working in the department (39 consultant, 37 trainee/non-consultant). Only 45.2% correctly identified high-risk body fluids. Sixty-eight per cent of anaesthetists ...
British Journal of Anaesthesia 84 (6): 767–70 (2000)
Ignorance of post-exposure prophylaxis guidelines following HIV needlestick injury may increase the risk of seroconversion P. Diprose*, C. D. Deakin and J. Smedley Department of Anaesthetics, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK *Corresponding author Needlestick injury is relatively common amongst healthcare workers, particularly those, such as anaesthetists, who regularly perform invasive procedures. The risk of seroconversion following needlestick injury may be reduced by knowledge of body fluids that are high risk and knowledge of post-exposure prophylaxis following possible HIV-contaminated needlestick injury. A structured questionnaire was used to establish knowledge regarding high HIV risk body fluids and measures to be taken following needlestick injury in anaesthetists working in a large teaching hospital. Completed questionnaires were obtained from all 76 anaesthetists working in the department (39 consultant, 37 trainee/non-consultant). Only 45.2% correctly identified high-risk body fluids. Sixty-eight per cent of anaesthetists knew the appropriate first aid measures to be taken following needlestick injury. Only 15% of anaesthetists were aware that post-exposure prophylaxis (oral medication) should be administered within 1 h of injury. This study reveals a surprisingly poor knowledge of high-risk body fluids and action to be taken following needlestick injury. Timely post-exposure prophylaxis, after needlestick exposure to high-risk body fluids, is believed to reduce the risk of seroconversion to HIV. Ignorance of this may increase the risk of seroconversion to HIV for anaesthetists and other healthcare professionals. Br J Anaesth 2000; 84: 767–70 Keywords: infection, HIV; education, continuing; anaesthesia, audit Accepted for publication: December 24, 1999
Needlestick injury from patients with known or suspected HIV infection is an important occupational risk for healthcare workers. The incidence of all injuries varies between occupational groups but is particularly prevalent in those regularly performing invasive procedures. Factors that determine risk of significant exposure to HIV include the frequency of needlestick incidents and the prevalence of HIV infection in the patient population.1 Risk of transmission of HIV from a single exposure to infected material depends on the size and the type of inoculum. Known inoculation risk factors include deep injury, hollow bore needles, blood from terminally ill HIV patients, and needles that have been in arteries or veins. Overall, the risk of acquiring HIV following needlestick injury from HIV infected blood has been estimated at three per 1000 injuries.2 3 The estimated yearly risk of HIV infection for anaesthetists in the US, for example, has been put at between 0.00013 and 0.032% depending on the seroprevalence of HIV infection within the patient population.4 In 1997 the Department of Health issued guidelines for health care workers on the management of occupational exposure to HIV.5 The guidelines recommended that postexposure prophylaxis, in the form of triple therapy usually
with zidovudine, lamivudine and indinavir, be offered to health care workers following high-risk needlestick injury with the aim of minimizing the risks of developing HIV infection. The guidelines emphasize that if post-exposure prophylaxis is to be most effective it should be commenced as soon as possible after the exposure and ideally within 1 h of injury. Despite clear guidelines, health care workers generally take inadequate measures following needlestick injury. For example, in a survey in the US only 45.4% of anaesthetists who sustained a needlestick injury that had some form of blood or high-risk fluid contamination sought any form of treatment.6 This audit aimed to discover whether anaesthetists within a large teaching hospital in the UK appreciated the risks from, and understood the necessary action following, needlestick injury particularly following the 1997 postexposure prophylaxis guidelines. The host Trust has a multi-disciplinary occupational health and safety service that is led by a consultant occupational physician. A comprehensive mechanism for timely management of occupational exposure to blood and body fluids has been in place since December 1996. Arrangements include a written policy on the management of needlestick
© The Board of Management and Trustees of the British Journal of Anaesthesia 2000
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and contamination incidents, a priority telephone ‘hotline’ for urgent reporting of incidents, 24 h access to urgent risk assessment and treatment of exposures (including advice from medical experts), and long-term counselling and follow-up by occupational health professionals. These systems were designed to ensure access to post-exposure prophylaxis for high-risk HIV exposures within 1 h of the incident. The policy was supported by an education programme comprising a letter to all trust employees, verbal presentation at induction for all junior doctors, verbal presentation and a written handout for consultant medical staff, and periodic poster and publicity campaigns. A verbal presentation covering the issue of occupational transmission of blood-borne infection and the local arrangements for management of contamination incidents was given at an anaesthetic department seminar in 1998. Approximately 6 months later this questionnaire survey was undertaken to determine knowledge of which body fluids are high risk for HIV transmission, appropriate first aid treatment immediately following exposure, and how soon after injury postexposure prophylaxis should be commenced.
