By Lynn Hadaway, MEd, RN, BC, CRNI
Editor's note: For tables, please refer to the August 2011 print issue of ICT.
Insertion of short peripheral intravenous catheters is an extremely frequent procedure in many healthcare settings. In fact, an estimated 330 million catheters are sold annually in the United States. Nurses are very familiar with the risk of these devices to patients including pain and vein wasting from multiple venipuncture attempts, nerve damage resulting in complex regional pain syndrome, inadvertent arterial insertion producing amputation with the injection of certain medications, infiltration and extravasation producing the need for surgical treatment, and thrombophlebitis requiring extended treatment with anticoagulants.
In this brief review, the focus shifts away from the patient to the healthcare worker (HCW) performing these catheter insertion procedures. To better understand IV catheter exposure risks to the HCW, a systematic literature review using an integrative approach was completed. A search of several large databases produced thousands of articles which resulted in 568 being selected for a close review and 187 included in the final analysis. These studies represent research in more than 30 countries and included all types of research designs.
Publications use numerous names for mechanism of injury and exposure types including percutaneous exposure (PCE), mucocutaneous exposure (MCE), accidental blood exposure, sharps injury, needlestick injury and blood and body fluid exposure. PCE and MCE are more global terms identifying the types of exposure rather than the specific mechanism of injury.
- PCE is defined as puncture of tissue with a sharp device contaminated with blood or blood-containing body fluid. The greatest risk of disease transmission comes from hollow-bore, blood-filled needles used to puncture veins and arteries, although a solid sharp such as a scalpel blade can also pose similar risk.
- MCE is defined as blood or blood-containing body fluid coming into contact with intact skin of the HCW, non-intact or broken skin of the HCW, and mucous membranes of the eyes, nose, or mouth. Of these methods, exposure to non-intact skin and mucous membranes would pose the greatest risk of disease transmission.
Diseases of greatest concern are HIV, hepatitis B and C; however, many other diseases are transmitted with blood exposure including malaria, dengue virus, syphilis, tuberculosis, herpes, diphtheria, gonorrhea, typhus, and Rocky Mountain spotted fever.(Zaidi, Beshyah, & Griffith, 2009) Other factors include the viral load within the patient at the time of the injury and the seroprevalence within a specific patient population. The Centers for Disease Control and Prevention (CDC) estimates of seroconversion are:
- Hepatitis B 6% to 30% after PCE
- Hepatitis C 0.5% to 10% after PCE
- HIV 0.3% after PCE
- HIV- 0.09% after MCE
Occupationally acquired HIV in HCWs has been tracked since 1981. No new cases have been added to the U.S. database since 2000. (Table 1) CDC data also estimates that three to eight HCWs will die annually from liver disease due to occupationally acquired hepatitis C. (CDC, 2007; Sepkowitz and Eisenberg, 2005; Tomkins and Ncube, 2005)
While no reports of MCE during insertion of short peripheral catheters were found in the 187 studies assessed during the literature review, nurses sporadically report anecdotally that they have had blood reach their faces during this procedure. These events need to be documented and analyzed so that efforts can be made to prevent them. Mandatory use of safety-engineered peripheral catheters over the past 10 years has greatly decreased the incidence of PCE, however they do still occur
From the reports of occupationally acquired HIV, there are details associated with MCE when restraining a combative patient, when holding pressure on a wound to create hemostasis, when there was regular contact with AIDS patients in HCWs with chronic skin disease, while attempting to clear an occluded arterial catheter and during multiple laboratory procedures.
Rigorous attention to prevention of both types of exposure must continue. Worldwide, the knowledge and implementation of Standard Pre-cautions remains a problem. HCWs need education about this approach that assumes all blood and body fluids from all patients are potentially infectious.
Continued emphasis on adaption of safety-engineered devices is critical. Rates of PCE vary when there is a legal mandate to provide these safer devices versus when adaption is on a voluntary basis. A passive safety mechanism is associated with fewer PCEs than an active mechanism. (Tosini et al., 2010) Passive devices do not require any action by the HCW for the safety mechanism to engage the needle. Active devices require the HCW to complete a step (e.g., pushing a sleeve over the needle or pushing a button) to cause the needle to be safely contained.
Other prevention strategies focus on proper documentation of all exposures. This will result in correct post-exposure monitoring and appropriate post-exposure prophylaxis and treatment. Appropriate use of personal protective equipment is also critical to prevention. Gloves must be worn for all venipuncture procedures. Additionally, the HCW must assess each situation and determine if a mask, goggles or face shield may be required to prevent blood splashes into the face during each venipuncture procedure.(Siegel, Rhinehart, Jackson and Chiarello, 2007) HCW education is paramount to achieve these goals. Knowledge of the seroprevalence for each disease within the patient population being served, application of standard precautions, and correct use of each device is essential to reducing these dangerous exposures.
According to EPINet data, reported numbers of PCEs are almost four times greater than MCEs. There is no documented evidence of MCE during insertion of short peripheral catheters and no documented or possible cases of seroconversion of HIV, HBV or HCV associated with venipuncture procedures. During insertion of peripheral catheters, blood can easily spill into the environment. More information is needed about blood splashes during this procedure including the direction and distance of such blood droplets that may become airborne. Our efforts have been very successful in reducing PCE with safety-engineered catheters, however we must continue the efforts to further reduce PCE. Additionally, more details of how and when MCE occurs with short peripheral catheters are needed.
CDC. (2007). Surveillance of Occupationally Acquired HIV/AIDS in Healthcare Personnel, as of December 2006. Retrieved from http://www.cdc.gov/ncidod/dhqp/pdf/bbp/fact_sheet_clearance_revised_090507Dec2006.pdf
EPINet. (2009). 2007 Percutaneous Injury Rates. International Healthcare Worker Safety Center.
Sepkowitz, K. A., & Eisenberg, L. (2005). Occupational deaths among healthcare workers. A Peer-Reviewed Journal Tracking and Analyzing Disease Trends Vol. 11, No. 7, July 2005, 1003.
Siegel, J., Rhinehart, E., Jackson, M., & Chiarello, L. (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Retrieved from http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
Tomkins, S., & Ncube, F. (2005). Occupationally acquired HIV: international reports to December 2002. Euro Surveill, 10(3), E050310 050312.
Tosini, W., Ciotti, C., Goyer, F., Lolom, I., L'HERITEAU, F., Abiteboul, D., et al. (2010). Needlestick Injury Rates According to Different Types of Safety-Engineered Devices: Results of a French Multicenter Study. Infection control and hospital epidemiology, 31(4), 402-407.
Zaidi, M. A., Beshyah, S. A., & Griffith, R. (2009). Needle Stick Injuries: An Overview of The Size of The Problem, Prevention And Manage-ment. Ibnosina Journal of Medicine and Biomedical Sciences, 2(2), 53.