmail.com

Code Number: ms10003

PMID: 21258159

DOI: 10.4103/0019-5359.75929

Abstract

Keywords: Blood and body fluid exposure, healthcare workers, India, sharps injuries

Introduction

Accidental sharps injury (SI) and blood or body fluid (BBF) exposure are occupational risks to healthcare workers (HCWs). The incidence of such exposure in the United States of America is estimated to be 600,000-800,000 annually and about 500,000 in Germany. ^[1],[2] The incidence from India is unknown although a few workers from this country have reported incidents ranging from 300 to 400 per annum for their institution. ^[3],[4] The data published from USA appears to differ from the Indian data significantly. ^[5] According to an estimate in the Indian press, the number of HCWs in India is 3 per 10,000 population. Using this calculation, the total number of HCWs in India would approximately be 3.5 million (calculating from the population of India, i.e., 1.15 billion). The incidence of exposure of HCWs is a big problem considering the total projected number of HCWs in India. Even if one were to extrapolate the data from the West to that of India, the gravity of the problem in India has not been studied or assessed yet, in the manner in which it needs to be. The aim of the study was to quantify the problem of exposure of HCWs to SI and BBF. Four Indian hospitals participated in data collection. They were Amrita Institute of medical sciences, Cochin; Escorts Hospital, New Delhi; Fortis Hospitals; Bangalore and Ruby Hospital, Pune. The hospitals are corporate teaching and/or charitable ones. The hospital infection control committees pooled their data using the Exposure Prevention Information network (EPINet) software of the International Health Care Worker Safety Research and Resource Center, University of Virginia.

Materials and Methods

Data of SI and BBF exposure from four Indian hospitals were pooled and analyzed. The data were collected on monthly basis and sent to a central station for analysis. All the centers used the same software - EPINet - to collect the data (appendix 1 and 2). The author′s center was considered the nodal center, where the data were collected and analyzed. The privacy regarding the hospital and patient identification was maintained during the data collection and analysis.

Definitions ^[6]

An SIis an occupationally related, unintentional injury that breaks the skin′s integrity, including needle punctures, lacerations from cutting instruments, and other sharp object injuries.

Needle stick-prevention safety devices are engineering controls used to protect HCWs from accidental needle stick injuries. Examples include needleless or protected needle devices designed to reduce the risk of SI by either eliminating the needle from the device or shielding the needle to protect HCWs from accidental needle sticks.

A necessary needle or other sharp device is one that is used to pierce skin or tissue or to cut.

An unnecessary needle or other sharp device is one that is not used to pierce skin or tissue or to cut, or a glass item for which a non-breakable alternative is available; examples include needles used to access ports on intravenous (IV) administration sets (since needleless or protected needle devices are available) or glass capillary tubes (since non-breakable plastic capillary tubes are available).

Potentially preventable sharp injuries are those occurring (a) between use or after use of a necessary needle or other sharp device or (b) from use of an unnecessary needle or other sharp device.

The data of both SI and BBF exposure were collected using the data collection forms at all the centers. These data collection forms were supplied by the International Health Care Worker Safety Council, University of Virginia. The variables analyzed were as per the format of the EPINet questionnaire. They were job categories, location at the hospital where the exposure occurred, whether the object causing injury was infected, whether the source of the contaminated item was known, whether the injured worker was the original user (defined as the HCW intending to use or using the device), type of the device causing injury, whether a safety device was used, the location on the corpus of the HCW and the depth of the injury, and the vaccination status against hepatitis.

Statistical analysis

The statistical analysis was carried out using SPSS software 10.0. The significance of incidence of injuries between various components was analyzed using chi-square test. Frequencies of incidence were calculated for each alternative, chi-square value was calculated and P values corresponding to this calculated chi-square value was noted. P<0.05 was considered significant. All the values were given as mean ± standard deviation.

