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Risk Groups for Needlestick Injury Among Healthcare Workers in Children‘s Hospital: A Cross-sectional Study

Risk groups for needlestick injury among Abstract Objective: Needlestick injuries are important for healthcare workers due to their morbidity and mortality. The aim of this study was to determine the risk group of needlestick injuries (NSIs) among healthcare workers, and possible risk groups, actions, and prevention practices of the healthcare workers. Material and Methods: This cross-sectional study included 249 healthcare workers(doctors, nursing staff, laboratory technicians and the cleaning personnel) in a tertiary care pediatric hospital in Turkey. Results: Among the 249 healthcare workers, there were 35 physicians, 124 nursing staff, 11 laboratory technicians and 79 cleaning personnel. Seventy (28.1%) were males, 179 (71.9%) were females. The most common equipment associated with needlestick injury were syringe needles ( 54.6 %), followed by intravenous cannula (peripheral catheter) (17.2%). In 103 (41.2%) cases, the injury occurred during use of the needle, with the greater part of injuries (24%) while establishing a venous access. Most healthcare workers experienced hand injuries (%82.7). Conclusion: This study revealed that the high risk group for needlestick injury was nurses followed by the cleaning personnel. Healthcare workers did not take the necessary measures for themselves. Needlestick injuries could be prevented easily by increasing the use of needles when needed, increasing awareness for using devices with safety features, promoting education and safe work practices for needles and related systems.


Introduction
Centers for Disease Control and Prevention (CDC) and the National Surveillance System for Healthcare Workers (NaSH) have well-defined needlestick injury (NSI) and it includes skin penetration resulting from a needle or other sharp object, exposed to blood, tissue, or other body fluid before the penetration (1).
For centuries, health workers, performing their own professional responsibilities, have faced contamination risk of bloodborne diseases. These professions are in the high risk group for infection with bloodborne pathogens because of exposure to blood and other body fluids (2). Most exposures among healthcare workers have been reported to be caused by percutaneous injuries with sharp objects contaminated with blood or body fluids (3)(4)(5)(6)(7). These sharp objects include needles, scalpels, lancets and even broken glass. The pathogens most commonly transmitted to healthcare workers are bloodborne pathogens included hepatitis B and C viruses (HBV, HCV) and the human immunodeficiency virus (HIV) (8). Among healthcare workers (HCW) and laboratory personnel worldwide, more than 25 blood-borne viruses have been reported associated with NSI suggesting the importance of these needlestick injuries and their possible consequences (9).
The purpose of this study was to determine the high risk group for needlestick injuries (NSIs) among healthcare workers, high risky actions and practices regarding the use of protective strategies against exposure to blood-borne pathogens.

Materials and Methods
This cross-sectional study was designed to evaluate the distrubition and risk factors for needle stick injury among healthcare workers in Dr. Behcet Uz Children Research and Training Hospital between the period of January 2014 and October 2015. The study population included doctors, nursing staff, laboratory technologists and the cleaning personnel. Data collection involved the medical files and records of the same hospital.
In the study, all needlestick injuries were recorded and required precautions were done by the infection control comitee.
Needlestick injury was defined as "any cut or prick to the respondents by a needle previously used on a patient is work related and sustained within the hospital premises. " Data collected were entered into a computer-based forms.
Statistical analysis was performed by using the Statistical Package for the Social Science (SPSS) software. Distribution of numeric variables was tested by both graphical methods and Shapiro-Wilk test. The difference between means of numeric variables was tested by Student's t test or Mann-Whitney U test, where appropriate. The difference between proportions was tested by Chi-Square or Fisher's exact test. p< 0.05 was considered statistically significant.
Among the HCW, 206 HCW (82.7%) had experienced hand injuries, and the most common pieces of equipment involved in NSIs were syringe needles (136 incidents; 54.6%), followed  by 43 reports of intravenous cannula or peripheral cathater(17.2%). In 103 (41.2%) cases, the injury occurred during the use of the needle and 60 injuries (24%) occurred while establishing a venous access (Table 1). Among the 249 HCW; 92 (36.9%) had not been wearing gloves at the time of the incident (Table 1).
All healthcare workers were informed about the contents of the exposure and control plan and were provided with adequate education and training to work safely with biohazardous material. Thirteen percent of the injured staff had Hepatitis B immunization and nine percent had Tetanus immunization after NSI.

