American Journal of Infection Control 42 (2014) 235-9
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Needlestick and sharps injuries among medical undergraduate students Anna-Christina Lauer a, Andreas Reddemann a, Claus-Peter Meier-Wronski MD b, Harald Bias b, Karin Gödecke Dipl-Ing c, Michael Arendt Dipl-Phys c, Harm Peters MD, PhD d, Manfred Gross MD, PhD, MBA a, * a
Department of Audiology and Phoniatrics, Charité-University Medicine Berlin, Berlin, Germany Occupational Health Service, Charité-University Medicine Berlin, Berlin, Germany Department of Prevention, Unfallkasse Berlin, Berlin, Germany d Dieter Scheffner Fachzentrum, Charité-University Medicine Berlin, Berlin, Germany b c
Key Words: Safety instruments Cross-sectional surveys Medical education Prevention Reporting rate
Background: Needlestick and sharps injuries (NSIs) can cause a transmission of bloodborne diseases. In this study, injury rate, accident mechanisms, and targets for preventive strategies were investigated at a major university hospital hosting different medical study programs. Methods: In 2009 and 2010, cross-sectional anonymous surveys were carried out among medical undergraduate students. Furthermore, all NSIs reported to the accident insurer from 2007 to 2010 were analyzed. This spans the comprehensive introduction of safety instruments in the university hospital in 2008. Results: The online survey was completed by 1,214 students in 2009 and 917 students in 2010. Results show an injury rate of 21.4% per year (mean value). Accidents are mostly related to vein puncture, surgical procedures, and instrument disposal. Comparing 2 parallel medical programs, the educational curriculum using objective structured clinical examinations, which are associated with significantly lower NSI incidences. The rate of under-reporting is 53% (mean value). Analysis of the injury reports made to the accident insurer showed a 50% decrease in NSIs surrounding the introduction of safe instruments. Conclusion: Undergraduate medical students are at high risk of NSIs. Safe instruments and university instructions can prevent NSIs. Reporting procedures should be part of medical undergraduate training. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Needlestick and sharps injuries (NSIs) are a hazard in regard to transmission of infectious bloodborne diseases, among them hepatitis B and C viruses and HIV. Health care workers and medical students are at risk of injuries because of daily procedures such as vein puncture or sewing.1-3 There is a high risk of experiencing a potentially infectious injury or splash of blood or body fluid during work hours.1,4-6 Because the prevalence of hepatitis B and C viruses and HIV among hospitalized patients is many times higher than in the general population,7 it is of great importance to take potential exposures seriously. However, as previous studies have
* Address correspondence to Manfred Gross, MD, PhD, MBA, Professor, CharitéUniversity Medicine Berlin, Department of Audiology and Phoniatrics, 13353 Berlin, Germany. E-mail addresses: [email protected], [email protected] (M. Gross). Conflicts of interest: None to report.
demonstrated, there is a lack of risk awareness and a high underreporting rate among medical staff and undergraduate medical students.2,3 A common phenomenon is the high rate of unreported exposures.4,5,8-10 Among other things, lack of risk awareness, lack of time, and ignorance of the reporting system as well as trivialization by superiors and shame have been evaluated as possible reasons for under-reporting.4,8 In this study, undergraduate medical students are the focus group. It is a fact that, among all accidents that are overall reported to the accident insurer, NSIs represent a major part. This observation gave impulse to the present investigation. A lack of clinical experience puts students at risk of experiencing blood and body fluid exposures. Undergraduate education could be vital for taking preventive action and promoting awareness among future physicians. There are suggestions that the quality of training prior to clinical traineeships can have a preventive effect on NSIs.11 The
0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2013.08.013
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current study’s main objectives are, first, to assess the present state at the university including reported and not reported injuries and, second, to identify existing preventive factors and approaches for future preventive strategies. First, all injury reports made to the accident insurer in the years 2007 to 2010 have been analyzed retrospectively. Second, an anonymous online questionnaire was created and sent to all undergraduate medical students of the faculty in 2009 and 2010. The analysis of the injury reports made to the accident insurer supported the development of the questionnaire. Furthermore, it provides an opportunity to evaluate whether the nationwide comprehensive introduction of safety instruments in 2008das a major step toward prevention of NSIsdhas in fact had an effect on the reported total NSI numbers at the faculty. The anonymous online survey is a method to reveal cases of unreported injuries and gather detailed information on injury circumstances. Additionally the students’ experiences were requested concerning instruction in the use of safety instruments, procedure tutorials, and postexposure measures. Interestingly, at the time of the surveys, there were 2 different study programs at the university simultanously: the regular study program and the reformed study program. The reformed study program represents a smaller amount of students (60 students per year vs 300 students per year, respectively) who have been allocated randomly to the study program. The regular study program is based mainly on written examinations, whereas the reformed study program is based on the objective structured clinical examinations, which also include vein puncture using an anatomic model. Thus, different curricula can be compared directly. METHODS The study was approved by the Ethics Committee of the Charité Berlin. Online survey An anonymous online questionnaire with 15 items concerning NSIs among medical students was designed. It was evaluated by a psychologist who is specialized in validating surveys and was piloted in a group of students. The questionnaire was sent to all students of the university via their personnel university e-mail addresses. In this way, it was ensured that participants were exclusively enrolled medical students. Survey requests were sent in the years 2010 and 2011 with 2 e-mail reminders, respectively. The questionnaire content was determined based on the literature and the analysis of the existing injury reports at the faculty as discussed below. The questionnaire concerned 5 basic topics: (1) Rate of NSIs, (2) circumstances and risk factors for NSIs, (3) reporting behavior, (4) present knowledge and student suggestions, and (5) personal data. Data about the incidents were collected for the years 2009 and 2010. NSIs were defined as injuries with needles or other sharp instruments that were contaminated with potentially infectious patient material. Needlestick and sharps injuries were listed separately. Other exposures, such as mucosal contacts, for example blood splashes into the eyes, as well as wound contacts were not included in this study. Injury reports Medical students reporting an NSI are obliged to complete a standard injury report. These reports are submitted to the accident insurer. In this study, all injury reports made to the accident insurer
Table 1 Characteristics of the study populations in 2009 and 2010 and mean values 2009
Total Median age, y Median study semester Sex Male Female Participation by study program Regular medical study program Reformed medical study program Model study program
2010
Mean value
n
%
n
%
%
1,214 25 8
100.0
917 24 7
100.0
100.0
409 805
33.7 66.3
331 586
36.1 63.9
34.9 65.1
1,023 191 0
84.3 15.7 0
617 89 211
67.3 9.7 23.0
75.7 12.7 11.5
NOTE. The characteristics of the study population are shown for both study years (2009 and 2010), including age, sex, study semester, and the attended study program. The study group can be considered to be representative for the students of the faculty in 2009 and 2010. Most participants attended the regular study program.
