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Needle Stick and Sharps Injuries and Factors Associated Among Health Care Workers in a Malaysian Hospital ARTICLE in EUROPEAN JOURNAL OF SOCIAL SCIENCES · MARCH 2010
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European Journal of Social Sciences – Volume 13, Number 3 (2010)
Needle Stick and Sharps Injuries and Factors Associated Among Health Care Workers in a Malaysian Hospital Lekhraj Rampal Corresponding Author, Consultant Epidemiologist, Department of Community Health Faculty of Medicine and Health Science, Universiti Putra Malaysia E-mail:
[email protected] Tel: 03- 89472411 Rosidah Zakaria Hospital Putrajaya, Ministry of Health Malaysia E-mail:
[email protected] Tel: 0163721373 Leong Whye Sook Department of Medicine, Nursing Unit, Faculty of Medicine and Health Science Universiti Putra Malaysia E-mail:
[email protected] Tel: 03- 89472437 Azhar Md Zain Dean, Faculty of Medicine and Health Science, Universiti Putra Malaysia E-mail:
[email protected] Tel: 03- 89472602 Abstract Introduction: Needle stick and sharps injuries (NSSIs) have been recognized as one of the occupational hazards among health care workers (HCWs). They increase risk of spread of diseases like HIV, Hepatitis B and Hepatitis C. The objective of this study was to determine the prevalence and factors associated with needle stick and sharps injuries. Methods: This cross sectional study was conducted in Serdang Hospital Malaysia using a self-administered validated questionnaire. The respondents consisted of 345 HCWs namely medical assistant officer, staff nurses, medical laboratory technician and community nurse. Data was analysed using SPSS version 17. Results: Results showed that the overall mean age of the 345 respondents was 29.7years and it ranged from 22 years to 45 years with a median of 29 years. The mean age for the males (28.9 years) did not differ significantly from the females (29.9 years). The overall prevalence of needle stick or sharps injuries was 23.5%. Staff nurses had the highest prevalence (27.9%). The causes of NSSI in 58% of cases were hypodermic needle and 27.2% cases were recapping. Medical ward reported the highest NSSIs (51.9%). Knowledge on body fluid transmitted by HIV/AIDS and blood products was high (99.1%). Majority stated that they throw needles or sharps immediately after use in sharp bins (92.7%), do not separate needles from syringes prior to disposal (98.0%) and do not dissemble needles or sharps with hand (98.5%) and do not recap needles after use (94.3%). Majority also stated that they were aware about universal precaution guideline (96.5%) and needle stick and sharps injury needs to be reported (99.1%). However, out of those health care workers (23.5%) who had NSSI, only 30.9% had reported the incident of needlestick 354
European Journal of Social Sciences – Volume 13, Number 3 (2010) and sharps injuries indicating that there were gaps between knowledge and practice among the HCWs. There was a statistically significant association between NSSIs and age (p=0.01) of respondent, working experience (p=0.001) and job categories (p=0.03). Conclusions: The prevalence of NSSI was 23.5%. Although the knowledge on Universal Precautions is good, the prevalence of NSSIs is still high and there are gaps between knowledge and practice related to HIV prevention. NSSIs continue to pose a serious occupational problem.
Keywords: Needle stick / sharp injuries, Factors Associated, Health Care Workers, Malaysia
1. Introduction Needle sticks and sharp injuries (NSSIs) have been recognized as one of the occupational hazards among health care workers (HCWs). An estimated 600,000 to 800,000 needle stick and other percutaneous injuries are reported annually among U.S. HCWs [1]. It is estimated that 100,000 needle stick injuries occur annually in UK alone [2] and 500,000 annually in Germany[3].Occupational exposures to percutaneous injuries are substantial source of infections with blood borne pathogens among health-care workers and can cause substantial health consequences and psychological stress for HCWs and their loved ones [4]. Occupational blood borne transmission of more than 50 different pathogens has been reported [5]. NSSIs increase risk of spread of diseases like HIV, Hepatitis B and Hepatitis C [6,7]. Sharps injuries are a major source of HCV infection among HCWs, accounting for almost 40% of HCV infections [8]. Jagger (2007) reported that the risk of occupational infection with HIV, although alarming, has never reached the scale of hepatitis B [9]. Out of the total of 94 documented and 170 possible cases of occupational HIV infection had been identified worldwide up to 1997, nearly two-thirds of cases were reported from the United States [10]. This could be due to the fact that most countries, especially those with a high population prevalence of HIV infection, have never instituted surveillance systems that would capture data on such case [9]. Certain groups of individuals are at greater risk than others because of the nature of their work. Numerous studies have found nurses to be the commonest group of HCWs experiencing needle stick injuries [11]. The objectives of the study were to determine the prevalence of needle sticks and sharps injuries and its associated factors among HCWs at Serdang Hospital.
