EMS and Occupational Injury, Delbridge, Rinnert 653

An Ounce of Prevention.. . Theodore R. Delbridge, MD, MPH, Kathy J. Rinnert, MD

I The American health care system is evolving from one that depends on high technology and costly acute care interventions to achieve societal health, to a system that emphasizes wellness and prevention. Undoubt- edly these changes will affect emer- gency medical services (EMS) sys- tems. Although developed to address the acute needs of the ill and injured, EMS systems and those responsible for delivering out-of-hospital emer- gency care are being looked upon to serve expanding roles. Among these potential responsibilities is increased participation in community health surveillance and in prevention pro- grams. ‘.’

Indeed, EMS involvement in pre- vention makes intuitive sense. Out- of-hospital emergency care providers may be in the best position to under- stand the immediate circumstances contributing to illness or injury, for they are at the scene. Furthermore, they are present throughout the com- munity, and as community members themselves often enjoy high credi- bility. in some areas, EMS providers may be the most accessible and most commonly sought medical practi- tioners.

A logical first step during preven- tion initiatives is to ensure the well- being of the workforce responsible for implementation of such mea- sures. Just as emergency physicians have come to recognize their own wellness as essential for the long- term ability to care for their patients, a similar philosophy applies to those who provide out-of-hospital emer- gency medical care. If they are to be effective at implementing and partic- ipating in community prevention programs, then they must understand the principles involved and apply them to their own circumstances.

Haddon’s matrix, as initially ap- plied to motor vehicle crashes, pro-

vides a tool for conceptualizing the relationships between event phases and human, agent, and environmen- tal factor^.^ It may identify targets for injury prevention strategies that rely on engineering, education, en- forcement, and economic incentives.

In this issue of Academic Emer- gency Medicine, O’Connor et al. re- port the effects of an engineering initiative intended to reduce uninten- tional needlesticks to out-of-hospital EMS provider^.^ The authors found that the introduction of IV catheters with self-capping needles was asso- ciated with a reduction in the inci- dence of needlestick injuries. Out-of- hospital emergency care providers reported no contaminated needle- stick during the initial 10-month pe- riod of self-capping needle use. Of note, other needleless systems, in- cluding those for phlebotomy and administering medications IV, were already being used to reduce injury occurrence during EMS procedures.

Obviously, EMS personnel regu- larly experience blood contact. One study found that the HIV seroprev- alence among patients transported by EMS personnel to either of 3 inner- city hospitals ranged from 4.1 to 8.3 per 100.’ .As O’Connor et al. point out, the risk of acquiring HIV via a contaminated needlestick from an in- fected patient is believed to be ap- proximately 0.3%.6.7 For nonimmun- ized individuals, the chance of acquiring hepatitis B virus via a con- taminated needlestick from an in- fected patient is between 6% and 30%.’.’ The cost of an initial evalu- ation and follow-up after a needle- stick injury in a hospital has previ- ously been estimated to be $373 per case? This does not include the costs of emotional distress or the treatment for those who subsequently experi- ence HIV or hepatitis seroconver- sion. Though the risks following

needlestick injuries may be limited, they are real and deserve attention.

The study design and data used by O’Connor et al. to determine the risk reduction resulting from the in- troduction of self-capping IV cathe- ter needles warrant discussion. As- sumptions about the number of IV attempts in both the pre- and post- introduction periods underlie the re- sults and might affect the conclu- sions reached. The investigators sampled 25% of patient records to estimate that in each period, before and after the new catheter was intro- duced, 6,500 patients experienced IV attempts. Statistical analyses dem- onstrating significant differences for contaminated needlesticks in the 2 periods are based on these estimated populations. Alternatively, the au- thors might have determined the needlestick rate for the cases actually sampled. Based on the information provided, this population consisted of 1,625 IV-attempt patients in each group. Assuming an even distribu- tion of needlestick injuries, we could expect there to be 3 and 0 contami- nated needlesticks in the periods be- fore and after the catheter was intro- duced. respectively. Using Fisher’s exact test, this difference is found to be nonsignificant (p = 0.25). The au- thors’ findings would have been strengthened by sampling more re- cords and finding a reduction of con- taminated needlesticks for that sam- ple. Hence, a degree of caution is warranted when interpreting the re- sults based on the investigators’ sample extrapolation.

The authors performed a second extrapolation from their estimated population of 6,500 IV-attempt pa- tients to 100,000 in order to make comparisons with other studies and other health care workers. They were correct to point out that, although there was no contaminated needle- stick in their post-intervention sam- ple, the upper 95% confidence limit for 100,000 IV-attempt patients was 49 needlesticks.

654 ACADEMIC EMERGENCY MEDICINE JUL 1996 VOL 3/NO 7

Interestingly, the IV catheters with self-capping needles should not affect the risk of uncontaminated needlestick injuries, those occumng before the catheter is used. Yet, O’Connor et al. noted a reduction in these events as well. One must won- der whether the education that ac- companied implementation of the new IV catheter system contributed to the prevention strategy or whether the willingness of EMS personnel to report needlestick injuries was also a possible factor.

The investigators focused on at- risk situations, those involving an IV attempt, as opposed to all EMS or ‘‘advanced life support” responses. Future studies also should attempt to quantify the total number of IV at- tempts, including the number of at- tempts per patient. Additionally, a cost-effective analysis for the IV catheters with self-capping needles, considering differences in EMS sys- tem patient populations, would be helpful.

The current investigation was retrospective, and other factors may have affected the findings. There- fore, the authors appropriately con- cluded that the IV catheters with self-capping needles were associated with, although not necessarily re- sponsible for, a reduction in the in- cidence of reported EMS provider needlestick injuries.

O’Connor and colleagues are to be commended. They have studied an important issue in a manner that enables one to reach meaningful conclusions. Furthermore, they have helped their EMS system address an injury problem with an engineering

solution that did not adversely affect the ability of providers to care for their patients. In doing so, they have hopefully raised the prevention con- sciousness of their EMS workers.

Emergency medical services sys- tems are gradually exploring their capabilities to implement commu- nity-wide prevention In this new era of health care, with increasing recognition of the value of health monitoring and prevention, there appears to be a new niche for EMS. The work of O’Connor and colleagues helps to remind us that our efforts must begin at home, where an ounce of prevention is worth at least a pound of cure!

Dr. Delbridge and Dr. Rinnert are at the Uni- versity of Pittsburgh, School of Medicine, Pittsburgh, PA, Department of Emergency Medicine.

Received: February 15, 1996; accepted: Feb- ruary 27. 1996.

Address for correspondence and reprints: Theodore R. Delbridge, MD. MPH, Depart- ment of Emergency Medicine, University of Pittsburgh, 230 McKee Place, Suite 400, Pittsburgh, PA 15213. Fax: 412-578-3241; e-mail: delbridg+@pitt.edu

Key words: emergency medical services; EMS; occupational injury; needlestick injury; HIV, hepatitis.

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