in 4 years from 2007 to 2010 were analyzed. In accordance with the online survey, mucosal contacts and wound contacts were not included. Fortunately, the analyzed period includes the introduction of safety devices at the faculty in 2008 so that possible effects on NSIs among students could be evaluated. Setting The project was performed at one of Germany’s major medical faculties educating more than 7,000 undergraduate medical students in 2010. One of the most interesting circumstances has been the existence of 2 parallel faculty programs: a regular one with more than 600 students a year based on the national standard education and a reformed program, which started as a trial in 1999. The reformed program with new teaching formats such as PBL, skills laboratory, and objective structured clinical examinations was limited to 60 new students a year selected by chance. Having had very good experience with the reformed program, the faculty decided to merge the regular and the reformed program and create a new model program bringing together the best elements of both. The model program was started in 2010. Because of legal regulations, the faculty needs to pursue the regular and the reformed program for at least another 5 years. Therefore, the faculty has the unique opportunity to compare different educational curricula. Statistical analysis Data collection was performed with Microsoft Office Excel (version 2003, Microsoft Corp, Redmond, WA). Statistical analysis was performed with SPSS Statistics (version 19; SPSS Inc, Chicago, IL). Nonparametric tests were performed. Values of P .05 were considered statistically significant. RESULTS Online survey Characteristics of the study populations are shown in Table 1. More than one-fifth of all participating students received at least 1 injury per year. Less than half of the injured students reported their injuries. The injury and reporting rates are shown in Table 2. The total counts of injuries were 377 in 2009 and 252 in 2010. In fact, out of all injured students, 82% (mean value of 2009 and 2010) were injured once, whereas 18% experienced 2 or more injuries in the respective year. The activities most frequently associated with
A.-C. Lauer et al. / American Journal of Infection Control 42 (2014) 235-9 Table 2 Rates of NSIs among medical undergraduate students and reporting rates in 2009 and 2010 and mean values 2009
Total Rate of injured students Not injured Injured 1 Needlestick injury 1 Sharps injury 1 Needlestick and sharps injury Reporting behavior Reported all injuries Reported at least one injury Reported none injury
2010
237
Table 3 Circumstances of NSIs among medical undergraduate students in 2009 and 2010 and mean values
Mean value
n
%
n
%
%
1,214
100.0
917
100.0
100.0
933 281 193 70 18
76.9 23.1 68.7 24.9 6.4
736 181 113 53 15
80.3 19.7 62.4 29.3 8.3
78.6 21.4 65.6 27.1 7.3
126 14 141
44.8 5.0 50.2
73 7 101
40.3 3.9 55.8
42.6 4.4 53.0
NOTE. The injury rates are given in total and separately for needlestick and sharps injuries, showing that approximately one-fifth of all students experience an NSI in 1 year and that two-thirds of all students experience a needlestick injury. It is apparent that, in both years, over half of the injuries were not reported.
NSIs and reasons that might have led to the accident are shown in Table 3. The comparison of the different study programs at the facility reveals differences in NSI rates: Referring to the mean values of both years, 23.5% of all students attending the regular study program were injured, in contrast to 14.5% of all students attending the reformed study program. This difference is significant (P < .05). The new model program, which is now replacing both previous study programs, is not included in the evaluation here. It was started in 2010 and is represented in the according survey by medical students in their first semester. Furthermore, the study semester has a significant influence on the injury rates of the students in both years: Injured students are in significantly higher study semesters (median, 10 [2009]; median, 9 [2010]) than uninjured students (median, 8 [2009]; median, 7 [2010]; P < .05). Another aspect of the online survey was the evaluation of the present student knowledge concerning the instruction in safety instruments and reporting of NSIs. Approximately 75% of all participants had been instructed in the use of safety instruments. For the most part, instructions had been given solely during practical trainings (35.5%); another part of the students had been instructed during a university course as well as during practical training (21.7%); and a smaller part of the students (16.3%) was solely instructed during university courses. A fraction of 25% of students remains, representing those who had not been instructed in the use of safety instruments at all. These students do not represent the younger students; in contrast, the median study semester among students without instructions is 10 in 2009 and 9 in 2010 and hence higher than in the overall study population (Table 1). Most participants decided that a standardized instruction in the use of safety devices should take place at the beginning of the clinical studies. In addition to that, the students were asked if and in which field they would like to be better informed. Approximately one-fifth of all participants stated that they were well informed about NSIs. The majority of the study participants wanted to be better informed about the reporting system and postexposure prophylaxis. Injury reports A major development was observed: From 2007 to 2010, the rate of reported NSIs decreased by 50%. The strongest decrease of reports was found between 2008 and 2009, which was 33% (n2007 ¼ 161, n2008 ¼ 151, n2009 ¼ 95, n2010 ¼ 79).