Discussion
Most of the NSI during the study period had occured in the departments of surgery, pediatric and neonatal intensive care unit, consistent with previous studies (10). This finding may support that departments such as the ICU in which invasive interventions such as injections, intravenous infusions, and drug preparation are more intensively performed have the higher risks (11). In contrast, a study about NSI among the hospital healthcare workers from Saudi Arabia has demonstrated no difference between medical and surgical departments regarding NSI risk (12). However, intensive care units have higher rates of NSIs as compared to medical wards and surgical ward (13,14). These results suggest that prevalence rates of NSIs across departments are not consistent in different countries, which most likely change with culture, governmental and hospital regulations despite universal recommendations.
In this study, nurses were reported as the major occupational group, followed by the cleaning personnel, which was consistent with the findings of Martins et al. Study (15). After nurses, the cleaning personnel were the second dominant occupation group with 31.7% of total NSIs in this study, which was higher than 21.6% needlestick injuries reported among the cleaning staff from India(16). This high incidence was thought to be due to inappropriate disposal at upstream, and inadequacy of the resources places these workers at risk as documented in Saudi Arabia (13) and the USA (17) .Nurses have been found to be the most occupational health group to have NSIs (18)(19)(20)(21). This can be explained by the facts that the nurses are responsible from most of the injections and intravenous fluid administration, basically nurses are healthcare group dealing with injections and sharp objects the most and the numbers of nurses are usually higher than any other occupational group inside hospitals.
Most of the incidents occur during using the needle (41.2%), with the greater part of injuries (24%) while establishing a venous access. The most common equipment involved in NSIs were syringe needles (136 or 54.6%), followed by intravenous cannula (43 or 17.2%) which was consistent with the same findings of previous studies (15,22,23). In this study, NSIs that occurred during recapping accounted for 11% of all NSIs, with a lower incidence than Iran (24) but higher than 2006/07 data from the United States (about 4%) (25). This could be due to the different levels of safety regulations held by hospitals.
In this study, most HCWs experienced hand injuries like the previous studies (13). This may be either due to inadequate training of HCWs or different experience levels about the optimal procedures or lack of access to safety needle devices in the instution to avoid recapping. NSIs during recapping might be prevented by the placement of sharps containers in convenient places to help facilitate effective and safe disposal plus increasing the awareness of NSIs and importance of bloodborne pathogens (26). Replacement of traditional needles with safety needle devices such as needleless sets, safety cannula, self-capping intravenous catheters, self retracting lancets, and auto-disposable syringes will reduce these injuries among the healthcare workers. Continous training is the main strategy to decrease the rate of NSIs. The number of NSI has been shown to decrease by 74-83% after the introduction of such safety-engineered alternatives (27,28). Especially in pediatric clinics in which younger children and toddlers can move rapidly and unexpectantly during injection, the safety devices shoud be used regularly.
Among the 249 respondents who had never received a NSI, 92 (36.9%) were wearing gloves at the time of the inci-dent. O'Sullivan et al. have reported in two teaching hospitals among Irish intern doctors that only 26% of the interns reported wearing gloves while performing intravenous cannulation, but this percentage was up to 94% in patients with high risk (29). This emphasizes the importance of taking perceived benefits and threats into consideration when planning to reduce NSSIs among HCWs, as it is suggested in some theories like the Health Belief Model (6). When the interns perceived higher risk of acquiring a disease and potential benefit of wearing gloves, they were reported to be more likely to comply with the standard precautions (29). Moreover, relatively low incidence of NSIs at HCWs working in the pediatric infectious disease ward suggests that HCW working in this service are more alert and concentrated than the other services since more contagious patients are treated in these departments. However, it should be kept in mind that in other services such as the NICU, PICU and Surgery wards, the status of the patients for blood-borne diseases are not known, and there is still great risk of infections for HCWs.
In 2007, the World Health Organization estimated the number of injuries as 2 million per year globally (30). Moreover, the European Biosafety Network estimated 1 million needlestick injuries annually (30). Another project estimated the rates of injuries on a global level to affect about 3.5 million individuals (1). The US Occupational Safety and Health Administration (OSHA) estimated that 5.6 million workers in the healthcare industry were at risk of occupational exposure to blood-borne diseases via percutaneous injury (31). 600.000 NSIs were estimated to happen among HCW in the US annually. The risk for blood or body fluid infection transmission among healthcare workers was reported to be two to nineteen times greater than general population (32). This study revealed that Turkish nurses, especially those working in the surgery department and intensive care units, are at high risk of blood or body fluid pathogen transmission from using of contaminated needles.
Several reports on needlestick prevention published between 1987 and 1992 focused on the appropriate design and convenient placement of puncture-resistant sharps disposal containers and the training of healthcare personel (33-39). Most of these studies documented only limited success for the prevention of disposal-related injuries and especially recapping. Universal (defined as standard now) precautions are important approaches that demonstrated preventing blood exposures to skin and mucous membranes effectively (40, 41). However, these precautions mainly focused on the use of barrier precautions (i.e., personal protective practices) and work-practice controls (e.g., care in handling sharp devices) while precuations for sharps injuries shoud be much more detailed than standart precautions.
This study had limitations due to its retrospective design. Our findings represent only one children training and research e216 Düzgöl et al. hospital in Turkey. However, this study has mainly focused on a special group of HCWs who were dealing with children which was different from previous studies focusing on adult studies.
In conclusion, effective training and awareness to NSIs and associated bloodborne pathogens, organizational safety regulations for exposure prevention (protection devices such as handling sharp devices, personal protective barrier methods) are essential to reduce the risk of such injuries. Regarding children's hospitals, safety devices such as safety needle systems might be a good strategy to reduce NSIs among HCW.