METHODS Study location: This study was carried out at Serdang Hospital Malaysia Study design: A cross-sectional study design was used. Estimated sample size: The estimated sample size for this study was 287. An additional 20% for non response was added to give a sample seize of 345 HCWs. Sampling frame: A list of all HCWs (assistant medical officer, staff nurses and medical laboratory technician and community nurses) in Serdang Hospital Malaysia. This study did not include doctors. Sampling technique: Simple random sampling technique using table of random number was used to select the respondents. Instrument: a structured pre tested validated questionnaire was used in this study Data analysis: Data was analyzed using Statistical Package for the Social Sciences (SPSS) version 17. Descriptive statistics were performed on the knowledge on blood borne diseases and universal precaution, socio-demographic data, work factors, and practice on universal precaution influence to needle stick or sharp injury. Age was computed from the information on date of birth and date of interview. Categorical variables were presented as percentages. The x2 test was used to evaluate the 355
European Journal of Social Sciences – Volume 13, Number 3 (2010) relationship between variables. Independent sample t-test was used to compare the means of two independent continuous variables. A p-value of < 0.05 was considered as statistically significant. Ethnic Approval: Ethical approval was obtained from Ministry of Health Medical Research Ethics Committee (MREC) and Ethics Committee of Faculty of Medicine and Health Science, UPM; Consent was also obtained from all respondents before being interviewed.
Results Response rate and socio-demographic characteristics All the 345 HCWs agreed to participate giving a response rate of 100%. Table 1 shows the sociodemographic characteristics of the respondents by age, sex, ethnicity, education level, job categories and working experience. Majority of the 345 HCW were females (87.5%). Majority were Malay 96.8%. The overall mean age of the 345 respondents was 29.7years (95% CI = 29.2 to 30.2) and it ranged from 22 years to 45 years with a median of 29 years. The mean age for the males (28.9 years) did not differ significantly from the females (29.9 years; p > 0.05). Majority (83.2%) of respondents had 10 years and below working experience. Among the 345 respondents majority (63.5%) were staff nurses, followed by community nurses (20.3%), assistant medical officers (11.0%) and medical laboratory technicians (5.2%). Table 1:
Socio-demographic characteristics of respondents
Variable Age group
Gender Ethnicity Job category
Education level Years of services
Description 20 – 24 years 25 – 29 years 30 – 34 years 35 – 39 years 40 years or more Female Male Malay Non-Malay Staff Nurse Community Health Nurse Assistant Medical Officer Medical Laboratory Technician Diploma/Degree Certificate < 10 years 10 years or more
Frequency N 30 165 97 40 13 302 43 334 11 219 70 38 18 256 89 287 58
% 8.7 47.8 28.1 11.6 3.8 87.5 12.5 96.8 3.2 63.5 20.3 11.0 5.2 74.2 25.8 83.2 16.8
Knowledge, attitude and practice of health care workers of biological hazards and preventive measures regarding needle stick and sharp injuries. Table 2 shows the level of knowledge, attitude and practice of health care workers of biological hazards and preventive measures regarding needle stick and sharp injuries. The results show that majority stated that were aware about universal precaution guideline (96.5%) and that needle stick and sharps injuries need to be reported (99.1%). Only minority did not know Hepatitis B (2.6%) and Hepatitis C (7%) can be transmitted by needle stick and sharp injuries. However, 18.8% of the HCW were unaware of the fact that HIV/AIDS can be transmitted by needlesticks and sharps injuries and 19.4% did not know that they need to wear gloves during handling phlebotomy administration. Majority (66.1%) of the HCW were of the impression that needles should be recapped after use and only 52.5% knew about needleless safety devices. Majority (98.3%) stated that they use gloves for phlebotomy, during withdrawing needles from patient (97.4%), wear gloves during manipulating sharp 356