2009 n
%
2010 n
%
Mean value %
Total (injured students) 281 100.0 181 100.0 100.0 Activities At the disposal of needles and sharp 82 29.2 53 29.3 29.2 instruments Assistance in the operating room (injured 61 21.7 44 24.3 23.0 by a third person) In the process of vein puncture 71 25.3 33 18.2 21.7 Suturing (student) 20 7.1 23 12.7 9.9 Recapping 14 5.0 15 8.3 6.6 In the process of intravenous cannulation 21 7.5 8 4.4 5.9 Injections (for example, immunizations) 8 2.8 8 4.4 3.6 Others 63 22.4 57 31.5 27.0 Reasons for needlestick and sharps injuries Inattentiveness 169 60.1 124 68.5 64.3 Stress/haste 138 49.1 120 66.3 57.7 Lack of experience of the student 70 24.9 59 32.6 28.8 Injury unavoidable (ie, patient moved 83 29.5 54 29.8 29.7 suddenly; injury caused by a third person) Lack of instruction of the student 34 12.1 31 17.1 14.6 Tiredness 36 12.8 25 13.8 13.3 Others 27 9.6 26 14.4 12.0 Reasons for not reporting Injury was superficial 83 29.5 60 33.1 31.3 Patient was not infectious (HIV or 78 27.8 51 28.2 28.0 hepatitis B or C virus) Reporting costs too much time (report; 58 20.6 41 22.7 21.6 follow-up examination) Ignorance of the system of reporting 41 14.6 39 21.5 18.1 Injury was classified as not dangerous 35 12.5 30 16.6 14.5 by a superior No time (for example, during an operation) 34 12.1 25 13.8 13.0 Shame 25 8.9 20 11.0 10.0 Doubts in effectiveness of postexposure 4 1.4 6 3.3 2.4 prophylaxis Ignorance of infection risks 5 1.8 3 1.7 1.7 Fear of positive test results 14 5.0 3 1.7 3.3 Others 46 16.4 39 21.5 19.0 NOTE. Multiple answers were possible. Most students reported that the NSIs occurred during instrument disposal or during a standard procedure such as vein puncture or assisting in the operating room. Inattentiveness and stress are identified as factors which are most often responsible for the incidents. The reasons for not reporting an injury indicate that students tend to trivialize NSIs.
DISCUSSION This study shows that undergraduate medical students are still at high risk of experiencing NSIs. The results of our study are in accordance with other investigations. Studies focussing on the incidence of NSIs per year, conducted among medical students in their final years, found injury rates from 11% to 30%.9,12,13 Typical risk situations, such as vein puncture and intravenous cannulation, are standard procedures for medical students in practical training. For those procedures, the facility has been supplied with safety devices since 2008. Following the Technical Guidelines for Biological Working Substances (TRBA 250, section 4.2.4.), the comprehensive introduction of safety instruments in hospitals was conducted in 2008.14 The evaluation of injury reports made to the accident insurer showed a strong decrease in injury rates from 2008 to 2009, which is probably related to the introduction of safety devices, but this strong decline is however followed by stabilization of reported injury rates toward 2010. Furthermore, the online survey discovered that a large part of students in their higher study semesters have not been instructed in safety instruments. Thus, there is a lack of instruction among undergraduate medical students. This is affirmed by the finding that the educational program of the
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reformed studies, compiling more structured practical training, has a preventive effect on the NSI rate. Often quoted risk factors for NSIs are stress and haste, as well as inattentiveness of the students, pointing to the fact that undergraduate medical students are integrated into daily routines and expected to adapt to stressful situations. Similar injury circumstances have been found in other cross-sectional studies.4,8 The risk of NSIs is significantly higher in advanced semesters, as shown in previous investigations.9 The online survey and the evaluation of the injury reports both showed that there is a high fraction of last year students among all injured students. This can be explained by the fact that students participate more often actively in patient care at the end of their studies, especially during their final practical year, which is moreover a combining element of all study programs at the faculty. All in all, it may be said that frequent exposure to standard procedures is associated with higher rates of NSIs. However, this provides the opportunity for a standardized intervention as well. As a consequence, instruction of medical students as to the correct use of safety devices available for vein puncture as well as explicit training and reminding to dispose of needle and sharps immediately could be used for prevention of NSIs. Merlin et al showed that procedural training of medical students in the United States prior to a medical rotation in Botswana could prevent NSIs.11 Despite the training of advanced procedural skills, educational advertising could also have a positive effect on the risk awareness and reporting behavior. Moreover, one striking result of this study is the enormously high rate of under-reporting among undergraduate medical students, consistent with previous studies showing under-reporting rates of over 50%.4,5,10 Looking at the reasons given for under-reporting, this indicates that injuries are often assessed as being low risk by the student or their superiors. It is also obvious that many students are not familiar with the reporting system. Whereas one approach could be to raise risk awareness among students’ superiors, it is however more feasible to educate the students how to manage an incident. In the longterm, this will also improve student supervision. As demonstrated in this study, three-quarters of all participating students wanted to be better informed, particularly in regard to the reporting system. In accordance with the results of the injury reports, the online survey could demonstrate that approximately one-fifth of all injuries were described as being caused by a third person in the operating room. Thus, it can be considered that those injuries are unlikely to be prevented by the student because, for example, the passing of sharp instruments might occur as a risky situation. To lower the risk of injuries