Infection DOI 10.1007/s15010-014-0598-0

BRIEF REPORT

Needlestick injuries: causes, preventability and psychological impact S. Wicker • A. V. Stirn • H. F. Rabenau • L. von Gierke • S. Wutzler • C. Stephan

Received: 15 October 2013 / Accepted: 29 January 2014  Springer-Verlag Berlin Heidelberg 2014

Abstract Needlestick injuries (NSI) pose a significant health hazard among healthcare personnel (HCP). The aim of our prospective observational study was to evaluate the psychological impact of NSI and assess measures to prevent NSI. The target group was the medical staff and students of Frankfurt University Hospital who had experienced a NSI (n = 370) during the 12-month study period. Data were retrieved from accident insurance reports, occupational follow-up examinations and a standardized anonymous questionnaire sent to the affected HCP. Analysis of the completed questionnaires (232/370) revealed that stress (48.3 %) and tiredness (36.6 %) were common factors contributing to the NSI and that [80 % of the respondents were concerned about the consequences of the NSI. Higher levels of anxiety were reported when the S. Wicker  L. von Gierke Occupational Health Service, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany e-mail: [email protected] A. V. Stirn Centrum for Integrative Psychiatry, ZIP Niemannsweg 147, 24105 Kiel, Germany H. F. Rabenau Institute of Medical Virology, University Hospital Frankfurt, Paul-Ehrlich Str. 40, 60596 Frankfurt am Main, Germany S. Wutzler Department of Trauma, Hand- and Reconstructive Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany C. Stephan (&) Department of Medicine II, Infectiology, HIV Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany e-mail: [email protected]

patient was known to have a chronic virus infection. Stressful working conditions, lack of adequate protective medical/technical equipment and poor work routines were suggested as factors contributing to NSI. Keywords Needlestick injury  Occupational infection  HIV  Hepatitis  Posttraumatic stress disorder

Introduction Needlestick injuries (NSI) and subsequent infections from bloodborne pathogens, such as hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV), pose significant health threats for health care personnel (HCP). Despite the implementation of measures to reduce NSI (e.g. introduction of safety devices), occupational exposure to bloodborne pathogens continues to occur. An estimated one million NSI occur in Europe each year (https://osha. europa.eu/en/sector/healthcare/prevention-sharp-injuriesworkplace). The issue of NSI in healthcare settings around the world has been extensively studied, especially in the context of high-risk procedures, prevalence of bloodborne diseases among patients and risk of transmission among HCP. Epidemiological studies on the incidence of NSI as well as cost of NSI have already been published [1, 2]. Occupational exposure to bloodborne pathogens can be a frightening experience, a great number of HCP may be scared and a few might even suffer long-term psychiatric consequences [3]. However, data are currently limited to the psychological impact of NSI, and such data are relatively limited as only few published studies and case reports discuss this subject [4–9]. Therefore, we conducted a follow-up study to evaluate the psychological

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impact of NSI among HCP and to assess measures to prevent NSI.

Methods This was a prospective observational study conducted at Frankfurt University Hospital (Frankfurt/Main, Germany), which is a tertiary care hospital with 1,187 beds, 4,223 employees and 3,775 medical students. Approximately 48,000 patients are admitted to the hospital annually, and healthcare is provided to 225,000 outpatients. In October 2010, new regulations were introduced at the hospital for the medical aftercare of HCP following NSI; these included an interdisciplinary collaboration between the University Hospital accident insurance doctor and occupational health consultants as well as infectious disease specialists. Data for analysis were retrieved from accident insurance reports by the treating physicians and occupational followup examinations. A standardized anonymous questionnaire was sent to the affected HCP together with the results of the first blood test on the day of the NSI and the times of the scheduled appointments for the required follow-up examinations after the NSI (usually after 6 weeks and 3 and 6 months). The questionnaire comprised the following questions with predetermined answers (in brackets): 1.

What was the cause of your needle stick injury (NSI)? • • • • • • •

2.

Could your NSI have been avoided? • • •

3.

If yes—how [further description] No Do not know

Does the NSI worry you? • • •

4.

Recently learned/unfamiliar technique Patient moved Injury by a third party, e.g. stitch or cutting damage by surgery assistant Safe device did not work correctly—which one? Tiredness/lacking in concentration Stress/lack of time Do not know—it just happened

No Yes—a little Yes—a great deal

Did you have a NSI with an infectious patient? • • • •

Yes, HIV Yes, hepatitis C Yes, hepatitis B No

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• 5.