Materials and methods Following ethics committee approval, a questionnaire was sent to all grades of anaesthetist (76 subjects) working for Southampton University Hospitals NHS Trust. This questionnaire asked the following. 1. What percentage of needlestick injuries from patients with known HIV infection are likely to result in transmission of the virus to the recipient? 2. Which of the following nine body fluids (presuming that they are not blood stained) may be considered as ‘high risk’ for the transmission of HIV: breast milk, synovial fluid, saliva, faeces, urine, peritoneal fluid, pleural fluid, vomit, cerebrospinal fluid? 3. Who should be contacted in the event of a needlestick injury? 4. What two first aid procedures should you perform to the needlestick site? 5. How soon after a ‘high risk’ needlestick injury should post-exposure prophylaxis commence? Any non-responders from the initial survey were sent a further questionnaire and then if necessary were directly approached. Differences between consultant and trainee/ non-consultant grades were analysed using a chi-squared test.
Results Completed questionnaires were obtained from 37 juniors (100%) and 39 consultants (98%).
Fig 1 Recommended time to first dose of post-exposure prophylaxis.
per 1000 injuries. Overall, only 26 (34%) anaesthetists were aware of the true risk (between 1:1000 and 9:1000 injuries) of transmission of HIV from a needlestick injury. Of all respondents, 17 (22%) overestimated the risk compared with 33 (43%) who underestimated the risk.
2. Which of the following nine body fluids (presuming that they are not blood stained) may be considered as ‘high risk’ for the transmission of HIV: breast milk, synovial fluid, saliva, faeces, urine, peritoneal fluid, pleural fluid, vomit, cerebrospinal fluid? For the high risk fluids (CSF, pleural, peritoneal, synovial, breast milk) only 14 (35%) consultant anaesthetists and 18 (49%) juniors correctly identified them as high risk. For low risk fluids (vomit, urine, faeces, saliva), 16 (41%) consultants and 21 (57%) juniors correctly identified the low risk fluids. Trainees/non-consultant grades were better than consultants in their knowledge of both high risk fluids (P⬍0.02) and low risk fluids (P⬍0.01).
3. Who should be contacted in the event of a needlestick injury? Thirty-eight out of 39 consultants (97%) and all trainees/ non-consultant grades correctly stated either the Accident and Emergency Department or the Occupational Health Department.
4. What two first aid procedures should you perform to the needlestick site? Following a needlestick injury the first priority should be to promote active bleeding of the wound and to wash the wound thoroughly with soap and running water. Overall, 68% of anaesthetists (25/39 consultants; 26/37 trainees/ non-consultant grades) correctly stated both measures.
1. What percentage of needlestick injuries from patients with known HIV infection are likely to result in transmission of the virus to the recipient?
5. How soon after a ‘high risk’ needlestick injury should post-exposure prophylaxis commence?
The risk of a needlestick injury from a patient with HIV resulting in seroconversion is estimated to be around three
Only 10 out of 76 anaesthetists (15%) were aware that postexposure prophylaxis following an HIV prone needlestick
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infection should be started within 1 h of the injury. Results are shown in Figure 1. Forty per cent (37/67) of anaesthetists who answered the question believed that post-exposure prophylaxis could be delayed for 24 h or more.