caused by a third person, a setting involving different staff members of the operating team would be needed. Risk situations such as instrument transfer could be included in training. A respective project has been done at the facility focussing partly on instrument transfer techniques, resulting in a reduction of NSIs (SiGOs project).15 In contrast to medical students, it is well-known that dental students sustain even more NSIs. According to Stewardson et al,16 at the University of Birmingham Dental School, the percentage of occupational exposures, including NSIs and mucosal and wound exposures, in dental undergraduates ranged between 52% in year 3, 46% in year 4, and 19% in year 5 undergraduates. The authors attribute the reduction of occupational exposures to increased clinical training. Other studies showed similarly high injury rates.17-19 It turned out that occupational skills may reduce the number of NSIs.16,17 Dental students have not been at focus of this study. The injury mechanisms are different from those found for medical students. The usage of safety devices is limited because a major part of the instruments are used in the oral cavity with narrow space.20
Further investigations could help identify approaches for prevention of NSIs among students in dental medicine. As a bias in this anonymous study, it has to be considered that injured students might have been more interested and therefore taken part more often in the online survey. Nevertheless, the overall attendance was unexpectedly high, with one-fifth to onequarter of all students contacted. Furthermore, the total injury counts of the online survey more than doubles the counts of the officially reported injuries. Taken together, this study has been able to show that, on the one hand, there is a high fraction of injured students every year. This means that there is still a need of education in order to improve the knowledge about prevention, injury reporting, and treatment. On the other hand, promising measures have been describedd primarily for instruction on safety instrumentsdand these have already shown preventive effects. CONCLUSION The comprehensive introduction of safety instruments was an effective measure to lower the rate of NSIs among undergraduate medical students; in this study, it was seen that it could be decreased by 50%. However, in 2009 and 2010, 21.4% were still injured. To lower injury the rates, further measures are needed. One strategy could be to ensure that safety mechanisms are used correctly by the students. Also other accident causes should be minimized, eg, by safe needle and sharps disposal and safe sewing technique. Consequently, the detailed instruction of students in the use of instruments and training in their procedural skills is of great importance. Objective structured clinical examinations can contribute to the prevention of NSIs. Nonetheless, not every injury will be preventable. That is why the reporting of NSIs should be included in preventive strategies. One result of this project was the revision of safety instructions at the facility and providing a memocard with specific first aid and reporting instructions for all students, health care personnel, and physicians. Transparent first aid recommendations and reporting system should be provided and discussed repeatedly during undergraduate medical training. References 1. Wicker S, Jung J, Allwinn R, Gottschalk R, Rabenau HF. Prevalence and prevention of needlestick injuries among health care workers in a German university hospital. Int Arch Occup Environ Health 2008;81:347-54. 2. Wicker S, Ludwig A-M, Gottschalk R, Rabenau HF. Needlestick injuries among health care workers: occupational hazard or avoidable hazard? Wiener Klinische Wochenschrift 2008;120:486-92. 3. Blitz J, van Rooyen M, Cameron D. Using an audit of medical student behavior to inform curriculum change. Teach Learn Med 2010;22:209-13. 4. Salzer HJ, Hoenigl M, Kessler HH, Stigler FL, Raggam RB, Rippel KE, et al. Lack of risk-awareness and reporting behavior towards HIV infection through needlestick injury among European medical students. Int J Hyg Environ Health 2011;214:407-10. 5. Wicker S, Nürnberger F, Schulze JB, Rabenau HF. Needlestick injuries among German medical students: time to take a different approach? Medical Educ 2008;42:742-5. 6. Hofmann F. Needlestick injuries in health care: frequencies, causes and preventive strategies. Gesundheitswesen 2002;64:259-66. 7. Wicker S, Cinatl J, Berger A, Doerr HW, Gottschalk R, Rabenau HF. Determination of risk of infection with blood-borne pathogens following a needlestick injury in hospital workers. Ann Occup Hyg 2008;52:615-22. 8. Sharma GK, Gilson MM, Nathan H, Makary MA. Needlestick injuries among medical students: incidence and implications. Acad Med 2009;84:1815-21. 9. Varsou O, Lemon JS, Dick FD. Sharps injuries among medical students. Occup Med (Oxford) 2009;59:509-11. 10. Moon CS, Hwang JH, Lee CS, Park KH, Kim ES. Exposure to blood and body fluid among medical students in Korea. Am J Infect Control 2010;38:582-3. 11. Merlin JS, Morrison G, Gluckman S, Lipschik G, Linkin DR, Lyon S, et al. Blood and body fluid exposures among US medical students in Botswana. J Gen Intern Med 2011;26:561-4.
A.-C. Lauer et al. / American Journal of Infection Control 42 (2014) 235-9 12. Schmid K, Schwager C, Drexler H. Needlestick injuries and other occupational exposures to body fluids amongst employees and medical students of a German university: incidence and follow-up. J Hosp Infect 2007;65:124-30. 13. Norsayani MY, Hassim IN. Study on incidence of needle stick injury and factors associated with this problem among medical students. J Occup Health 2003;45: 172-8. 14. BAuA: B.f.A.u.A. (TRBA) 250, Abschnitt 4.2.4. Technical Rules for Biological Agents 250. Available from: http://www.baua.de/de/Themen-von-A-Z/ Biologische-Arbeitsstoffe/TRBA/TRBA-250.html. Accessed March 2013. 15. Zschernack S, Friesdorf W, Gödecke K, Penth S, Reschke R. Sigos - Final report health and safety in the operating room; 2004. Available from: http:// www.infektionsschutz.gesundheitsdienstportal.de/_docs/quellen/SIGOS.pdf [in German]. Accessed December 23, 2013.
