Blood contamination of tourniquets used in routine phlebotomy Gilda Forseter, BA, AS, RN Carol Joline, BA, RN, CIC Gary P. Wormser, MD Valhalla,
New
York
Hepatitis B and, more recently, human immunodeficiency virus (HIV) infection have increased concern about potential exposures to blood in the hospital environment.“4 This study evaluated the frequency of blood contamination of phlebotomy tourniquets and staff perceptions and practices concerning tourniquets. METHODS
This study was carried out in two phases during the fall of 1987. In the first phase 102 tourniquets were collected at random from house officers, ward medication carts, intensive care units, the hemodialysis unit, and the phlebotomy and intravenous team carts. We estimate that tourniquets collected represented a substantial proportion (~50%) of those in use at the medical center at the time. Personnel were not informed as to the reason for the collection. Tourniquets with stains suggestive of blood were tested by the leucomalachite method.5 This catalytic test, which is widely used in forensic laboratories, is capable of detecting blood at a dilution of at least 1: 20,000.’ As controls new tourniquets were coded and stained with either povidone-iodine (No. lo), blood (No. lo), or ink (No. 4). In the second phase an anonymous questionnaire on tourniquet practices was distributed to the medical, surgical, pediatric, neurology, and anesthesiology residents, the intravenous and phlebotomy teams, and the nurses in the hemodialysis unit. From icine,
the Division of Infectious Diseases, New York Medical College.
Reprint requests: eases, Professor New York Medical 17/47/22019
386
Department
of Med-
Gary P. Wormser, MD, Chief, Infectious Disof Medicine, Macy Pavilion, Room 209SE, College, Valhalla, NY 10595.
RESULTS
One hundred two tourniquets were examined for possible blood contamination. Ninety-six of the tourniquets were made of latex and six were of rubber with Velcro fastener closures. Fortythree (42%) had staining suggestive of blood contamination. Of these, 37 were latex and 6 had Velcro fasteners. Thirty-one (30%) tested positive for the presence of blood. This represented 27 of 37 (73%) latex tourniquets and 4 of 6 (67%) of the tourniquets with Velcro fasteners. Among the controls, 10 of 10 tourniquets inoculated with blood tested positive for blood, whereas those contaminated with a povidoneiodine preparation (No. 10) or ink (No. 4) tested negative for blood. One hundred fifteen questionnaires were completed and returned. Respondents included 36 (88%) of the 41 medical residents, 16 (94%) of the 17 surgical residents, 12 (100%) of the pediatric residents, 4 (100%) of the neurology residents, 8 (67%) of the 12 anesthesiology residents, 7 (100%) of the intravenous team members, 14 (88%) of the 16 phlebotomy team members, and 18 (78%) of the 23 hemodialysis nurses. Responses to questions pertinent to the issue of blood contamination of tourniquets are found in Table 1. DISCUSSION
The era of the acquired immunodeficiency syndrome has prompted a closer look at infection control practices.6e12 All possible sources of body fluid contamination should be reevaluated in an effort to minimize the risk of infection to hospital workers and patients. In light of this concern we studied the infre-
Volume December
18 Number 1990
6
Blood contamination
quently considered tourniquet, which is used by medical personnel for routine phlebotomy. Our study found t.hat blood contamination of tourniquets was common, occurring in 3 1(30%) of the 102 tourniquets examined, as measured by a standard chemical method.5 Although a number of chemical substances are known to give false-positive reactions in such testing,5 there are several reasons to believe that the rate of contamination found in our study was accurate or, if incorrect, an underestimate. First, only visibly stained tourniquets were tested; therefore smaller amounts of blood contamination could have been missed entirely. Second, when surveyed, the vast majority (79%) of our staff admitted