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Safeguarding Healthcare Workers

With 3.5 million healthcare workers in India constantly at risk to health hazards, hospitals are taking initiatives on healthcare worker safety, says Sonal Shukla

Have we ever thought about the health safety of the doctor or nurse or ward boy who takes care of the patients suffering from HIV, hepatitis or swine flue? Protecting healthcare workers from the many risks they are subjected to is a big challenge for Indian hospitals. Recently, the H1N1 Influenza pandemic had exemplified the shortcomings of the health system in preventing transmission to healthcare workers.

A well-discussed case was published a few years ago in Asian Labour Update (ALU) issue of April-June 2003, regarding a staff nurse who unknowing got a needle stick injury and landed up being HIV positive. So much so, that she was asked to leave the hospital without compensation or treatment cost. She was deserted by her in-laws, only her family members accepted her, realising that she became positive while taking care of patients. According to experts, today 3.5 million healthcare workers in India are constantly at risk from getting exposed to such health hazards.

Safety First

"The tragic irony of the present situation is that the healthcare workers at greatest risk-those in countries where the prevalence of blood-borne pathogens in patient populations are highest-are afforded the least protection. In resource-limited countries, healthcare workers are not systematically vaccinated against hepatitis B. Although their training is often subsidised by their Governments, the expense of protecting that national investment by providing a life-saving vaccination is most often viewed as optional," opines Dr Janine Jagger, Professor of Research of Internal Medicine and Infectious Diseases at the University of Virginia.

Healthcare staff runs the daily risk of contracting life-threatening infections from blood borne pathogens including HIV, hepatitis B and hepatitis C. In the US, from these sharps injuries there have been 57 documented cases of HIV sero conversion among healthcare personnel through 2001. Two thousand workers a year become infected with hepatitis C, and 400 contract hepatitis B. More than 20 additional types of infectious agents have been transmitted through needle stick injuries, including tuberculosis, syphilis, malaria, herpes, diphtheria, gonorrhea, typhus and Rocky Mountain spotted fever. Exposure to HIV, HBV or HCV also has implications on personal relationships, future employment, and even insurance coverage.

"Only 0.0001 ml of blood exposure is sufficient to lead to healthcare worker becoming hepatitis B positive once exposed to blood or body fluid exposure of a hepatitis positive patient," shares Dr Sanjeev Singh, Senior Medical Administrator, Amrita Institute of Medical Sciences and Research Centre, Kochi.

As often occurs, when infectious disease outbreaks are caused by an emerging agent, healthcare workers is the group that is most affected. According to WHO, 8,098 cases occurred during the SARS outbreak, and 774 (9.6 per cent) people died. Healthcare workers accounted for 1,707 (21 per cent) of the cases.

Awareness on the issue of healthcare worker safety on a pan India basis is variable. Some healthcare institutions are very keenly aware of the issue while there are others for whom ignorance is bliss. As a result of this, most healthcare institutions are absolutely unaware of the magnitude of the problem. However, this scenario in healthcare facilities across India is now gradually changing. Anecdotal reports are available from some healthcare institutions in India, and now five healthcare institutions across India have compiled their data on the subject of exposure to blood borne pathogens, that they plan to publish very soon.

Waking Up To the Cause

Jehangir Hospital claims to have achieved 100 per cent reporting of all needle stick injury incidents

Ruby Hall Clinic has sharps injury protocol in place and any staff that has needle stick injury is given the required Prophylaxis

The Indian healthcare industry is slowly waking up to the issue of healthcare worker's safety in the work place. Surveillance and monitoring of infection rates, needle stick injuries, safety incidents etc are now common in many progressive hospitals in India. There is no Indian data and all policies, discussion and guidelines are based on Western data. Hence five hospitals in India decided to innovate and be ready to share data to work towards the cause of healthcare worker safety. These five hospitals are Amrita Institute of Medical Sciences, Kochi; Fortis Hospital (formerly Wockhardt Hospital,) Bangalore, Escorts Hospital, Delhi, Fortis Hospital, Noida and Ruby Hall Clinic, Pune. All data was collected in the Epinet software developed by University of Virginia faculty. The data collection was started in July 2008 and is being collected till date. AIMS served as a secretariat for collating and statistically testing the data.

Case Studies

Jehangir Hospital, Pune: In Jehangir Hospital, awareness about safety protocols among hospital staff was initially low. But with continual training and awareness programmes, the hospital has managed to overcome this issue. "Non-reporting of safety incidents among staff was also a major issue earlier. But recently we have achieved 100 per cent reporting of all needle stick injury incidents," shares George Eapen, CEO, Jehangir Hospital. Other healthcare worker safety incidents are also being reported promptly in the hospital.