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16. Stewardson DA, Palenik CJ, McHugh ES, Burke FJ. Occupational exposures occurring in students in a UK dental school. Eur J Dent Educ 2002;6: 104-13. 17. Wicker S, Rabenau HF. Occupational exposures to bloodborne viruses among German dental professionals and students in a clinical setting. Int Arch Occup Environ Health 2010;83:77-83. 18. Devries B, Cossart YE. Needlestick injury in medical students. Med J Aust 1994; 160:398-400. 19. McCarthy GM, Britton JE. A survey of final-year dental, medical and nursing students: occupational injuries and infection control. J Can Dent Assoc 2000; 66:561. 20. McDonald RI, Walsh LJ, Savage NW. Analysis of workplace injuries in a dental school environment. Aust Dent J 1997;42:109-13.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Needlestick and sharps injuries among medical undergraduate students Anna-Christina Lauer a, Andreas Reddemann a, Claus-Peter Meier-Wronski MD b, Harald Bias b, Karin Gödecke Dipl-Ing c, Michael Arendt Dipl-Phys c, Harm Peters MD, PhD d, Manfred Gross MD, PhD, MBA a, * a
Department of Audiology and Phoniatrics, Charité-University Medicine Berlin, Berlin, Germany Occupational Health Service, Charité-University Medicine Berlin, Berlin, Germany Department of Prevention, Unfallkasse Berlin, Berlin, Germany d Dieter Scheffner Fachzentrum, Charité-University Medicine Berlin, Berlin, Germany b c
Key Words: Safety instruments Cross-sectional surveys Medical education Prevention Reporting rate
Background: Needlestick and sharps injuries (NSIs) can cause a transmission of bloodborne diseases. In this study, injury rate, accident mechanisms, and targets for preventive strategies were investigated at a major university hospital hosting different medical study programs. Methods: In 2009 and 2010, cross-sectional anonymous surveys were carried out among medical undergraduate students. Furthermore, all NSIs reported to the accident insurer from 2007 to 2010 were analyzed. This spans the comprehensive introduction of safety instruments in the university hospital in 2008. Results: The online survey was completed by 1,214 students in 2009 and 917 students in 2010. Results show an injury rate of 21.4% per year (mean value). Accidents are mostly related to vein puncture, surgical procedures, and instrument disposal. Comparing 2 parallel medical programs, the educational curriculum using objective structured clinical examinations, which are associated with significantly lower NSI incidences. The rate of under-reporting is 53% (mean value). Analysis of the injury reports made to the accident insurer showed a 50% decrease in NSIs surrounding the introduction of safe instruments. Conclusion: Undergraduate medical students are at high risk of NSIs. Safe instruments and university instructions can prevent NSIs. Reporting procedures should be part of medical undergraduate training. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Needlestick and sharps injuries (NSIs) are a hazard in regard to transmission of infectious bloodborne diseases, among them hepatitis B and C viruses and HIV. Health care workers and medical students are at risk of injuries because of daily procedures such as vein puncture or sewing.1-3 There is a high risk of experiencing a potentially infectious injury or splash of blood or body fluid during work hours.1,4-6 Because the prevalence of hepatitis B and C viruses and HIV among hospitalized patients is many times higher than in the general population,7 it is of great importance to take potential exposures seriously. However, as previous studies have
* Address correspondence to Manfred Gross, MD, PhD, MBA, Professor, CharitéUniversity Medicine Berlin, Department of Audiology and Phoniatrics, 13353 Berlin, Germany. E-mail addresses: [email protected], [email protected] (M. Gross). Conflicts of interest: None to report.
demonstrated, there is a lack of risk awareness and a high underreporting rate among medical staff and undergraduate medical students.2,3 A common phenomenon is the high rate of unreported exposures.4,5,8-10 Among other things, lack of risk awareness, lack of time, and ignorance of the reporting system as well as trivialization by superiors and shame have been evaluated as possible reasons for under-reporting.4,8 In this study, undergraduate medical students are the focus group. It is a fact that, among all accidents that are overall reported to the accident insurer, NSIs represent a major part. This observation gave impulse to the present investigation. A lack of clinical experience puts students at risk of experiencing blood and body fluid exposures. Undergraduate education could be vital for taking preventive action and promoting awareness among future physicians. There are suggestions that the quality of training prior to clinical traineeships can have a preventive effect on NSIs.11 The
0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2013.08.013
236
A.-C. Lauer et al. / American Journal of Infection Control 42 (2014) 235-9
current study’s main objectives are, first, to assess the present state at the university including reported and not reported injuries and, second, to identify existing preventive factors and approaches for future preventive strategies. First, all injury reports made to the accident insurer in the years 2007 to 2010 have been analyzed retrospectively. Second, an anonymous online questionnaire was created and sent to all undergraduate medical students of the faculty in 2009 and 2010. The analysis of the injury reports made to the accident insurer supported the development of the questionnaire. Furthermore, it provides an opportunity to evaluate whether the nationwide comprehensive introduction of safety instruments in 2008das a major step toward prevention of NSIsdhas in fact had an effect on the reported total NSI numbers at the faculty. The anonymous online survey is a method to reveal cases of unreported injuries and gather detailed information on injury circumstances. Additionally the students’ experiences were requested concerning instruction in the use of safety instruments, procedure tutorials, and postexposure measures. Interestingly, at the time of the surveys, there were 2 different study programs at the university simultanously: the regular study program and the reformed study program. The reformed study program represents a smaller amount of students (60 students per year vs 300 students per year, respectively) who have been allocated randomly to the study program. The regular study program is based mainly on written examinations, whereas the reformed study program is based on the objective structured clinical examinations, which also include vein puncture using an anatomic model. Thus, different curricula can be compared directly. METHODS The study was approved by the Ethics Committee of the Charité Berlin. Online survey An anonymous online questionnaire with 15 items concerning NSIs among medical students was designed. It was evaluated by a psychologist who is specialized in validating surveys and was piloted in a group of students. The questionnaire was sent to all students of the university via their personnel university e-mail addresses. In this way, it was ensured that participants were exclusively enrolled medical students. Survey requests were sent in the years 2010 and 2011 with 2 e-mail reminders, respectively. The questionnaire content was determined based on the literature and the analysis of the existing injury reports at the faculty as discussed below. The questionnaire concerned 5 basic topics: (1) Rate of NSIs, (2) circumstances and risk factors for NSIs, (3) reporting behavior, (4) present knowledge and student suggestions, and (5) personal data. Data about the incidents were collected for the years 2009 and 2010. NSIs were defined as injuries with needles or other sharp instruments that were contaminated with potentially infectious patient material. Needlestick and sharps injuries were listed separately. Other exposures, such as mucosal contacts, for example blood splashes into the eyes, as well as wound contacts were not included in this study. Injury reports Medical students reporting an NSI are obliged to complete a standard injury report. These reports are submitted to the accident insurer. In this study, all injury reports made to the accident insurer
Table 1 Characteristics of the study populations in 2009 and 2010 and mean values 2009
Total Median age, y Median study semester Sex Male Female Participation by study program Regular medical study program Reformed medical study program Model study program
2010
Mean value
n
%
n
%
%
1,214 25 8
100.0
917 24 7
100.0
100.0
409 805
33.7 66.3
331 586
36.1 63.9
34.9 65.1
1,023 191 0
84.3 15.7 0
617 89 211
67.3 9.7 23.0
75.7 12.7 11.5
NOTE. The characteristics of the study population are shown for both study years (2009 and 2010), including age, sex, study semester, and the attended study program. The study group can be considered to be representative for the students of the faculty in 2009 and 2010. Most participants attended the regular study program.