to having witnessed blood stains on tourniquets (Table 1). Third, the preparation of povidone-iodine used in our hospital, a substance that would likely soil tourniquets periodically and that might be confused with blood, did not give false-positive reactions with the chemical test used in this study. The specific source of contaminated tourniquets was not determined in this study (linkage had been removed by time of testing). However, a follow-up questionnaire did help to clarify why the high rate of blood contamination was observed (Table 1). Our staff often (96/l 12; 86%) reused tourniquets. Reuse on multiple patients (~6) was frequent, reported by 61 (60%) of 102 respondents, with 32/102 (31%) reusing their tourniquet on more than 20 patients before discarding. Fifty-four (50%) of 108 respondents had personally contaminated a tourniquet with blood three times or more. Although our staff frequently noticed blood spills on tourniquets, they cleaned tourniquets between patients considerably less often. Only 29/103 (28%) of the respondents routinely cleaned tourniquets between patients. A preferred approach according to 86 of 113 (76%) of our respondents was to discard a blood-stained tourniquet. However, it is obvious that many contaminated tourniquets remain in use, suggesting that either blood spills on tourniquets frequently go unnoticed, or less actual concern is given to blood contamination than may have been interpreted from the survey findings. Furthermore, it is likely that the hands of staff members may have been exposed to blood in
of tourniquets used in phlebotomy
387
this manner on occasion, because only 42 of 114 (37%) routinely wore gloves during tourniquet use. It is also highly probable that the skin of patients undergoing phlebotomy was similarly exposed at times to the blood of other patients. Among the different groups of staff members surveyed, the nurses in the hemodialysis unit had the most consistent and careful tourniquet technique. All wore gloves during phlebotomy procedures, and all confined tourniquets to individual patients. These practices could be attributed to implementation of a specific written policy for tourniquet use in their unit. Despite the frequency of reuse and high rate of contamination, tourniquets have rarely been associated with the spread of nosocomial infections. A brief report suggested that tourniquets may play a role in transmission of methicillinresistant StuphyZococcus utLreus,‘3 but to our knowledge transmission of blood-borne agents has not been demonstrated. However, it is unclear how carefully this route of transmission has been previously considered. Spread of HIV by exposure to contaminated fomites such as tourniquets would be unlikely, because the virus is present in relatively low concentrations in blood and is rapidly killed by drying.14-16 However, the situation for hepatitis B may be different. Hepatitis B is not easily killed by drying and has been shown to remain viable for at least 7 days in a desiccated state.” Furthermore, degree of contact with blood per se, rather than frequency of inoculation injury, may be the most important correlate with transmission of hepatitis B to health care workers.18-21 The infectiousness of dried blood specifically, however, has not been established. Although contamination of tourniquets has been associated with little health risk, disease transmission remains theoretically possible. Present tourniquet practices as documented in this study are clearly undesirable and do not conform to the concepts implicit in the recently issued guidelines for “universal precautions .“l* Consequently, the following measures are proposed: 1. All patients should be supplied with their own tourniquets. Labeling of tourniquets
Table 1. Use of tourniquets by health care workers Professional
groups
surveyed
Residents Selected
survey
Blood drawing Drew Drew
blood blood
Tourniquet
Medical
responses
experience,
Surgical
Neurology
Anesthesiology
intravenous team
Phlebotomy team
No. (%)
>2 yr >lO times/wk
