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  1. 1. HealthMED - Volume 6 / Number 2 / 2012How do employees respect general precautionprinciples?: The case of emergency rooms ofselected hospitals of Mazandaran university ofmedical sciences-2010Mahmood Moosazadeh1, Mohammadreza Amiresmaili2, Mohammadreza Parsaee3, Asghar Nezammahalleh41 Research center for modeling in health, Kerman university of medical Sciences, Kerman, Iran,2 Research center for Health services management, Kerman university of medical Sciences, Kerman, Iran,3 Health deputy of Mazandaran University of Medical Sciences, Sari, Iran,4 Disease Expert Health deputy of Mazandaran University of Medical Sciences, Sari, Iran. Abstract compliance with personal protection issues, using engineering controls, implementing cognitive Introduction: Clinical employees all over the approaches, behavior modification strategies andworld are at risk of contamination by several mi- combining theoretical bases with educational expe-croorganisms. In order to avoid this, following ge- riences to promote skills in practicing standardneral precaution developed by center for disease principles of general precaution is necessary.control and prevention is recommended. Key words: General precaution, emergency Objective: we aimed to study degree and quality room, hospital, Mazandaran, Iranof following the general precaution principles aga-inst patient blood and secretion among employeesof emergency departments in to provide practical Introductionrecommendation to improve employees’ safety. Infection in a medical center may transmit Methods: The present descriptive-analytical from patient to employees, patient to another pa-study was carried out cross sectional. Research tient, staff to the patient or it can be spread frompopulation comprised of all employees working infected substances such as sputum, blood, urineat emergency rooms of selected hospitals(n=220). and other biological products contained pathoge-Data were collected using a checklist. They were nic elements. Health care workers contact withanalyzed using frequency tables, mean, standard blood transmitted pathogens is regarded as andeviation) and Chi-square test through SPSS16. important occupational risk for these personnel. Results: Employees compliance with Gene- (1-3). Hepatitis B (HBV) transmission risk fo-ral Precaution was assessed weak (35.1%) re- llowing accidental needle injury is about 20 to 40garding hand washing, however, they had better percent, this number is 1-4 per thousand for riskperformance in wearing gloves, using patient care of HIV transmission and 1.2-10 percent for risk ofequipment and doing safe injection, with scores hepatitis C (HCV) transmission. In addition, pros-60.5%, 78.1%, 47.7% respectively. The relation- pective studies have estimated the average risk ofship between gender, education, job title, age, par- HIV transmission after percutaneous exposure toticipation in training sessions and overall compli- HIV infected blood around 0.3 percent (95% CI:ance rate was significant (P.V<0.05). 0.2-0.5) and 0.09 (95% CI: 0.006-0.5) after expo- Conclusion: The overall compliance rate with sure to mucous membranes. However, there areGeneral precautions principles among employees considerable shortcomings in following generalwas not satisfactory. This needs urgent attention to precautions among employees (4-5). According toimprove the situation since the risk of hepatitis B a study in tabriz city of Iran, 51.7% of employeesand hiv virus transmission through blood and se- had weak performance in observing general pre-cretion is very high . Implementing infection con- caution principles regarding contact with blood,trol standards, taking actions to improve employees skin and mucous membranes (6-7). In a study inJournal of Society for development in new net environment in B&H 585