Jehangir Hospital implemented its safety programme through the aegis of the Risk Management and Safety Committee. Elements of the safety programme directed at safety of the healthcare worker include needle stick injury prevention and immunisation, fire safety, disaster management, laboratory safety, radiation safety, hazardous materials management, infection control, security management, lifestyle management, ergonomics etc. "Training and awareness campaigns remain the backbone of the safety programme," says Eapen.

The hospital started off with establishing the Hospital Infection Control Committee back in 2002. Healthcare-associated infection and needle stick injuries were the priority. Initially, the surveillance systems were established and employee safety protocols like the needle stick injury reporting and post-exposure prophylaxis were implemented. "Over the years, from unreported needle stick injuries, we have now achieved 100 per cent reporting of all incidents. Although the incidence of needle stick injury has still not zeroed, continued efforts are being made to eradicate them and the associated risk of transmission of HIV and hepatitis," says Eapen.

The Safety Incident Reporting programme was established in 2006 in Jehangir hospital. Since then, over 1,000 incidents have been reported, out of which almost 10 per cent are related to employee safety. Incidents of mercury spills, falls, accidental ingestions, exposure to blood or blood products etc have been reported. Suitable and timely action with a preventive action programme on the reported incident has reduced the recurrence of incidents substantially in the hospital.

The hospital has also initiated a hospital-wide Hazmat (Hazardous Materials Management) programme. This programme is aimed at identifying all the hazardous materials and preventing accidents involving them. This is done through the availability of Material Safety Data Sheets (MSDS) in all areas. MSDS outlines the physical and chemical properties of the material and also the measures to be taken in case of accidental exposure. Measures to avoid radiation hazards, like use of lead aprons, thyroid guards, scrotal guards and the use of Thermoluminiscent Dosimeter (TLD) badges for radiation monitoring are required as per the Atomic Energy Regulatory Board (AERB) and have been institutionalised at Jehangir Hospital. Hazards Identification and Risk Analysis (HIRA) is done on a periodic basis. All potential risks are identified through comprehensive environment of care rounds and corrective action taken on identified risks.

"Decision makers must understand that healthcare worker safety is an important issue and support all activities" - Dr Anita Arora, Secretary HIS-I, Escorts Heart Institute New Delhi

"Only 0.0001 ml of blood exposure is sufficient to lead to healthcare worker becoming hepatitis B positive" - Dr Sanjeev Singh Senior Medical Administrator AIMS Kochi

"We make sure that nobody recaps the needle and throws the sharp into the sharp containers" - Dr Murali R Chakravarthy Chairman-Hospital infection control committee Fortis Hospital,Bangaluru

Escorts Heart Institute and Research Centre, New Delhi: The hospital has created an environment of 'Safety First'. "All healthcare workers at the time of joining undergo induction training where they are made aware of the safe practices in the hospital. They are trained on the safe use and disposal of needles and other sharps, and the mechanism of reporting all needle stick and other sharps-related injuries," shares Dr Anita Arora, Secretary, HIS-I, Escorts Heart Institute and Research Centre, New Delhi.

Their hepatitis vaccination status is determined, so that at entry either they are adequately protected or they are administered the vaccine as per hospital protocol. Constant reminders are in place through the use of posters on biomedical waste and sharps disposal. Posters on the safe use of sharps including whom to report to in case of a needle stick injury are pasted at each nursing station and other critical areas of the hospital.

AIMS, Kochi: AIMS Kochi implemented waste management, segregation, collection and transportation practices. The hospital did pilot testing of safety devices and implemented puncture proof containers for sharps and broken ampules. "We gave confidence to all healthcare workers that reporting is important and that they will not be penalised. We also have been sharing data with all stakeholders to understand the reasons for the injuries," says Dr Singh. The hospital infection control committee organises training and education sessions for all stakeholders.

JJ Hospital, Mumbai: Every six months, JJ Hospital conducts a training programme for healthcare workers. This training is given to doctors, nurses and lab technicians, not only for HIV but also hepatitis B and C and many other blood borne infections. "JJ hospital was the first hospital to start HIV OPD. We then started an initiative with NACO to give training about bio-safety precautions to all medical officers. However today there is no separate programme for lab technicians and ward boys - ideally they who carry all the debris-so every institute is supposed to give them the training," quips an official from JJ hospital. According to her, just 30 years back the supply of glows and syringes was inadequate, however today with the advent of HIV and hepatitis-all the medical colleges are getting adequate supply of gloves and disposable syringes. And it is the responsibility of the healthcare worker to be more careful while dealing with patients and therefore, they must wear or use necessary protection devices.

Fortis Hospital, Bangaluru: The hospital has an infection control committee which conducts audit rounds for safe practices on regular basis in the hospital. "We make sure that nobody recaps the needle and throws the sharp into the sharp containers. We have needle stick injury as one of the health quality indicators," shares Dr Murali R Chakravarthy Chief Anesthesiologist, Chairman, Hospital infection control committee, Fortis Hospital, Bangaluru. The hospital has an auditor at every level in the organisation. "For example, in OT if the person gets exposed to any injury and doesn't report, then we have one more person (circulating nurse) who will report to the infection committee about the injury," adds Chakravarthy.