30136 19/35
(83) (54)
6/12 11/12
(50) (92)
15/16 7115
(94) (47)
414 (100) 1 I4 (25)
818 (100) 818 (100)
617 (86) 617 (86)
8114 13114
(57) (93)
29136
(81)
7112
(58)
14116
(88)
214 (50)
718 (88)
617 (86)
14114
(100)
417 (57)
10113
(77)
212 (100)
417 (57)
417
(57)
5114
(36)
217 (29)
3113
(23)
1 I2 (50)
l/7
o/7
(0)
O/l4
(0)
(67)
314
(75)
518 (63)
717 (100)
14114
(100)
practice, No. (%)
Had tourniquet in personal possession Had possessed tourniquet for 23 days Had possessed tourniquet for >3 mo Routinely reused tourniquets Reused tourniquets on 26 patients Reused tourniquets on >20 patients Used tourniquets for 26 days Used tourniquets for >30 days Always wore gloves during tourniquet procedures Handled tourniquets differently if patient on isolation Would discard tourniquet after use on an isolation patient Would leave tourniquet in room if patient was on isolation
Why tourniquets Saw no should niquets Reused cause Reused cause readily tional
Pediatric
14/28(50) 2128
(7)
31 l35(89)
9112
(75)
22/36
(61)
6110
(60)
8115
(53)
II4
(25)
318 (38)
717 (100)
13114
(93)
9136
(25)
2110
(20)
5115
(33)
1 I4 (25)
218 (25)
617 (86)
6114
(43)
17136
(47)
418 (50)
9115
(60)
1 I4 (25)
318 (38)
217 (29)
2114
(14)
8136
(22)
218 (25)
3115
(20)
114 (25)
218 (25)
1 I7 (14)
O/l4
(0)
7136
(19)
29/35(83)
lo/l5
(14)
O/l2
(0)
5115
(33)
1 I4 (25)
418 (50)
217 (29)
5114
(36)
9112
(75)
14116
(88)
314 (75)
718 (88)
717 (100)
14114
(100)
2112
(17)
17129
(59)
419 (44)
9114
(64)
313 (100)
717 (100)
o/7
(0)
11129
(38)
319 (33)
1114
(7)
o/3
o/7
617
(86)
(0)
(0)
12/12
(100)
reused, No. (%)
reason why one not reuse touron >l person tourniquets beconvenient tourniquets beof lack of available additourniquets
Blood contamination,
10136
(28)
2112
(17)
l/16(6)
214 (50)
218 (25)
717 (100)
5114
(36)
15/36(42)
5112
(42)
8116
(50)
1 I4 (25)
418 (50)
o/7
(0)
9114
(64)
21 l36(58)
8112
(67)
8116
(50)
1 I4 (25)
518 (63)
o/7
(0)
6/14
(43)
27136
(75)
7112
(58)
12116
(75)
314 (75)
818 (100)
517 (71)
13/14
(93)
12135
(34)
6111
(55)
6115
(40)
213 (67)
218 (25)
717 (100)
31 I36
(86)
9111
(82)
12115
(80)
1 I4 (25)
618 (75)
7/7
7110
(70)
8114
(57)
214 (50)
418 (50)
No. (%)
Thought about blood contamination before survey Thought that blood contaminates tourniquet 51% per use Noticed blood spills on tourniquets Personally contaminated tourniquet s3 times Routinely cleaned tourniquets between patients Would discard tourniquet soiled with blood
1 g/36(53) 6135
(17)
2110
(20)
3115
(20)
l/4
(25)
29136
(81)
6112
(50)
16116
(100)
414 (100)
9112
(75)
11114
(79)
5/6(83)
7114
(50)
418 (50)
o/7
(0)
2113
(15)
718 (88)
7/7
(100)
(100)
12112
‘Results are expressed as the number of specific responses, compared with the total number of respondents who answered a particular In some instances, due to multiple responses to a single question, the total number of responses exceeded the number of respondents,
(100)
question.
Professional Hemodislysis nurses
16/18 (89) 10/18(56) 6/18
(33)
Total’
93/115(81) 75/113(66) 85/115(74)
5/5
(100)
48/83(58)
5/5
(100)
14/83(17)
(100)
96/112(86)
17/17
118 (13)
61/102
l/8
32/102(31)
(13)
315 (60)
41/97
215 (40)
19/97(20)
18/18(100)
42/114(37)
12114
(86)
95/110(86)
3/12
(25)
45/93(48)
6112
(50)
39/93(42)
7/16(44)
36/113(32)
O/16(0)
42/113
9/16
(56)
with patient names may help in restricting use to a single patient. Tourniquets not assigned to a specific patient should either be disposed of after use, given high-level disinfection, or sterilized, as recommended for other hospital equipment that may come into contact with blood.12 Hospital staff should wear gloves routinely during tourniquet procedures and wash hands afterward. Ample supplies of new tourniquets should be readily available for staff use. (60)
(42)
References
(37)
58/113(51)
15/18(83)
90/115
(78)
14/18(78)
58/109
(53)
11/17
(65)
88/112
(79)
2/16
(13)
54/108
(50)
(100)
29/103(28)
(28)
86/113(76)
ll/ll 5/18
We thank Mr. Fred Drummond and Ms. Lynda Mack for their assistance in this study and Dr. R. Nadelman, Dr. H. Horowitz, and Mr. Murray Forseter for reviewing the manuscript.
