Dr. Ekta Rishi, A08231, Dr. Abhinav Dhami, Dr. Pukhraj Rishi
Introduction
Needle stick injury (NSI) can occur during various procedures like needle recapping, operative procedures, blood collection, intravenous line administration, checking blood sugar and due to improper sharps/needle disposal.[1] NSI is the second most common cause of occupational injury within the National Health Services (NHS).[2] Over the years, Ophthalmology has evolved as a unique microsurgical practice and surgeons are at a constant risk of sustaining such injuries. The ophthalmic theatre is the 2nd most common reported location for NSI and accounts for 17% of the high risk sharp injuries as reported by the health practice authority of the United Kingdom in 2007.[2] With the advancement in ophthalmic microsurgical instruments, sutures, and working under high magnification with dim room light, poses a great risk to the ophthalmic surgeons and assistants for sharp injuries. Mansour et al attributed this to the special working circumstances which render the ophthalmologists at a greater risk for sustaining NSI as compared to other medical specialties.[4] The reported authentic data of NSI in India is scarce due to infrequent reporting.[3] NSI pose a serious risk for occupational transmission of blood pathogens such as Human immunodeficiency virus (HIV), Hepatitis B, and C virus (HBV, HCV).[5]
The consequences of a sharp injury reach far beyond the immediate risk of blood borne virus transmission as such events are highly stressful and have the potential to affect an individual’s career, family, and patients.[6-12]
The number of intravitreal injections performed have increased dramatically over the past decade and have increased risk for the ophthalmic personal for NSI.[13]
There is very limited data for the reported NSI in an ophthalmic set-up. Pubmed search for keywords <needle stick injury>, <Ophthalmology> revealed only three articles.[13-15]
The purpose of this study was to determine the risk factors for NSI in a tertiary care ophthalmic practice over a 7 year period. The cost for conducting investigations for both the patient and the injured medical personnel, and risk assessment for contamination with pathogens was also assessed.
Materials and methods
This study was a retrospective database review of all needle prick injuries recorded between 2010 and 2016 at a tertiary eye care center in India. The institution has six fully functional centers within the city, equipped for both outpatient (OP) and inpatient (IP) management. The institute has two mobile surgical units in buses for conducting cataract surgeries in the villages which are accompanied by well-equipped mobile pathology laboratory for sample blood collection and testing. The institute offers teaching and training to ophthalmic post-graduates, fellows (trainee doctors), nursing staff, optometrist, paramedical staff and ophthalmic secretaries. This study was conducted according to the tents of Helsinki Declaration. Prior IRB approval was obtained. Each subject consented by signing a written informed consent
The procedure for sharp needle and instrument disposal is followed as per a standard protocol in all the centers. All the new recruits (staff and students) joining the institute are made aware of the protocols so as to minimize the rate of needle stick injuries. The protocol for handling sharp needle dictates minimal manipulation of needle or sharp instruments with hands or finger. Re-capping of sharp instruments is avoided and inter-individual handling from one person to another during a surgical procedure is kept to a minimum. Particularly, in the OPD, care is taken to dispose needles in sharp disposal bins that are provided with colored labels in each room. Meanwhile, in the operating rooms, extreme caution is taken during surgery by using trays to pass the sharp instruments between the surgeon and nursing assistant. All needles are disposed in the sharp-proof containers immediately after use in the operation theatre (OT). A special area in the OT is designated for trolleys to place sharp instruments. All syringes are disposed in a separate container marked with a red colored liner.
The protocol in the event of an accidental NSI is described as follows in (Sharp_injury_form.pdf), three copies of the incident report form is raised by the concerned health care worker and one form each is sent to the main laboratory, the Human resource department (HRD) and to the Hospital infection control (HIC) committee. The patient flow is depicted in Figure 1.