According to Dr Chakravarthy, over a period of time, number of reporting of sharp injuries in the hospital has improved. "We used to come to know about three to four sharp injuries a year three years ago, today we have 3-4 sharp injuries reported very month, which means people are coming forward to report. It is crucial to report needle stick injuries to know why it occurred. Anatomy of the needle stick injury is more important than the consequences. We came to know injuries occur between injecting and disposal of the needle, therefore now we are planning to have sharp disposable unit on the bedside. After injection they will immediately dispose to the bed side," adds Chakravarthy.

Ruby Hall H Clinic, Pune: The hospital has actively set up a surveillance and reporting system, the doctors are able to document cases and even take interventions to ensure the safety of the healthcare workers. The hospital uses safety devices for Phlebotomy, and for intra cath procedures in the ICUs. "The management is very supportive when it comes to healthcare worker's safety. We have a sharps injury protocol in place and any staff that has needle stick injury is given the required Prophylaxis," shares Dr Nita Munshi, Head of the Department of Pathology, Ruby Hall Clinic, Pune.

Regular lectures are conducted for all categories of staff to make them aware of the safety issues. The hospital has been using the Epinet from BD to record its data of sharps injuries and share it with other hospitals across India, to see how the issue can be tackled.

Protect and Preserve

"In countries where safety-engineered needles and sharp devices have been introduced on a wide scale, there has been a significant drop in needle stick injury rates," shares Dr Jagger. Of the various initiatives towards safety of healthcare workers in India, with the introduction of the mandatory Biomedical Waste Management and Handling Rules 1998, sharps disposal was the first to be addressed. With increased emphasis on segregation, arose the need for the provision of sharps containers, needle cutters and needle destroyers. Industry rose to the occasion and many providers came forward promoting their already nationally but mostly internationally existing products. Other members of the industry created low cost alternatives to provide competition to the international suppliers.

"Today there is an increase in the use of puncture proof containers which also has contributed in a big way in preventing needle sticks injuries," says Dr Singh.

Today, safety devices, instruments and gear that will offer protection for the healthcare worker are available in the Indian market. Safety shoes, emergency eye washers, emergency showers, Hazmat suits, respirators etc are now common items in the purchase budget of progressive hospitals. TLD badges, thyroid guards, scrotal guards, lead gowns are mandatory as per AERB and are available in the Indian market. Sharps protection products, like sharps containers, heel stick lancets etc are also now commonly available.

Healthcare worker safety is a high priority area of concern in many developed countries like America, Europe and Australia. They are aware of the magnitude of the issue and have taken various steps to promote and even make mandatory the use of safer devices at the workplace in healthcare institutions in their countries. "In the Western countries, the scenario is a bit better. The main reason being that the healthcare set-ups use safety devices for sharps. Therefore, the incidence of needle stick injuries, and thus, the related risk associated with it reduces. In the US, there is legislation that all hospitals must use safety devices. This was done due to the efforts of Dr Jannine Jaeger. Otherwise, there is a significant under reporting in the West too," says Dr Munshi.

In the US, Federal laws and Occupational Safety and Health Administration (OSHA) mandates have moved needle stick prevention to the top of the safety agenda. The Needle stick Safety and Prevention Act, which passed in 2000, has helped protect healthcare workers and prevent spread of diseases. The law requires medical facilities to provide healthcare workers access to medical products, like syringes and blood-drawing devices that are equipped with safety features.

The law also mandated that the OSHA revise the 'Bloodborne Pathogen Standard' to require front line workers to select and evaluate safety devices, which it did in 2001.

Some African and Asian countries are also realising the importance of the issue of healthcare worker safety and are working towards creating a safer working environment.

The Way Forward

Underreporting, denial mode and cowboy attitude of doctors-'nothing will happen to me!', are few of the main challenges that the hospitals face today while trying to set up surveillance committees for the cause. "Hospital also might not support the healthcare worker due to various reasons. One of them could be that anti retroviral therapy costs approximately Rs 15,000 per employee. If the person becomes HIV positive, they will terminate him/her from the service," opines Dr Chakravarthy.

The JCI and NABH standards have very specific requirements for safety of the healthcare worker. With many hospitals already accredited or in the process, will surely go a long way in ensuring the safety of the healthcare worker. "Key decision makers in Indian hospitals must understand that healthcare worker safety is an extremely important issue and support all activities related to this endeavour, including budgeting for expenses incurred in the event of an injury," concludes Dr Arora.

Prioritising patient and staff safety is a challenge that must be met with a comprehensive effort, or else hospitals may face negative consequences in the long run, including litigation and cost of compensation.

sonal.shukla@expressindia.com