in 4 years from 2007 to 2010 were analyzed. In accordance with the online survey, mucosal contacts and wound contacts were not included. Fortunately, the analyzed period includes the introduction of safety devices at the faculty in 2008 so that possible effects on NSIs among students could be evaluated. Setting The project was performed at one of Germany’s major medical faculties educating more than 7,000 undergraduate medical students in 2010. One of the most interesting circumstances has been the existence of 2 parallel faculty programs: a regular one with more than 600 students a year based on the national standard education and a reformed program, which started as a trial in 1999. The reformed program with new teaching formats such as PBL, skills laboratory, and objective structured clinical examinations was limited to 60 new students a year selected by chance. Having had very good experience with the reformed program, the faculty decided to merge the regular and the reformed program and create a new model program bringing together the best elements of both. The model program was started in 2010. Because of legal regulations, the faculty needs to pursue the regular and the reformed program for at least another 5 years. Therefore, the faculty has the unique opportunity to compare different educational curricula. Statistical analysis Data collection was performed with Microsoft Office Excel (version 2003, Microsoft Corp, Redmond, WA). Statistical analysis was performed with SPSS Statistics (version 19; SPSS Inc, Chicago, IL). Nonparametric tests were performed. Values of P .05 were considered statistically significant. RESULTS Online survey Characteristics of the study populations are shown in Table 1. More than one-fifth of all participating students received at least 1 injury per year. Less than half of the injured students reported their injuries. The injury and reporting rates are shown in Table 2. The total counts of injuries were 377 in 2009 and 252 in 2010. In fact, out of all injured students, 82% (mean value of 2009 and 2010) were injured once, whereas 18% experienced 2 or more injuries in the respective year. The activities most frequently associated with
A.-C. Lauer et al. / American Journal of Infection Control 42 (2014) 235-9 Table 2 Rates of NSIs among medical undergraduate students and reporting rates in 2009 and 2010 and mean values 2009
Total Rate of injured students Not injured Injured 1 Needlestick injury 1 Sharps injury 1 Needlestick and sharps injury Reporting behavior Reported all injuries Reported at least one injury Reported none injury
2010
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Table 3 Circumstances of NSIs among medical undergraduate students in 2009 and 2010 and mean values
Mean value
n
%
n
%
%
1,214
100.0
917
100.0
100.0
933 281 193 70 18
76.9 23.1 68.7 24.9 6.4
736 181 113 53 15
80.3 19.7 62.4 29.3 8.3
78.6 21.4 65.6 27.1 7.3
126 14 141
44.8 5.0 50.2
73 7 101
40.3 3.9 55.8
42.6 4.4 53.0
NOTE. The injury rates are given in total and separately for needlestick and sharps injuries, showing that approximately one-fifth of all students experience an NSI in 1 year and that two-thirds of all students experience a needlestick injury. It is apparent that, in both years, over half of the injuries were not reported.
NSIs and reasons that might have led to the accident are shown in Table 3. The comparison of the different study programs at the facility reveals differences in NSI rates: Referring to the mean values of both years, 23.5% of all students attending the regular study program were injured, in contrast to 14.5% of all students attending the reformed study program. This difference is significant (P < .05). The new model program, which is now replacing both previous study programs, is not included in the evaluation here. It was started in 2010 and is represented in the according survey by medical students in their first semester. Furthermore, the study semester has a significant influence on the injury rates of the students in both years: Injured students are in significantly higher study semesters (median, 10 [2009]; median, 9 [2010]) than uninjured students (median, 8 [2009]; median, 7 [2010]; P < .05). Another aspect of the online survey was the evaluation of the present student knowledge concerning the instruction in safety instruments and reporting of NSIs. Approximately 75% of all participants had been instructed in the use of safety instruments. For the most part, instructions had been given solely during practical trainings (35.5%); another part of the students had been instructed during a university course as well as during practical training (21.7%); and a smaller part of the students (16.3%) was solely instructed during university courses. A fraction of 25% of students remains, representing those who had not been instructed in the use of safety instruments at all. These students do not represent the younger students; in contrast, the median study semester among students without instructions is 10 in 2009 and 9 in 2010 and hence higher than in the overall study population (Table 1). Most participants decided that a standardized instruction in the use of safety devices should take place at the beginning of the clinical studies. In addition to that, the students were asked if and in which field they would like to be better informed. Approximately one-fifth of all participants stated that they were well informed about NSIs. The majority of the study participants wanted to be better informed about the reporting system and postexposure prophylaxis. Injury reports A major development was observed: From 2007 to 2010, the rate of reported NSIs decreased by 50%. The strongest decrease of reports was found between 2008 and 2009, which was 33% (n2007 ¼ 161, n2008 ¼ 151, n2009 ¼ 95, n2010 ¼ 79).