  2. 2. HealthMED - Volume 6 / Number 2 / 2012Shiraz of Iran, knowledge and attitudes of 63.3 tion, then section of demographic and general andpercent of medical students in observing cautio- question on the existence of essential equipmentnary actions were good, however, it did not com- were completed through interviews. To preventply with their practice pattern (8). observers registration error, only four observers Among all health workers who are at risk of in- were recruited for data collection. Harmony of thefection with blood and secretion borne pathogens, data collection was guaranteed by preparing ma-emergency department workers are at a higher risk nual and providing theoretical and practical edu-of contamination with mentioned factors (1). cation to the observers. Study population compri- The Center for Disease Control and Prevention sed of employees of Emergency rooms of Emam,(CDC) developed universal precautions to minimi- Booali, Fatemezahra, Razi and Emamebehshhar,ze the chance of contamination of health care wor- who were all included in the study.kers with pathogens transmitted by blood in 1994. To assess the compliance with universal pre-These precautions are designed for preventing em- caution, each of the indices were provided withployees contact with patients’ blood, secretions, all three options ( Yes, No and makes no sense) inbody fluids, fecal material, injured skin and muco- the checklist. The “makes no sense” answers inus membranes. Studies suggest that health workers each section were removed and only yes and nocontact with blood and secretion decreases as they answers were considered. The sum of yes answersobserve general precautions and following these to the sum of yes and no answers were calculatedprecautions is the best way for health workers pro- and interpreted as :0-24.9% very poor, 25-49.9%tection against occupational HIV and other blood poor, 50-64.9% moderate, 65-74.9% good, andand secretion transmitted infections (1-4). 75-100% very good, according to previous study Therefore, this study was carried out to deter- (6). Descriptive statistics (frequency tables, mean,mine degree of following general precaution aga- standard deviation) and inferential tests (Chi-squ-inst diseases transmitted via patient blood, body are test) were used for data analysis, all analysisfluids, secretions and fecal at emergency rooms were performed in SPSS 16.of selected hospitals of Mazandaran university ofmedical sciences. Results Methods 220 participated in the study (54.4 percent fe- male). Mean age of the participants was 35.11±7. This descriptive – analytical study was carri- The majority of the participants (59.5 percent)ed out cross-sectional. Data collection tool was were in the nursing group. Most of them (39.5a checklist containing four parts. First part of the percent) were in service less than five years. 63.6checklist studied demographic characteristics, the percent of employees participated in the study hadsecond part contained general questions and the training courses while 69.1 percent stated that theythird part investigated the equipment necessary for have read the educational materials, instructionsdeployment of universal precaution and the fourth or books about the universal precautions.part covered questions regarding standards obser- Finding on the Availability of supplies for appl-vation. Checklist validity is confirmed in previous ying universal precautions in the emergency clinicstudy (6). Checklist Reliability was confirmed by showed that: 96.4 percent had access to Gloves,test- retest method (79% for general questions and 37.3 percent to gown, 82.7 percent to Glasses,71% for all questions ). We applied single-blind 75.5 percent to masks and protector to cover themethod for data collection. To ensure this pro- face, 37.7 percent to water with electronic or footcess, at first emergency room employees rooster pedal, 100 percent to cotton and alcohol, soap andwas prepared and a unique number was alloca- to safety box.ted to each of the employees, which was brought Although 35.1Percent of employees washon every page of the checklists. In order to avoid their hands after contact with blood, body fluids,observation bias, at first questions on following secretions, body waste, and contaminated instru-standard precautions were completed by observa- ments, and in the intervals between contacts with586 Journal of Society for development in new net environment in B&H
