ORIGINAL ARTICLE
Percutaneous and Mucocutaneous Exposure Among Orthopaedic Surgeons: Immediate Management and Compliance With CDC Protocol Hemil H. Maniar, MS, Akhil A. Tawari, MS, Michael Suk, MD, JD, MPH, FACS, Thomas R. Bowen, MD, and Daniel S. Horwitz, MD
Background: Orthopaedic surgeons are at a high risk of sustaining a percutaneous or mucocutaneous exposure to blood and body fluids. The Center for Disease Control and Prevention recommends a wash with soap and water and notification of the concerned hospital authorities after any percutaneous/mucocutaneous exposure, but a systematic amenability with these guidelines is not always seen. This cross-sectional study was undertaken to determine current knowledge and practices of orthopaedic surgeons in case of a percutaneous sharp injury exposure, emphasizes the immediate first aid steps taken after an exposure, the degree of reporting, and to explore the reasons for noncompliance. Finally, we sought to create awareness about the prevailing Center for Disease Control and Prevention guidelines after any exposure to blood or body fluids.
Materials and Methods: We conducted a cross-sectional survey using an anonymous prepared questionnaire. The study population included exclusively orthopaedic surgeons, including residents, fellows, and attending physicians at 4 US institutions. The questionnaire was also available online on the OTA Web site as a part of survey monkey. The questionnaire comprised 9 multiple choice questions, and more than 1 response could be given for some questions. The questions addressed previous needle stick/sharp injury exposure, number of times that had happened, whether reported to the hospital administration, reason for nonreporting, and risk perception for transmission of blood-borne pathogens (human immunodeficiency virus, HBsAg, and hepatitis C virus). The questions were also asked based on what should be done in four different clinical settings based on respondents risk perception. Results: Of fifty eight attendings, 7 fellows, 45 residents, and 7 respondents who did not indicate their position participated in the survey for a total of 117 respondents. Out of 99, 24 had sustained it once, 18 twice, 11 three times, and 35 at least 4 times. When questioned about informing the incident to the hospital administration, 38% had always reported the incident, 33% had never Accepted for publication April 29, 2015. From the Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA. The authors report no conflict of interest. Waiver of patient consent granted by institutional review board for retrospective chart review. Reprints: Daniel S. Horwitz, MD, Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N. Academy Avenue, Danville, PA 17822-2130 (e-mail: [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Orthop Trauma Volume 29, Number 10, October 2015
reported the incident, and the remaining 29% had not reported it every time. Of note, 87% gave the correct response about the risk of transmission of human immunodeficiency virus after an exposure. On questioning about the risk of hepatitis B transmission, from an HBsAg- and HBeAg-positive source, 13% gave the correct response, whereas from HBsAg-positive and HBeAgnegative source, 30% gave the correct response. Regarding transmission of hepatitis C virus from a positive source, 36% responded correctly. The surgeons seemingly attempted to risk stratify their exposure, and they were more likely to report their exposure in the higher risk scenarios.
Conclusions: This study demonstrates that orthopaedic surgeons of all levels of training are at high risk of occupational exposure to blood-borne pathogens. Moreover, despite the level of training, the majority of surgeons do not follow the recommended steps, although we do not know the reasons for such behavior. Also, there is a low awareness of the significant risk of hepatitis transmission among orthopaedic surgeons treating a population with a high prevalence of undiagnosed hepatitis. Key Words: percutaneous, mucocutaneous, exposure, orthopaedic surgeons (J Orthop Trauma 2015;29:e391–e395)
A
s per the Center for Disease Control and Prevention (CDC), an approximate 385,000 health care workers are exposed to blood and body fluids through needlesticks and other sharps-related injuries per year in the United States. Twenty-three percent occur in surgical settings, with the physicians performing interventional procedures being at most risk.1,2 Percutaneous exposure predisposes to blood-borne infections, notably hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).3 Orthopaedic surgeons are at a high risk of sustaining a percutaneous exposure to blood due to their close contact with sharp instruments/implants such as Kirschner wires, drill bits, and even bone spikes in addition to sharp needles and scalpels. The CDC recommends a wash with soap and water and notification of the concerned hospital authorities after any blood or body fluid exposure,4 but a thorough compliance with these guidelines is not always seen. Currently, there is paucity of published data on the incidence and reporting rates of percutaneous injuries, especially among orthopaedic surgeons. Also, there is no literature www.jorthotrauma.com |
e391
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Orthop Trauma Volume 29, Number 10, October 2015
Maniar et al
on the prevailing compliance to CDC guidelines as far as immediate first aid to a percutaneous exposure, a decision made quickly in the operating room (OR), which can have serious consequences for life. This cross-sectional study was undertaken to determine current knowledge and practices of orthopaedic surgeons in case of a percutaneous sharp injury exposure in the OR, emphasizes the immediate recommended first aid steps taken after an exposure, to define the proportion of surgeons with sharp injuries exposed to blood or body fluids, the degree of reporting, and to explore the reasons for noncompliance. We hypothesized that a high proportion of orthopaedic surgeons are exposed to blood-borne pathogens, and that they do not reliably report them. Finally, we sought to create awareness about the prevailing CDC guidelines after any exposure to blood or body fluids.
