Exposure Injuries in an Academic Institution: Prevalence and factors influencing post exposure management.

Introduction

Dental practitioners are considered to be at high risk for occupational exposure, especially needle stick injuries.¹ The Centers for Disease Control and Prevention (CDC) defined occupational exposure as: “Exposures that occur through needlesticks or cuts from other sharp instruments contaminated with an infected patient’s blood (including blood-contaminated saliva) or through contact of the eye, nose, mouth, or skin with a patient’s blood.”² Needlestick injuries (NSIs) are considered one of the most serious health concerns in general and in dental practice, specifically due to their dangerous health consequences and frequently recorded incidents.³ NSIs are accidental skin penetrating wounds caused by sharp instruments in a medical setting.³ They are defined as “an accidental skin penetrating wound caused by hollow-bore needles such as hypodermic needles, blood-collection needles, Intravenous (IV) catheter stylets, and needles used to connect parts of IV delivery system, scalpels, and broken glass.”³

Exposure to NSI could result in several consequences that jeopardize general practitioners’ health.⁴ Approximately 3 out of 35 million HCWs worldwide are exposed to NSIs every year and are prone to blood-borne pathogens.⁴ Although NSI are associated with 20 different transmitted pathogens, blood-borne infections such as hepatitis C virus (HCV), hepatitis B virus (HBV), and human immunodeficiency virus (HIV) are the most prevalent diseases in the dental field.⁴ In addition to infectious diseases, hidden consequences that negatively affect general practitioners are usually not mentioned.⁵ Economic burden and psychological issues, such as stress and anxiety, and in extreme cases, can lead to disability and mortality.⁵ Mishaps, lack of experience, stress, and obligation overburden are considered causes of high exposure to NSI.⁶ Needlestick injuries usually occur when practitioners open, use, or discard instruments.⁶

In dentistry, approximately three in ten dental assistants experienced at least one NSI (29.8%) in private dental clinics, and the reported injuries were significantly associated with a lack of infection control knowledge, non-compliance with vaccination protocols, and working in dental clinics that had no infection control unit.⁵ Previous studies identified certain limitations in the investigation of NSIs, such as limitation of the resources, recall bias caused by self-reporting of NSIs, and lack of awareness about the importance of reporting, which resulted in underreporting of the incidents.^5,7 Furthermore, owing to the underreporting of incidents, it is difficult to estimate the actual occurrence of NSI incidents.⁸ A study conducted in 2018 showed that many factors contribute to underreporting issues, such as lack of knowledge about the importance of reporting incidents and the fear of getting blamed.⁸ Reporting of NSI is fundamental for prevention and treatment as it allows the assessment of the necessity for post-exposure prophylaxis, enables early diagnosis of infectious diseases, and reduces the stress of the exposed staff.⁹

The Occupational Safety and Health Administration (OSHA) stated that dental care providers should adhere to certain protocols for handling NSI.¹⁰ Injured dental practitioners are anticipated to perform immediate post-exposure evaluation and management, inform the supervisor, and proceed with writing the report.¹⁰ As HIV, hepatitis B, and hepatitis C are some of the risks associated with NSI, immediate prophylaxis is mandatory.¹⁰ Medical attention should be paid within hours of the incident.¹⁰ If the source is suspected of any blood disease, hepatitis B and C, and HIV blood tests are required.¹⁰ Post-management, B vaccines and HBIG are used as prophylactic treatments.¹⁰ The report should be finalized by practitioners and supervisors.¹⁰ According to the Centers for Disease Control (CDC), follow-up depends on the risk assessment of the patient starting at six weeks, three months, and six months.¹¹ The awareness and knowledge regarding preventive measures for NSI are deficient, which results in life-threatening blood-borne infections due to unsafe injection practices and lack of standard precautions.¹² Therefore, this study aimed to investigate the prevalence and associated risk factors of NSI in the Eastern Province of Saudi Arabia.