  3. 3. HealthMED - Volume 6 / Number 2 / 2012Table 1. Percentage of universal precaution compliance in emergency rooms of selected hospitals ofMazandaran University of Medical Sciences General compliance of Safe Patient care wearing Hand Variable universal precautions injection equipment gloves washing 51.3 47.7 78.1 60.5 35.1 Percentagepatients, 60.5 percent of studied employees used Overall compliance of comprehensive pre-gloves prior to contact with blood, secretions and cautions was poor (34.5%) among physicians ofcontaminated waste and equipment, before con- Texas Medical School of America (10).tact with mucous membranes and injured skin and In another study, the mean score of knowled-before diagnostic and therapeutic measures. 78.1 ge and attitude of Iranian physicians was accepta-percent of the staff disinfected or wiped out pati- ble (70%) about precautions during contact withent care equipment in a proper way. blood and secretion But the average score of their 47.7 percent of workers respected safe injec- performance was reported poor (26%)(11).tion i.e. avoiding needles and sharp instruments Although, prevention of exposure with microor-manipulation, not bending needles, not recapping ganisms is one of the most important factors in redu-needles and putting needle and sharp instruments cing the incidence of infectious diseases, our studyin the safety box. indicated that universal precaution compliance was poor (35.1%) in respect to hand washing and most Discussion and conclusion of the staff (65.4%) in the emergency room did not wash their hands after each contact with patients This study indicated that, employees of emer- and 74.4% of them did not wash their hands whilegency rooms compliance with general precaution examining several areas of patients body to preventwere at intermediate level (see table 1), This a sign transmission of microorganisms from one area to ot-which needs immediate attention by administra- her parts of the body. Chi-square test results showedtors since it has been shown in previous studies that compliance with this precaution (washing han-(14-21) the incompliance with principles of pre- ds) in women (43.1%) was more than men (32.6%)vention against blood borne diseases, body fluids, more in nurses (40.6%) than physicians and hou-secretions and patient wastes increases the risk of sekeeping employees and more in employees whohepatitis B virus and HIV transmission. participated training sessions (see table 2). Besides the observed difference according gen- In a study in the West Algeria 95 percent of nur-der, profession, working experience and attending ses washed their hands after removing gloves andtraining courses were significant (PV<0.05; see 69 percent of them washed their hands betweentable 2). In spite of intermediate overall complian- examinations and serving patients (13). Previousce of employees with general precautions, nursing studies on knowledge and practice of health wor-assistants had better performance in this regard kers and medical students reported, employees’(51.3% vs. 67.7%). perception of preventive measures weak, nurses The study conducted by Nazari (2006), appl- adoption in observing personal precautions ina-ying the principles of universal precautions by ppropriate. Unavailability of soap, solutions andmidwives working in medical universities were hand washing liquids, in addition to low knowled-at intermediate level, also Chi-square test did not ge and attitudes of personnel and time shortageshow any significant difference between universi- have been reported as the main reasons not was-ties (9). In a study in three hospitals carried out by hing hands. Besides, confidence to their own skillsDepartment of Environmental Health, Johns Hop- and a sense of safety against disease have been re-kins University, the compliance of health workers ported as the most common barriers toward obser-with standard precautions in women were more ving standard precautions. (22-27).than men and mean score was highest for nurses Universal Precautions compliance was at inter-and technicians and least for physicians (12,13). mediate level (60.5%) regarding to wearing glo-Journal of Society for development in new net environment in B&H 587