MATERIALS AND METHODS After obtaining approval from an institutional review board, we conducted a cross-sectional survey using an anonymous prepared questionnaire. The study population comprised exclusively orthopaedic surgeons, including residents, fellows, and attending physicians at 4 US institutions, all of which were tertiary care hospitals with affiliated academic centers. The questionnaire was also available online on the OTA Web site as a part of survey monkey. Before administering the questionnaire, a note was given explaining the purpose of the study in detail. All the orthopaedic surgeons willing to complete the questionnaire were included. The completion of the questionnaire implied consent. After completing the survey, the physicians were again given a note regarding the CDC protocols to be followed after sustaining any exposure, thereby enhancing their knowledge. The questionnaire comprised 9 multiple choice questions, and more than 1 response could be given for some questions. Apart from the basic deidentified sociodemographic data, the surgeons taking the survey had to indicate their current position (resident/fellow/attending), type of specialty (General, Trauma, Arthroplasty, Spine, SportsMedicine, Pediatric, Hand), and years of practice. The questions addressed previous needle stick/sharp injury exposure, number of times that had happened, whether reported to the hospital administration, reason for nonreporting and risk perception for transmission of bloodborne pathogens (HIV, HBsAg, and HCV). The questions were also asked based on what should be done in 4 different clinical settings; low-risk patient with a solid bore needle/instrument, low-risk patient and a hollow bore needle/instrument, high-risk patient and a solid bore needle/instrument, and high-risk patient and a hollow bore needle/instrument. The options to choose from included replacing the gloves and continuing with surgery, squeezing or attempting to bleed the injury, washing hands with soap and water, washing hands with chlorhexidine, washing hands with iodine, washing hands with alcohol, washing hands with whatever is most convenient, reporting the incident to hospital authorities, and not knowing what
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to do. Finally, the surgeons were asked about the recommended CDC guidelines.
RESULTS Of 58 attendings, 7 fellows, 45 residents, and 7 respondents who did not indicate their position participated in the survey, for a total of 117 respondents. Of the 58 attendings, 34 were trauma specialists, 10 were general orthopaedic consultants, 6 hands specialists, 4 sports specialists, and 2 each of spine and shoulder specialists.
Percutaneous Exposure Out of 117, 99 replied in the affirmative to having a percutaneous exposure in the OR. Out of 99, 24 had sustained it once, 18 twice, 11 three times, and 35 at least 4 times. Of 58 attendings, 54 had sustained a sharp injury exposure. The attending surgeon’s years of practice and number of sharp injury exposures are tabulated in Table 1. Surgeons with less than 5 years of experience reported an average of 2.75 incidents (1.2 per year), surgeons with 5–10 years of experience reported an average of 3.4 incidents (0.5 per year), and surgeons with greater than 10 years’ experience reported an average of 3.7 incidents (0.2 per year). A Poisson regression concluded these differences among groups were not statistically significant. When questioned about informing the incident to the hospital administration, 38% had always reported the incident, 33% had never reported the incident and the remaining 29% had not reported it every time. Of note, 58% did not report based on their judgment that the patient had a low-risk profile, 38% faced problems with lack of time, while the remaining 4% did not know that the administration was to be informed in such a scenario.
Knowledge Regarding Pathogen Transmission Of note, 87% gave the correct response about the risk of transmission of HIV after an exposure. On questioning about the risk of hepatitis B transmission, from an HBsAgand HBeAg-positive source, 13% gave the correct response, whereas from HBsAg-positive and HBeAgnegative source, 30% gave the correct response. Regarding transmission of HCV from a positive source, 36% responded correctly. There was no significant difference in the knowledge levels of the attendings, the residents, and the fellows.
TABLE 1. Attending Surgeon’s Years in Practice and Number of Exposures Number of Sharp Injury Exposures 1 2 3 3+
Attending Surgeons’ Years in Practice 10, 4, 1 2, 1, 1, 17, 4, 3, 8, 3, 3, 8 15, 5, 1, 4, 9, 8, 3, 3, 3 19, 3, 15, 8, 7, 10, 20, 11, 36, 8, 13, 3, 18, 8, 3, 18, 3, 13, 8, 18, 3, 8, 20, 13, 18, 20, 18, 20, 8, 18, 18, 3
Total 3 10 9 32
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J Orthop Trauma Volume 29, Number 10, October 2015
Awareness and Practices in Different Case Scenarios Table 2 shows details on awareness and practices pertaining to 4 relevant clinical scenarios in increasing order of risk perception: low-risk patient and solid bore needle; low-risk patient and hollow bore needle; high-risk patient and solid bore needle; high-risk patient and hollow bore needle. On an average, 10% of the respondents would follow all the steps recommended by the CDC subsequent to any exposure. On an average, 81% would use water, soap, saline, or any antiseptics after the exposure, whereas 19% would only replace the gloves and continue with the procedure.