1. Wormser GP, Joline C, Sivak SL, Arlin ZA. Human immunodeficiency virus infections: considerations for health care workers. Bull NY Acad Med 1988;64:20315. 2. Centers for Disease Control. Update: human immunodeficiency virus infections in health care workers exposed to blood of infected patients. MMWR 1987;36: 285-9. 3. Kennedy PB, Gwaltney JM Jr. Brief report: the detection of blood on gloved hands of central sterile supply personnel and cleaned instruments used for procedures on patient units. Infect Control Hosp Epidemiol 1988; 9:117-8. 4. Wormser GP, Medure-Collins R, Mack L. Blood contamination of medical records. Infect Control Hosp Epidemiol 1989;10:118-9. RE. Identification of blood: leucomalachite 5. Gaensslen green and leucocrystal violet tests. In: Sourcebook in forensic serology, immunology, and biochemistry. Washington, DC: US Department of Justice, National Institute of Justice, US Government Printing Office, 1983:108-9. 6. Centers for Disease Control. Acquired immune deficiency syndrome (AIDS): precautions for clinical and laboratory staffs. MMWR 1982;31:557-80. 7. Centers for Disease Control. Acquired immunodeficiency syndrome (AIDS): precautions for health-care workers and allied professionals. MMWR 1983;32: 450-l. a. Centers for Disease Control. Recommendations for preventing transmission of infection with human Tlymphotropic virus type IIIllymphadenopathyassociated virus in the workplace. MMWR 1985;34:68195. 9. Centers for Disease Control. Recommendations for preventing possible transmission of human Tlymphotropic virus type III/lymphadenopathyassociated virus from tears. MMWR 1985;34:533-4. for Disease Control. Recommendations for 10. Centers preventing transmission of infection with human Tlymphotropic virus type IIIilymphadenopathy-
American
390
11. 12.
13.
14.
15.
16.
Forseter et al.
associated virus during invasive procedures. MMWR 1986;35:221-3. Centers for Disease Control. Recommended infection control practices for dentistry. MMWR 1986;35:237-42. Centers for Disease Control. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987;36(suppl 2):lS18. Berman DS, Schaefler S, Simberkoff MS, Rahal JJ. Tourniquets and nosocomial methicillin-resistant Staphylococcu.s aureus infections. N Engl J Med 1986; 315:514-5. Friedland GH, Klein RS. Transmission of the human immunodeficiency virus. N Engl J Med 1987;317:112535. Levy JA, Kaminsky LS, Morrow JW, et al. Infection by the retrovirus associated with the acquired immunodeficiency syndrome: clinical, biological, molecular features. Ann Intern Med 1985;103:694-9. Resnick L, Veren K, Salahuddin SZ, et al. Stability and
INFECTION
Journal
of
CONTROL
inactivation of HTLV-IIULAV under clinical and laboratory environments. JAMA 1986;255:1887-91. 17. Bond WW, Favero MS, Peterson NJ, Gravelle CR, Ebert JW, Maynard JE. Survival of hepatitis B virus after drying and storage for one week. Lancet 198 1; 1:550-l. 18. Jacobson JT, Orlob RB, Clayton JL. Infection acquired in clinical laboratories in Utah. J Clin Microbial 1985;21:486-9. 19. Callender ME, White YS, Williams R. Hepatitis B virus infection in medical and health care personnel. Br Med J 1982;284:324-6. 20. Hadler SC, Doto IL, Maynard JE, et al. Occupational risk of hepatitis B infection in hosptial workers. Infect Control Hosp Epidemiol 1985;6:24-31. 21. Pattison CP, Boyer KM, Maynard JE, Kelly PC. Epidemic hepatitis in a clinical laboratory: possible association with computer card handling. JAMA 1974; 230:854-7.