  4. 4. 588 patient care General precautions variable washing hands wearing gloves Safe injection equipment overall yes No p yes no p yes N0 p yes no p yes no p Male 32.6 67.4 64.7 35.3 66.6 33.4 43 57 48.1 51.9 Gender 0.0002 0.2 0.0001 0.0001 0.0001 female 43.1 56.9 57.6 42.4 87.8 12.2 56.1 43.9 58.6 41.4 <15 42 58 45.8 54.2 76.5 23.5 50.9 49.1 52.1 47.9 25-34 35.7 64.3 69.2 30.8 79.6 20.4 47.6 42.4 53.9 46.1 Age group 0.4 0.0001 0.0001 0.0001 0.0001 35-44 38.3 61.7 51.2 48.8 71.4 28.6 48 52 49.8 50.2 HealthMED - Volume 6 / Number 2 / 2012 45≤ 50 50 100 0 100 0 87.5 12.5 86.2 13.8 physician 31 69 57.9 42.1 57.9 42.1 44.3 55.7 45.3 54.7 Nursing 40.6 59.4 62.7 37.3 84 16 53.6 46.4 57.1 42.9 Job title Nursing assistant 41.9 58.1 0.0001 73.9 26.1 0.0001 94 6 0.0001 69.5 30.5 0.0001 67.7 32.3 0.0001 Housekeeping 38.3 61.7 30.8 69.2 71.8 28.2 7.7 92.3 31.9 58.1 employees <5 39.4 60.6 50.6 49.4 75 25 47.4 52.6 50.7 49.3 5-9 32.5 67.5 63 37 71.3 28.7 48.2 51.8 50.7 49.3 working 10-19 41.2 58.8 0.09 75.7 25 0.0001 82.2 17.8 0.0001 49.3 50.7 0.0001 57.7 42.3 0.0001 experience 20-24 37.1 62.9 56 44 90.9 9.1 58 42 57.1 42.9 25≤ 50 50 100 0 100 0 85.7 14.3 84.6 15.4 participation in Yes 46.3 53.7 66.1 33.9 80.4 19.6 51.4 48.6 58 42 0.0001 0.0001 0.1 0.0001 0.0001 training sessions No 24.4 75.6 50.6 49.4 73.7 26.3 46.8 53.2 45.7 54.3 Table 2. Compliance with different aspects of general precaution among studied employees availability of Yes 39.5 60.5 63.1 36.9 80.8 19.2 50 50 55 45 0.ooo1 0.0001 0.0001 0.0001 0.0001 equipment No 5 95 0 100 8.3 91.7 50 50 20.6 79.4Journal of Society for development in new net environment in B&H
  5. 5. HealthMED - Volume 6 / Number 2 / 2012ves. Wearing gloves in male personnel were more to gender, working experience and age (P<0.05)than women (64.7% versus 57.6%), in nurses however, differences were not significant with(62.7%) were more than physicians (57.9%) and participating in training sessions (P>0.05). Res-housekeeping employees (30.8%), in personnel pect to safe injection was at a poor level (47.7%).with 10-19 years working experience were more Chi-square test showed that safe injection com-than employees with less than 10 years experien- pliance in women were more than men (56.1%ce and more than 20 years and in Personnel aged versus 43%), in nurses (53.6%) more than physi-over 45 years (100%) and 25-34 years (69.2%) cians(44.3%) and housekeeping personnel(7.7%),were more than employees in other age groups. in workers with more than 20 years working expe-Also wearing gloves in individuals who had par- rience more than employees with less than 20 ye-ticipated in training sessions were more than who ars working experience, in age group above 45had not participated training sessions. Chi-square years (87.5%) more than other age groups and thetest did not show any significant statistical diffe- employees who participated in training sessionsrence between sex and wearing gloves (P>0.05). (51.4%) were more than those who have not par- Differences observed in wearing gloves in ticipated in training sessions (46.8%). Observedterms of work experience, age and participation difference in all of mentioned measures were si-in training sessions was statistically significant gnificant (P<0.05). A study conducted in Nigeria(P<0.05). A study on observing preventing measu- indicated that 48% of medical students were da-res of viral hepatitis reported that 53% of staff do maged with the needle tip (28). Another study innot wear gloves while working and 97% of who US showed the most of whom injured with sharpwore gloves do not change the gloves. Similarly a objects were in nursing category (29). Also Rafi-study at Johns Hopkins University regarding ge- ee(17) showed that in most studied centers need-neral precautions showed that 97% of employees les and blood contaminated wastes and fluids weredid not use gloves (12). collected in a single bin with other home wastes Additionally in a study of observing standard and equipment disinfection is not conducted pro-precautions among nurses of university hospital perly. This is a matter of concern since previousin the west of Algeria, the use of gloves in male studies reported that the risk of hepatitis B fo-nurses were more than female nurses (13) that is llowing needle injury is 33% (18-21).similar to the results of present study. Universal This study indicated that factors such as parti-precaution compliance of dealing with patient cipating in training sessions, availability of neces-care equipment in hospitals (proper transportation, sary equipment for observing general precautions,disinfection or removal of disposables contami- gender, education, occupational category and agenated with blood, body fluids and secretions) were were effective on compliance with general precau-Very well (78.1%) in studied nurses. tion principles. Similarly, previous studies have