Results

Cumulative data for 50 months were collected from four Indian hospitals (hospital A:8 months; B:6 months; C:12 months and D: 26months). Two hundred and forty-three SIs and 22 reported BBFs were noted from the data. [Table - 1] shows the bed strength, staff pattern of each hospital and also the hospital wise distribution of NSI and BBF exposure. The data sent by each of the participating hospitals were as follows: A:12; B:6; C:6 and D:26. Since the number of months of data collection was different for each participating hospital, the injuries per month were also calculated. [Table - 2] shows injuries per month of exposure in each of the hospitals according to the location where the injury occurred. Significant variance between hospitals in the number of injuries per month (P<0.001) was noted. It was found that hospital A had significantly higher injuries in the operation theater (OT) in comparison to the other hospitals (4.1 injuries per month in comparison to the monthly incidence of 1.1) and hospital C had higher injuries inside the patient′s room (4.6 in comparison to the overall monthly injury rate of 2.1). The exposure based on job categories was analyzed [Table - 3]; it showed that more than half of the injuries reported were among nurses (55%). Among others, more than 35% of HCWs (apart from nurses and doctors) suffered SI. The location of injury was analyzed and is shown in [Table - 4]. This revealed that HCWs suffered injuries most commonly in the patient′s room/ward (35%). The other locations where HCWs commonly got exposed to BBF were operating room or recovery room (15.23%), outpatient room (10.3%) and intensive care units (ICUs) (10.3%). The source of the accident was analyzed and is given in [Table - 5]. In about 65% of the events, the source was identifiable, while in about 20% it was not identifiable. [Table - 6] shows the data about the incidence of injury among the original user. More than 50% of the times, the original user was exposed; but in about 38%, the events occurred in HCWs who were not the original users. The type of the instrument that caused the SI is shown in [Table - 7]. The needle on a disposable syringe was the commonest source of injury (41.5%) in our study. The other instruments causing injury in descending order of frequency were stylet of the intravenous cannula (9%), hypodermic needle not attached to a syringe (9%), suture needles (7%) and winged steel needles (5%). Twenty-two unnecessary injuries (as defined above) ^[9] (about 10% of the total in our study) occurred from objects such as needle on the intravenous drip set. [Table - 8] in consensus with [Table - 2] shows increased incidence of injury with suture needle in hospital A. Eighty-one (about 30%) potentially preventable SIs (defined above) ^[9] occurred in our study. We encountered 18 injuries between the steps of procedure, 42 after performing the procedure but before disposal, and 21 due to unattended sharps after use. [Table - 9] shows the incidence of contaminated sharps. Only about 11% were uncontaminated. More than 85% of the injuries that occurred were due to contaminated and/or unknown sources. The stages of use at which injury occurred were analyzed and are shown in [Table - 10]. It revealed that the most common occurrence was during use (about 30%), after use prior to disposal (17%) or during recapping the needle (9.5%). Six percent occurred during multistep procedure, disassembling device or equipment, due to device left on floor, table, bed or other inappropriate areas, after disposal, due to item protruding from trash bag, etc. [Table - 11] shows the purpose for which the sharp was used. The most common activity causing injury due to sharps was while administering an injection using a hypodermic needle. Unknown purposes and "others" seemed to contribute to a high level of the exposures (70%). A majority of the exposures occurred in the absence of a safety device (77%). Commonest use of a sharp instrument in our study was for performing either intravenous or intramuscular injection (33%). [Table - 12] shows if the presence of safety design on the sharp object causing SI mattered. About 77% of the injuries were found to occur due to use of unprotected instruments. The total number of BBF exposure in our study was twenty-two. Most of the exposures were splash of blood and blood products on the face and eyes (68%). The OT and emergency room appeared to be the most common areas where BBF exposure occurred. P value was <0.001 for all the variables. This indicates that the risk of the injury for different alternatives under each variable is significantly different. For example, under "Injuries according to job categories", the risk was the highest for nurses and least for doctors.

Discussion

The data analyzed in this prospective study were pooled data from four Indian hospitals. The data were prospectively collected during 2 years spanning from the year 2008 to 2009, using a common data collection form from EPINet. The said forms may be obtained electronically through http://www.healthsystem.virginia.edu/internet/epinet/about_epinet.cfm. The participating hospitals are fairly large sized, as can be noted from the number of employees, hospital, and ICU beds [Table - 1]. The frequency of injury among nurses in this study was high, which is similar to the European and American data. ^{[4],[7],[8],.[9]} What is peculiar in the current Indian data is that a large number of HCWs other than nurses and doctors had SI and BBF. This unique finding is probably because of improper waste segregation, which is rampant in India. ^[9] Stringent waste segregation laws in the West may have provided safe ambience to the HCWs who are not the primary users of the sharps. ^{[8],[9],[10],[11],[12]} Jagger and coworkers reported the incidence of SI in housekeeping personnel as 5% in contrast to more than 35% in this study. It is important for the hospital infection control committees in India to apply their mind on this issue and create suitable systems to eliminate it. It is also unfortunate that the HCWs involved in housekeeping generally belong to lower educational and socioeconomic strata. So, it is not uncommon to find them ignorant about the adverse outcome of SI and BBF exposure. From these Indian data, we find that between the nurses and the housekeeping HCWs, most of the avoidable injuries occur unlike the data from developed countries. This, in the author′s opinion, is the important take-home message of this work. It is also likely that due to ignorance, they may not report the injuries to the relevant authorities and obtain prophylaxis.

The common locations of care causing injuries were: patient′s room (35%), outside patient′s room (10%), ICU (10%) and OT (15%). The data from the advanced countries ^[12] show the following incidence: in the patient′s room 35%, outside patient′s room 2%, ICU 7% and OT 22%. These comparisons show similarity to Indian data. The frequency of injury in the patient′s room is similar. But the incidence outside the patient′s room and the OT varies in contrast to the Indian data. The non availability of sharp disposal units by the bed side in the Indian hospitals may be reflected by the high prevalence of injuries in and outside the patient′s room.

In this study, in majority of the instances, the source was known (64.2%), while in nearly 20% of the instances, the source was unknown.

