Bloodborne pathogen exposure in the OR—What research has taught us and where we need to go

Article Outline

• ABSTRACT
• Behavioral Objectives
• Pathogens of Greatest Concern
• Mechanisms of Bloodborne Pathogen Transmission
• Research on Percutaneous Injuries
  • Glove Use.
  • Precaution compliance.
  • Underreporting of needle stick injuries.
• Social and Economic Costs of Contracting a Bloodborne Disease
• Regulation of Hazards
• How Can HCWs be Protected?
  • Policies and procedures.
  • Product evaluation.
  • Training and education.
  • Safety engineered, needle stick avoidance devices.
  • Sharps-injury log.
• Gaps in the Literature
• Promoting Safe Practices
• Notes
• Copyright

ABSTRACT 

The article “Bloodborne pathogen exposure in the OR—What research has taught us and where we need to go” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, education program professional, Center for Perioperative Education.

Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is April 30, 2009.

Complete the examination answer sheet and learner evaluation found on pages 851–852 and mail with appropriate fee to

AORN Customer Service

c/o Home Study Program

2170 S Parker Rd, Suite 300

Denver, CO 80231-5711

or fax the information with a credit card number to (303) 750-3212.

You also may access this Home Study via AORN Online at http://www.aorn.org/journal/homestudy/default.htm.

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Behavioral Objectives 

After reading and studying the article on bloodborne pathogen exposure in the OR, nurses will be able to

Contracting a disease from bloodborne pathogen infectious agents has been identified as an occupational hazard for perioperative staff members for more than two decades.¹ In 1996, there were 786,885 occupational exposures to bloodborne or other body fluid pathogens in the United States, a calculated rate of 30 exposures per 100 hospital beds.²

Although standard precautions were introduced to health care workers (HCWs) in the 1980s, research continues to report that there is less than 100% compliance among HCWs with measures demonstrated to decrease disease transmission.² Despite the known hazards, HCWs in the surgical setting continue to take risks by practicing without the appropriate equipment, such as protective gowns, eyewear, or waterproof garments.²

Hospital administrators and managers must be aggressive in providing optimal safety programs, which are required under new Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey requirements. An institution that has good safety programs in place will experience multiple benefits, such as

Knowledge and understanding of occupational hazards and the potential exposure to bloodborne pathogens should be derived from evidenced based practice. This article discusses bloodborne pathogens and mechanisms of transmission, compliance with universal guidelines, and the social and economic costs of contracting a bloodborne illness from an occupational source. Steps to ensure that HCWs are protected also are outlined.

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Pathogens of Greatest Concern 

The pathogens of greatest concern are HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV).⁴ Although national data on occupationally acquired HIV infections in the United States are not complete, cases compiled through 1996 show that three surgical technicians and six surgeons contracted HIV from occupational exposures.⁵ These numbers are considered a low estimate.⁵ As of December 2001, the Center for Disease Control and Prevention (CDC) had received reports of 57 documented cases of occupational HIV transmission and 138 cases of possible occupational HIV transmission to HCWs in the United States.⁴

According to the CDC, the risk of HBV infection after a single needle stick injury with a contaminated needle varies from 6% to 30% depending on the antigen status of the source patient.⁴ More than 8,500 HCWs have contracted HBV.⁶, ⁷ From those numbers, many will die as a result of chronic HBV infection.

Cases of HBV in HCWs declined from more than 10,000 in 1983 to fewer than 400 in 2001; this is due, in part, to widespread immunization of HCWs.⁴ Hepatitis C virus, however, continues to be a risk for HCWs because no vaccine currently is available nor is there viable treatment to prevent an infection postexposure. The risk of HCV transmission depends on the status of the source and ranges from 2.7% to 10%.⁸ The number of HCWs who become infected with HCV each year is not known.⁴

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Mechanisms of Bloodborne Pathogen Transmission 

