Patricia Lynch, RN, Y8Aa* b Mary C. White, RN, MPH, PhDC Seattle, Washington, and San Francisco, California

Background: Occupational blood exposures among operating room personnel have been substantially underreported in incident reports. Recent research has indicated several common factors influencing exposure rates: surgical service (thoracic, neurosurgery, orthopedic), length of operation, and emergency status. Methods: This report examines further data from a study of 8502 surgical cases in nine hospitals, in which a site coordinator and circulating nurses reported consecutive case information, including blood contacts that occurred during the procedures. For three of the participating hospitals, incident reports of blood exposures among operating room personnel that occurred during a 12-month period before the study were also tabulated. Results: Incident reports underreported parenteral exposures (punctures, mucous membrane and nonintact skin contact with patient blood) by as much as a factor of 25. Individual hospital rates of occupational surgical blood exposure varied considerably. Conclusions: To ensure that resources to prevent occupational blood exposure are allocated appropriately, on the basis of actual risk, among all personnel, hospitals must actively monitor blood exposures in their operating rooms. (AJIC AM J INFECT CONTROL 1993;21:357-63)

Blood exposure is associated with increased risk for infection with blood-borne pathogens, including hepatitis B, and presumably hepatitis C and HIV.‘, * Several investigations identified oc- cupational categories of health care personnel who had higher rates of serologic markers for hepatitis B than than did persons who performed other work. Surgical personnel were among those occupational categories with increased risk dur- ing the course of a career.3

From Epidemiology Associate9 and School of Public Health and Community Medicine, University of Washingtonb Seattle, Wash- ington, and Department of Mental Health, Community and Admin- istrative Nursing, University of California, San Francisco, California.c

Supported by a grant from the 3M Corporation, St. Paul, Minn. Reprint requests: Patricia Lynch, RN, MBA, 8237 4th Ave. N.E., Seattle, WA 98115.

Copyright 0 1993 by the Association for Practitioners in Infection Control, Inc.

0196-6553193 $01.00 + 0.10 17/O/51294

Hospitals usually rely on personnel incident or accident reports describing blood exposures to determine their frequency of occurrence and the epidemiologic factors associated with them. These incident reports are nearly always completed by the person who had the blood exposure, and completing incident reports may be linked to receiving post-exposure management. Addition- ally, incident reports may be required for worker’s compensation or to meet requirements from other regulatory agencies or the hospital’s insurance company.

Effort and resources to reduce frequency of blood exposure are often allocated on the basis of evaluation of incident reports. Several research projects in which the investigators analyzed inci- dent report data suggest that operative blood exposures constitute only a small proportion of occupational blood exposure risk.4s 5

Studies performed in operating rooms have used dedicated observer&’ or circulating nurs-

357

358 Lynch and White AJIC

December 1993

Instructions: Complete this form if there is a blood exposure. Blood exposure is defined as visible blood present on the skin or mucous membranes, or when a puncture occurs. If more than one person has been exposed during a procedure, please complete a separate form for each person. Please check the one correct answer, or fill in the information in the blocks as indicated.

1. Report No.

2. Type of Case 1. q bum 2. q eye 3. 0 general surgical 4. 0 gynecologic 5. 0 multiservice trauma 6. 0 neurosurgical 7. 0 obstetric 8. 0 oral maxillofaciaUENT 9. 0 transplant organ

10. 0 otthopedic 11. 0 thoracic/cardiac 12. 0 urology 13. 0 other 0. 0 unknown

3. Time of Day 1. Weekday

q 7am-3pm q 3pm-llpm q llpm-7am

2. Weekend q 7am-3pm q 3pm-llpm q llpm-7 am

0. q unknown

4. Emergency Case 1. on0 2. 0 yes

5. Length of Surgery 1. hours 2. minutes

6. Job Classification 1. 0 surgeon. assistant surgeon.

resident MD surgeon, resident MD assistant surgeon 2. 0 scrub assistant 3. 0 circulator 4. 0 anesthesia personnel 5. 0 student nurse 6. 0 medical student I. 0 other 0. 0 unknown

7. 15pe of Exposure 1. 0 puncture with blood exposure 2. q mucous membrane 3. 0 nonintact skin 4. 0 intact skin

8. Activity at the Time of Exposure 1. 0 incising 2. q suturing 3. c3 passing instrument 4. 0 receiving passed instrument 5. 0 suction/suction irrigation 6. 0 changing suction 7. 0 injecting 8. q IV manipulation 9. 0 sharps manipulation