Materials and methods

Results

The prevalence of NSI in this study was 100, with a peak of 28 incidences in 2021 (Figure 1), and more injuries were reported during November (15 reports) (Figure 2). Table 1 presents the descriptive analysis of the collected data. NSI were more common among females (n = 61, 62.2%). The results also showed that over 8% of the incidents occurred during the afternoon clinical sessions, with NSI being more prevalent among students (55.6%), followed by Interns (29.3%). The most frequently reported sharp injury was the needle (71.9%). An explanation of the incidence was provided for most cases (68.4%). Immediate post exposure management and first aid were provided in 85.7% of reported cases. Serological tests were performed in 86.6% of the cases, of which 62.5% underwent the test performed on the same day as the incidence. The most common reason for injury was engaging in an unsafe working procedure (63.2%) ( Table 1).

Figure 1. Number of reported exposure injuries per year.

Figure 2. Month-wise number of reported exposure injuries.

Of the 46 incidences caused by needlestick, only 65.2% of the cases had explained the incidence. If the source of injury was an endodontic instrument, the explanation was provided in 71.4% of a total of 7 reported injuries. Remarkably, the cause or explanation of the incidence was completely provided for all exposures that occurred by the surgical instrument ( Table 2). While, if the injury occurred from a needle, the explanation was provided significantly fewer times than for other sources of injury (p = 0.016).

Compared to other sharps, needlestick were significantly associated with a higher incidence of exposure injuries (p = 0.016). In the current study, immediate post-exposure management was significantly higher if the incidence happened in the morning clinical session than in the afternoon clinical session (p = 0.035) ( Table 2). With regards to providing first aid after injury, it was found that a significantly high proportion received first aid 97.7% immediately after the injury, while only 2.3% did not receive immediate first aid after the injury (p = 0.000). In addition, a significantly higher proportion of females (93.4%) proceeded with the serology test than males (74.3%) (p = 0.0130). Similarly, irrespective of the position of the person who got injured, females had a significantly higher incidence of injuries (p = 0.002) ( Table 2).

Table 3 shows that none of the demographic factors were associated with exposure injuries.

Discussion

The dearth of literature on the prevalence of exposure injuries among dental care providers in Saudi Arabia and worldwide highlights the need to address this critical research topic. This study evaluated the prevalence of exposure injuries among faculty members and dental students in an academic institution. The current investigation showed that the prevalence of exposure injuries was highest among students, females, and during afternoon sessions. The most common sources were needles. This is the first study to report the prevalence of exposure injuries in an academic institution, given the seriousness of the consequences. The findings of the current study can guide decision and policy makers in prioritizing training and awareness regarding post exposure management.

In the present study, needles were found to be the cause in two-thirds of the reported exposure injuries, followed by surgical instruments and endodontic files, similar to what was reported in Pakistan,⁸ Jeddah,⁵ Jezan,¹⁴ and Najran.³ These findings highlight the risk of exposure injuries associated with the instruments used in dental procedures, from administering local anesthesia to root canal treatment and ending with dental surgeries. There are many critical steps that increase the risk of exposure when using needles, for example, during injection of local anesthesia (LA), recapping, irrigation, suturing, fine-needle aspiration biopsy, or disposal of the needle. Compared with other uses of needles, needle pricks from dental anesthetic needles account for the highest proportion of needle exposure.¹⁵ These injuries occur more specifically during cheek retraction when the LA is injected.¹⁵ This incident can be prevented if the operator uses a modified retraction technique that involves retracting the cheeks using an examination mirror.¹⁵ Other preventive measures can be taken during needle capping, such as the one-handed scooping technique, using a disposable syringe, and using a safe (retractable) syringe.¹⁶

Moreover, we found that students followed by interns had more exposure injuries than did other dental care providers or employees. This observation is in agreement with a previous study in Riyadh, Saudi Arabia, which reported a significantly higher incidence of injuries among undergraduate students and interns.⁶ In another study, more than one-fifth of the interns sustained at least one NSI during clinical training.¹³ Students were the most affected dental care providers.¹⁹ On the other hand, Andrade et al. stated that incidences of sharp injuries increase with the age of the worker.²⁰ Additionally, Cheng et al. found that experienced clinicians reported more exposure injuries.²¹ A study conducted in 2021 showed that dental students in their undergraduate education in Saudi Arabia experience higher levels of anxiety, stress, and depression.¹⁷ This could be one of the reasons for the observed higher frequency among students.¹⁷ Coping and management strategies are recommended, and programs can be developed to improve students’ quality of life and mental health.¹⁷

Besides equipment-related factors, there are some demographic-related risk factors associated with an increased risk of NSI, which include gender, position, education, and age of the operator.⁷ Almost two-thirds of the reported incidents were among females, supporting previous studies.^{5,6,13,14,19,22} It is unclear whether females experienced a greater number of NSI exposures or whether they were more inclined to report NSI.¹³ Another reason that might explain the observed gender differences may be related to females being more anxious and stressed than males during clinical practice.¹⁷ This fact is believed to be true because females are more concerned about their health and the importance of post-exposure protocols.

