Literature Reviews
Lai KK, Fontecchio SA, Kelley AL, et al. Knowledge of the transmission of tuberculosis and infection control measures for tuberculosis among healthcare workers. Infect Control Hosp Epidemiol 1996; 17:168-170.
Two hundred seventy-five of 325 health care workers (85%) who attended an all-day infection control training program at the University of Massachusetts Medical Center (UMMC) in Worcester filled out a questionnaire to test their knowledge of tuberculosis transmission and infection control measures for preventing TB's transmission among HCWs. Results showed that HCWs need to be re-educated about TB.
Questionnaires were distributed at the outset of the training program, which focused on infection control and the bloodborne pathogens standard. Questions asked included the risks of contracting TB at work, modes of transmission, employee health services available for purified protein derivative (PPD) skin testing and exposure work-ups, TB infection control measures, and participants' recent experiences with TB education and training.
UMMC, a 375-bed tertiary care teaching facility that employs about 4,000 HCWs, had six active TB cases in its patient population in 1993 and eight in 1994. Of the 275 HCWs who completed the questionnaire, 200 had TB patient contact (66 doctors, 83 nurses, and 51 others). Two hundred thirty-three participants (85%) agreed that HCWs were at risk for TB at work.
Of the 75 HCWs with no patient contact, 49 (65%) said masks should be worn, and 40 (53%) said they would use gowns for TB protection. In contrast, 175 (88%) of the workers who had TB patient contact thought masks should be worn, and 70 (35%) said they would use gowns. One hundred seventy-four (87%) said respiratory precautions should be instituted.
One hundred eighty-two (91%) of the HCWs with patient contact agreed that they were at risk for TB at work, but less than half of the workers who had TB patient contact had received TB education in the past two years. Only 88% were aware of the need for at least a yearly PPD skin test and a chest X-ray for employees with positive PPDs or newly converted skin tests.
A number of HCWs with patient contact were unsure of TB transmission modes. Some even thought TB could be transmitted through shaking hands, sexual contact, drinking fountains, and mosquito bites.
The authors note that Centers for Disease Control and Prevention guidelines emphasize the need for education and training of HCWs about TB. Nevertheless, "Our brief survey showed that our HCWs with and without patient contact differed significantly in the knowledge of the transmission of TB and infection control measures for the prevention of its transmission and, furthermore, HCWs with patient contact had gaps in their understanding of TB transmission and infection control as well," the authors state. "The fact that 35% of HCWs with patient contact thought that they needed gowns to take care of TB patients showed their lack of understanding of the modes of transmission of TB."
All HCWs require re-education
The researchers note that educational efforts must focus on TB prevention and control, in addition to the bloodborne pathogens standard. All HCWs -- including students, residents, fellows, physicians, nurses, technologists, administrators, and volunteers -- need to be re-educated about clinical presentations, identification of high-risk groups, modes of transmission, infection control measures, and the availability of employee health services for counseling and PPD skin testing.
"This will heighten awareness and decrease the delay of diagnosis, facilitate early and efficient isolation, and prevent unnecessary exposures of HCWs to TB," the authors state. *
Manian FA. Blood and body fluid exposures among surgeons: A survey of attitudes and perceptions five years following universal precautions. Infect Control Hosp Epidemiol 1996; 17:172-174.
A survey of surgeons at an 859-bed tertiary care suburban community medical center in the Midwest five years after adoption of universal precautions (UP) revealed that 29% estimated having at least one potentially serious blood or body fluid exposure (BBE) per month. Nevertheless, failure to report BBEs (usually needlesticks) to the employee health department was common.
In fact, most surgeons in practice for at least 10 years never reported those exposures. The most commonly cited reason for not reporting was perceived low risk of acquiring bloodborne infections. Some also indicated they did not know how to report, while others said they were "too lazy" to report BBEs.
St. John's Mercy Medical Center in Creve Coeur, MO, adopted a formal UP policy in 1988, which remains in effect. All staff physicians, including surgeons, were apprised of the policy through written communications and departmental meetings. The potential for transmission of bloodborne pathogens in the health care setting was emphasized, and infection control inservices are provided annually. Attendance by surgeons generally is poor.
For this study, anonymous questionnaires were mailed to all attending surgeons at the medical center requesting information on surgical specialty, years in practice, and estimated average monthly number of potentially serious BBEs.
BBEs were defined as "exposure to blood or other potentially infectious body fluids by puncture injury (e.g., needlestick, scalpel cut), direct exposure of nonintact skin (e.g., skin with cuts or breaks), or mucosal exposure (e.g., mouth and eyes)."
Additional information requested included the most common types of injuries resulting in BBEs, estimated frequency of reporting them, reasons for not reporting them to the employee health department, and any perceived change in the rate of such exposures during the previous five years (1988 to 1993).
Of 277 questionnaires mailed, 119 (43%) were returned. Responses were received from surgeons in 10 specialties, with obstetrics/gynecology representing 26% of responses. General/vascular accounted for 18%; orthopedic, 13%; otolaryngology, 13%; ophthalmology, 8%; plastic, 8%; oral, 5%; cardiothoracic, 3%; genitourinary, 3%; and neurosurgery, 3%.
Of all responders, 15% had been in practice for less than five years, 22% for five to nine years, 38% for 10 to 19 years, and 25% for more than 20 years.
Estimated monthly frequency of BBEs was less than one for 71% of responders, one to three for 16%, and four or more for 13%.
Needlestick injury was ranked as the most common cause of BBEs by 57% of responders, followed by mucosal exposure (16%), exposure to nonintact skin (15%), miscellaneous injuries (12%), and scalpel cuts (4%). Miscellaneous injuries included cuts from bone edges, sutures, wires, pins, and other sharp objects.
BBE reporting rates to the employee health department were estimated by 115 surgeons as:
* never, 75 (65%);
* 10% to 50% of the time, 10 (9%);
* 50% to 75% of the time, seven (6%);
* always, 23 (20%).
The most frequently cited reason for not reporting BBEs to the employee health department was perception of low risk of infection transmission (63%), followed by not knowing how to report (20%), and miscellaneous reasons (17%). The latter include being "too lazy to report" and regular self-testing for HIV and hepatitis. Routine preoperative testing of patients for HIV and hepatitis B was cited by only 1% of responders.
Of 116 responders estimating the trend in frequency of BBEs over the previous five years, 59% reported a reduction, 4% reported an increase, and 37% felt there had been no significant change in the number of BBEs.
The proportion of surgeons indicating they had incurred at least four BBEs per month differed significantly by years of surgical practice, ranging from 0% for those in practice less than five years to 28% for those in practice 20 or more years.
Similarly, significant differences emerged in the proportion of surgeons never reporting BBEs to employee health, with 72% of those in practice 20 or more years never reporting, and 47% of those in practice less than five years never reporting BBEs to employee health.
The author concludes that despite adoption of UP and the emphasis on bloodborne pathogens transmission, BBEs among surgeons remain common.
"The finding that longer-practicing surgeons were significantly less likely to perceive BBEs as important and also less likely to report them to the employee health department suggest that the higher frequency of BBEs among these surgeons may at least in part reflect their relative lack of concern regarding such injuries," the author states.
The finding that 20% of surgeons did not know how to report BBEs suggests that periodic reminders on proper procedure for reporting to the employee health department are necessary.
In conclusion, the author notes that surgeons' perceptions that potentially serious BBEs are not important injuries worthy of reporting and follow-up "are likely to hinder future efforts aimed at further reducing the rate of such exposures among these healthcare workers." *
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