Health professionals’ knowledge of prevention strategies and protocol following percutaneous injury

Prevention strategies and protocols for the manage­ ment of percutaneous injuries are developed for the purpose of preventing transmission of HIV and other infections. However, implementation thereof requires health professionals to be conversant with the content of protocols and ways to prevent percutaneous inju­ ries. The purpose of the study was to determine health professionals’ knowledge of prevention strategies and protocols following percutaneous injury. The purpose was addressed within a quantitative survey design. Data were collected by means of a self-administered ques­ tionnaire. The study was conducted at a public-sector tertiary academic hospital in Gauteng. Seven units within the hospital were randomly selected for investigation. These included, trauma, intensive care, medical, surgi­ cal, maternity, theatre and paediatrics. A population of 800 health professionals worked within the sampled units. Health professionals were stratified according to the following three categories, doctors, registered and enrolled nurses and medical and nursing students. A sample size of 200 health professionals was purposively selected of which a response rate of 79.5% (n= 159) was achieved. The sample consisted of 76.7 % (n=122) reg­ istered and enrolled nurses, 13.2% (n=21) doctors and 8.8% (n=14) medical and nursing students; 1.3% (n=2) did not specify their health professional category. Awareness of the existence of a protocol for percutane­ ous injury amounted to 96.2% (n=153). General knowl­ edge of the contents of the protocol reflected a differ­ ent picture; only 26.4% (n=42) of health professionals could accurately quote the procedure following a per­ cutaneous injury as recommended by the South Afri­ can Institute of Medical Research (SAIMR) protocol. The lack of knowledge of the existence of a protocol was most evident in the medical and surgical units. A total of 16.4% (n=26) of health professionals reported Abstrak Voorkomende strategieë en protokolle vir die hantering van naaldprik-beserings is ontwikkel ten einde die oordrag van HIV en ander infeksies te voorkom. Implemented ng vereis dat gesondheidspersoneel kennis van die inhoud van die protokolle asook voorkomingstrategieë moet dra. Die doel van hierdie studie was om gesondheidspersoneel se kennis ten opsigte van voorkomingstrategieë en protokolle na naaldprikbesering te bepaal. Die doel is aangespreek deur kwantitiewe opname ontwerp. Data is deur middel van self geadministreerde vraelyse ingesamel. Die studie is in ’n publieke sektor tersiere akademiese hospitaal in Gauteng uitgevoer. Sewe eenhede in die hospitaal is aan die hand van ewekansige steekproef geselekteer. Die geselekteerde eenhede het die trauma, intensiewe sorg, mediese, sjirurgiese, verloskunde, teater and pediatriese eenhede ingesluit. ’n Totale populasie van 800 gesondheidspersoneel is in die geselekteerde eenhede werksaam. Gesondheidspersoneel is volgens drie kategorieeë, naamlik, mediese dokters, geregistreerde en ingeskrewe verpleegkundiges, en mediese en verpleegkunde studente gestratifiseer. ’n Streekproef van 200 gesondheidspersoneel is aan die hand van ’n doelgerigte streekproef geselekteer waarin ’n terugvoersyfer van 79.5% (n=159) bereik is. Die streekproef samestelling was soos volg: 76.7% (n=122) geregistreerde en ingeskrewe verpleegkundiges; 13.2% (n=21) mediese dokters en 8.8% (n=14) mediese en verpleegkunde studente; 1.3% (n=2) het nie hul gesondheidspersoneel kategories aangemeld nie. Die bewusheid van die bestaan van ’n protokol vir naaldprik-beserings was 96.2% (n=153). Algemene kennis van die inhoud van die protokol het egter ‘n ander prentjie gereflekteer; slegs 26.4% (n=42) van die gesondheidspersoneel kon die prosedure soos deur die SAIMR protokol voorgestel, korrek aanhaal. Die afwesigheid van kennis ten opsigte van die bestaan 22 Curationis December 2003 having sustained a percutaneous injury. A doctor (33.3%) was more likely to sustain a percutaneous in­ jury than a nurse(15.6%). Intensive care units reported the highest incidence of percutaneous injuries (31%; n=9). Health professionals were unlikely to report a per­ cutaneous injury; as only 53.8% (n=14) reported the injury. The results of this research indicate that although knowledge of protocol and prevention strategies was inadequate these alone are insufficient to reduce the incidence of percutaneous injury. die protokol was die mees waarneembaarste in die mediese en sjirurgiese eenhede. Slegs 16.4% (n=26) van gesondheidspersoneel het ’n naaldprik-besering aangemeld. Ook is die moontlikheid groter dat geneeshere eerder as verpleegkundiges, naaldprik-beserings kon opdoen. Die intensiewesorg eenheid het die hoogste insidensie van beserings gerapporteer (31%, n=9). Gesondheidpersoneel neig dartoe om nie die besering aan te meld nie aangesien slegs 53.8% (n=14) die besering aangemeld het. Die resultate van hierdie studie dui aan dat alhoewel kennis rakende die protokol en voorkomingstrategiee onvoldoende is, hierdie faktore op hul eie egter onvoldoende is on die insidensie van naaldprikbeserings te verlaag.