DISCUSSION As per the CD, an exposure that might place health care personnel at risk for HBV, HCV, or HIV infection is defined as percutaneous injury (eg, a needlestick or cut with a sharp object) or contact of mucous membrane or nonintact skin (eg, exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or other body fluids that are potentially infectious.4 For the orthopaedic surgeon, mucous membrane exposure would comprise splashes of infected blood or fluids into the eyes, nose, or mouth. Our data demonstrates that the orthopaedic surgeons of all levels of trainings are at severe risk of occupational exposure to blood-borne pathogens. In our study, a majority of the respondents had sustained a percutaneous sharp injury, and almost half of them had sustained it 3 times or more. Attending surgeons with a greater number of years of practice had a higher absolute number of injuries over time, on average, but a lower rate of injuries per year. Percutaneous and mucocutaneous exposures have been decreasing among nonsurgical health care providers, but a similar trend is not seen among workers in surgical settings.2 Percutaneous sharp injury among orthopaedic surgeons is a known professional hazard that can have serious implications for life. Even after taking all the precautions, there are chances that one may have a percutaneous or a mucocutaneous exposure.
Management and Compliance With CDC Protocol
Our data demonstrate that most exposed orthopaedic surgeons do not disclose the incident despite wide-spread knowledge of the mandate to report all occupational exposures. Nearly, all (96%) of the surgeons were aware that the hospital authorities should be informed after any exposure, but only a minority (38%) of the surgeons had reported every exposure. The most common reason for nonreporting was the perceived low-risk profile of the patient (58%). Although the currently used tests for detection of HIV, HBsAg, and HCV have a very high sensitivity rate, false-negative results can still be obtained during the window period, especially with tests that depend upon antibody levels (HIV tests).5 In addition, patients in the United States are not routinely screened for these viral infections and the surgeon’s perception of “low risk” may be erroneous. As per a National Surveillance System for Healthcare Workers report regarding 30,945 reported exposures from 1995 to 2007, 12.6% of source patients were infected with HCV, HIV, or HBV.6 This has serious implications, as in the event of unfortunate subsequent seroconversion, the affected surgeon will not be entitled to workers compensation in the absence of reporting. Moreover, not reporting on time can delay usage of postexposure prophylaxis and thereby reduce its effectiveness.7 Hence, it is paramount to report every blood or body fluid exposure, irrespective of the perceived risk, as recommended by the CDC. Also, for the injured individual, reporting prompts evaluation of the potential need for postexposure prophylaxis allows early detection of seroconversion (if any) and largely helps in decreasing anxiety. Of note, 38% of the respondents did not report it due to lack of time, which is also consistent with the findings of several studies that have implicated extensive working hours as an obstruction to practicing safe procedures.8,9 This study demonstrates that a there is a high percentage of awareness about the average risk of HIV transmission (0.3% after an exposure)10 with 87% of the surgeons giving the correct response. However, the awareness regarding the transmission risks of hepatitis B and hepatitis C virus was very low. Thirteen percent gave the correct response concerning the average risk for developing clinical hepatitis from
TABLE 2. Responses in Different Case Scenarios
Wash with soap and water, changing gloves, and informing the hospital administration Wash with soap and water, iodine, chlorhexidine, alcohol, or whatever is available Replace the gloves and continue with the surgery Inform the administration Squeeze and attempt to bleed the injury
Low-Risk Patient and Solid Bore Needle, %
Low-Risk Patient and Hollow Bore Needle, %
High-Risk Patient and Solid Bore Needle, %
High-Risk Patient and Hollow Bore Needle, %
6
11
12
11
77
87
83
78
23
13
17
22
34 33
50 40
70 37
86 36
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Maniar et al
J Orthop Trauma Volume 29, Number 10, October 2015
CONCLUSIONS
HBsAg- and HBeAg-positive source (22%–31%), whereas 30% gave the accurate answer (1%–6%) from an HBsAgpositive but HBeAg-negative source.11–13 Regarding average incidence of anti-HCV seroconversion (1.8%), 36% responded correctly.11,14 We believe that the first step in the following safe procedures after any exposure to blood and body fluids is having adequate knowledge about the risk of disease transmission. Hence, we recommend regular training and knowledge update pertaining to percutaneous and mucocutaneous exposure. As per the CDC, the steps to be followed in the OR after any blood or body fluids exposure are to wash needlesticks and cuts with soap and water. The splashes to the nose, mouth, or skin should be flushed with water, while the eyes should be irrigated with water, saline, or any of the sterile irrigants. One should report the incident to the medical supervisor and immediately seek medical treatment. As per our direct communication with the CDC, it does not