10. 0 glove leak, tear 11. 0 equipment (saws, drills) power 12. 0 strikethrough 13. 0 spatter from surgical activity 14. 0 blood-improper location 15. 0 other

9. Device Causing Injury 1. 0 hollow needle 2. 0 solid needle 3. 0 scalpel 4. 0 wire 5. 0 saw 6. 0 Bovie 7. 0 staple 8. 0 bone 9. 0 other

10. 0 no device 0. 0 unknown

10. Location of Exposure 1. 0 fingers 2. 0 hand, not fingers 3. 0 facial mucous membrane 4. 0 face, not mucous membrane 5. Oneck 6. 0 arm(s) 7. 0 body 8. q legs/feet 9. 0 other 0. 0 unknown

11. Is it likely that the patient was exposed to blood from the heaIth care worker? 1. On0 2. 0 yes

12. Is blood visible on surgical scrub? 1. On0 2. El yes

Fig. 1. COBEX Blood Exposure Report Form. (Continued on page 359.)

AJIC Volume 21, Number 6 Lynch and White 359

COBEX Study Definitions and Instructions

Instructions: Please select one correct answer for each question. Consult your COBEX study coordinator if you have questions.

1. Report Number: Leave this blank. After all reports are collected, number each report sequentially.

2. Time: Select the time of day when fheproce~ure began.

3. Case Type: When more than one procedure is performed, selecr the most imporfantprocedure. If there is blood exposure, select the case- type associated with that procedure.

4. Emergent: Select “yes” only for emergency cases.

5. Length of Surgery: Record duration from the time the patients enter the room until they leave in hours and minutes.

6. Job Class: Choose the best answer.

7. Exposure Type: Choose the best answer; Puncture- with used sharp outranks all others: Nonintact skin outranks mucous membrane and intact skin: Mucous membrane outranks intact skin.

8. Activity: Choose the best answer. Read the list carefully before selecting your answer.

l “Passing instrument” and “receiving passed instrument” are coded differently.

l Strikethrough means bled on the skin of the individual.

l IV manipulation refers to all intravascular devices.

l Manipulating sharps refers to all sharp tools and objects unless identified elsewhere.

l Blood in improper location refers to bloody fluid where it could not have been anticipated.

9. Device: “Wire” includes all pins and wires.

IO. Lucatiun: If more than one location was exposed, choose the most important site, remembering that puncture.s outrank all others.

1 I. Patient Exposure:

l Did the punctured health care worker likely bleed in contact with patient tissue?

l Did the sharp that punctured the HCW subsequently have contact with patient tissue? (This could happen with indwelling pins, wires, suture needles, bone spurs.)

12. Visible Blood on Sorgical Scrub: Choose correct answer.

This information will be held strictly confidential.

Fig. 1. (Continued from page 358.) COBEX Blood Exposure Report Form.

es”, I’ to identify and record information about such projects even though the accuracy of the data exposures. Studies performed in the operating collected is undisputed. room invariably identify more operative blood The Occupational Safety and Health Adminis- exposures than do studies based on incident tration (OSHA) requires health care facilities to reports. Observational studies are expensive, how- use personal protective equipment, engineering ever, and individual hospitals are unlikely to fund controls, and changes in work practices to reduce

360 Lynch and White AJIC

December 1993

Table 1. Characteristics of nine participating community and university hospitals, including number of blood exposures and intact skin contacts

Hospttal Hospital

tyw No. of beds

Cases per month*

Study casest

Total contacts

No. 54

Community 535 1035 857 42 5 Community 352 650 1004 177 18 University 330 700 558 123 22 Community 400 900 1179 89 8 Community 300 600 1002 91 9 Community 130 500 942 36 4 Community 410 1050 998 110 11 Community 365 2000 1056 83 8 University 523 1500 906 285 31

*Total num&r of surgical cases. tOnly cases that met definition for inclusion in study.

occupational blood exposure.12 OSHA required full implementation of the blood-borne pathogens standard by July 1992.