Unknown—e.g. used hollow needle from trash bag.

What could be actively done in the future to avoid NSI accidents? (open description of answer).

The observation period lasted 12 months (July 2012– June 2013). The study was approved by Frankfurt University Hospital’s data protection officer and by the Ethics Committee of the J.W. Goethe University Faculty of Medicine (Reference No. 106/12). Statistical analyses Statistical analyses of frequency distributions were performed using chi-square test with Yates-correction and Fisher’s exact test. A p value of \0.05 was assumed as statistically significant. Calculations of significance were performed using the program BiAS for Windows 9.04 (Epsilon Verlag, Hochheim-Darmstadt, Germany).

Results A total of 370 NSI were reported to the University Hospital accident insurance physician from July 1, 2012 to June 30, 2013. The index patients for 90.3 % of NSI (334/370) underwent serum testing for HBV, HCV and HIV; for the remaining 9.7 % of NSI the index patient was either unknown (e.g. for NSI caused by cannulae of unknown index patients) or blood testing was not carried out (e.g. because of outpatient treatment). A total of 13.5 % of the tested index patients (45/334) tested positive for at least one bloodborne infection, with 3.3 % (11/334) testing positive for HIV, 9.8 % (33/334) having positive HCV PCR tests and 0.6 % (2/334) tested positive for active HBV infection. Two index patients were co-infected with HCV and HIV. Overall, 62.7 % of the affected HCP (232/370) completed the anonymous questionnaire. Significantly (p = 0.0065) more HCP filled in the questionnaire (84.4 %, 38/45) when the index patient was known to have a chronic infection. Stress was found to be the most important factor associated with a NSI episode (112/232), followed by tiredness (85/232). Thirty-one NSI were caused by a third party and 12 NSI were due to movement by the patient. Other reasons included lack of training in certain skills (10/232) and failure of the medical devices (9/232). In terms of the preventability of the NSI, 55.2 % (128/ 232) of respondents stated that the NSI could have been prevented, 34.1 % (79/232) were unsure and 10.8 % (25/ 232) stated that the NSI could not have been prevented. Overall, 118 HCP provided feedback on ways to improve workplace safety and to avoid NSI. Of these, 40.7 % (48/ 118) proposed that a change in the stressful working

Needlestick injuries Table 1 Anxiety level after needlestick injury Level of anxiety following NSI

Totala

HCP involved in blood exposure from patients with known HIV, HCV, or HBV infection

p value

HCP involved in blood exposure from patients with known HIVinfection

HCP involved in blood p value exposure from patients (HIV vs with known HCVHCV) infection

Yes, a lot

13.8 % (32/232)

52.6 % (20/38)

\0.0001

80 % (8/10)

42.3 % (11/26)

0.0652

Yes, somewhat

66.4 % (154/232)

42.1 % (16/38)

0.0071

20 % (2/10)

50 % (13/26)

0.1422

No

19.8 % (46/232)

5.3 % (2/38)

0.0514



7.7 % (2/26)



NSI Needlestick injury, HCP healthcare personnel, HIV human immunodeficiency virusm, HCV hepatitis C virus, HBV hepatitis B virus a

A total of 232 HCP experiencing a NSI completed and returned the anonymous questionnaire

conditions would the incidence of NSI, citing that they believed that ‘‘working under immense time pressure’’ was the reason for their NSI. Paying more attention and concentrating better were cited by 23.7 % (28/118) of these HCP as a way to prevent NSI. Other potential ways to prevent specific NSI included better medical/technical equipment, such as protective goggles (9.3 %; 11/118), sharps containers (5.9 %; 7/118) and improved work routine (18.6 %; 22/118). The beneficial effects of such measures can not be quantified. The anxiety level of the HCP after NSI was significantly higher when the index patient was known to have a chronic infection. HCP exposed to blood of patients with a known HIV infection were more anxious than the others (see Table 1).