endorse any specific type of soap. A common practice among orthopaedic surgeons after sustaining an exposure is pouring antiseptic agents such as chlorhexidine, alcohol containing agents, or iodine solutions on the wound. Although these agents are used in the initial surgical prep, no evidence exists that using antiseptics for wound care reduces the risk of blood-borne transmission. The CDC neither supports nor opposes their use; however, it does not recommend the application of caustic agents (eg, bleach) or the injection of antiseptics or disinfectants into the wound.4 Our data reveals that surgeons seemingly attempt to risk stratify their exposure. They are more likely to report their exposure to the hospital administration only in the perceived higher risk scenarios as is evident from the responses to the 4 clinical case scenarios. Only a minority of the respondents (10%) would have practiced all the steps as recommended by the CDC. Although on an average, 81% would use water, soap, saline, or any antiseptics after the exposure, the remaining 19% would simply replace the gloves and continue with the procedure irrespective of the case scenarios. Several participants responded to practicing squeezing and attempting to bleed the wound (36%). Although the wounds should be allowed to bleed freely, the CDC does not recommend squeezing the punctured sites. Also, it is imperative to seek medical treatment early, as the postexposure prophylaxis is dependably effective only within a short span of time. A greater benefit of postexposure prophylaxis was reported when it was initiated within 36 hours after exposure as compared with 72 hours after exposure in macaques.15 We understand that our study had various limitations. First, there is a possibility of underreporting of the sharp injuries based on recall inaccuracies. In addition, the four tertiary care hospitals cannot truly represent all orthopaedic facilities. One may argue that in a smaller center where the orthopaedic surgeon is not exposed to seropositive patients as often, she/he would be more cautious when dealing with such patients. The 4 centers, however, were chosen with the belief that with a higher surgical load, the exposure risk and may be the awareness levels about sharp injuries would be higher in these institutions.
1. Lee JM, Botteman MF, Xanthakos N, et al. Needlestick injuries in the United States. Epidemiologic, economic, and quality of life issues. AAOHN J. 2005;53:117–133. 2. Voide C, Darling KE, Kenfak-Foguena A, et al. Underreporting of needlestick and sharps injuries among healthcare workers in a Swiss University Hospital. Swiss Med Wkly. 2012;142. 3. Tarantola A, Abiteboul D, Rachline A. Infection risks following accidental exposure to blood or body fluids in health care workers: a review of pathogens transmitted in published cases. Am J Infect Control. 2006;34: 367–375. 4. Centers for Disease Control And Prevention. Bloodborne infectious diseases: HIV/AIDS, hepatitis B, hepatitis C. 2014. Available at: http://www. cdc.gov/niosh/topics/bbp/emergnedl.html. Accessed October 11, 2014. 5. Taylor D, Durigon M, Davis H, et al. Probability of a false negative HIV antibody test result during the window period: a tool for pre- and posttest counselling. Int J STD AIDS. 2014;26:215–224. 6. MacCannell T, Laramie AK, Gomaa A, et al. Occupational exposure of health care personnel to hepatitis B and hepatitis C: prevention and surveillance strategies. Clin Liver Dis. 2010;14:23–36. 7. Landovitz RJ, Currier JS. Clinical practice. Postexposure prophylaxis for HIV infection. N Engl J Med. 2009;361:1768–1775. 8. Ayas NT, Barger LK, Cade BE, et al. Extended work duration and the risk of self-reported percutaneous injuries in interns. JAMA. 2006;296: 1055–1062. 9. Ilhan MN, Durukan E, Aras E, et al. Long working hours increase the risk of sharp and needlestick injury in nurses: the need for new policy implication. J Adv Nurs. 2006;56:563–568. 10. Chin RL. Postexposure prophylaxis for HIV. Emerg Med Clin North Am. 2010;28:421–429. 11. Centers for Disease Control and Prevention. Updated U.S. public health service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2001;50:1–52. 12. Mast EE, Alter MJ. Prevention of hepatitis B virus infection among health-care workers. In: Ellis RW, ed. Hepatitis B Vaccines in Clinical Practice. New York, NY: Marcel Dekker; 1993:295–307. 13. Werner BG, Grady GF. Accidental hepatitis-B-surface-antigen-positive inoculations: use of e antigen to estimate infectivity. Ann Intern Med. 1982;97:367–369. 14. Alter MJ. The epidemiology of acute and chronic hepatitis C. Clin Liver Dis. 1997;1:559–568. 15. Otten RA, Smith DK, Adams DR, et al. Efficacy of postexposure prophylaxis after intravaginal exposure of pig-tailed macaques to a humanderived retrovirus (human immunodeficiency virus type 2). J Virol. 2000; 74:9771–9775.
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This study demonstrates that orthopaedic surgeons of all levels of training are at high risk of occupational exposure to blood-borne pathogens. Moreover, despite the level of training, the majority of surgeons do not follow the recommended steps although we do not know the reasons for such behavior. Also, there is a low awareness of the significant risk of hepatitis transmission among orthopaedic surgeons treating a population with a high prevalence of undiagnosed hepatitis.