Occupational exposure to bloodborne pathogens can occur in four different ways: cutaneous contact, mucous membrane contact, percutaneous penetration, and aerosolization of blood. The first mode of transmission is through cutaneous contact, and intact skin is the first line of defense that helps to prevent contamination. Most cutaneous exposures, however, occur as a result of breaks in the skin that go unnoticed by the HCW.⁶ Many HCWs, especially OR personnel, develop breaks in their skin that are thought to be a result of repeated scrubbing and hand washing and dermatitis linked to latex glove use;⁶ thus the very item used to protect HCWs also may be putting some of them at risk. Latex sensitivity is reported to be 3% in HCWs as a whole and 6% in OR personnel.⁶

The second mode of transmission is through mucous membranes (ie, the lining of the mouth, nostrils, eyes, and genital mucosa), which are more vulnerable to disease organisms than intact skin. According to one group of researchers, there is a 0.9% chance of contracting HIV through mucous membrane contamination.² These researchers reported four documented cases of US health care workers who seroconverted after exposure to HIV-infected blood as a result of contact with mucous membranes.⁶ A single case in Italy also was documented. Many examples of HBV and HCV infection after mucous membrane exposure have been reported.⁶

The third mode of transmission is the percutaneous route, also known as the transcutaneous or parenteral route. This type of transmission occurs when an item, which may include a sharp instrument such as a hollow-bore or blunt needle, a scalpel, or even rigid tissue (eg, bone, teeth) penetrates the skin.⁶ There is approximately a 0.3% risk of seroconversion for HIV for all health care providers after a needle stick injury or cut occurs.⁶ The risk increases to a 30% chance of infection for contact with HBV and 1.8% to 10% for contact with HCV from a contaminated percutaneous injury.

The last mode of transmission has not been well researched. In a preliminary study, the exposure of aerosolized blood in the OR was assessed by monitoring the breathing zones of the primary and assistant surgeons using a personal cascade impactor (ie, air sampler designed to determine the breathing zone concentration of aerosol by particle size fraction).⁹, ¹⁰ The data from this study demonstrated that the mucous membrane lining of the upper respiratory tract as well as the alveolar macrophages in the gasexchange region are prone to exposure to aerosolized blood in the OR.⁹ In a similar study conducted more recently, researchers found that use of high-speed cutters in spinal surgery produced an aerosol that may be contaminated withpathogens from an infected or colonized patient.¹¹ The study demonstrated that the aerosol spread throughout the surgical suite, contaminating all personnel present during the surgical procedure.¹¹

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Research on Percutaneous Injuries 

Perioperative personnel are particularly vulnerable to percutaneous exposure because surgeries are invasive procedures that require

Many of the devices used in the OR put perioperative personnel at greater risk for injury, and many pieces of equipment used in the OR are potential vehicles for blood exposure injuries. In an extensive literature review of needle stick injuries, a group of researchers found evidence suggesting that the rate of injury in OR personnel is dramatically higher than that observed in HCWs working in general hospital settings.¹³

According to one group of researchers, percutaneous injury rates in OR personnel range from 1.7% to 15%.⁶ The findings were dependent on the type of surgery and other factors. The circulating nurse sustained the greatest number of injuries, and the risk of those injuries increased after the first hour of surgery. One group of researchers examined the frequency of blood contamination and percutaneous injury, the causes of injury, and factors that may increase or decrease the risk for individuals during surgical procedures.¹⁴ They determined that 50% of the procedures studied had at least one individual who became infected with blood. Cuts or needle stick injuries occurred during 15% of the surgical procedures.¹⁴

One researcher estimated that annually, 1,762 HCWs are susceptible to seroconversion after a needle stick injury.¹⁵ Data demonstrates that 64.7% of all serconversions will occur in nursing personnel because of the number of nurses employed and the frequency with which they use sharps and sustain needle stick injuries.¹⁵

An extensive literature review of needle stick injuries in the United States reported that 44% of 1,918 injuries reported were sustained by nurses and only 15% by physicians, according to the 2001 EPINet database.¹⁶ Furthermore, the literature review described several epidemiological studies that examined the frequency of needle stick injuries in the OR and found a significantly higher risk of injury in this subgroup.¹⁶

Glove Use. 