Awareness of the existence of a protocol for percutane ous injury amounted to 96.2% (n=153).General knowl edge of the contents of the protocol reflected a differ ent picture; only 26.4% (n=42) of health professionals could accurately quote the procedure following a per cutaneous injury as recommended by the South Afri can Institute of Medical Research (SAIMR) protocol.The lack of knowledge of the existence of a protocol was most evident in the medical and surgical units.
A total of 16.4% (n=26) of health professionals reported

Introduction
Reported exposure of health professionals to blood-borne pathogens through accidental percutaneous injury have been widely published (Clark, Sloan & Aiken, 2002: 1115;Brook & Bauer, 2002: 71).Prevention strategies and protocols for the management of percutaneous injury and exposure to blood is a high profile topic, with many such protocols being widely distributed within the health care setting.However, by February 2001,57 health profession als, including 24 registered nurses, in the United States reported to have contracted HIV infection due to percuta neous exposure to HIV infected blood.Despite the imple mentation of prevention strategies and protocols for the management of percutaneous injury, research findings con tinue to reveal that some health professionals are not com pliant with these strategies and protocols (Gordon, 1999:174).Hence, many health professionals in South Af rica are putting themselves at risk of contracting HIV.As a result, it is expected that between 18-35 health profession als worldwide will sero-convert annually due to percutane ous exposure to HIV (Brook & Bauer, 2002:71).