ACKNOWLEDGMENTS The authors thank Dr Paul Tornetta, Dr J. Tracy Watson, and Dr Andrew Sems, without whose participation it would not have been possible to carry out the project. REFERENCES
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Percutaneous and Mucocutaneous Exposure Among Orthopaedic Surgeons: Immediate Management and Compliance With CDC Protocol Hemil H. Maniar, MS, Akhil A. Tawari, MS, Michael Suk, MD, JD, MPH, FACS, Thomas R. Bowen, MD, and Daniel S. Horwitz, MD
Background: Orthopaedic surgeons are at a high risk of sustaining a percutaneous or mucocutaneous exposure to blood and body fluids. The Center for Disease Control and Prevention recommends a wash with soap and water and notification of the concerned hospital authorities after any percutaneous/mucocutaneous exposure, but a systematic amenability with these guidelines is not always seen. This cross-sectional study was undertaken to determine current knowledge and practices of orthopaedic surgeons in case of a percutaneous sharp injury exposure, emphasizes the immediate first aid steps taken after an exposure, the degree of reporting, and to explore the reasons for noncompliance. Finally, we sought to create awareness about the prevailing Center for Disease Control and Prevention guidelines after any exposure to blood or body fluids.
Materials and Methods: We conducted a cross-sectional survey using an anonymous prepared questionnaire. The study population included exclusively orthopaedic surgeons, including residents, fellows, and attending physicians at 4 US institutions. The questionnaire was also available online on the OTA Web site as a part of survey monkey. The questionnaire comprised 9 multiple choice questions, and more than 1 response could be given for some questions. The questions addressed previous needle stick/sharp injury exposure, number of times that had happened, whether reported to the hospital administration, reason for nonreporting, and risk perception for transmission of blood-borne pathogens (human immunodeficiency virus, HBsAg, and hepatitis C virus). The questions were also asked based on what should be done in four different clinical settings based on respondents risk perception. Results: Of fifty eight attendings, 7 fellows, 45 residents, and 7 respondents who did not indicate their position participated in the survey for a total of 117 respondents. Out of 99, 24 had sustained it once, 18 twice, 11 three times, and 35 at least 4 times. When questioned about informing the incident to the hospital administration, 38% had always reported the incident, 33% had never Accepted for publication April 29, 2015. From the Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA. The authors report no conflict of interest. Waiver of patient consent granted by institutional review board for retrospective chart review. Reprints: Daniel S. Horwitz, MD, Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N. Academy Avenue, Danville, PA 17822-2130 (e-mail: [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Orthop Trauma Volume 29, Number 10, October 2015
reported the incident, and the remaining 29% had not reported it every time. Of note, 87% gave the correct response about the risk of transmission of human immunodeficiency virus after an exposure. On questioning about the risk of hepatitis B transmission, from an HBsAg- and HBeAg-positive source, 13% gave the correct response, whereas from HBsAg-positive and HBeAgnegative source, 30% gave the correct response. Regarding transmission of hepatitis C virus from a positive source, 36% responded correctly. The surgeons seemingly attempted to risk stratify their exposure, and they were more likely to report their exposure in the higher risk scenarios.
Conclusions: This study demonstrates that orthopaedic surgeons of all levels of training are at high risk of occupational exposure to blood-borne pathogens. Moreover, despite the level of training, the majority of surgeons do not follow the recommended steps, although we do not know the reasons for such behavior. Also, there is a low awareness of the significant risk of hepatitis transmission among orthopaedic surgeons treating a population with a high prevalence of undiagnosed hepatitis. Key Words: percutaneous, mucocutaneous, exposure, orthopaedic surgeons (J Orthop Trauma 2015;29:e391–e395)
A
s per the Center for Disease Control and Prevention (CDC), an approximate 385,000 health care workers are exposed to blood and body fluids through needlesticks and other sharps-related injuries per year in the United States. Twenty-three percent occur in surgical settings, with the physicians performing interventional procedures being at most risk.1,2 Percutaneous exposure predisposes to blood-borne infections, notably hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).3 Orthopaedic surgeons are at a high risk of sustaining a percutaneous exposure to blood due to their close contact with sharp instruments/implants such as Kirschner wires, drill bits, and even bone spikes in addition to sharp needles and scalpels. The CDC recommends a wash with soap and water and notification of the concerned hospital authorities after any blood or body fluid exposure,4 but a thorough compliance with these guidelines is not always seen. Currently, there is paucity of published data on the incidence and reporting rates of percutaneous injuries, especially among orthopaedic surgeons. Also, there is no literature www.jorthotrauma.com |
e391
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Orthop Trauma Volume 29, Number 10, October 2015
Maniar et al
on the prevailing compliance to CDC guidelines as far as immediate first aid to a percutaneous exposure, a decision made quickly in the operating room (OR), which can have serious consequences for life. This cross-sectional study was undertaken to determine current knowledge and practices of orthopaedic surgeons in case of a percutaneous sharp injury exposure in the OR, emphasizes the immediate recommended first aid steps taken after an exposure, to define the proportion of surgeons with sharp injuries exposed to blood or body fluids, the degree of reporting, and to explore the reasons for noncompliance. We hypothesized that a high proportion of orthopaedic surgeons are exposed to blood-borne pathogens, and that they do not reliably report them. Finally, we sought to create awareness about the prevailing CDC guidelines after any exposure to blood or body fluids.