The NSI analysis form is filled after investigating the cause for injury and corrective and preventive action is taken in the manner subsequently described. After obtaining their consent, the patient’ and the injured personnel’s blood samples are collected. A record is kept in HRD for future follow-up or analysis. Counseling of the patient and the injured personnel is done by the concerned physician. Laboratory tests performed include HIV screening in the 1st two hours of NSI and post-exposure prophylaxis within 72 hours. If the patient tests HIV positive, antiretroviral therapy is started immediately and continued for 4 weeks in accordance with the National AIDS control organization (NACO) guidelines.[8] The Health care worker (HCW) is counseled and assessed for HIV1&2 (Enzyme linked immunoassay) antibodies at 6months interval. Hepatitis B and C antibodies are tested within first 2 hours and then at 3rd and 6th month interval. The levels of Hepatitis B antibodies are measured for the HCW at 3rd and 6th month and if the levels are below 10mIU/ml, booster dose of Hepatitis B vaccination is administered.
Disposal of all sharps is done in yellow puncture-proof containers instilled with 1% sodium hypochlorite solution.
Every OPD, patient ward, and OT is provided with adequate number of containers. Care is taken to avoid overfilling these containers and the containers are handed over to the housekeeping staff once they are three-quarters full. All housekeeping staff are adequately trained in maintaining precautions while handling sharp instruments for disposal. All general waste is segregated and disposed in white polythene bio-degradable bags that are then placed in big bins designated for it in the garbage area. The city corporation vehicles daily clears the waste. This is in accordance with World Health Organization (WHO) protocol for safe management of waste from health care organizations.
Results
One hundred and forty NSI were reported over a period of 7 years from 2010 to 2016.Ophthalmic fellows, under training in the institute suffered maximum needle pricks (n=33; 24%), followed by the nursing staff (n=32; 23%) consultants (n=30; 21%). The postgraduates and the biomedical staff accounted for (n=14; 14%) and (n=14; 10%), respectively. The least NSI were encountered by housekeeping/ maintenance staff (n= 8; 6%) followed by the anesthesiologist and staff secretaries (n=2; 1%) .
The maximum NSI occuring in the OT (n=94 ; 67%) followed by laboratory (n=1712%) and the ward (n=14;10%). The minimum number was reported in OPD and in needle disposal (n=9 ;6%) and (n=6; 4%) each respectively.
The maximum number of pricks (n= 10;20%) occurred while operating and while passing the sharp instruments. The NSI encountered while discarding the needles and while administering injection were (n=7; 14%) and (n=5; 10%) each respectively .
The cost for 1st collection of blood sample for HIV 1, HIV2, HCV, and HBsAg (ELISA) were Rs1070, Rs 430, and Rs.580, respectively and the cost of the antibody vaccination was Rs.660. The total cost to the institute per staff members for the 1st sample was Rs.2740. The cost for the 2nd and 3rd sample testing was Rs 2080 each, per staff member. The same cost of 2nd and 3rd sample testing for the patients (Rs 2080 per head), was borne by the hospital. The cost of the second dose of post-exposure prophylactic vaccination for the staff was Rs180.The cost incurred by the hospital for testing one patient and one injured staff member was Rs 9180. The overall cost incurred for managing all the 140 NSI, amounted to Rs12,85,200.00 ($19,219.38).
The maximum number of pricks (n=35 ;25%) were observed in 2011, followed by (n=28; 20%) NSI in 2010 and 2012 each respectively. The least (n=10; 7%) NSI were observed in 2013, while 2014 and 2015 accounted (n=18 ;13%) and (n=21; 15.0%) each respectively.None of the reported subjects with NSI had seroconversion to HBsAg, HIV and HCV, in the 7 years duration.There was a progressive decrease in number of NSI after a proper education programme was started .with videos of needle disposal to all new recruits.
The data delineates the negligible number of NSI occurring in our institute even with the steady increase in the number of IP and OP patients per year.
Discussion
This study provides significant data regarding the self-reported risk for NSI amongst health workers in a tertiary eye-care ophthalmic practice in south Asia.