One study revealed that during 2,292 procedures, 249 glove tears and 70 injuries from sharp objects were documented.¹⁷ In 63% of the glove tears, there was visible contact with the patient's blood. The cause of the glove tear could be identified in only 33% of the cases. These findings suggest that most glove tears are the result of unknown causes.

In one study, it was documented that surgical personnel who double gloved not only reduced the perforation rate for the inner glove by more than 60% but also prevented cutaneous hand exposure to blood.¹⁷ In addition, the study found that if those same individuals wore face shields, waterproof gowns, and water-proof boots, they could prevent more than half the number of cutaneous exposures involving sites other than the hand.¹⁸ In a more recent study, researchers compared the efficiency of single and double gloving and found that perforations occurred 18.5% of the time during conventional orthopedic procedures and 5.8% of the time during arthroscopic procedures.¹⁹ Risk of contamination from blood was 13 times higher when the single-gloving technique was used rather than double gloving.

Precaution compliance. 

One study assessed and characterized self-reported levels of compliance with standard precautions among hospital-based HCWs who were at risk for a bloodborne pathogen exposure and determined correlates of compliance.³ They found that the highest levels of compliance among staff members were for wearing gloves, disposing of sharps, and appropriate disposal of contaminated waste. The lowest levels of compliance were related to needle recapping, wearing protective eyewear and outer clothing, and spill clean up.

Underreporting of needle stick injuries. 

According to the federal government, HCWs experience between 600,000 and one million needle stick injuries each year.²⁰ Research has demonstrated, however, that less than 30% of all needle stick injuries are reported,²⁰ and HCWs do not adhere to exposure reporting protocols consistently. Perioperative personnel experience the highest percutaneous injury rates; however, they report the fewest exposures of any group.²¹ This underreporting hinders efforts of the American Nurses Association and other agencies trying to protect HCWs. Without accurate data, the Occupational Safety and Health Administration (OSHA) may have a difficult time justifying a requirement for safer devices. Many of the exposures go unreported because reporting procedures are cumbersome and take too long to fill out on a busy shift. Nurses also fear reprisals or embarrassment from the situation.

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Social and Economic Costs of Contracting a Bloodborne Disease 

There are many costs associated with contracting a bloodborne illness from an occupational source. Those costs include human costs, medical expenses, and organizational losses.²¹ Human costs include not only physical pain, discomfort, and injury, but also psychological and emotional trauma. Multiple personal consequences may occur for a HCW after a needle stick injury involving patients who are HCV or HIV positive. These may include

Those who survive will incur huge medical bills, whether paid for through privately owned insurance or the employer's workers compensation insurance as a work-related injury. Researchers who examined the costs incurred when treating a body substance exposure found those costs ranged from $141 for initial treatment to nearly $1,700 for prophylactic treatment and follow-up care for one year.²¹ Costs of treatment for HCV conversion reached nearly $14,000 and included a referral to a gastrointestinal service for treatment with interferon and ribavirin. If an exposure leads to chronic hepatitis and consequently necessitates a liver transplant, the costs rise significantly. The cost for a liver transplant and subsequent hospitalization is approximately $140,000. This cost does not include the antirejection medications and follow-up care that can exceed $10,000 a year.²¹

Treatment costs can vary significantly; however, this is just one example of what an employer may incur from one employee's exposure. This does not include continuously paying the employees salary during disability and compensating for the lost manpower via overtime expenses for other employees performing the work of the injured worker. The employer may need to hire and train new employees to replace the employee on disability. The injured employee may return but be unable to perform at the same level as before the injury. The employer also may encounter additional costs, such as an accident investigation, legal fees, or a fine citation from OSHA, and the accreditation status of the institution could be affected.²¹