Discussion Occupational transmission of bloodborne pathogens among HCP is rare but such incidents have been repeatedly published in the literature [10]. Accidental occurrence of a NSI is a considerable stress factor, and the psychological impact of the uncertainty of the infection status of the index patient status places the affected HCP under even more stress, possibly leading to serious health issues [4, 6]. Our study demonstrated that HCP experience quite high level of anxiety after NSI, with [80 % of the HCP completing the questionnaire reporting a high level of concern regarding their NSI. Incidents in which the index patient was known to have a chronic virus infection caused significantly higher levels of anxiety (see Table 1). Current guidelines for the management of NSI do not discuss the possibility of mental health problems after occupational blood exposure(s). In contrast, however, our data highlight the importance of including access to trained mental health professionals as a possible component of comprehensive postexposure care. The early detection of high anxiety levels and early treatment of insufficient coping strategies are prerequisites to avoiding serious and/

or long-term consequences [3]. The importance of such measures in emphasized in recent studies which suggest that HCP quit their profession and require psychiatric care for posttraumatic stress disorder due to NSI [4–6]. Our study also reflects difficult working conditions, with stress (48.3 %) and tiredness (36.6 %) being the most common factors in NSI. Thus, it seems likely that the prevention of occupational risks is directly associated with improvement in working conditions. Our study has a number of limitations. First, the results from a single academic institution may not be applicable to other institutions. Second, underreporting of NSI and sampling bias (response rate of the anonymous questionnaire was 62.7 %) may both challenge the results as being a representative cross-section of the real world. The impact of HCP’s self-assessment of the risk posed by the infectious state of the index patient is problematic, if present, as it may not reflect the reality at the moment of a NSI, possibly leading to either under- or overestimation of the actual risk. Knowledge of the infectiousness of blood is often an area of uncertainty, depending on individual factors—such as in the case of HIV, including actual therapy status and treatment response. The consequences, however, may be missing the opportunity to provide medical care, or alternatively, exposure to unnecessary worries. Given these considerations, our analysis may reflect only the limited reality of those who were aware of the risk and therefore presented for care after NSI and not include the perceptions of HCP who disregarded the NSI. Third, retrospective biases are likely to contaminate the interpretation of causes/circumstances related to the injuries, and the anxiety measure was a subjective assessment of the affected HCP. In conclusion, our self-developed questionnaire-based investigation of NSI among HCP revealed stress and tiredness as common factors for the injury and that [80 % of the affected HCP were concerned about possible health threats. We were able to identify an increasing level of anxiety in HCP experiencing a NSI when the index patient was known to have a chronic virus infection. To what

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extent NSI translates into adverse effects for the affected HCP, such as a trigger for disability, requires further research activity and was beyond the scope of this study. Conflict of interest The authors declare that they no conflict of interest related to this paper.

References 1. Makary MA, Al-Attar A, Holzmueller CG, et al. Needlestick injuries among surgeons in training. N Engl J Med. 2007;356:2693–9. 2. Beltrami EM, Williams IT, Shapiro CN, Chamberland ME. Risk and management of blood-borne infections in health care workers. Clin Microbiol Rev. 2000;13:385–407. 3. Gerberding JL. Occupational exposure to HIV. N Engl J Med. 2003;349:1091–2. 4. Naghavi SHR, Shabestari O, Alcolado J. Post-traumatic stress disorder in trainee doctors with previous needlestick injuries. Occup Med (Lond). 2013;63:260–5.

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5. Worthington MG, Ross JJ, Bergeron EK. Posttraumatic stress disorder after occupational HIV exposure: two cases and a literature review. Infect Control Hosp Epidemiol. 2006;27:215–7. 6. Green B, Griffiths EC. Psychiatric consequences of needlestick injury. Occup Med (Lond). 2013;63:183–8. 7. Zhang MX, Yu Y. A study of the psychological impact of sharps injuries on health care workers in China. Am J Infect Control. 2013;41:186–7. 8. Howsepian AA. Post-traumatic stress disorder following needlestick contaminated with suspected HIV-positive blood. Gen Hosp Psychiatry. 1998;20:123–4. 9. Cockcroft A, Oakley K, Gooch C, Mastin S. Anxiety and perception of risk of HIV and hepatitis B infection among healthcare workers reporting accidental exposures to blood and other body fluids. AIDS Care. 1994;6:205–14. 10. Brum MCB, Filho FFD, Yates ZB, Viana MCV, Chaves EBM, Trindade DM. HIV seroconversion in a health care worker who underwent postexposure prophylaxis following needlestick injury. Am J Infect Control. 2013;41:471–2.

Needlestick injuries: causes, preventability and psychological impact.

Needlestick injuries (NSI) pose a significant health hazard among healthcare personnel (HCP). The aim of our prospective observational study was to ev...
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