2009 n
%
2010 n
%
Mean value %
Total (injured students) 281 100.0 181 100.0 100.0 Activities At the disposal of needles and sharp 82 29.2 53 29.3 29.2 instruments Assistance in the operating room (injured 61 21.7 44 24.3 23.0 by a third person) In the process of vein puncture 71 25.3 33 18.2 21.7 Suturing (student) 20 7.1 23 12.7 9.9 Recapping 14 5.0 15 8.3 6.6 In the process of intravenous cannulation 21 7.5 8 4.4 5.9 Injections (for example, immunizations) 8 2.8 8 4.4 3.6 Others 63 22.4 57 31.5 27.0 Reasons for needlestick and sharps injuries Inattentiveness 169 60.1 124 68.5 64.3 Stress/haste 138 49.1 120 66.3 57.7 Lack of experience of the student 70 24.9 59 32.6 28.8 Injury unavoidable (ie, patient moved 83 29.5 54 29.8 29.7 suddenly; injury caused by a third person) Lack of instruction of the student 34 12.1 31 17.1 14.6 Tiredness 36 12.8 25 13.8 13.3 Others 27 9.6 26 14.4 12.0 Reasons for not reporting Injury was superficial 83 29.5 60 33.1 31.3 Patient was not infectious (HIV or 78 27.8 51 28.2 28.0 hepatitis B or C virus) Reporting costs too much time (report; 58 20.6 41 22.7 21.6 follow-up examination) Ignorance of the system of reporting 41 14.6 39 21.5 18.1 Injury was classified as not dangerous 35 12.5 30 16.6 14.5 by a superior No time (for example, during an operation) 34 12.1 25 13.8 13.0 Shame 25 8.9 20 11.0 10.0 Doubts in effectiveness of postexposure 4 1.4 6 3.3 2.4 prophylaxis Ignorance of infection risks 5 1.8 3 1.7 1.7 Fear of positive test results 14 5.0 3 1.7 3.3 Others 46 16.4 39 21.5 19.0 NOTE. Multiple answers were possible. Most students reported that the NSIs occurred during instrument disposal or during a standard procedure such as vein puncture or assisting in the operating room. Inattentiveness and stress are identified as factors which are most often responsible for the incidents. The reasons for not reporting an injury indicate that students tend to trivialize NSIs.
DISCUSSION This study shows that undergraduate medical students are still at high risk of experiencing NSIs. The results of our study are in accordance with other investigations. Studies focussing on the incidence of NSIs per year, conducted among medical students in their final years, found injury rates from 11% to 30%.9,12,13 Typical risk situations, such as vein puncture and intravenous cannulation, are standard procedures for medical students in practical training. For those procedures, the facility has been supplied with safety devices since 2008. Following the Technical Guidelines for Biological Working Substances (TRBA 250, section 4.2.4.), the comprehensive introduction of safety instruments in hospitals was conducted in 2008.14 The evaluation of injury reports made to the accident insurer showed a strong decrease in injury rates from 2008 to 2009, which is probably related to the introduction of safety devices, but this strong decline is however followed by stabilization of reported injury rates toward 2010. Furthermore, the online survey discovered that a large part of students in their higher study semesters have not been instructed in safety instruments. Thus, there is a lack of instruction among undergraduate medical students. This is affirmed by the finding that the educational program of the
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reformed studies, compiling more structured practical training, has a preventive effect on the NSI rate. Often quoted risk factors for NSIs are stress and haste, as well as inattentiveness of the students, pointing to the fact that undergraduate medical students are integrated into daily routines and expected to adapt to stressful situations. Similar injury circumstances have been found in other cross-sectional studies.4,8 The risk of NSIs is significantly higher in advanced semesters, as shown in previous investigations.9 The online survey and the evaluation of the injury reports both showed that there is a high fraction of last year students among all injured students. This can be explained by the fact that students participate more often actively in patient care at the end of their studies, especially during their final practical year, which is moreover a combining element of all study programs at the faculty. All in all, it may be said that frequent exposure to standard procedures is associated with higher rates of NSIs. However, this provides the opportunity for a standardized intervention as well. As a consequence, instruction of medical students as to the correct use of safety devices available for vein puncture as well as explicit training and reminding to dispose of needle and sharps immediately could be used for prevention of NSIs. Merlin et al showed that procedural training of medical students in the United States prior to a medical rotation in Botswana could prevent NSIs.11 Despite the training of advanced procedural skills, educational advertising could also have a positive effect on the risk awareness and reporting behavior. Moreover, one striking result of this study is the enormously high rate of under-reporting among undergraduate medical students, consistent with previous studies showing under-reporting rates of over 50%.4,5,10 Looking at the reasons given for under-reporting, this indicates that injuries are often assessed as being low risk by the student or their superiors. It is also obvious that many students are not familiar with the reporting system. Whereas one approach could be to raise risk awareness among students’ superiors, it is however more feasible to educate the students how to manage an incident. In the longterm, this will also improve student supervision. As demonstrated in this study, three-quarters of all participating students wanted to be better informed, particularly in regard to the reporting system. In accordance with the results of the injury reports, the online survey could demonstrate that approximately one-fifth of all injuries were described as being caused by a third person in the operating room. Thus, it can be considered that those injuries are unlikely to be prevented by the student because, for example, the passing of sharp instruments might occur as a risky situation. To lower the risk of injuries caused by a third person, a setting involving different staff members of the operating team would be needed. Risk situations such as instrument transfer could be included in training. A respective project has been done at the facility focussing partly on instrument transfer techniques, resulting in a reduction of NSIs (SiGOs project).15 In contrast to medical students, it is well-known that dental students sustain even more NSIs. According to Stewardson et al,16 at the University of Birmingham Dental School, the percentage of occupational exposures, including NSIs and mucosal and wound exposures, in dental undergraduates ranged between 52% in year 3, 46% in year 4, and 19% in year 5 undergraduates. The authors attribute the reduction of occupational exposures to increased clinical training. Other studies showed similarly high injury rates.17-19 It turned out that occupational skills may reduce the number of NSIs.16,17 Dental students have not been at focus of this study. The injury mechanisms are different from those found for medical students. The usage of safety devices is limited because a major part of the instruments are used in the oral cavity with narrow space.20