New
York
Hepatitis B and, more recently, human immunodeficiency virus (HIV) infection have increased concern about potential exposures to blood in the hospital environment.“4 This study evaluated the frequency of blood contamination of phlebotomy tourniquets and staff perceptions and practices concerning tourniquets. METHODS
This study was carried out in two phases during the fall of 1987. In the first phase 102 tourniquets were collected at random from house officers, ward medication carts, intensive care units, the hemodialysis unit, and the phlebotomy and intravenous team carts. We estimate that tourniquets collected represented a substantial proportion (~50%) of those in use at the medical center at the time. Personnel were not informed as to the reason for the collection. Tourniquets with stains suggestive of blood were tested by the leucomalachite method.5 This catalytic test, which is widely used in forensic laboratories, is capable of detecting blood at a dilution of at least 1: 20,000.’ As controls new tourniquets were coded and stained with either povidone-iodine (No. lo), blood (No. lo), or ink (No. 4). In the second phase an anonymous questionnaire on tourniquet practices was distributed to the medical, surgical, pediatric, neurology, and anesthesiology residents, the intravenous and phlebotomy teams, and the nurses in the hemodialysis unit. From icine,
the Division of Infectious Diseases, New York Medical College.
Reprint requests: eases, Professor New York Medical 17/47/22019
386
Department
of Med-
Gary P. Wormser, MD, Chief, Infectious Disof Medicine, Macy Pavilion, Room 209SE, College, Valhalla, NY 10595.
RESULTS
One hundred two tourniquets were examined for possible blood contamination. Ninety-six of the tourniquets were made of latex and six were of rubber with Velcro fastener closures. Fortythree (42%) had staining suggestive of blood contamination. Of these, 37 were latex and 6 had Velcro fasteners. Thirty-one (30%) tested positive for the presence of blood. This represented 27 of 37 (73%) latex tourniquets and 4 of 6 (67%) of the tourniquets with Velcro fasteners. Among the controls, 10 of 10 tourniquets inoculated with blood tested positive for blood, whereas those contaminated with a povidoneiodine preparation (No. 10) or ink (No. 4) tested negative for blood. One hundred fifteen questionnaires were completed and returned. Respondents included 36 (88%) of the 41 medical residents, 16 (94%) of the 17 surgical residents, 12 (100%) of the pediatric residents, 4 (100%) of the neurology residents, 8 (67%) of the 12 anesthesiology residents, 7 (100%) of the intravenous team members, 14 (88%) of the 16 phlebotomy team members, and 18 (78%) of the 23 hemodialysis nurses. Responses to questions pertinent to the issue of blood contamination of tourniquets are found in Table 1. DISCUSSION
The era of the acquired immunodeficiency syndrome has prompted a closer look at infection control practices.6e12 All possible sources of body fluid contamination should be reevaluated in an effort to minimize the risk of infection to hospital workers and patients. In light of this concern we studied the infre-
Volume December
18 Number 1990
6
Blood contamination
quently considered tourniquet, which is used by medical personnel for routine phlebotomy. Our study found t.hat blood contamination of tourniquets was common, occurring in 3 1(30%) of the 102 tourniquets examined, as measured by a standard chemical method.5 Although a number of chemical substances are known to give false-positive reactions in such testing,5 there are several reasons to believe that the rate of contamination found in our study was accurate or, if incorrect, an underestimate. First, only visibly stained tourniquets were tested; therefore smaller amounts of blood contamination could have been missed entirely. Second, when surveyed, the vast majority (79%) of our staff admitted to having witnessed blood stains on tourniquets (Table 1). Third, the preparation of povidone-iodine