re- Chi-square test results indicated that compli- ported following factors efficient on observing ge-ance with universal precautions standards of de- neral precaution principles: understanding organi-aling with patient care equipment in female em- zational commitment to safety, perceived conflictployees were more than male employees (87.7% of interest between the need to protect themselvesversus 66.7%), in nursing assistants (94%) more and the need to provide medical care to patients,than nurses, housekeeping personnel (71.8%) and occupational category, gender, individual percep-physicians (9.57%) , in workers with more than 20 tion of risk and knowledge of disease transmissi-years working experience more than employees on, on the other hand, factors such as multiplicitywith less than 20 years experience, in age group of staff duties, work stress, lack of time and skillsabove 45 years (100%) more than other age gro- to ensure against the blood and secretions transmi-ups and in employees who participated in training tted diseases has been the main barriers of respec-sessions (80.4%) more than those who have not ting general precaution principles (10,12,30-33).participate in training sessions (73.7%). Implementing infection control standards, me- Observed differences regarding dealing with asures to improve staff compliance with personalpatient care equipment was significant in relation protection issues, engineering control, cognitiveJournal of Society for development in new net environment in B&H 589
  6. 6. HealthMED - Volume 6 / Number 2 / 2012approaches, behavior modification strategies and 8. Henderson DK, et al: Risk for occupational transmi-combining theoretical education with experience to ssion of human immunodeficiency virus (HIV-1) asso- ciated with clinical exposures: a prospective evaluati-enhance skills are necessary prerequisites for appl- on. Ann Intern Med., 113:10, 1990.ying standard principles of universal precautions. Annual training of personnel and repeating this 9. Nazari M, Pakgohar M, Babaei GH and Geran-training on universal precautions, providing all mayeh M. Comparative study of the relation between knowledge and practice of safety principles for He-supplies and equipment that reduces the risk of in- patitis B prevention among midwives and midwiferyfectious disease, should be considered as a priority students of hospitals affiliated with Tehran universityby authorities. of medical sciences-2001, Research journal of medi- cal council, 24(2), 165-171, 2006. Suggestions 10. Michasen A, Delclos GL,Felknor SA,Davidson, AL”compliance with universal precautions among According to the results of this study there were physicians” PMID: 9048319 (pubmed-indexed forsome weaknesses in applying various aspects medline): j occup environ med. 1997 feb; 39(2):130-7.of universal precautions in emergency clinics of 11. Bennett G,Mansell I,”universal precautions: a sur-hospitals, therefore, it is essential to give special vey of community nurses experience and practice”attention to the employees on- Job training pro- PMID:15086627(pubmed-indexed for medline),jgrams, employees’ Initial training and training of clin nurs. 2004 may;13(4):413-21.medical and nursing students. According to results 12. Gershon RR, Vlahov D. Felknor SA, Vesley D,of this study, a proper plan for providing personal ”compliance with universal precaution among he-protection equipments and improving employees’ alth care workera at three regional hospitals”compliance with general precaution standards PMID:7503434(pubmed-indexed for medline)Am j infect control.1995 Aug;23(4):225-36.should be developed. 13. Beghdale B , Belhadi 2, Shabane W, Ghomari O, kando uci AB Standard precautions practices among Reference nurses in a university ho spital in western Algeria, PMID: 19086684 , 20(5):445-53 (2008)1. Ziazarifi A, Yeganeh B and Gooya MM. Manual of protecting employees of medical center against disea- 14. Brunner & Saudarths,”medical surgical in nur- ses, Tehran, Nashre seda publication, 2002,p.18.