Needle stick injuries among surgeons in training
N Engl J Med 2007;356:2693-9
Makary M, Al-Attar A, Holzmueller C, Sexton B, Sin D, Gilson M, Sulkowski M, Pronovost P
Purpose Due the fact that comprehensive information coupled with clear descriptive details is not available regarding needle stick injuries for surgeons in training, it makes it difficult to develop working strategies for the prevention of such injuries. The purpose of this study was to investigate the prevalence and details surrounding needle stick injuries as well as the behavior associated with the reporting, or lack thereof, of these injuries amongst surgeons in training.
Background It has been reported that healthcare workers sustain approximately 600,000 to 800,000 needle stick and other percutaneous injuries every year. The potential for catastrophic health consequences is huge; additionally the psychological stress involved with sustaining a needle stick injury is insurmountable. It is common sense to acknowledge that all healthcare workers who perform invasive procedures with needles and other sharp instruments are at high risk for injury, and it has been demonstrated that those who work in the operating room present the greatest risk. Surgeons, especially those in training, are considered the highest risk of exposure to blood borne pathogens since they use sharp instruments while operating and are in the learning mode for skill acquisition. Currently there is a very high prevalence of human immunodeficiency virus (HIV) and hepatitis B and C viruses (HBV, HCV) amongst hospitalized surgical patients. Recently reported in the literature from an urban academic hospital is that fact that 20 to 38% of all procedures involved exposure to HIV, HBV, or HCV. Those are very alarming statistics.
As the science for prevention and treatment of these horrific diseases continues to proliferate, timely reporting of exposures by those us who sustain an injury is paramount to ensure appropriate counseling, facilitate prophylaxis or early treatment, and establish legal prerequisites for workers compensation. Failure to report exposures precludes interventions that could benefit the injured party, placing healthcare workers at unnecessary risk. Information regarding how often needle stick and other sharp instrument injuries occur, the circumstances surrounding them, and the barriers to reporting them, are very limited.
Methodology The research design encompassed a survey approach. The chosen sample (respondents), were surgeons in training at residency programs certified by the Accreditation Council for Graduate Medical Education in the United States. The study participants were recruited to answer survey questions after they completed the January 2003 American Board of Surgery In-Service Training Examination. Participation was voluntary and return of the survey was considered implied consent. Approval for the study was obtained from the institutional review board from the Johns Hopkins University. The survey instrument was developed in 2002 by a panel of surgical residents and faculty, with specialists in infectious disease and occupational safety involvement. The instrument was pilot tested and assessed for validity and feasibility. The survey requested information from the respondents about a year of clinical training, typical demographic information, numbers of past needle stick injuries during training, needle stick injuries that had occurred involving high risk patients, and an expanded additional set of questions about the most recent event. Additional data gathered included:
Results There was a 95% response rate; of the 741 surgical residents invited to participate, 702 returned completed survey forms. Eighty three percent (83%) of the respondents had a needle stick injury during their training and the total number of needle stick injuries increased according to the year of training. By the 5th year of training, 99% of the surgeons in training had a needle stick injury, and for 53% of those, the injury involved a high risk patient. Details of the most recent needle stick injury were provided and included the following information: 67% of the sample who had an exposure reported that the injury was self inflicted, 72% reported that the injury occurred in the operating room, and 52% reported that the injury occurred while suturing. Fifty seven percent reported a feeling of being rushed as the cause of the injury and 20% felt that the injury could not have been prevented. Ninety percent (90%) of the respondents identified a single “cause” for the injury. An astounding 51% did not report their injury and of those involving high risk patients, 16% of that total did not report. Some of the main reasons cited for not reporting included statements that it takes too much time and no utility in reporting. Factors that were significantly associated with not reporting included the male gender, lack of involvement with the patient, occurrence in the operating room, the lack of knowledge of the injury by another person, and the total number of needle stick injuries during training.
Conclusion Needle stick injuries pose a huge occupational risk for surgical trainees. The numbers of those who reported an injury in this study was remarkable; the numbers of those who sustained an injury and did not reported it for treatment and prevention was also remarkable. The risks of under-reporting and delaying or forgoing treatment are significant. The infections that can be contracted affect virtually all aspects of one’s life; personal and social, and career -wise. Reporting the injury enables counseling regarding the risks involved and the prevention of secondary transmission. It allows for medical evaluation and if warranted antiretroviral therapy. Interesting to note, antiretroviral therapy administered within 24 to 36 hours after exposure has been associated with an 81% reduction in HIV infection. Although no post exposure prophylaxis is available for the hepatitis C virus, testing with HCV RNA can identify HCV infection at an early state. During this early stage, treatment is highly effective in preventing the catastrophic chronicity. Additionally critically important is that reporting of these injuries can establish the causal relation of the exposure and subsequent complications.
It was my intent that as all of you as professional anesthesia providers read through this article, you noticed how important this study is to those in our distinct field. While obviously not ‘surgeons in training’, our exposure to occupational risks such as needle stick and/or percutaneous injuries is equally as threatening and can result in detriment and serious consequences no different than those experienced by ‘surgeons in training’. My educated guess is that our exposure rate is higher than it should be or than we want to believe it is, that our reporting of occurrences is as low as those studied in this article, and that our reasons for NOT reporting occurrences or for NOT seeking treatment is comparable to those cited in this study: the ‘surgeons in training’. The analogy that I hoped I wouldn’t have to make forced me to come to the realization that I needed to indeed believe it was true. Whether students in anesthesia training or as practicing anesthesia providers, we are every day, in almost every task we perform, subjected to the risks of exposure to a life threatening disease. We suture central lines in place, we use scalpels while performing the task of central line insertion, we suture arterial lines in place, we use large needles for epidural insertion techniques, and we use large and small needles for intravenous insertion and for spinal anesthesia and other regional anesthesia techniques. It is critical and non-negotiable that we understand the importance of prevention of exposure as well as the importance of reporting incidents and seeking appropriate counseling, guidance and treatment. It is the reporting of such incidents that cannot only save our lives, it can assist us in serious development of prevention strategies.
Mary A. Golinski, PhD, CRNA