A recently completed research project known as the Collaborative Operative Blood Exposure (COBEX) study reported results from a multi- center evaluation of cutaneous blood contacts and blood exposures that occurred after each of the participating hospitals had implemented the OSHA blood-borne pathogens standard.” A total of seven community and two university hospital operating rooms participated; they collected in- formation on 8502 surgical cases in which 1054 instances of blood contact or exposure occurred. This is a report from the COBEX study, empha- sizing individual differences among the partici- pating hospitals, estimating the magnitude of underreporting by incident reports, identifying probable successes from implementation of OSHA requirements, and including observations about methods for further reducing the incidence of blood exposure.

METHODS

Study methods and definitions are described in the original report of the findings.”

Study hospitals

Nine community and university hospitals, geo- graphically distributed in urban and suburban locations in seven states, participated in the study. Characteristics of the hospitals are presented in Table 1.

Definitions Cutaneous coontact was defined as visible blood

on the intact skin of health care providers. Paren-

ted exposure was defined as visible blood on nonintact skin or mucous membranes of person- nel, or when a puncture or cut with a used sharp occurred.

Surgical procedures were eligible for inclusion if they were performed in the operating room and assisted by hospital operating room personnel. Endoscopic procedures, vaginal deliveries, and procedures performed in other areas of the hos- pital were excluded.

Data collection Incident reports. Each hospital required that

written incident, accident, or injury reports be completed describing all situations in which per- sonnel were punctured by used sharps or in- curred mucous membrane or nonintact skin con- tact with blood or bloody fluid. These reports were linked to personnel receiving postexposure management for blood exposures and were nec- essary for administrative purposes. The degree of compliance with the requirement for completing incident reports had not been previously as- sessed. Incident reports describing operative blood exposures for a 12-month period before publication of the OSHA blood-borne pathogens standard were obtained from three COBEX study hospitals. The number and characteristics of the operative blood exposures were tabulated and compared with reports from the operating rooms of these hospitals as they participated in the COBEX study.

Operating room cases. Each hospital appointed a site coordinator to train all the circulating nurses on definitions and methods for completing case and exposure reports. A case report was required for each procedure that met the surgery

AJIC Volume 21, Number 6 Lynch and White 361

Table 2. Occupational perioperative blood exposures reported by incident reports compared with reports of punctures, mucous membrane exposures, and nonintact skin exposures from the Collaborative Operative Blood Exposure (COBEX) study

No. of beds

Incident reports COEIEX

Esthated Pare-al annual

Incident reports, Cases exposweslno. parenteral 12 months* annually of casest exposures

University 330 Community 410 University 523

34 6,400 291558 437 11 12,600 2ot998 252 17 i 8,000 421906 a28

*Rates were not calculated because different denominator bases were used. tParenfera/ is defined as a puncture with a used sharp or a blood contact with mucous membranes or nonintact skin.

definition, and a blood exposure report was required for each cutaneous blood contact or exposure. The reports required less than 1 minute to complete. (Figure 1).

The circulating nurses were instructed to ask, “Did you have a blood exposure?” any time that personnel, including surgeons, appeared to have had an exposure. The question, “Did anyone have a blood exposure?” was posed at the end of every case, prompting personnel to check themselves. The circulators completed case reports for each surgical procedure and exposure reports for ev- eryone answering in the affirmative, ensuring anonymity and confidentiality.

Data were collected on the case, including surgical service, length and type of procedure, emergency status, date and time, and anatomic location of the operation. Data collected on the blood contacts and exposures included job classi- fication, type of exposure, anatomic location, and activity at the time of exposure. Methods of analysis are described elsewhere. 1 ’

Training materials included an instructional video and sample forms. Issues that required clarification were discussed with an investigator to ensure consistency.

Besides training the circulators, the site coor- dinators were responsible for examining each report for completeness and for sending the reports to one of the investigators (P.L.) for further review and data entry. The site coordinators were operating room directors, ICPs, or operating room nurse educators. The site coordinators also provided encouragement and reminders to per- sonnel to complete case and exposure reports.

RESULTE

A full account of the study results is reported in detail elsewhere. * ’

Desdpthm idwmathm

There were 8502 surgical cases that met the case definition performed in the nine hospitals; 864 cases (10.2% case-contact rate) resulted in one or more blood contacts to 1054 individuals (12.4% person-contact rate). Of the contacts, 132 were punctures (2.2% person-exposures per case).