The "finger print" of both seem to be the same. ^[12] This observation from our data and the western one suggests the requirement of emphasis on use of safety designed hypodermic needles and intravenous cannulae. There seems to be a global consensus that most injuries occurred during use. ^[12] In their study of the SI data from the USA, Jagger and coworkers found that out of 16,871 injuries over a 5-year period, 94% were caused by conventional devices and only 6% by safety devices. ^[12] This observation is important; one of the most positive influences in reducing the SI caused by intravenous cannulae and other sharps used in the OTs occurred due to use of safety engineered devices.

The incidence of BBF in our study was only 22 from the four participating hospitals over a cumulated period of 20 months. The finding of lesser number of BBF reported in the Indian data, compared to data from the West, is surprising. This observation in our data may point toward underreporting. The reason why more SI have been reported in contrast to BBF is probably because of increased awareness due to enormous amount of time spent by the infection control team in training the staff members on the hazards of SI and its prevention. The probable high incidence of underreporting of BBF exposure in contrast to the reporting of SI indicates to the hospital infection control committees that they should put more effort to sensitize the HCWs toward the possible dangers of BBF exposure.

There is some degree of underreporting of SI in the Indian data, the degree of which is difficult to determine. It was reported that the average sharp object injury rate is 33 injuries per 100 occupied beds from the analysis of data from USA. The estimated prevalence (after adjusting for underreporting) of SIs sustained annually by hospital-based HCW sin the USA was 384,325 (95% confidence interval:311, 091-463,922). ^[5] Underreporting is a global phenomenon. ^[11],[12]

This study suffers from a few inadequacies. Although the study is expected to reflect the prevalence incidence of accidental exposure of HCWs, it may not be so. The participating hospitals are all corporate hospitals located in major cities of India. Therefore, the data from these hospitals may not be a true reflection of the prevailing conditions in the not-so-affluent parts of India. The purpose of this study was merely to understand the prevalence of the SI and BBF in India. The denominators for the calculations are the number of HCW days which is not taken into account in this study. The future data from the authors′ group will include the denominators in the required calculations.

Conclusion

The data of this prospective multicentric study show a high incidence of injuries among HCWs. More than a third of these injuries were preventable. There is likely to be underreporting among the participating hospitals, the incidence of which is unknown. The future endeavor of the authors of this work will be to collate data from more hospitals from India to enable better representation.

References

1.	NIOSH alert: Preventing needlestick injuries in health care settings. Washington, DC: National institute for occupational safety and health, 1999 (publication number 2000-108).  Back to cited text no. 1
2.	Kerwat K, Goedecke M, Wulf H. Needlestick injuries. Anasthesiol Intensivmed Notfallmed Schmerzther 2009;44:344-5..   Back to cited text no. 2
3.	Jayanth ST, Kirupakaran H, BrahmadathanKN, Gnanaraj L, Kang G. Needle stick injuries in a tertiary care hospital. Indian J Med Microbiol 2009;27:44-7.  Back to cited text no. 3  [PUBMED]
4.	Mehta A, Rodrigues C, Ghag S, Bavi P, Shenai S, Dastur F. Needlestick injuries in a tertiary care centre in Mumbai, India. J Hosp Infect 2005;60:368-73.  Back to cited text no. 4
5.	Panlilio AL, Orelien JG, Srivastava PU, Jagger J, Cohn RD, CardoDM, et al. Estimate of the annual number of percutaneous injuries among hospital-based healthcare workers in the United States, 1997-1998. Infect Control Hosp Epidemiol 2004;25:556-62.  Back to cited text no. 5
6.	Greene ES, Berry AJ, Arnold WP 3rd, Jagger J. Percutaneous injuries in anesthesia personnel. Anesth Analg 1996;83:273-8.   Back to cited text no. 6
7.	Jahan S. Epidemiology of needlestick injuries among health care workers in a secondary care hospital in Saudi Arabia. Ann Saudi Med 2005;25:233-8.  Back to cited text no. 7  [PUBMED]
8.	Hernndez Navarrete MJ, Campins Martí M, Martínez Sánchez EV, Ramos Pérez F, García de Codes Ilario A, Arribas Llorente JL; Grupo de Trabajo EPINETAC. Occupational exposures to blood and biological material in healthcare workers. EPINETAC Project 1996-2000 Med Clin (Barc) 2004;122:81-6.   Back to cited text no. 8
9.	Rao PH. Report: Hospital waste management--awareness and practices: a study of three states in India. Waste Manag Res 2008;26:297-303.  Back to cited text no. 9
10.	ShiaoJS, McLaws ML, Lin MH, Jagger J, Chen CJ. Chinese EPINet and recall rates for percutaneous injuries: an epidemic proportion of underreporting in the Taiwan healthcare system. J Occup Health 2009;51:132-6.  Back to cited text no. 10
11.	Watterson L. Sharp thinking. Nurs Stand 2005;20:20-2.   Back to cited text no. 11
12.	Trim JC. A review of needle-protective devices to prevent sharps injuries. Br J Nurs 2004;13:146-53.  Back to cited text no. 12

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