Should caring for patients in a healthcare setting be considered a dangerous occupation? Far beyond slips, trips and falls, should we be giving healthcare workers hazard pay for putting themselves at risk of acquiring a fatal disease by virtue of the work they are doing?
If a hospital does everything they can to protect their employees, then the answer to these questions is “No.” But are healthcare organizations really doing all they can? Several studies on healthcare exposures would lead one to believe they are not.
Every day, nurses and providers empty suction cups, spray dirty bedpans, clean urine bottles and cut open catheter bags – activities that result in splashes that could expose them to infections from C. diff to hepatitis C. A 2003 study showed that 39 percent of registered nurses and 27 percent of licensed practical nurses experienced at least one mucocutaneous blood exposure (splash) in 3 months.
Yet, many of these splashes go unreported, in part, because splashes are accepted as unavoidable. Also, they are considered a “hassle” because after a splash, the healthcare provider has to report to employee health (time) and receive a battery of tests (money) as does the patient (more money plus patient worry). If any possible infections are found, a round of prophylaxis is needed (even more money).
Splashes can be reduced though. Procedures can be changed and new equipment implemented, such as disinfection appliances.
Broad Impact of Splashes
A study led by Doebbeling et. al. at the Veterans Administration found that in the previous three months, roughly 38 percent of RNs had experienced some sort of mucocutaneous blood exposure (a splash containing blood that lands on a caregiver where it could transfer a pathogen such as the eyes, nose or mouth).1 They also found that only about 73 percent of these injuries were reported.
Another study by Gershon et. al. that surveyed many different types of healthcare workers found that about 29 percent of respondents had some sort of exposure incident in the previous six months, of which, only about 44 percent were reported.2
These are shocking rates of potentially life-threatening incidents occurring in healthcare facilities. Part of the reason for these rates is the common nature of the sources of mucoutaneous blood exposures. These splashes occur during processes and procedures that healthcare workers complete dozens of times a day. The sheer frequency opens healthcare workers to more opportunity for risk while also desensitizing them to the danger and the need to take proper precautions.
Gershon et. al. measured numerous “safety climate” factors to determine how healthcare organizations protect their staff and how staff utilize the available measures to protect themselves. The factors included:
- Senior management support
- Workplace barriers to safe practice
- Cleanliness and orderliness of workplace
- Communication and lack of conflict between co-workers
- Safety-related feedback and training
- Availability of personal protective equipment (PPE) and engineering controls.
A portion of this study was a survey regarding healthcare workers’ self-reported compliance with Universal (or Standard) Precautions. In other words, the study asked healthcare workers to report how often they protect themselves using the PPE and engineering controls put in place by the support of senior management.
The results show that staff are very compliant when it comes to handling sharps appropriately – 92 percent dispose of sharps in sharps containers and take extra care when handling scalpels or other sharp objects. However, only 40 percent report wearing eye shields when there could be a splash to eyes and just 35 percent wear a mask when there could be a splash to the mouth!
Even excluding the personal health ramifications, the cost of an exposure is not low. Many things must be taken into consideration, such as lost time from work, cost of exposure panels for both the patient and employee, cost of care in the ER or staff health and cost of post-exposure prophylaxis.
We also should consider the emotional cost to the exposed individual. How might this change their lives? How might they now be putting their loved ones at risk for disease? Will they be willing to come back to work to put themselves back in this dangerous situation? These are all burdens on the system, whether or not they readily are evident as dollars spent.
In order to decrease exposures to pathogens in a healthcare setting, which in turn decrease cost to the organization in this difficult healthcare climate, we must focus on innovative ways to effect change.
To create significant change, as stated in the study by Gershon, there must be a culture of safety. Senior leadership must endorse measures that will lead to a safer environment. These include availability of PPE, design of the environment to decrease contamination and utilizing devices that are engineered to be safer.
PPE should be available at every possible point of care. Each room should have a designated place for various types of PPE. Many organizations now are designing cabinet-type dispensers into the layout of the patient room. This makes it more evident when stock has been depleted and can be designed in a more aesthetically pleasing manner than the wall-mounted version.
There also are masks available that have a clear plastic eye shield attached. If these are the only masks accessible, it removes the option to leave eyes exposed when a mask is worn. (However, if only 35 percent of healthcare workers are wearing a mask when there is potential for exposure, a gap will still exist. So, pressing for total compliance of universal precautions still is vital.)
Another option to consider in order to decrease risk of splashes are disinfection appliances – also known as bedpan washers. If installed in a patient room or soiled utility room, this device eliminates the need to empty urinals, bedpans, suction canisters and other collection devices into a toilet or hopper – all common sources of splash incidences that are repeated countless times a day. It also eliminates the possibility of spray-back when washing out these containers.
Safety needles are a very common engineering control most organizations have adopted. It is imperative to provide appropriate education when implementing these devices, as it represents a change in practice that can prove to be difficult for seasoned nurses. Compliance should be monitored as well as issues with any particular device.
It is well understood that exposures are happening in healthcare and are likely drastically underreported. It is up to healthcare organizations to understand the hazards present in their facilities and design a program and environment that will keep their caregivers safe from harm. It may not be easy, it may not be free, but in the end the organization and its employees will be more successful for having made the investment.
Jacie Volkman, MPH, CIC is on the board of APIC (Assoc. for Professionals in Infection Control); owns Safe Patient Surveys Inc, an infection prevention consulting company; and is a consultant for MEIKO, a disinfection appliance manufacturer. She also is the director of Infection Prevention at Mission Health System.
1Doebbeling BN, Vaughn TE, McCoy KD, Beekmann SE, Woolson RF, Ferguson KJ, Torner JC. (2003) Percutaneous injury, blood exposure, and adherence to standard precautions: are hospital-based health care providers still at risk? Clin Infect Dis, 37(8), 1006-13.
2Gershon RR, Karkashian CD, Grosch JW, Murphy LR, Escamilla-Cejudo A, Flanagan PA, Bernacki E, Kasting C, Martin L. (2000) Hospital safety climate and its relationship with safe work practices and workplace exposure incidents. Am J Infect Control, Jun;28(3), 211-21.