Operative blood exposures described in incident reports for 12-month periods before OSHA imple- mentation were obtained from each of three hospitals; these were compared to reports ob- tained from the same hospitals during their par- ticipation in the COBEX study. A comparison of the results and the predicted true incidence of parenteral exposure at each hospital are presented in Table 2. Incident reports from the three study hospitals identified a total of 62 perioperative blood exposures in 12 months, In the same hospitals in a lo-week period, the COBEX study identified 91 puncture, mucous membrane, or nonintact skin exposures. This would predict 15 17 perioperative, parenteral exposures among per- sonnel in the three hospitals in a 12-month period, approximately 25 times higher than incident reports suggest.

Bkodc4mtactatwarlausb0&yrWiee

Blood contacts to the fingers and hands, arms, body, legs and feet, facial mucous membranes, and facial and neck skin in each hospital were compared. The results are presented in Table 3.

In the 8502 surgical cases, there were only 24 instances of strike through to the trunk, defined as blood soaking through the attire and contacting the skin of the personnel at sites other than feet and legs. Some of these instances involved blood

362 Lynch and White AJIC

December 1993

Table 3. Blood contact during 8502 surgical procedures in nine hospital operating rooms, 1992

Hospital

Site 1 2 3 4 5 6 7 6 9 TOTAL

Body and extremities

Legs, feet 6 29 33 8 7 0 17 3 19 122 Arms 3 9 13 13 10 4 6 4 20 82 Body 2 a 2 0 5 0 1 1 5 24 TOTAL 11 46 48 21 22 4 24 8 44 228

Face, neck, and mucous membranes

Mucous membrane 1 0 3 0 0 0 0 3 7 14 Not mucous membrane 14 58 24 25 13 4 26 32 56 252 TOTAL 15 58 27 25 13 4 26 35 63 266

Hands and fingers Hands and fingers 23 70 47 39 57 28 59 39 175 537 Punctures (no.) 9 a 23 13 12 11 17 12 20 125 Punctures (%) 39 11 49 33 21 39 29 31 14 23

soaking through surgical gowns, but often the individuals were circulating nurses who do not wear surgical gowns and the strike through only involved the scrub suit.

There were 14 instances of mucous membrane contact; seven of these occurred on the orthopedic service of one hospital. However, there were 252 instances of blood spatter to the face or neck of surgical personnel.

DISCUSSION

The number of exposures and blood contacts among the hospitals participating in the COBEX study fell within the range for operative blood exposure in published reports that used more rigorous and expensive methods.6, 7* lo The com- parability of the COBEX study results with other published reports suggests that hospitals can use the COBEX study methods to identify their own risk patterns and evaluate the results of interven- tions to reduce blood exposure.

The aggregate results of studies performed in the nine COBEX hospitals and eight hospitals described in published report@-” are all in the same range. Parenteral contacts occur in 1% to 15% of surgical cases, with most study results clustered around 4%. It is likely that more paren- teral blood exposures occur in the operating rooms than in all other areas of the hospital combined.

The nine study hospitals varied considerably in frequency of perioperative blood contact, from a low incidence of 3.6% to a high of 24.4% of cases resulting in one or more exposures. Two of the COBEX hospitals were identified as independent variables associated with high risk for parenteral

exposure to blood. l l The wide range of reported blood contacts and exposures may have been caused by study design (absence of a dedicated observer), case mix of the surgical procedures (proportion of high risk procedures), differences in the success of prevention methods used in the operating rooms, a combination of all three factors, or other variables not studied.

The individual hospitals were quite different from each other. Recommendations intended to reduce risk of exposure that would be entirely appropriate for one could be excessive or too little for another. It is essential for operating rooms to evaluate systematically their own patterns for exposure and develop prevention strategies on the basis of this assessment.

Strategies to prevent blood contacts and expo- sures tend to be expensive. Needleless IV connec- tors, needleless injection devices, double gloves, training in different practices, and most other strategies either cost personnel training time or increase the budget for devices. Prevention re- sources are often allocated on the basis of risk perceived from analysis of incident reports, which our findings show to greatly under-represent the true exposure rate. Unless the magnitude of surgical blood exposure is documented, hospitals may not allocate their prevention budget in a cost-effective manner.

Modlflcatlon of risk by case mix or practice factors

Risk of blood exposure is increased by factors related to case mix. Thoracic, neurosurgical, and orthopedic procedures; cases with longer dura- tion; and emergency procedures have all been

AJIC Volume 21, Number 6 Lynch and White 363

associated with increased risk of occupational blood exposure in operating rooms.’