Background
A percutaneous injury is an injury resulting in exposure to blood, semen, cerebral spinal fluid, pleural fluid or other serous fluid by means of a needle stick injury, or injury with a contaminated sharp instrument.Specific factors place health professionals at greater risk of sustaining percuta neous injuries.Previous research has identified that percu taneous injuries are most likely to occur during the drawing of blood samples and during suturing (Fokin & Robiesek, 2000:14;Henderson, 1999:7;Karstaedt & Pantanowitz, 2001:59).Other reported causes of injury include, a patient that moved unexpectedly, a carelessly placed sharp, acci dentally mishandled needles and full hazardous waste con tainers (Gordon, 1999:174).Although prohibited in hospi tals in the United States, recapping of needles was a large contributor towards percutaneous injury (Cutlip, 2000:6).Apart from procedures, other risk factors for sustaining percutaneous injuries include, nurses on units with less than adequate resources, low staffing levels and poor nurse leadership.Within these units nurses were typically twice as likely to report the presence of risks due to staff care lessness, inexperience and inadequate knowledge or sup plies (Clark, Sloan & Aiken, 2002:1115).Thus personal and work related factors do influence the risk of percutaneous injury.
Other personal and work related factors include health pro fessional category and time of day.Researchers agree that nurses are the most at risk of sustaining a percutaneous injury (Cutlip, 2000:5), with reported incidences ranging from 4.3% (Clark et al" 2002(Clark et al" :1115) ) to 65% (Henderson, 1999:23).The reported incidence of percutaneous injures for doc tors was 15% (Fokin & Robiesek, 2000:14).The time of day also appears to influence the incidence of percutaneous injury.In a study carried out in the United States, 61% of percutaneous injuries occurred during the day (Gordon, 1999:174) whilst Henderson (1999:23) concluded that 63% of percutaneous injuries occurred in the afternoon.
Risk factors may be minimised through the implementation of prevention strategies and the introduction of a protocol for the management of percutaneous injuries.Prevention strategies and a management protocol are issued by the South African Institute for Medical Research (SAIMR) now called the Now National Health Laboratory.Health profes sionals are required to know the content of the protocol.The protocol can be divided into three steps: these include washing of the site of injury, reporting the percutaneous injury and finally steps taken to prevent the transmission of pathogens.
Immediate washing of the injuiy site is the first step recom mended in the protocol.The rationale for this is that re search findings support the hypothesis that most of the blood inoculum following percutaneous injury stays at the site of introduction for a substantial period of time, with a gradual release into the vasculature and lymphatics (Fokin & Robiesek, 2000:14).The second step involves immediate reporting of the percutaneous injury and exposure to blood.Reporting of a percutaneous exposure to blood is impor tant for the following reasons: employers are compelled by law to keep a record of percutaneous injuries and expo sures to HIV positive blood.Reporting also affords the health professional the opportunity to have the risk of con-tracting HIV assessed and to receive post-exposure prophy laxis (Brook & Bauer, 2002:71).Regardless of the benefits, fewer than half (43%) of health professionals in the United States report percutaneous injuries to authorities (Henderson, 1999:7).Health professionals give the follow ing reasons for not reporting a percutaneous injury: they fear loss of employment; denial may keep health profes sionals from reporting these incidents and health profes sionals are concerned about being ostracised by employ ers or supervisors through punitive means (Gordon, 1999:174).The third step of the protocol is receiving post exposure prophylaxis in order to prevent transmission of pathogens.The three pathogens believed to pose the most common and significant risk to health professionals exposed through a percutaneous injury are hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency vi rus (HIV) (Cutlip, 2000:5).HIV is of particular concern in South Africa as it is estimated that 24.5% of pregnant women in South Africa are HIV positive.
Prior to commencing post exposure prophylaxis the health professional's risk of contracting one of the pathogens must be assessed.This involves testing the source patient and the health professional for HBV and HIV.The nature of the injury also affects the risk.It is generally shown that HIV seroconversion is more likely to occur in the following in stances, percutaneous injury with a large-diameter needle, deep injury, visible blood on the device, injury sustained during an emergency procedure and the stage of the dis ease in the source patient (Fokin & Robiesek, 2000:14;Cutlip, 2000:5).
The rate of seroconversion after percutaneous exposure to HIV infected blood is 0.3% (Fokin & Robiesek, 2000:14).However, should the health professional receive immediate post exposure prophylaxis following the percutaneous in jury the chance of developing HIV infection could be re duced by 79%.The best results are obtained if post expo sure prophylaxis is commenced within one to two hours following exposure and continued for four weeks (Church, 1997:309;Whitfeld, 2000:33).The drug of choice for post exposure prophylaxis following percutaneous exposure to HIV infected blood is Zidovudine (ZDV or AZT).Addi tional antiviral agents such as Lamivudine (3TC) and/or Indinavir should be considered depending on the degree of risk of exposure.
protocol.In a study conducted in the United States, 50% of registered nurses were unaware of a protocol for the man agement of percutaneous injury (Gordon, 1999:175).Health professionals also require knowledge of strategies for the prevention of percutaneous exposure to blood.Health pro fessionals who have limited knowledge of prevention strat egies and protocol for the management of percutaneous injury are placing themselves at risk of contracting HIV or other infections.

Purpose
The purpose of the study was to determine health profes sionals' knowledge of prevention strategies and protocol following percutaneous injury, with the intention of mak ing recommendations for the prevention and management of percutaneous injury.

Objectives
The purpose of the study was addressed through the fol lowing objectives: • Assess the knowledge health professionals have about protocol following percutaneous injury; • Describe the incidence of percutaneous injury among health professionals over a one year period in relation to health professional category, time ofday and unit allocation and application of knowledge of the protocol following a percutaneous injury; • Identify and describe the practices of health professionals that resulted in their percutaneous injury; • Determine the application of strategies to preventpercutaneous injury.

Research design
The purpose of the research was addressed within a sur vey design and through the use of descriptive methods.Data were collected by means of a self-administered ques tionnaire.Data collection was designed in accordance with quantitative methods.Data were analysed by means of descriptive statistics.
Effective prevention strategies and prompt and correct ac tion following a percutaneous injury are necessary to pre vent the transmission of HIV and other infections to health professionals.These include preventing personal and work related percutaneous injury risk factors and management following a percutaneous injury including: washing of the site, reporting the percutaneous injury and finally, steps taken to prevent transmission of pathogens.

Problem statement
In order for a standard protocol for the management of percutaneous injury to be effective health professionals require knowledge of the existence and content of such a

Research setting
The study was conducted at a public-sector tertiary aca demic hospital in Gauteng.The SAIMR has formulated, distributed and implemented a standard protocol for the management of percutaneous injuries within this hospital.

Population and Sampling
Seven units within the hospital were randomly selected for investigation.These included trauma, intensive care, medi cal, surgical, maternity, theatre and paediatrics.A popula tion of 800 health professionals worked within the sampled units.Health professionals were stratified according to the following three categories: doctors, registered and enrolled nurses, medical and nursing students.As the number of health professionals within in each unit differed, 25% of the staff for each unit was purposively sampled amounting to a sample size of two hundred (n=200).Criteria for inclu sion were health professional's age (18 to 65 years of age) and full time employee or student status.Agency and parttime staff were excluded.