European Journal of Social Sciences – Volume 13, Number 3 (2010) bin (95.4%) and during disposal contaminated needles or sharps (96.5%). Majority also stated that they throw needles or sharps immediately after use in sharp bin (92.7%), do not separate needles from syringes prior to disposal (98.0%) and do not dissemble needles or sharps with hand (98.5%) and do not recap needles after use (94.3%). The results also show that out of the 345 respondents, 81 had experienced needle stick or sharps injury giving an overall prevalence of 23.5%. However, out of these 81 health care workers who had NSSI, only 25 (30.9%) had reported the incident of NSSI. Those HCW who had stated that they had experienced NSSI, were then asked the work place where there had experienced it. Table 3 shows work place at the time of needle stick or sharp injuries. Majority (51.9%) experienced NSSI in the medical ward. They were then also asked the type of devices involved in needle stick or sharps injuries. Out of the 81 HCW who had NSSI, majority (58%) reported hypodermic needle, followed by suture needle (21%), butterfly needle (8.6%), venofix / branula (7.4%) and lancet (5%). Table 2:
Respondents’ knowledge, attitude and practice regarding biological hazards and preventive measures in needle stick and sharp injuries Item
Description
Do you know about the universal precaution guidelines? Do you know about the needleless safety device? Can Hepatitis B be transmitted by needle stick and sharp injuries? Can Hepatitis C be transmitted by needle stick and sharp injuries? Can HIV/AIDS be transmitted by needle stick and sharp injuries? Do you need to wear gloves during phlebotomy? Do you use gloves during phlebotomy? Do you wear gloves when withdrawing a needle from a patient? Should needles be recapped/bent after use? Do you recap needles after use? Do you disassemble used needle or sharp with your hands? Do you wear gloves when disposing of contaminated needles or sharps? Do you separate the needle from the syringe prior to disposal? Do you throw used needles or sharps into the sharp bin immediately? Do you wear gloves when manipulating the sharp bin? Do needle stick and sharp injuries need to be reported? Have you ever had a needle stick or sharp injury? Was the incident of needle stick or sharp injury reported?
357
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Frequency N 333 12 181 164 336 9 321 24 280 65 278 67 339 6 336 9 228 117 20 325 5 340 333 12 7 338 320 25 329 16 342 3 81 264 25 56
% 96.5 3.5 52.5 47.5 97.4 2.6 93.0 7.0 81.2 18.8 80.6 19.4 98.3 1.7 97.4 2.6 66.1 33.9 5.8 94.2 1.5 98.5 96.5 3.5 2.0 98.0 92.7 7.3 95.4 4.6 99.1 0.9 23.5 76.5 30.9 69.1
European Journal of Social Sciences – Volume 13, Number 3 (2010) Table 3:
Work place at the time of needle stick or sharp injuries Frequency
Location
N 42 13 8 7 7 2 2
Medical Wards Labor Room Operation Theatre Emergency Department Intensive Care Units Surgical Wards Laboratories
% 51.9 16.0 9.9 8.6 8.6 2.5 2.5
Procedure performed at the time of needle stick or sharps injuries The respondents were also asked what was the procedure performed at the time of NSSIs occurred among respondents who had experienced NSSI. Table 4 shows the activities at time of needle stick or sharp injuries. Out of the 81 respondents who had experienced needle stick or sharps injury, 22 (27.2%) were recapping needle or sharp devices at the time of needle stick or sharp injuries, followed by handling needle or sharps devices on tray (21.1%), suturing (18.5%), passing or transferring needle (13.6%), transit disposal needle or sharp devices (12.3%) and dissembling needle or sharp devices (7.4%). Table 4:
Activities at time of needle stick or sharp injuries Frequency
Activity
N 22 17 15 11 10 6
Recapping needle Handling needle or sharp on a tray Suturing Passing or transferring needle or sharp Transit of disposal needle or sharp device Disassembling needle or sharp device
% 27.2 21.0 18.5 13.6 12.3 7.4
Relationship between prevalence of needle sticks/sharps injury and age, gender, ethnicity, educational level, job category and working experience Table 5 shows the relationship between prevalence of NSSI and age, gender, ethnicity, educational level, job category and working experience. The results show that there was a significant relationship between prevalence of NSSIs and age (p0.05). Overall the results showed that there was a significant relationship between prevalence of NSSIs and job category (p 10 years
Needle stick/sharp injuries Yes No Frequency N % N % 4 13.3 26 86.7 36 21.8 129 78.2 17 17.5 80 82.5 18 45.0 22 55.0 6 46.2 7 53.8 8 18.6 35 81.4 73 24.2 229 75.8 78 23.4 256 76.6 1 50.0 1 50.0 2 22.2 7 77.8 61 27.9 158 72.1 8 11.4 62 88.6 7 18.4 31 81.6 5 27.8 13 72.2 1 100 0 0 64 25.1 191 74.9 16 18.0 73 82.0 66 23.1 220 76.9 15 25.4 44 74.6
Value x2
p
17.9
0.001
0.65
0.42
0.79
0.67
8.72
0.03
1.87 Diploma vs. Certificate 0.15
0.17
0.69