Hospitals are unlikely to change the case mix, but they may encourage increased barrier protec- tion for the higher risk cases or identify specific practice changes to reduce the risk of contact and exposure. For example, fully fluid-resistant gowns, rather than gowns with fluid-resistant panels, may be cost-effective for longer cases or for cases known, in the hospital’s own experience, to result in exposure. Double gloves or replacing gloves every hour in cases likely to result in glove abrasion or tears may be helpful. Face shields or spatter guards for orthopedic cases with power equipment or vigorous irrigation may reduce spatter to the face and neck.

Factors associated with hospital practices also affect risk: no-touch instrument passing, dou- ble gloves, blunted instruments, fluid-resistant gowns, protective eyewear, protective attire of circulators and anesthesia personnel, and sharps management have all been suggested for risk reduction.

Risk associated wtth Job classification

Surgeons had more than half of all exposures. More than half of all exposures involved fingers and hands; double gloves have been reported to reduce the frequency of blood contact sig- nificantly.‘O

Circulating nurses and anesthesia personnel frequently were bare-armed, and this accounted for many of the cutaneous contacts to arms. Additionally, they often manipulated intravascu- lar devices bare-handed and got blood on their fingers.

OSHA requirements have emphasized reducing risk of strike through and mucous membrane contacts; use of protective gowns and eyewear is mandated. Previous studies, performed before OSHA requirements had been implemented in the study hospitals, reported strike through of surgical gowns and spatters to eyes of personnel to be more common than reported by the COBEX study hospitals.9

Surgical team members, except for anesthesia personnel and circulators, were frequently spat- tered on the lower face and neck and also had bloody fluid run off or under the drapes onto their feet and legs. These anatomic locations are commonly without any barrier protection, and further research and product development are warranted.

From this and other work, it is clear that blood contact and parenteral exposures among operat- ing room personnel occur more frequently than recorded in incident reports. A number of factors, including loss of confidentiality and annoyance at additional paperwork, may influence personnel to omit incident reports.

Research has begun to elicit risk factors that influence blood exposures. However, the COBEX study results suggest that individual operating rooms differ in terms of the factors that influence occupational blood contacts and exposures. Be- cause of the seriousness of the problem and the increasing need to use resources economically and effectively, it is necessary that hospitals monitor their own experience to identify rational prevention strategies.

References 1. Denes AE, Smith JL, Maynard JE, et al. Hepatitis B

infection in physicians: results of a nationwide seroepide- miologic study. JAMA 1978;239:2 10-2.

2. Dienstag JL, Ryan DM. Occupational exposure to hepatitis B virus in hospital personnel: infection or immunization. Am J Epidemiol 1982;115:26-39.

3. McKinney WP, Young MJ. The cumulative probability of occupationally-acquired HIV infection: the risks of re- peated exposures during a surgical career. Infect Control Hosp Epidemol 1990;11:243-7.

4. McCormick RD, Meisch MG, Ircink FG, Maki DG. Epide- miology of hospital sharps injuries: a prospective study in the pre-AIDS and AIDS eras. Am J Med 1991;(Suppl 3B):301S7S.

5. Jagger J, Hunt EH, Pearson R. Sharp object injuries in the hospital: causes and strategies for prevention. AM J INFEST

CONTROL 1990;18:227-31. 6. Popejoy SL, Fry DE. Blood contact and exposure in

the operating room. Surg Gynecol Obstet 1991;172: 480-3.

7. Panlilio AL, Foy DR, Edwards JR, et al. Blood con- tacts during surgical procedures. JAMA 199 1;265: 1533-7.

8. Tokars JI, Bell DM, Culver DH, et al. Percutaneous injuries during surgical procedures. JAMA 1992;267: 2899-904.

9. Quebbeman EJ, Telford GL, Hubbard S, et al. Risk of blood contamination and injury to operating room personnel. Ann Surg 1991;214:614-20.

10. Gerberding JL, Littell C, Tarington A, et al. Risk of exposure to patients’ blood during surgery at San Fran- cisco General Hospital. N Engl J Med 1990;322: 1788-93.

11. White MC, Lynch P. Blood contact and exposures among operating room personnel: a multicenter study. AJIC AM J INFECT CONTROL 1993;21:243-8.

12. Department of Labor, Occupational Safety and Health Administration. Occupational exposure to bloodbome pathogens; final rule, 29 CFR Part 1910: 1030. Federal Register 1991;56:64003-182.