The onus does not fall solely on the employer. Health care workers who are injured on the job must report the injury. Failing to do so may make it difficult to obtain worker's compensation and other benefits or the benefits may be denied altogether.²² Failing to use appropriate personal protective equipment (PPE) may incur punitive disciplinary action, job discrimination, denial of worker's compensation claims, and loss of future employment opportunities.² These are salient reminders of the importance for the early introduction and training of safe needle-handling techniques.¹⁵

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Regulation of Hazards 

Although nurses are better protected from environmental hazards now than they were 100 years ago, many of the new technologies and illnesses of today present additional health risks. New legislative mandates and regulatory standards require employers to

Many aspects of the job require vigilant adherence to policies, procedures, and regulations that protect nursing staff members so they can provide safe and adequate nursing care to patients. Many hazards can be avoided, reduced, or managed by adhering to sound policies, procedures, and regulations, and in so doing, risk can be managed more effectively.¹⁶ Perioperative infection control programs meant to improve compliance with standard precautions must address the perceptions that may influence compliance.², ⁷, ²³

Policies and standard operating procedures of hospitals and other health care settings should be developed and enforced by complying with local, state, and federal regulations. Many guidelines are available from professional organizations, such as AORN and governmental agencies, including but not limited to, the

Even with numerous agencies over-seeing the environment, many occupational risks still exist, and newer methods should be developed to reduce the risk of HCWs contracting an illness from bloodborne pathogens. The cost of safety devices and the unwillingness of personnel to modify their practice behavior may make many interventions difficult to implement. Administrators and management teams should share ideas and work collectively with employees to develop acceptable prevention programs.²¹

One method of managing the highrisk perioperative environment is developing risk management services or teams. A successful risk management plan always seeks to provide working conditions that will not put the health and safety of the workforce at risk.²⁴ At a minimum, these programs should contain four key elements: administration, prevention, correction, and documentation. Often, governmental agencies, health care settings, and nurses themselves do not communicate well. For instance, legislation and regulations are in place only to provide the framework for protection from occupational injuries and illnesses.⁷ Gaps in education, enforcement, observance, and regulation still exist. Filling these gaps before they become potential killers is the joint responsibility of employers and employees.⁷

The Needlestick Safety and Prevention Act of November 2000 provides stricter guidelines for the protection of HCWs.²⁵ As part of the Needlestick Safety and Prevention Act, new provisions of the bloodborne pathogens standard took effect July 17, 2001. The revised provisions specify types of engineering controls, such as safer medical devices in the health care setting, and add new requirements for employers. Employers must review their exposure control plans annually to reflect changes in technology that will help eliminate or reduce exposure to bloodborne pathogens. Employers also must involve nonmanagerial workers in evaluating and selecting safety engineered devices and maintain a sharps injury log that ensures employee privacy and contains, at a minimum, the type and brand of device involved in the incident, if known; the location of the incident; and a description of the incident.

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How Can HCWs be Protected? 

If the health care workplace is going to become safer in the next decade, a better understanding is needed of what drives HCWs’ behavior and adherence to universal or standard guidelines.²⁶ Health care facilities must invest enough resources into wide-ranging programs that attempt to reduce occupational exposures. Although hazards associated with working in the OR always will be present, behaviors associated with protection can be modified to decrease the chances of exposure. Increasing awareness through education, communication, and effective leadership will promote a healthier workforce. It is the combination of these changes that will lead effectively to improved safety not only for HCWs but also for patients.

With the Needlestick Safety and Prevention Act in place, injury prevention is a shared responsibility between employer and employee. Instituting appropriate policies and procedures; jointly evaluating products; ensuring adequate staff member training and education; identifying and using safety engineered, needle stick avoidance devices; and maintaining an injury log are all methods to prevent injury.

Policies and procedures. 

Employers have to evaluate policies and procedures concerning exposure control on an annual basis and should not wait for their accreditation review process. This ensures that all policies are up to date and match what products are being used by staff members.

Product evaluation. 