[Text sing”, 8 th edition 1996:1379-80. in Persian] 15. Gruedemann B J,Fernsebner B. In: Comprehensi-2. Hakimzadeh, K. Manual of Aids and Hepatitis Pre- ve perioperative nursing. Boston, Jones and Barlett vention, Tehran, Nashre seda Publication, 2001. [Text Publishers.1995;245-51. in Persian] 16. Henry k, Campbell S. Collier p and Williams CO:3. Mali K and Motamediheravi M. Manual of HIV, Hepa- Compliance With Universal Precautions and needle titis B and Hepatitis C transmission prevention, Tehran handling and disposal practices among emergency Nashremolasadra publication, 2001. [Text in Persian] department staff at two community hospitals. AJEC, 1994; 22(3): 129-37.4. Harrison’s Internal medicine principles, Translated by Mohammad Parchebaf, Poorsina publications, 17. Rafiei Gh. Study on the practice of Hepatitis C pre- first edition, 2001. [Text in Persian] vention criteria in several main Hem dialysis centers of Tehran-1998, research journal of zanjan universi-5. Lewis JE: History of the AIDS Epidemic. In Hopp JW, ty of medical sciences, 34,2001. Rogers EA (eds): AIDS and the Allied Health Profe- ssions. Philadelphia: FA Davis Company, 1989. 18. Patrick Cervini, MD1 and Chaim Bell,” Needlestick Injury and Inadequate Post-Exposure Practice in6. Jodati AR, Mohammadibilankouhi E and Astangi S, Medical Students” PMCID: PMC1490117, J Gen Study of Universal precaution practice by operation Intern Med. 2005 May; 20(5): 419–421. theater employees, Tabriz university of medical scien- ces research journal, issue 59,35-33, 2003 19. Panlilio, A., et al.: “Estimate of the Annual Num- ber of Percutaneous Injuries in U.S. Healthcare7. Popejoy S and Fry DE: Blood contact and exposure in Workers,”Infection Control and Hospital Epidemi- the operating room. Gynecology and Obstetrics Sur- ology. 21(2):157, February 2000. gery, 1991; 172(6): 480-3.590 Journal of Society for development in new net environment in B&H
  7. 7. HealthMED - Volume 6 / Number 2 / 201220. Rebecca M, Douglas S. “Needlestick injuries and 32. Torbatti SS, Guss DA. “Emergency department ma- potential body fluid exposure in the emergency de- nagement of occupational exposures to HIV-infected partment”, From the Department of Emergency fluids. J Emerg Med 1999;17:261-4. Medicine, Dalhousie University, Halifax, NS CJEM 2003; 5(1): 36-37. 33. Moran GJ. Emergency department management of blood and body fluid exposures. Ann Emerg Med21. Graaf R, Houweling H, van Zessen G. “ Occupa- 2000;35:47-62. tional risk of HIV infection among western health care professionals posted in AIDS endemic are- as.” Netherlands Institute of Mental Health and Corresponding Author Addiction, Utrecht, The Netherlands , 1998 Aug; Mohammadreza Amiresmaili, 10(4): 441-52. Research center for Health services management,22. Motamed N , Baba Mahmoode F , Khalilian A , pev- Kerman university of medical Sciences, kangeirati M , No2arin , knowledge and practices Kerman, of health care workers and medical student towar- Iran, ds universal precautions in hospitals in Mazanda- E-mail:, ran Province , East Mediterr Health j. 2006 sep, 12(5):653-62 .(2823. Askarian M , Know ledge , attitude , and practices regarding contact precautions among Iranian physi- cians , infect control hosp Epidemiol , 2006 Aug , 27(8):8 , 8-72 .24. Askarian M, Khalooee A, Emroodi NN,”Personal hy- giene and safety governmental hospital staff shiraz, islamic Republic of Iran”, PMID:17333821(pubmed- indexed for medline),East Mediterr Health J.2006 Nov;12(6):768-74.25. Williams c , Compbell s , Henry K , Collier p . Vari- ables influencing worker compliance with universal precautions in the emergency department, Am j in- fect control , 1994 jun, 22(3) : 177 – 826. Gachigo Jn, Naidoo S. HIV/AIDS: The knowledge attitudes and behavior of dentists Nairobi kenya. sad J 2001 Dec; 56(12): 587-91.(4227. Diekena DJ , Albanese MA , Schuldt SS , Doebbeling BNL , Blood and body fluid exposures daring clini- cal training : relation to knowledge of universal pre- cautions . Gen intern Med, 299, Feb, 11(2): 109-11.28. Okeke EN, Ladep NG,Agaba EI, et al. Hepatitis B vaccination status and needle stick injuries among medical students in a Nigereian university. Niger J Med.2008;17(3):330-2.29. Niosh A Preventing needlestick injuries in health care Settings November1999. DHHS(NIOSH)Publi- cation No.2000:108.30. Perry, J.: “Improving Your Sharps Safety Program, “ Outpatient Surgery Magazine. 4(9):94-96, Sep- tember 2003.(3931. Larson E, kretzer EK. Compliance with handwas- hing and barrier Precautions. Jhosp infect 1995; 30 (l): 88-106.Journal of Society for development in new net environment in B&H 591
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