Critical Care Plus
Trauma Workers Disregard Exposure Risks
New methods needed for precaution compliance
By Julie Crawshaw
Universal hospital mandates haven’t caused trauma health care workers to comply with universal barrier precautions, a new study from Louisiana shows. A research team headed by Atul Madan, MD, chief surgical resident at the department of surgery at the Tulane University School of Medicine observed both physicians and nursing staff resuscitating patients at Charity Hospital. They found compliance rates for individual-barrier protection in 104 health care workers were: gloves, 98%; eyewear (any type), 52%; gowns, 38%; masks, 10%; and eyewear (with side protectors), 9%.
Only two of 59 health care workers attending bleeding patients used full-barrier protections, for an overall compliance rate of only 38%. No difference in compliance rates occurred during the study period.1
Madan’s team found that many of their fellow physicians and nursing staff members were nonchalant about using appropriate universal precautions when they resuscitated trauma patients. The level of physician or staff member experience did not affect their rate of barrier precaution compliance. Physicians wore eye protection more often than did the nursing staff but still had poor overall barrier-protection compliance.
"We believe our data have serious implications for urban trauma centers," Madan says. "We know that many [health care workers] simultaneously underestimate the risk of blood-borne pathogens and overestimate their compliance with appropriate protections."
Barrier precautions were considered properly used if worn at all times when the workers were in direct contact with a patient. Researchers recorded times and types of all observed procedures, the presence or absence of obvious external hemorrhage, the type of staff (nursing staff vs. physician), and whether the worker arrived before or after the patient did.
A fourth-year medical student observer (unknown to any health care workers) recorded compliance with four protections: gloves, masks, gowns, and eyewear. Eyewear was divided into those types with and without side protection.
Only those workers who were in direct contact with a patient were included in this study, and no health care worker had any knowledge that he was being observed. The medical student stood on an observation platform often used by other medical students.
The "It Can’t Happen To Me" Syndrome at Work
Though Madan believes a certain amount of precautionary deficit is institutional-dependent, he says if you look at all of the available data, compliance rates are poor overall. "I think it’s partly kind of a cavalier attitude," Madan says. "People think It’s not going to happen to me.’ " He says that in the operating room, everyone is trained to use appropriate universal precautions. "You wouldn’t think of entering an OR without gown, mask, and gloves. But in trauma resuscitations, the urgency people feel gets in the way," he says. "Ironically, when physicians have to protect the patient more than themselves, they seem to be more compliant."
A previous study of which Madan was also the lead author2 showed that the number of HIV-positive trauma patients is significantly higher than in the general population. "In patients suffering from penetrating traumas like bullet and knife wounds, the HIV-positive rate was eight times higher than in the general population," Madan says. "Moreover, most of the health care workers attending these cases—often without sufficient barrier precautions—did not know their patients were HIV-positive."
Madan is more concerned about hepatitis C transmission as a blood-borne disease. "It’s a lot more prevalent than HIV and there’s no vaccine like there is for Hepatitis B," he says.
This study reported evidence of external hemorrhage as the only factor predictive of barrier protection compliance, but visible blood was associated with mixed changes. Researchers found higher rates of eyewear compliance when patients were visibly bleeding, but gown compliance for these cases was actually lower. That may be because penetrating trauma wounds have more external bleeding than do wounds from blunt traumas and thus afford a greater opportunity for the patient’s blood to wind up on the health care worker.
Recent research3 reports nosocomial bloodstream infections are a leading cause of death in the United States. However, Madan sees blood-borne pathogen transmission from health care worker to patient as less likely in trauma units than in ICUs.
Third Study Now in Progress
Madan’s team is currently researching other reasons health care workers aren’t using universal precautions. He points out that at a large trauma center, where 15-20 resuscitations are performed every day, the process becomes routine. "Unless barrier precautions are equally routine, it’s very easy to ignore them," he says.
Once the current study is completed, Madan anticipates looking for ways to change the status quo. "The final piece will be determining how we can encourage using barrier precautions all the time," he says.
David E. Rentz, MD, MPH, an emergency medicine physician at Louisiana State University’s Charity Hospital, participated in the noncompliance study. He calls the lack of universal precaution compliance an excellent example of what happens when people become desensitized to high-risk behaviors associated with tasks they perform repeatedly.
"When you take risks but don’t see any ramifications, you become desensitized to the possibility of blood-borne pathogen transmissions," he says. He points out that a health care worker racing into trauma resuscitation may simply not take the 20 seconds needed to put on a face mask or protective eyewear. "When the patient is bleeding many of us just accept the risk unless the blood is squirting us in the face," Rentz says.
Rentz believes that changing precaution-compliance behavior will take more than education. "Education goes on all the time," he says. "It may require a crisis before people change."
References
1. Madan A, et al. Noncompliance of health care workers with universal precautions during trauma resuscitations. South Med J. 2000;94:277-280.
2. Madan A, Flint L. Higher risk of HIV transmission during trauma resuscitation. J Louisiana State Med Soc. 2000;152:567-571.
3. Centers for Disease Control. Emerging Infectious Diseases. 2001;7:2.
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