Discussion The general understanding of HIV transmission in terms of high-risk body fluids, risks from needlestick injury, and appropriate action following a high HIV-risk needlestick injury was surprisingly poor. Only one third of all anaesthetists questioned appreciated the true risk of seroconversion following a high HIV risk needlestick injury, with 43% underestimating the risk. Less than half of all anaesthetists correctly identified high-risk body fluids, with consultant grades, whom may be advising trainee grades on appropriate action following needlestick injury, having significantly less knowledge than trainees. Other high risk fluids for the transmission of HIV such as amniotic fluid, vaginal secretions, semen, pericardial fluid, and unfixed organs and tissues were not tested in the questionnaire since we felt that anaesthetists are not exposed routinely to these fluids in everyday practice. One third of anaesthetists did not know that correct action following a needlestick injury was to promote active bleeding of the wound and to wash the wound thoroughly with soap and running water. Of particular concern was the finding that only 15% of anaesthetists knew correctly that post-exposure prophylaxis should be commenced within 1 h of the needlestick injury. Anaesthetists are at risk of needlestick injuries, frequently handling needles and other sharp implements with potentially infected blood or CSF contamination. The rate of (unprotected) skin contact with blood has been estimated to be 18% for peripheral i.v. cannulation, 18% for insertion of a central venous catheter, and 85% for arterial cannulation.7 A recent US study found that the rate of anaesthetists reporting a contaminated needlestick injury was 1.34 per 1000 anaesthetics performed.4 A recently published study investigated surgeons with respect to their knowledge of post-exposure prophylaxis.8 They found that 10 of the 26 surgeons questioned knew that post-exposure prophylaxis should be obtained within 1 h of the injury. Interestingly only two out of the 26 knew where to obtain post-exposure prophylaxis outside of normal working hours. Although we specifically studied anaesthetists’ awareness of needlestick guidelines, there may be circumstances where high-risk fluids come into contact with broken skin or mucous membranes. In these situations post-exposure prophylaxis may be appropriate and further advice should be obtained from the specialists in occupational health medicine, ideally, again, within 1 h of the time of exposure. The risk of seroconversion from this type of contact with HIV infected fluid has been estimated as less than one in 1000 exposures. In view of the active needlestick management policy and education programmes in this trust, and the medical
background of the subjects, we were surprised that the knowledge amongst anaesthetists was so poor. This population may well be putting themselves at unnecessary risk of seroconversion to HIV both by failing to appreciate the risks of the body fluids they are handling and by not recognizing the need in high-risk cases to receive postexposure prophylaxis within 1 h of injury. Current guidance from the Association of Anaesthetists entitled ‘HIV and other blood borne viruses–guidance for anaesthetists’9 was published prior to recommendations regarding post-exposure prophylaxis. The Royal College of Anaesthetists’ FRCA examinations syllabus10 does however require a knowledge of ‘precautions in the management of the infective patient (e.g. HBV, HIV)’ and ‘implications for the anaesthetist of HIV infection’. Perhaps more emphasis on personal actions following needlestick injury is required. The risk of exposure to potentially infected body fluids may be minimized by adherence to a policy of universal precautions. This includes the wearing of disposable gloves, using eye protection where appropriate, avoiding re-sheathing needles, not passing needles directly to another person, ensuring that all sharps are placed in disposal bins and regarding blood and the other high-risk fluids from any patient as potentially infected.11 The ignorance of post-exposure prophylaxis guidelines is likely to be similar amongst anaesthetists in other hospitals and probably other healthcare workers. Since timely postexposure prophylaxis after high risk needlestick injuries is thought to reduce the risk of HIV seroconversion, we believe that many healthcare professionals may be putting themselves at increased risk of seroconversion after an HIV infected needlestick injury as a result of delay. Further dissemination of knowledge regarding high-risk fluids, risks from needlestick injury and appropriate action following a high HIV-risk needlestick injury is required. With the introduction of clinical governance, we believe that this issue is of priority in terms of risk management, teaching and continuing professional development.
Acknowledgement The authors would like to thank all the anaesthetists who took part in this study.
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