In our study, the highest incidence of NSI were observed amongst the training fellows in the institute, accounting for (n= 34 ; 24%) of the total number. This was followed by the nursing staff and consultants each accounting for (n=32 ; 23% ) and (n=29 ; 23%) of the total NSI respectively. Ghauri AJ et al, and Alshihry AM, observed most NSI being reported amongst the nursing staff, 54% and 50% respectively, followed by doctors accounting 40% and 19% respectively in their study.[4,6] Jayanth ST et al conducted a study of needle prick injury in tertiary hospital and observed that nursing staff accounted 28% of the NSI and interns/trainees accounted for 9% respectively.[5] Maximum NSI being observed amongst the fellows can be attributed due to the fact that our hospital is a tertiary ophthalmic institute and provides training to a large number of fellows and post graduates in variable ophthalmic sub-specialties. The high volume of surgical assistance work and relatively limited wet lab experience and the surgical learning curve could attribute to such risk.
In our study, the highest number of needle pricks (n=94 ; 67% ) occurred in OT, followed by laboratory and ward, accounting (n=17 ; 12% ) and (n=14 ; 10% ), respectively. Ghauri AJ and Alshihry AM, each reported 52% and 55% of NSI in the ophthalmic theatre and this corresponds with our results.[4,6] This can be attributed to the fact that most of the ophthalmic procedures are conducted in the OT and ours being a tertiary care centre the number of surgeries are higher on a per day basis and thus increasing the chances of NSI in both the OT and ward.
In our study, the two most common settings for NSI in the operating room were while passing sharp instruments by hand, and the other while operating, each accounting for (n=10; 20%). This was comparable with the results obtained in the study by Alshihry et al where they observed the maximum number (31%) of NSI while handling instruments during operating procedures. [6]Ghauri AJ et al observed 46% and Alshihry AM observed 21% cases of NSI while discarding the needles in comparison to (n=7; 14%) observed in our study. Needle discarding procedures accounted for the second most common cause of NSI in our study.[4] The other causes of NSI as observed by Alshihry AM, during various surgical steps/procedures were, while recapping the needles (55%), passing the instrument (35%), unpacking the instrument sets and uncovering the needles (5%). Dissimilar results were observed in comparison with our study as needle recapping accounted for 8% of NSI. This can be attributed to the initial training course given in sharp disposal to all staff members at the time of joining the institute.
In our study, the highest number of NSI was observed amongst anterior segment surgeons (n=23; 79% ) in comparison to the posterior segment surgeons accounting for (n=6; 21% ). No references were available in literature on the prevalence of NSI between anterior and posterior segment surgeons. This can be attributed to the higher frequency of anterior segment surgeries performed in a day by a single surgeon as compared to a posterior segment surgery and faster handling of sharp instruments exposing them to a higher risk.
The cost of the post-exposure for staff in our institute inclusive of the vaccination and patient blood sample is Rs.9180 ($144). Thus, the total expense for 171 NSI was Rs. 12,85,200.00 ($19,219.38). The cost of a similar single NSI treatment in United States ranges between $500-3000. The annual economic burden for NSI in United States is estimated to be between 118 million to 591 million dollars.[8,9] In United Kingdom, the cost for initial testing and treatment is €3500, while the long term cost of treating HCV and HIV is €700,000,[8]. The short term cost at a tertiary care hospital in Mumbai is Rs9000 for each health care worker per needle prick.[12]
In the current study, the year-wise incidence of NSI with maximum number of pricks (n=35; 25%) were observed in 2011, followed by (n=28; 20% ) NSI in 2010 and 2012 respectively, with a decrease in NSI frequency (n=10; 7%) in 2013, 2014(13%) and 2015(15%) respectively. This can be attributed to the intensified training of staff and new recruits by showing them preventive videos and demonstrating how to discard sharp instrument by HIC committee. The training initiative for NSI prophylaxis was started in 2012 in our institute. Even with the best efforts in educating the staff on periodic basis, still accidental NSI does occur, thus necessitating the need for repetitive and regular training for proper disposal of needles and highlight the emphasis for extreme precaution in handling sharps. We observed no seroconversion in all 5 years for all staff members exposed to NSI. Centre for disease control and prevention estimated the seroconversion rate for HBsAg, HCV and HIV to be 22-31%, 0.5% and 0.3%, respectively. The worldwide reported incidence of HIV seroconversion is in 296 cases after occupational exposure, of which 56 are documented while 138 are possibly occupationally acquired. In India, two possible cases of occupationally acquired HIV infection have been reported from Chandigarh.[5]