used in our hospital, a substance that would likely soil tourniquets periodically and that might be confused with blood, did not give false-positive reactions with the chemical test used in this study. The specific source of contaminated tourniquets was not determined in this study (linkage had been removed by time of testing). However, a follow-up questionnaire did help to clarify why the high rate of blood contamination was observed (Table 1). Our staff often (96/l 12; 86%) reused tourniquets. Reuse on multiple patients (~6) was frequent, reported by 61 (60%) of 102 respondents, with 32/102 (31%) reusing their tourniquet on more than 20 patients before discarding. Fifty-four (50%) of 108 respondents had personally contaminated a tourniquet with blood three times or more. Although our staff frequently noticed blood spills on tourniquets, they cleaned tourniquets between patients considerably less often. Only 29/103 (28%) of the respondents routinely cleaned tourniquets between patients. A preferred approach according to 86 of 113 (76%) of our respondents was to discard a blood-stained tourniquet. However, it is obvious that many contaminated tourniquets remain in use, suggesting that either blood spills on tourniquets frequently go unnoticed, or less actual concern is given to blood contamination than may have been interpreted from the survey findings. Furthermore, it is likely that the hands of staff members may have been exposed to blood in
of tourniquets used in phlebotomy
387
this manner on occasion, because only 42 of 114 (37%) routinely wore gloves during tourniquet use. It is also highly probable that the skin of patients undergoing phlebotomy was similarly exposed at times to the blood of other patients. Among the different groups of staff members surveyed, the nurses in the hemodialysis unit had the most consistent and careful tourniquet technique. All wore gloves during phlebotomy procedures, and all confined tourniquets to individual patients. These practices could be attributed to implementation of a specific written policy for tourniquet use in their unit. Despite the frequency of reuse and high rate of contamination, tourniquets have rarely been associated with the spread of nosocomial infections. A brief report suggested that tourniquets may play a role in transmission of methicillinresistant StuphyZococcus utLreus,‘3 but to our knowledge transmission of blood-borne agents has not been demonstrated. However, it is unclear how carefully this route of transmission has been previously considered. Spread of HIV by exposure to contaminated fomites such as tourniquets would be unlikely, because the virus is present in relatively low concentrations in blood and is rapidly killed by drying.14-16 However, the situation for hepatitis B may be different. Hepatitis B is not easily killed by drying and has been shown to remain viable for at least 7 days in a desiccated state.” Furthermore, degree of contact with blood per se, rather than frequency of inoculation injury, may be the most important correlate with transmission of hepatitis B to health care workers.18-21 The infectiousness of dried blood specifically, however, has not been established. Although contamination of tourniquets has been associated with little health risk, disease transmission remains theoretically possible. Present tourniquet practices as documented in this study are clearly undesirable and do not conform to the concepts implicit in the recently issued guidelines for “universal precautions .“l* Consequently, the following measures are proposed: 1. All patients should be supplied with their own tourniquets. Labeling of tourniquets
Table 1. Use of tourniquets by health care workers Professional
groups
surveyed
Residents Selected
survey
Blood drawing Drew Drew
blood blood
Tourniquet
Medical
responses
experience,
Surgical
Neurology
Anesthesiology
intravenous team
Phlebotomy team
No. (%)
>2 yr >lO times/wk
30136 19/35
(83) (54)
6/12 11/12
(50) (92)
15/16 7115