MATERIALS AND METHODS After obtaining approval from an institutional review board, we conducted a cross-sectional survey using an anonymous prepared questionnaire. The study population comprised exclusively orthopaedic surgeons, including residents, fellows, and attending physicians at 4 US institutions, all of which were tertiary care hospitals with affiliated academic centers. The questionnaire was also available online on the OTA Web site as a part of survey monkey. Before administering the questionnaire, a note was given explaining the purpose of the study in detail. All the orthopaedic surgeons willing to complete the questionnaire were included. The completion of the questionnaire implied consent. After completing the survey, the physicians were again given a note regarding the CDC protocols to be followed after sustaining any exposure, thereby enhancing their knowledge. The questionnaire comprised 9 multiple choice questions, and more than 1 response could be given for some questions. Apart from the basic deidentified sociodemographic data, the surgeons taking the survey had to indicate their current position (resident/fellow/attending), type of specialty (General, Trauma, Arthroplasty, Spine, SportsMedicine, Pediatric, Hand), and years of practice. The questions addressed previous needle stick/sharp injury exposure, number of times that had happened, whether reported to the hospital administration, reason for nonreporting and risk perception for transmission of bloodborne pathogens (HIV, HBsAg, and HCV). The questions were also asked based on what should be done in 4 different clinical settings; low-risk patient with a solid bore needle/instrument, low-risk patient and a hollow bore needle/instrument, high-risk patient and a solid bore needle/instrument, and high-risk patient and a hollow bore needle/instrument. The options to choose from included replacing the gloves and continuing with surgery, squeezing or attempting to bleed the injury, washing hands with soap and water, washing hands with chlorhexidine, washing hands with iodine, washing hands with alcohol, washing hands with whatever is most convenient, reporting the incident to hospital authorities, and not knowing what
e392
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to do. Finally, the surgeons were asked about the recommended CDC guidelines.
RESULTS Of 58 attendings, 7 fellows, 45 residents, and 7 respondents who did not indicate their position participated in the survey, for a total of 117 respondents. Of the 58 attendings, 34 were trauma specialists, 10 were general orthopaedic consultants, 6 hands specialists, 4 sports specialists, and 2 each of spine and shoulder specialists.
Percutaneous Exposure Out of 117, 99 replied in the affirmative to having a percutaneous exposure in the OR. Out of 99, 24 had sustained it once, 18 twice, 11 three times, and 35 at least 4 times. Of 58 attendings, 54 had sustained a sharp injury exposure. The attending surgeon’s years of practice and number of sharp injury exposures are tabulated in Table 1. Surgeons with less than 5 years of experience reported an average of 2.75 incidents (1.2 per year), surgeons with 5–10 years of experience reported an average of 3.4 incidents (0.5 per year), and surgeons with greater than 10 years’ experience reported an average of 3.7 incidents (0.2 per year). A Poisson regression concluded these differences among groups were not statistically significant. When questioned about informing the incident to the hospital administration, 38% had always reported the incident, 33% had never reported the incident and the remaining 29% had not reported it every time. Of note, 58% did not report based on their judgment that the patient had a low-risk profile, 38% faced problems with lack of time, while the remaining 4% did not know that the administration was to be informed in such a scenario.
Knowledge Regarding Pathogen Transmission Of note, 87% gave the correct response about the risk of transmission of HIV after an exposure. On questioning about the risk of hepatitis B transmission, from an HBsAgand HBeAg-positive source, 13% gave the correct response, whereas from HBsAg-positive and HBeAgnegative source, 30% gave the correct response. Regarding transmission of HCV from a positive source, 36% responded correctly. There was no significant difference in the knowledge levels of the attendings, the residents, and the fellows.
TABLE 1. Attending Surgeon’s Years in Practice and Number of Exposures Number of Sharp Injury Exposures 1 2 3 3+
Attending Surgeons’ Years in Practice 10, 4, 1 2, 1, 1, 17, 4, 3, 8, 3, 3, 8 15, 5, 1, 4, 9, 8, 3, 3, 3 19, 3, 15, 8, 7, 10, 20, 11, 36, 8, 13, 3, 18, 8, 3, 18, 3, 13, 8, 18, 3, 8, 20, 13, 18, 20, 18, 20, 8, 18, 18, 3
Total 3 10 9 32
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Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Orthop Trauma Volume 29, Number 10, October 2015
Awareness and Practices in Different Case Scenarios Table 2 shows details on awareness and practices pertaining to 4 relevant clinical scenarios in increasing order of risk perception: low-risk patient and solid bore needle; low-risk patient and hollow bore needle; high-risk patient and solid bore needle; high-risk patient and hollow bore needle. On an average, 10% of the respondents would follow all the steps recommended by the CDC subsequent to any exposure. On an average, 81% would use water, soap, saline, or any antiseptics after the exposure, whereas 19% would only replace the gloves and continue with the procedure.