Data Collection
This study replicated two studies conducted in the United States by independent researchers.The Centre of Disease Control (1995) conducted the first study and Aiken, Sloan and Klocinski (1997) conducted the second study.The questionnaire items were derived from these two studies, and from the standard protocol developed by the SAIMR.
Data were collected by means of a self-administered ques tionnaire, which was distributed at the beginning of each shift and collected at the end of the same shift.The follow ing questions were addressed: awareness about the exist ence of a protocol, awareness of the content of the proto col, channels health professionals should use to report percutaneous injury, time period in which percutaneous injury should be reported and when post-exposure prophylaxis should be commenced.The incidence of percutaneous injury was observed, type of injury sus tained, time of day that the injury was sustained and health professional category.Action taken following percutaneous injury involved questioning the method of reporting the exposure and whether post-exposure prophylaxis was implemented taken.Finally, health pro fessionals were required to describe the action that lead to the percutaneous injury and the steps they would take in order to prevent a percutaneous injury.

Knowledge of the SAIM R protocol
The knowledge health professionals have about proto col following percutaneous exposure to blood, includes awareness of existence of a protocol and knowledge of the content of the SAIMR protocol.Almost all partici pants (96.2%, n=153) were aware of the existence of a protocol for percutaneous injury.Knowledge of the con tent of the protocol reflected a different picture; only 26.4% (n=42) of health professionals could accurately explain the procedure following a percutaneous injury as recommended within the standard SAIMR protocol.In order to be described as having knowledge about protocol a health professional was required to give all of the following information: wash the wound under run ning water, report the incident immediately to the charge person or casualty, have blood taken from oneself and from the patient for HIV, syphilis and hepatitis B and finally, access the need for post-exposure prophylaxis, which must be commenced immediately if deemed necessary.
Most health professionals would only wash the injury un der running water.Health professionals lacked knowledge of the correct method and route of reporting a percutane ous injury and in taking of blood samples following percu taneous injury.The correct channels of reporting and method of reporting percutaneous injury was explained by 30% (n=48) of the respondents.Immediate reporting of an injury was indicated by 70% (n=l 11) of health profession als.A further 18.9% (n=30) of health professionals felt that it is only necessary to report the injury and commence post exposure prophylaxis more than one day after the injury.The remaining 4.4% (n=7) of health professionals would not consider reporting a percutaneous injury at all.Lack of knowledge of the existence of a protocol was most evident in the medical and surgical units.In these units 61% and 67% of health professionals respectively were aware of the existence of a protocol.All (100%) health pro fessionals within the trauma unit, labour ward and theatre had knowledge of the existence of the SAIMR protocol.
Health professionals in the medical (14.6%) and surgical (12.5%) wards were least likely to correctly state the proce dure to be followed, after percutaneous exposure to blood.Health professionals in the labour ward (31.6%) and ICU (31%) were most likely to correctly state the procedure to be followed after a percutaneous injury (see Table 1).Incidence of percutaneous exposure to blood The incidence of percutaneous exposure to blood among health professionals is described in relation to health professional category, time of day and unit allocation.A total of 16.4% (n=26) of health professionals reported having sustained a percutaneous injury in a one year period.The SAIMR (1999) reports an incidence of 8.2% of percutane ous injuries among staff over a one-year period at an academic hospital.The result obtained in this study was twice as high as that reported by the SAIMR Of the 26 indi viduals sustaining percutaneous injuries 73.1% (n=19) were nurses and 26.9% (n=7) were doctors.None of the students reported having sustained a percutaneous injury.However, only 15.6% (n=19) of nurses sustained injuries as opposed to 33.3% (n=7) of doctors.
The incidence of percutaneous injury re ported among nurses (15.6%) is lower than expected with reference to previous studies.However, the incidence of percutaneous in juries reported among doctors (33.3%) within this study is higher than the 15% reported in previous research (Fokin & Robiesek, 2000:14).There was no difference in the incidence of injuries sus tained at night and during the day; 50% (n=13) of injuries were sustained during the day.It can be concluded from this result that health professionals working within this public sector tertiary institution are equally exposed to the risk factors associated with sustaining a percutaneous in jury during day and night timework.
Intensive care unit staff reported the highest incidence of percutaneous injuries; 31% (n=9) of ICU staff reported sus taining a percutaneous injury.The percutaneous injuries sustained in ICU's constituted 34.6% of the total injuries sustained within the hospital.Other at risk areas were the trauma unit where 18.2% of staff reported percutaneous injuries and theatre where 17.2% (n=29) of staff reported percutaneous injuries.Health professionals working in sur gical and medical units were least likely to sustain a percu taneous injury; 7.5% (n=41) of health professionals in the medical unit and 4.2% (n=47) of health professionals in the surgical unit reported a percutaneous injury (see Table 2).