(94) (47)
414 (100) 1 I4 (25)
818 (100) 818 (100)
617 (86) 617 (86)
8114 13114
(57) (93)
29136
(81)
7112
(58)
14116
(88)
214 (50)
718 (88)
617 (86)
14114
(100)
417 (57)
10113
(77)
212 (100)
417 (57)
417
(57)
5114
(36)
217 (29)
3113
(23)
1 I2 (50)
l/7
o/7
(0)
O/l4
(0)
(67)
314
(75)
518 (63)
717 (100)
14114
(100)
practice, No. (%)
Had tourniquet in personal possession Had possessed tourniquet for 23 days Had possessed tourniquet for >3 mo Routinely reused tourniquets Reused tourniquets on 26 patients Reused tourniquets on >20 patients Used tourniquets for 26 days Used tourniquets for >30 days Always wore gloves during tourniquet procedures Handled tourniquets differently if patient on isolation Would discard tourniquet after use on an isolation patient Would leave tourniquet in room if patient was on isolation
Why tourniquets Saw no should niquets Reused cause Reused cause readily tional
Pediatric
14/28(50) 2128
(7)
31 l35(89)
9112
(75)
22/36
(61)
6110
(60)
8115
(53)
II4
(25)
318 (38)
717 (100)
13114
(93)
9136
(25)
2110
(20)
5115
(33)
1 I4 (25)
218 (25)
617 (86)
6114
(43)
17136
(47)
418 (50)
9115
(60)
1 I4 (25)
318 (38)
217 (29)
2114
(14)
8136
(22)
218 (25)
3115
(20)
114 (25)
218 (25)
1 I7 (14)
O/l4
(0)
7136
(19)
29/35(83)
lo/l5
(14)
O/l2
(0)
5115
(33)
1 I4 (25)
418 (50)
217 (29)
5114
(36)
9112
(75)
14116
(88)
314 (75)
718 (88)
717 (100)
14114
(100)
2112
(17)
17129
(59)
419 (44)
9114
(64)
313 (100)
717 (100)
o/7
(0)
11129
(38)
319 (33)
1114
(7)
o/3
o/7
617
(86)
(0)
(0)
12/12
(100)
reused, No. (%)
reason why one not reuse touron >l person tourniquets beconvenient tourniquets beof lack of available additourniquets
Blood contamination,
10136
(28)
2112
(17)
l/16(6)
214 (50)
218 (25)
717 (100)
5114
(36)
15/36(42)
5112
(42)
8116
(50)
1 I4 (25)
418 (50)
o/7
(0)
9114
(64)
21 l36(58)
8112
(67)
8116
(50)
1 I4 (25)
518 (63)
o/7
(0)
6/14
(43)
27136
(75)
7112
(58)
12116
(75)
314 (75)
818 (100)
517 (71)
13/14
(93)
12135
(34)
6111
(55)
6115
(40)
213 (67)
218 (25)
717 (100)
31 I36
(86)
9111
(82)
12115
(80)
1 I4 (25)
618 (75)
7/7
7110
(70)
8114
(57)
214 (50)
418 (50)
No. (%)
Thought about blood contamination before survey Thought that blood contaminates tourniquet 51% per use Noticed blood spills on tourniquets Personally contaminated tourniquet s3 times Routinely cleaned tourniquets between patients Would discard tourniquet soiled with blood
1 g/36(53) 6135
(17)
2110
(20)
3115
(20)
l/4
(25)
29136
(81)
6112
(50)
16116
(100)
414 (100)
9112
(75)
11114
(79)
5/6(83)
7114
(50)
418 (50)
o/7
(0)
2113
(15)
718 (88)
7/7
(100)
(100)
12112
‘Results are expressed as the number of specific responses, compared with the total number of respondents who answered a particular In some instances, due to multiple responses to a single question, the total number of responses exceeded the number of respondents,
(100)
question.
Professional Hemodislysis nurses
16/18 (89) 10/18(56) 6/18
(33)
Total’
93/115(81) 75/113(66) 85/115(74)
5/5
(100)
48/83(58)
5/5
(100)
14/83(17)
(100)
96/112(86)
17/17
118 (13)
61/102
l/8
32/102(31)
(13)
315 (60)
41/97
215 (40)
19/97(20)
18/18(100)
42/114(37)
12114
(86)
95/110(86)
3/12
(25)
45/93(48)
6112
(50)
39/93(42)
7/16(44)
36/113(32)
O/16(0)
42/113
9/16
(56)
with patient names may help in restricting use to a single patient. Tourniquets not assigned to a specific patient should either be disposed of after use, given high-level disinfection, or sterilized, as recommended for other hospital equipment that may come into contact with blood.12 Hospital staff should wear gloves routinely during tourniquet procedures and wash hands afterward. Ample supplies of new tourniquets should be readily available for staff use. (60)
(42)
References
(37)
58/113(51)
15/18(83)
90/115
(78)
14/18(78)
58/109
(53)
11/17
(65)
88/112
(79)
2/16
(13)
54/108
(50)
(100)
29/103(28)
(28)
86/113(76)
ll/ll 5/18
We thank Mr. Fred Drummond and Ms. Lynda Mack for their assistance in this study and Dr. R. Nadelman, Dr. H. Horowitz, and Mr. Murray Forseter for reviewing the manuscript.