Discussion The prevalence of needle stick or sharps injuries among HCWs in this study carried out in 2008 was 23.5% which is slightly lower compared to prevalence of 24.9% reported by Lee and Hassim in 2005 [12]. However this is much lower than 74% reported by Maqbool Alam in a study carried out in 2002 at the 100-bed Armed Forces Hospital, Saudi Arabia [13], 74% reported by Gurubacharya et al in their study carried out in Nepal in 2003 [14] and 39.4% reported by Hofranipour et al, 2009 in Iran [15]. In our study the prevalence was highest in staff nurses. Similar results have been reported in several other studies [16,17]. This can be explained by the fact that nurses administer most of the injections and are responsible for venipunctures, intravenous fluid administration and other procedures which require the use of needles. Gerberding in 1991 stated that one reason that may account for the increased vulnerability of injury among nurses is the greater amount of time nurses spent in direct patient contact [18]. Our study showed that there was no significant association between gender with needle stick and sharp injury. Similar results have also been reported by Hadadi et al. (2008) [16]. Prospective studies have reported that the estimated risk for HIV infection after a percutaneous exposure to HIV infected blood is approximately 0.3% [19-20]. Pruss-Ustun et al reported that an estimated of more than three million HCWs experience a percutaneous injury with a contaminated sharp object each year and these exposures result in about 16,000 infections of HCV, 66,000 of HBV and about 1,000 of HIV that lead to about 1,100 deaths and significant disability. They also estimated that 4.4% (0.8%–18.5%) of HIV infections among HCWs may be attributable to occupational sharps injuries worldwide [8]. There is a widespread availability of safety-engineered needles and sharp devices. The new generation of devices has shown a high degree of safety efficacy, especially those used for vascular access and drawing blood, the procedures that are associated with the greatest risk of blood-borne pathogen transmission. Jagger and Bentley in 1997 [21] and Mendelson et al [22] in 2000 have reported reductions of 83% and 89% in the number of needle sticks after the introduction of safety engineered intravenous catheters. Lamontagne et al. in 2007 reported a 74% reduction in the 359
European Journal of Social Sciences – Volume 13, Number 3 (2010) number of injuries from needles for drawing blood after the introduction of safety-engineered alternatives [23]. The recapping of needles has been prohibited under the Occupation Safety and Health Administration (OSHA) blood-borne pathogen standard [24]. Our study also showed that majority (66.1%) of the HCW had the misconception that needles should be recapped after use and only 52.5% knew about needleless safety devices. The availability and compliance to adopting safety-engineered devices will help in the reduction of NSSI and risk of blood-borne infections including HIV/AIDS. Timely reporting of occupational exposures to an employee health service is required to ensure appropriate counselling, facilitate prophylaxis or early treatment, and establish legal prerequisites for workers' compensation [25]. This study result showed that although majority (96.5%) stated that they know about the Universal precaution guidelines, however, there are gaps in the knowledge and practice. Majority (99.1%) reported that needle stick and sharp injuries need to be reported, however, only 30.9% who had needle stick and sharp injuries reported the incident. The failure to report NSSI has been highlighted in this study. Knowledge is not sufficient, it must be accompanied by practice. These health care workers expose themselves with unnecessary risk of not reporting thus depriving themselves of the benefit of intervention.
Conclusions The prevalence of needle stick or sharp injuries among HCWs in this hospital was 23.5%. There are gaps in the knowledge and practice among the HCWs. Only 30.9% who had needle stick and sharps injuries reported the incident. The is a need to report NSSIs to the relevant authorities so as to facilitate and ensure appropriate counselling, prophylaxis or early treatment. There is also a need for strict compliance to adopting safety-engineered devices which will help in the reduction of NSSI and risk of blood-borne infections.
Acknowledgement We are grateful to Tan Sri Datuk Sri Dr. Hj. Mohd. Ismail b. Merican, Director General, Ministry of Health Malaysia and Dean, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia for permission to publish this paper. Our thanks are also due to the Director and staff of Serdang Hospital for their assistance and cooperation.
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