Actions taken following percutaneous exposure
Actions taken following percutaneous injury among health professionals are described in relation to reporting of the injury and whether post exposure prophylaxis was taken.
Of the 26 health professionals sustaining percutaneous injuries over a one-year period, 53.8% (n=14) reported the injury.Health professionals in this study stated that they did not report the percutaneous injury for the following reasons: the risk of contracting HIV was negligible, did not know that they should report the percutaneous injury, did not know the route of reporting the percutaneous injury and reported the stigma attached to sustaining a percuta neous injury.
Post-exposure prophylaxis was taken by 50% (n=13) of health professionals who sustained a percutaneous injury.Health professionals who did not take post-exposure prophylaxis posited the following reasons: • In the hospital in which the study was conducted, health professionals are required to report the per cutaneous injury at a different department to which the injury is sustained, and this serves as an incon venience; • Health professionals felt that there was no risk of them contracting HIV or any other infection from the injury, so it was unnecessary to take post-expo sure prophylaxis.

•
Health professionals were reluctant to take post ex posure prophylaxis due to the side effects.Of the health professionals who had received post-expo sure prophylaxis, 74% reported side effects.The most common side effect reported in literature was nau sea (Bartlett & Gallant, 2000:70).
Health professionals reported reluctance to take post-exposure prophylaxis due to the long duration of the treatment regime.Bartlett and Gallant (2000:70) reported that if health professionals do choose to take post exposure prophylaxis they stop the medi cation before completing the four-week programme.

Means of sustaining the percutaneous injury
Most injuries were acquired whilst taking a blood sample (15.40%) and due to incorrect disposal of sharps (11.5%).
Refer to Table 3 for the means by which percutaneous inju ries were sustained.

Prevention strategies
Health professionals were requested to recommend strate gies for the prevention of percutaneous injuries.The fol lowing recommendations were made: The prevention strategies recommended by the health Curationis professionals can be elaborated upon using the findings of the study to formulate recommendations for the preven tion and management of percutaneous injuries and thus the prevention of occupationally acquired HIV and other infections.

Recommendations
Recom mendations for the prevention of occupationally acquired HIV should contain the following components; firstly, the standard protocol for the management of a percutaneous injury should be distributed to all health professionals.This protocol should also include the prevention of hepatitis B and C through percutaneous injury.Secondly, distribution of antiretrovirals for post exposure prophylaxis should be available 24 hours a day as 'starter packs'.A starter pack includes 7 days worth of -AZT, 3TC, and indinavir.Thirdly, a format of reporting percutaneous injuries should be devised and reporting should be mandatory.Fourthly, ongoing follow-up of the HIV exposed health professional is required.This will as sist in identifying adverse reactions to antiretroviral therapy and seroconversion rates among HIV exposed health professionals.Finally, improvement of labora tory testing and rapid acquisition of HIV serology testing is necessary.Such laboratory services should be available 24 hours a day.
Percutaneous exposure to HIV infected blood may be re duced by staff education, implementation of prevention strategies and the use of a standard protocol for the man agement of a percutaneous injury.In addition managers of health institutions and policy makers must also address the effect of staffing levels and work environments on these percutaneous injuries.

Conclusions
In conclusion, health professionals in this study were aware of a protocol for the management of percutaneous injury.However, the general knowledge of the content of the pro tocol was poor.The lack of knowledge of the existence and content of a protocol for the management of a percutane ous injury was most evident in the medical and surgical units.A total of 16.4% of health professionals reported having sustained a percutaneous injury, with doctors be ing more likely to sustain a percutaneous injury than nurses.Intensive care unit staff reported the highest incidence of percutaneous injuries.Health professionals were unlikely to report a percutaneous injury and were reluctant to take post exposure prophylaxis.
The results of this research indicate that protocol and pre vention strategies alone are insufficient to reduce the inci dence of percutaneous injury.Remedying problems of understaffing, inadequate administrative support, poor morale in hospitals and beliefs around percutaneous injury are among the most important steps in building a safer working environment.

Table 1 :
Awareness and content knowledge of the S A IM R protocol

Table 2 :
Incidence of percutaneous injuries per unit

Table 3 :
M eans of sustaining the percutaneous injury