1. Wormser GP, Joline C, Sivak SL, Arlin ZA. Human immunodeficiency virus infections: considerations for health care workers. Bull NY Acad Med 1988;64:20315. 2. Centers for Disease Control. Update: human immunodeficiency virus infections in health care workers exposed to blood of infected patients. MMWR 1987;36: 285-9. 3. Kennedy PB, Gwaltney JM Jr. Brief report: the detection of blood on gloved hands of central sterile supply personnel and cleaned instruments used for procedures on patient units. Infect Control Hosp Epidemiol 1988; 9:117-8. 4. Wormser GP, Medure-Collins R, Mack L. Blood contamination of medical records. Infect Control Hosp Epidemiol 1989;10:118-9. RE. Identification of blood: leucomalachite 5. Gaensslen green and leucocrystal violet tests. In: Sourcebook in forensic serology, immunology, and biochemistry. Washington, DC: US Department of Justice, National Institute of Justice, US Government Printing Office, 1983:108-9. 6. Centers for Disease Control. Acquired immune deficiency syndrome (AIDS): precautions for clinical and laboratory staffs. MMWR 1982;31:557-80. 7. Centers for Disease Control. Acquired immunodeficiency syndrome (AIDS): precautions for health-care workers and allied professionals. MMWR 1983;32: 450-l. a. Centers for Disease Control. Recommendations for preventing transmission of infection with human Tlymphotropic virus type IIIllymphadenopathyassociated virus in the workplace. MMWR 1985;34:68195. 9. Centers for Disease Control. Recommendations for preventing possible transmission of human Tlymphotropic virus type III/lymphadenopathyassociated virus from tears. MMWR 1985;34:533-4. for Disease Control. Recommendations for 10. Centers preventing transmission of infection with human Tlymphotropic virus type IIIilymphadenopathy-
American
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11. 12.
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14.
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16.
Forseter et al.
associated virus during invasive procedures. MMWR 1986;35:221-3. Centers for Disease Control. Recommended infection control practices for dentistry. MMWR 1986;35:237-42. Centers for Disease Control. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987;36(suppl 2):lS18. Berman DS, Schaefler S, Simberkoff MS, Rahal JJ. Tourniquets and nosocomial methicillin-resistant Staphylococcu.s aureus infections. N Engl J Med 1986; 315:514-5. Friedland GH, Klein RS. Transmission of the human immunodeficiency virus. N Engl J Med 1987;317:112535. Levy JA, Kaminsky LS, Morrow JW, et al. Infection by the retrovirus associated with the acquired immunodeficiency syndrome: clinical, biological, molecular features. Ann Intern Med 1985;103:694-9. Resnick L, Veren K, Salahuddin SZ, et al. Stability and
INFECTION
Journal
of
CONTROL
inactivation of HTLV-IIULAV under clinical and laboratory environments. JAMA 1986;255:1887-91. 17. Bond WW, Favero MS, Peterson NJ, Gravelle CR, Ebert JW, Maynard JE. Survival of hepatitis B virus after drying and storage for one week. Lancet 198 1; 1:550-l. 18. Jacobson JT, Orlob RB, Clayton JL. Infection acquired in clinical laboratories in Utah. J Clin Microbial 1985;21:486-9. 19. Callender ME, White YS, Williams R. Hepatitis B virus infection in medical and health care personnel. Br Med J 1982;284:324-6. 20. Hadler SC, Doto IL, Maynard JE, et al. Occupational risk of hepatitis B infection in hosptial workers. Infect Control Hosp Epidemiol 1985;6:24-31. 21. Pattison CP, Boyer KM, Maynard JE, Kelly PC. Epidemic hepatitis in a clinical laboratory: possible association with computer card handling. JAMA 1974; 230:854-7.