Table 6 describes the year wise frequency of anti-VEGF injection versus the number of NSI in the span of 5 years. We reported no cases of NSI due to anti-VEGF injections, even after an exponential increase in the use of anti-VEGF injection per year. There is scarce literature of NSI related to anti-VEGF. Shah et al, described the use of intravitreal bevacizumab is widely prevalent among retina specialists in the United States and conducted a cross sectional survey study for assessment of needle prick injury associated with anti-VEGF injection. The survey concluded that at least one third of the retina specialists perceive the practice of direct application of adhesive stickers to syringes as a risk for NSI. About 8% of the retinal physicians had experienced at least 1 NSI while performing intravitreal injection. In our study we reported no NSI related to anti-VEGF injection, as the drug is drawn from a single bevacizumab vial with a minispike(BraunTM) into multiple individual.[13]
In conclusion, to reduce the risk of occupational injury with NSI risk factors for NSi include training perssonel performing or assisting anterior segment surgeries while exchanging instruments. It is in this view that all hospital personnels should be made aware of the risks for NSI, protocol for incident reporting, safe instrument handling, needle disposal mechanism and on-going staff training
References:
1.Bidira K, Woldie M, Nemera G. Prevalence and predictors of needle stick injury among nurses in public hospitals of Jimma Zone, South West Ethiopia. International Journal of Nursing and Midwifery. 2014 Nov 30;6(7):90-6.
2.Adams S, Stojkovic SG, Leveson SH. Needlestick injuries during surgical procedures: a multidisciplinary online study. Occupational medicine. 2010 Mar 1;60(2):139-44.
3.Muralidhar S, Singh PK, Jain RK, Malhotra M, Bala M. Needle stick injuries among health care workers in a tertiary care hospital of India.
4.Ghauri AJ, Amissah-Arthur KN, Rashid A, Mushtaq B, Nessim M, Elsherbiny S. Sharps injuries in ophthalmic practice. Eye. 2011 Apr 1;25(4):443-8.
5.Jayanth ST, Kirupakaran H, Brahmadathan KN, Gnanaraj L, Kang G. Needle stick injuries in a tertiary care hospital. Indian journal of medical microbiology. 2009 Jan 1;27(1):44.
6.Alshihry AM. Pattern of Sharps Injuries in Ophthalmic Practice.Epidemiology: Open Access. 2013 Sep 20;2013.
7.Prüss‐Üstün A, Rapiti E, Hutin Y. Estimation of the global burden of disease attributable to contaminated sharps injuries among health‐care workers.American journal of industrial medicine. 2005 Dec 1;48(6):482-90.
8.Centers for Disease Control and Prevention. Workbook for designing, implementing and evaluating a sharps injury prevention program. 2004. Im Internet: www. cdc. gov/sharpssafety/pdf/sharpsworkbook_2008. pdf. 2007:9130-0.
9.US Public Health Service. Updated US Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports/Centers for Disease Control. 2001 Jun 29;50(RR-11):1.
10.Marcus R. Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus.New England journal of medicine. 1988 Oct 27;319(17):1118-23.
11.International Review of Modern Surgery. Infection Control. The rising cost of needle stick injuries. BD UK Limited, 2005
12.Rodrigues C. Needle stick injuries & the health care worker—The time to act is now. Indian Journal of Medical Research. 2010 Mar 1;131(3):384.
13.Shah SU, Koenig MJ, Dacquay Y, Mozayan A, Hubschman JP. Assessment of the risk of needlestick injuries associated with intravitreal injections. Retina. 2014 Apr 1;34(4):781-4.
14.Trottmann F, Mojon D. Pattern of injuries to the surgical team during ophthalmosurgical interventions. Klinische Monatsblatter fur Augenheilkunde. 2013 Feb;230(2):150-6.
Mansour AM. Needlestick injuries in ophthalmology. Ophthalmic surgery. 1989 May;20(5):367-9
Legends :
Figure1: Flowchart describing the hospital protocol following NSI
Figure 2 A-D: A, shows the disposal of side-port needle disposal, B; shows the disposal of needle hub in the container, C; shows disposal of the needle in the red labeled colored container, D; shows not to recap needles.
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