DISCUSSION As per the CD, an exposure that might place health care personnel at risk for HBV, HCV, or HIV infection is defined as percutaneous injury (eg, a needlestick or cut with a sharp object) or contact of mucous membrane or nonintact skin (eg, exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or other body fluids that are potentially infectious.4 For the orthopaedic surgeon, mucous membrane exposure would comprise splashes of infected blood or fluids into the eyes, nose, or mouth. Our data demonstrates that the orthopaedic surgeons of all levels of trainings are at severe risk of occupational exposure to blood-borne pathogens. In our study, a majority of the respondents had sustained a percutaneous sharp injury, and almost half of them had sustained it 3 times or more. Attending surgeons with a greater number of years of practice had a higher absolute number of injuries over time, on average, but a lower rate of injuries per year. Percutaneous and mucocutaneous exposures have been decreasing among nonsurgical health care providers, but a similar trend is not seen among workers in surgical settings.2 Percutaneous sharp injury among orthopaedic surgeons is a known professional hazard that can have serious implications for life. Even after taking all the precautions, there are chances that one may have a percutaneous or a mucocutaneous exposure.
Management and Compliance With CDC Protocol
Our data demonstrate that most exposed orthopaedic surgeons do not disclose the incident despite wide-spread knowledge of the mandate to report all occupational exposures. Nearly, all (96%) of the surgeons were aware that the hospital authorities should be informed after any exposure, but only a minority (38%) of the surgeons had reported every exposure. The most common reason for nonreporting was the perceived low-risk profile of the patient (58%). Although the currently used tests for detection of HIV, HBsAg, and HCV have a very high sensitivity rate, false-negative results can still be obtained during the window period, especially with tests that depend upon antibody levels (HIV tests).5 In addition, patients in the United States are not routinely screened for these viral infections and the surgeon’s perception of “low risk” may be erroneous. As per a National Surveillance System for Healthcare Workers report regarding 30,945 reported exposures from 1995 to 2007, 12.6% of source patients were infected with HCV, HIV, or HBV.6 This has serious implications, as in the event of unfortunate subsequent seroconversion, the affected surgeon will not be entitled to workers compensation in the absence of reporting. Moreover, not reporting on time can delay usage of postexposure prophylaxis and thereby reduce its effectiveness.7 Hence, it is paramount to report every blood or body fluid exposure, irrespective of the perceived risk, as recommended by the CDC. Also, for the injured individual, reporting prompts evaluation of the potential need for postexposure prophylaxis allows early detection of seroconversion (if any) and largely helps in decreasing anxiety. Of note, 38% of the respondents did not report it due to lack of time, which is also consistent with the findings of several studies that have implicated extensive working hours as an obstruction to practicing safe procedures.8,9 This study demonstrates that a there is a high percentage of awareness about the average risk of HIV transmission (0.3% after an exposure)10 with 87% of the surgeons giving the correct response. However, the awareness regarding the transmission risks of hepatitis B and hepatitis C virus was very low. Thirteen percent gave the correct response concerning the average risk for developing clinical hepatitis from
TABLE 2. Responses in Different Case Scenarios
Wash with soap and water, changing gloves, and informing the hospital administration Wash with soap and water, iodine, chlorhexidine, alcohol, or whatever is available Replace the gloves and continue with the surgery Inform the administration Squeeze and attempt to bleed the injury
Low-Risk Patient and Solid Bore Needle, %
Low-Risk Patient and Hollow Bore Needle, %
High-Risk Patient and Solid Bore Needle, %
High-Risk Patient and Hollow Bore Needle, %
6
11
12
11
77
87
83
78
23
13
17
22
34 33
50 40
70 37
86 36
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Maniar et al
J Orthop Trauma Volume 29, Number 10, October 2015
CONCLUSIONS
HBsAg- and HBeAg-positive source (22%–31%), whereas 30% gave the accurate answer (1%–6%) from an HBsAgpositive but HBeAg-negative source.11–13 Regarding average incidence of anti-HCV seroconversion (1.8%), 36% responded correctly.11,14 We believe that the first step in the following safe procedures after any exposure to blood and body fluids is having adequate knowledge about the risk of disease transmission. Hence, we recommend regular training and knowledge update pertaining to percutaneous and mucocutaneous exposure. As per the CDC, the steps to be followed in the OR after any blood or body fluids exposure are to wash needlesticks and cuts with soap and water. The splashes to the nose, mouth, or skin should be flushed with water, while the eyes should be irrigated with water, saline, or any of the sterile irrigants. One should report the incident to the medical supervisor and immediately seek medical treatment. As per our direct communication with the CDC, it does not endorse any specific type of soap. A common practice among orthopaedic surgeons after sustaining an exposure is pouring