Prevention planning charges employees with actively seeking out and deciding what products should be used in the work setting; this is logical, because employees are the ultimate users of the products. Selection, evaluation, and implementation of new devices can be a daunting task that must be undertaken by individuals who will use the devices under review. This is necessary to provide protection.

Training and education. 

Participating in purchasing decisions results in increased responsibilities for training and educating HCWs. This responsibility falls on both the employer and employees to ensure that everyone is trained on current technologies and products being used in the facility.

Safety engineered, needle stick avoidance devices. 

Needle stick injuries are preventable. The CDC established through research that 86% of needle stick injuries could be prevented with use of safety engineered needle stick avoidance devices.¹⁶ Producing safety engineered sharps injury-avoidance devices is essential in preventing percutaneous injuries; however, they constitute only part of a strategy that includes education and collection of appropriate surveillance data.²⁷

Sharps-injury log. 

Maintaining a sharps-injury log is another intervention that identifies the number of employees injured as well as annotating the products and circumstances involved in the injury. This helps to identify true numbers of incidents. It also helps nurses and other HCWs feel comfortable reporting all injuries that occur on the job and not feel intimidated by the employer for fear of repercussions as a result of an injury. Ultimately, use of a sharps-injury log provides current information on the risk of needle stick injuries and bloodborne pathogen transmission and helps identify interventional strategies to reduce these risks.

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Gaps in the Literature 

Although environmental and occupational health issues have been addressed during the last decade, they are not new problems. Research findings have been obtained from multiple specialties and comparisons made with other health care populations to help identify environmental and occupational risk factors associated with bloodborne pathogen exposures of perioperative personnel. Missing from the literature is empirical evidence conducted by nursing professionals concerning bloodborne pathogen exposures in the OR. Much of the literature is more than five years old and does not address perioperative nurses or RN first assistants specifically. Currently, documentation regarding the complexity of the problem must be found outside of professional nursing journals. This may be due in part to the fact that nursing currently is concentrating on patient-safety rather than employee-safety issues.

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Promoting Safe Practices 

Nurses should not accept intolerable work conditions and unsafe patient care situations.²⁸ Perioperative nurses are in an excellent position to take the lead role in preventing occupational exposures to bloodborne pathogens and decreasing the risk factors associated with the job. All perioperative nurses should

Although it may be difficult to change certain aspects of the perioperative physical environment, HCWs can promote safe practices by modifying behaviors and attitudes toward standard precautions and compliance with reporting protocols. This is not a simple task to accomplish. These safety measures are going to require a fresh perspective and new strategies. Measurable results will require professional HCW competence and accountability and effective management to improve techniques in reporting, safety, and education. Current work environments must be adapted through comprehensive orientation programs before significant changes can be implemented successfully.

Implementing these ideas can lead to a safer work environment and can act as a workforce multiplier. Safety goes hand-in-hand with knowledge, skill, and competency. If perioperative nurses are lax in safety and protection practices, long-term injury can result. Potential hazards should be identified and safe practices established. Perioperative nurses should make full and appropriate use of the safety and control measures established by the facilities in which they work and the procedures set in place to protect them from occupational hazards. Substantial opportunities exist for reducing percutaneous and mucocutaneous exposures and for preventing occupational blood exposures in the surgical setting.²⁹

To make a significant impact, numerous changes and a sustained effort must be made to fully understand the complexity of the environment and the wide variety of products and instruments used. Exposure surveillance will play an important role as a foundation for clinical trials that document the efficacy of safer products and procedures for future prevention initiatives. It will be an investment that ultimately benefits not only OR personnel, but also the patients for whom they care. Research into occupational safety is necessary to

As new technologies and procedures evolve, all hazards in the perioperative environment may not necessarily be fully understood or viewed as a hazard. That is why perioperative HCWs must decrease their chances of a bloodborne pathogen exposure through education, patient and staff member identification, and change in behaviors related to the use of PPE and standard precautions.

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Notes 

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    • Full-Text PDF (2904 KB)
    • CrossRef