Further investigations could help identify approaches for prevention of NSIs among students in dental medicine. As a bias in this anonymous study, it has to be considered that injured students might have been more interested and therefore taken part more often in the online survey. Nevertheless, the overall attendance was unexpectedly high, with one-fifth to onequarter of all students contacted. Furthermore, the total injury counts of the online survey more than doubles the counts of the officially reported injuries. Taken together, this study has been able to show that, on the one hand, there is a high fraction of injured students every year. This means that there is still a need of education in order to improve the knowledge about prevention, injury reporting, and treatment. On the other hand, promising measures have been describedd primarily for instruction on safety instrumentsdand these have already shown preventive effects. CONCLUSION The comprehensive introduction of safety instruments was an effective measure to lower the rate of NSIs among undergraduate medical students; in this study, it was seen that it could be decreased by 50%. However, in 2009 and 2010, 21.4% were still injured. To lower injury the rates, further measures are needed. One strategy could be to ensure that safety mechanisms are used correctly by the students. Also other accident causes should be minimized, eg, by safe needle and sharps disposal and safe sewing technique. Consequently, the detailed instruction of students in the use of instruments and training in their procedural skills is of great importance. Objective structured clinical examinations can contribute to the prevention of NSIs. Nonetheless, not every injury will be preventable. That is why the reporting of NSIs should be included in preventive strategies. One result of this project was the revision of safety instructions at the facility and providing a memocard with specific first aid and reporting instructions for all students, health care personnel, and physicians. Transparent first aid recommendations and reporting system should be provided and discussed repeatedly during undergraduate medical training. References 1. Wicker S, Jung J, Allwinn R, Gottschalk R, Rabenau HF. Prevalence and prevention of needlestick injuries among health care workers in a German university hospital. Int Arch Occup Environ Health 2008;81:347-54. 2. Wicker S, Ludwig A-M, Gottschalk R, Rabenau HF. Needlestick injuries among health care workers: occupational hazard or avoidable hazard? Wiener Klinische Wochenschrift 2008;120:486-92. 3. Blitz J, van Rooyen M, Cameron D. Using an audit of medical student behavior to inform curriculum change. Teach Learn Med 2010;22:209-13. 4. Salzer HJ, Hoenigl M, Kessler HH, Stigler FL, Raggam RB, Rippel KE, et al. Lack of risk-awareness and reporting behavior towards HIV infection through needlestick injury among European medical students. Int J Hyg Environ Health 2011;214:407-10. 5. Wicker S, Nürnberger F, Schulze JB, Rabenau HF. Needlestick injuries among German medical students: time to take a different approach? Medical Educ 2008;42:742-5. 6. Hofmann F. Needlestick injuries in health care: frequencies, causes and preventive strategies. Gesundheitswesen 2002;64:259-66. 7. Wicker S, Cinatl J, Berger A, Doerr HW, Gottschalk R, Rabenau HF. Determination of risk of infection with blood-borne pathogens following a needlestick injury in hospital workers. Ann Occup Hyg 2008;52:615-22. 8. Sharma GK, Gilson MM, Nathan H, Makary MA. Needlestick injuries among medical students: incidence and implications. Acad Med 2009;84:1815-21. 9. Varsou O, Lemon JS, Dick FD. Sharps injuries among medical students. Occup Med (Oxford) 2009;59:509-11. 10. Moon CS, Hwang JH, Lee CS, Park KH, Kim ES. Exposure to blood and body fluid among medical students in Korea. Am J Infect Control 2010;38:582-3. 11. Merlin JS, Morrison G, Gluckman S, Lipschik G, Linkin DR, Lyon S, et al. Blood and body fluid exposures among US medical students in Botswana. J Gen Intern Med 2011;26:561-4.
A.-C. Lauer et al. / American Journal of Infection Control 42 (2014) 235-9 12. Schmid K, Schwager C, Drexler H. Needlestick injuries and other occupational exposures to body fluids amongst employees and medical students of a German university: incidence and follow-up. J Hosp Infect 2007;65:124-30. 13. Norsayani MY, Hassim IN. Study on incidence of needle stick injury and factors associated with this problem among medical students. J Occup Health 2003;45: 172-8. 14. BAuA: B.f.A.u.A. (TRBA) 250, Abschnitt 4.2.4. Technical Rules for Biological Agents 250. Available from: http://www.baua.de/de/Themen-von-A-Z/ Biologische-Arbeitsstoffe/TRBA/TRBA-250.html. Accessed March 2013. 15. Zschernack S, Friesdorf W, Gödecke K, Penth S, Reschke R. Sigos - Final report health and safety in the operating room; 2004. Available from: http:// www.infektionsschutz.gesundheitsdienstportal.de/_docs/quellen/SIGOS.pdf [in German]. Accessed December 23, 2013.
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16. Stewardson DA, Palenik CJ, McHugh ES, Burke FJ. Occupational exposures occurring in students in a UK dental school. Eur J Dent Educ 2002;6: 104-13. 17. Wicker S, Rabenau HF. Occupational exposures to bloodborne viruses among German dental professionals and students in a clinical setting. Int Arch Occup Environ Health 2010;83:77-83. 18. Devries B, Cossart YE. Needlestick injury in medical students. Med J Aust 1994; 160:398-400. 19. McCarthy GM, Britton JE. A survey of final-year dental, medical and nursing students: occupational injuries and infection control. J Can Dent Assoc 2000; 66:561. 20. McDonald RI, Walsh LJ, Savage NW. Analysis of workplace injuries in a dental school environment. Aust Dent J 1997;42:109-13.