antiseptic agents such as chlorhexidine, alcohol containing agents, or iodine solutions on the wound. Although these agents are used in the initial surgical prep, no evidence exists that using antiseptics for wound care reduces the risk of blood-borne transmission. The CDC neither supports nor opposes their use; however, it does not recommend the application of caustic agents (eg, bleach) or the injection of antiseptics or disinfectants into the wound.4 Our data reveals that surgeons seemingly attempt to risk stratify their exposure. They are more likely to report their exposure to the hospital administration only in the perceived higher risk scenarios as is evident from the responses to the 4 clinical case scenarios. Only a minority of the respondents (10%) would have practiced all the steps as recommended by the CDC. Although on an average, 81% would use water, soap, saline, or any antiseptics after the exposure, the remaining 19% would simply replace the gloves and continue with the procedure irrespective of the case scenarios. Several participants responded to practicing squeezing and attempting to bleed the wound (36%). Although the wounds should be allowed to bleed freely, the CDC does not recommend squeezing the punctured sites. Also, it is imperative to seek medical treatment early, as the postexposure prophylaxis is dependably effective only within a short span of time. A greater benefit of postexposure prophylaxis was reported when it was initiated within 36 hours after exposure as compared with 72 hours after exposure in macaques.15 We understand that our study had various limitations. First, there is a possibility of underreporting of the sharp injuries based on recall inaccuracies. In addition, the four tertiary care hospitals cannot truly represent all orthopaedic facilities. One may argue that in a smaller center where the orthopaedic surgeon is not exposed to seropositive patients as often, she/he would be more cautious when dealing with such patients. The 4 centers, however, were chosen with the belief that with a higher surgical load, the exposure risk and may be the awareness levels about sharp injuries would be higher in these institutions.
1. Lee JM, Botteman MF, Xanthakos N, et al. Needlestick injuries in the United States. Epidemiologic, economic, and quality of life issues. AAOHN J. 2005;53:117–133. 2. Voide C, Darling KE, Kenfak-Foguena A, et al. Underreporting of needlestick and sharps injuries among healthcare workers in a Swiss University Hospital. Swiss Med Wkly. 2012;142. 3. Tarantola A, Abiteboul D, Rachline A. Infection risks following accidental exposure to blood or body fluids in health care workers: a review of pathogens transmitted in published cases. Am J Infect Control. 2006;34: 367–375. 4. Centers for Disease Control And Prevention. Bloodborne infectious diseases: HIV/AIDS, hepatitis B, hepatitis C. 2014. Available at: http://www. cdc.gov/niosh/topics/bbp/emergnedl.html. Accessed October 11, 2014. 5. Taylor D, Durigon M, Davis H, et al. Probability of a false negative HIV antibody test result during the window period: a tool for pre- and posttest counselling. Int J STD AIDS. 2014;26:215–224. 6. MacCannell T, Laramie AK, Gomaa A, et al. Occupational exposure of health care personnel to hepatitis B and hepatitis C: prevention and surveillance strategies. Clin Liver Dis. 2010;14:23–36. 7. Landovitz RJ, Currier JS. Clinical practice. Postexposure prophylaxis for HIV infection. N Engl J Med. 2009;361:1768–1775. 8. Ayas NT, Barger LK, Cade BE, et al. Extended work duration and the risk of self-reported percutaneous injuries in interns. JAMA. 2006;296: 1055–1062. 9. Ilhan MN, Durukan E, Aras E, et al. Long working hours increase the risk of sharp and needlestick injury in nurses: the need for new policy implication. J Adv Nurs. 2006;56:563–568. 10. Chin RL. Postexposure prophylaxis for HIV. Emerg Med Clin North Am. 2010;28:421–429. 11. Centers for Disease Control and Prevention. Updated U.S. public health service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2001;50:1–52. 12. Mast EE, Alter MJ. Prevention of hepatitis B virus infection among health-care workers. In: Ellis RW, ed. Hepatitis B Vaccines in Clinical Practice. New York, NY: Marcel Dekker; 1993:295–307. 13. Werner BG, Grady GF. Accidental hepatitis-B-surface-antigen-positive inoculations: use of e antigen to estimate infectivity. Ann Intern Med. 1982;97:367–369. 14. Alter MJ. The epidemiology of acute and chronic hepatitis C. Clin Liver Dis. 1997;1:559–568. 15. Otten RA, Smith DK, Adams DR, et al. Efficacy of postexposure prophylaxis after intravaginal exposure of pig-tailed macaques to a humanderived retrovirus (human immunodeficiency virus type 2). J Virol. 2000; 74:9771–9775.
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This study demonstrates that orthopaedic surgeons of all levels of training are at high risk of occupational exposure to blood-borne pathogens. Moreover, despite the level of training, the majority of surgeons do not follow the recommended steps although we do not know the reasons for such behavior. Also, there is a low awareness of the significant risk of hepatitis transmission among orthopaedic surgeons treating a population with a high prevalence of undiagnosed hepatitis.
ACKNOWLEDGMENTS The authors thank Dr Paul Tornetta, Dr J. Tracy Watson, and Dr Andrew Sems, without whose participation it would not have been possible to carry out the project. REFERENCES
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