A higher incidence of exposure injuries occurred during afternoon clinical sessions, in line with a recent study by Huang et al., which indicated that the majority of NSI exposures occurred between 1:00-3:00 PM.¹³ This might be related to healthcare providers working in a hurry to finish their procedures at the end of the day with more fatigue and less energy. This observation agrees with that of Fernandes et al.¹⁹ who found that the NSI was higher in the afternoon. In addition to psychological factors, experience and hand skills are contributing factors to increasing the chances of NSI.¹³ The lapse of concentration and fatigue can be minimized if healthcare providers are working with well-trained chairside assistants because inadequate training can increase the risk of having NSI with the dentist and the assistant, which is called peer-inflicted NSI.¹³

Reporting of exposure injuries is one of the mandatory guidelines that must be implemented to ensure accurate risk assessment and minimize exposure to bloodborne pathogens.¹⁸ In the current study, the peak of reported injuries was in 2021 post the COVID-19 period where reinforcing the infection control protocols after quarantine might have led the practitioner to be more committed to guidelines and report any injuries. In the same context, the majority of the cases were in the last quarter of the year, similar to what was reported by Huang et al.¹³ As the end of the year, students are prone to a variety of stresses associated with their studies; they are required to complete cases, specific requirements, performance evaluations, and clinical examinations. As future dentists who will provide dental care for the general population, dental students must be trained to effectively prevent occupational exposure.^23,24 This highlights the importance of documenting the frequency and circumstances of exposure injuries in identifying unsafe working circumstances and having an accurate risk assessment to minimize the NSI and hence the transmission of blood-borne pathogens. Implementing standard universal precautions in dental institutions is the best strategy for preventing occupational exposure.^23,24

A closer look at those injuries occurring in IAU academic institution shows that the overall rate of compliance with immediate post-exposure management was much higher than in other studies in Taiwan and Sweden.²³ Possible explanations for the high rate include¹ hospital policy that encouraged reporting,² the role of the hospital’s infection prevention team, and³ increased awareness over the years of the risks of infection transmission by needlestick injury. It is also important to mention that our protocol of post-exposure management includes first aid such as washing the injury site with water or using antiseptics to clean the wound, seeking guidance from doctors or the relevant department of the institution, and reporting followed by performing the required serological tests.

The main reason for incompliance with post exposure management was time.²³ When analyzing the time elapsed between the time of injury and further medical assessment by performing serological tests, it was found that in most cases, the ideally recommended time was respected. Nevertheless, the prevalence of individuals who delayed seeking postexposure care remains high. This condition is worrying because post exposure management becomes ineffective as time elapses.¹⁹

Trends in the frequency and profile of NSI exposure should be carefully monitored and evaluated, which allows the identification of hazardous practices and diminishes the risk of future exposure.¹ Reporting NSI is one of the mandatory guidelines that must be performed to ensure accurate risk assessment and minimize exposure to bloodborne pathogens.^25–27 Poor reporting contributes to an unclear picture of the incidence of needlestick injuries and hampers effective preventive measures.²⁵ Therefore, healthcare providers, including students and interns, should be encouraged to report incidences anonymously and increase their awareness that such reporting will not affect their grades or performance.

This study has certain limitations that need to be addressed. First, retrospective studies may have imposed a risk of recall bias. In addition, many confounding factors may be present but were not collected. The data were also extracted from one site, and future studies should include multiple institutions to allow better analysis of risk factors in comparison to different policies and post exposure protocols. Lastly, the retrospective nature of the study allows only the establishment of an association, but cannot determine causation.

Conclusion

The incidence of exposure injuries in the current study was high and mainly caused by needles. Females and students reported more exposure injuries, with these injuries occurring more frequently during the afternoon sessions. Post exposure management is influenced by sex, cause of injury, and time of occurrence. There is a need for continuous safety training, especially among students.