Sharma, Giriraj K. MS; Gilson, Marta M. PhD; Nathan, Hari MD; Makary, Martin A. MD, MPH
Medical students face clinical situations in which the possibility of exposure to blood is similar to that faced by residents and physicians. However, the students’ underdeveloped technical skill sets may place them at a risk of injury greater than that faced by their senior colleagues. Needlestick injuries can result in chronic infection, social stigma, and long-term disability.1–4 In addition, a needlestick can lead to significant psychological stress for the medical student and his or her loved ones.1
Recent estimates are that the current prevalences of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) are high in the health care setting. Up to 20% to 38% of urban hospitalized patients test positive for a blood-borne pathogen and, thus, are classified as “high-risk” patients.5 (We define a high-risk patient as one with a history of intravenous drug use or infection with HIV, HBV, or HCV.) It is estimated that 600,000 to 800,000 needlestick and other percutaneous injuries are reported annually among U.S. health care workers,6 and there is evidence of vast underreporting of injuries to employee health services.1,7,8 The prevalence of blood-borne pathogens is high, and needlestick injuries are common in the hospital setting, but postexposure prophylaxis is effective in preventing HIV and HBV infection as well as HCV chronicity. Thus, timely reporting is critical to ensuring the prevention of sometimes catastrophic medical and personal consequences.
Whereas previous studies have focused on needlestick injuries to health care professionals in general, the incidence of needlestick injuries and the rates of reporting among medical students are largely unknown. Current literature estimates the incidence of needlestick injuries in medical school to be between 12%9 and 50%.3 The goal of this study was to determine the incidence of needlestick injuries in medical school by using data obtained from a sample of surgery residents. We aimed our efforts at underscoring and quantifying an understudied problem in medical schools. By sampling surgery residents, we obtained data that represented a subset of medical students, which allowed us to analyze associations pertaining specifically to surgeons-in-training. We further sought to examine the circumstances of such injuries and the behaviors associated with reporting to an employee health office any needlestick injuries sustained during medical school.
The design and methods of the study were published elsewhere1 but are briefly described here. A survey was presented to surgeons-in-training at 17 U.S. general surgery residency programs certified by the Accreditation Council for Graduate Medical Education. First- and second-year residents included trainees in subspecialties (plastic surgery, otolaryngology, urology, and orthopedics) who rotated through general surgery as part of their curriculum. All participants were surveyed after completion of the January 2003 American Board of Surgery In-Service Training Examination, a standardized nationwide exam administered to all general surgery residents. Participation was voluntary, and we considered that it provided consent for study involvement. The Johns Hopkins University School of Medicine institutional review board approved the study.
We asked survey respondents to indicate their postgraduate year of clinical training, sex, the number of needlestick injuries sustained during medical school (if applicable), the number of needlestick injuries sustained during residency training (if applicable), and the occurrence of any needlestick injury involving a high-risk patient. Additional questions about the most recent needlestick injury inquired whether a high-risk patient was involved, what the perceived causes and circumstances of the injury were, whether the injury was reported to the employee health office, what were the medical student's reasons for not reporting the injury (if applicable), and whether anyone besides the medical student was aware of the needlestick injury. For questions regarding the cause of the needlestick injury, the reporting behavior, and the identity of other persons who were aware of the injury, we asked respondents to select all answers that applied. Because the focus of this report is needlestick injuries during medical school, we included only the answers to the detailed set of questions given by those residents whose most recent needlestick injury occurred during medical school. Finally, we asked all respondents which blood-borne pathogen they feared the most.
We used frequencies, means, medians, and other descriptive statistics to summarize the study population. We used Fisher's exact test to compare proportions of binary variables between respondents with and without needlestick injuries during medical school, and we used univariate and multivariate logistic regression analyses to assess the relationship of needlestick injuries during medical school to needlestick injuries during residency, needlestick injuries involving high-risk patients, and the reporting of the most recent needlestick injury to an employee health service. We considered P < .05 to be statistically significant. We performed all analyses by using SAS software (version 9.1; SAS Institute Inc., Cary, North Carolina).
The overall response rate for completed survey forms was 95% (702 of 741). Outliers excluded from data analysis were one respondent who listed more than 100 needlestick injuries and two respondents who did not report the number of needlestick injuries sustained. Of the 699 respondents, 582 (83%) reported that they sustained a needlestick injury at some point during their surgical training,1 and 415 (59%) reported at least one needlestick injury during medical school. For the 415 respondents who incurred a needlestick injury during medical school, the median total number of needlestick injuries per respondent was 2 (mean: 2.2; interquartile range: 1-2); 295 (71%) of the 415 respondents were male (Table 1).
Surgeons-in-training who incurred a needlestick injury during medical school had 2.6 times the odds of having a needlestick injury during residency as did those who had not sustained such an injury during medical school (Table 1). They also had 2.5 times the odds of having a needlestick injury involving a high-risk patient (a patient with a history of intravenous drug use or infection with HIV, HBV, or HCV) as did those without a needlestick injury during medical school. Of those who ever sustained a needlestick injury, the surgeons-in-training who received a needlestick injury during medical school had 1.5 times the odds of not reporting their most recent needlestick injury to the employee health office as did those who had not received such an injury during medical school.
Of 415 respondents who sustained needlestick injury during medical school, 89 (21%) indicated that they sustained their most recent needlestick injury during medical school (Table 2). Most of these 89 medical school needlestick injuries were self-inflicted (72%), involved a solid-bore needle (78%), occurred in the operating room (67%), or occurred when the respondent felt rushed (57%). More than 10% of the students felt that their most recent needlestick injury during medical school was due to a lack of skill or fatigue or was unpreventable. Of the 89 respondents reporting that their most recent needlestick injury occurred during medical school, 42 (47%) did not report the injury to an employee health service (Table 3). Among the options provided on the survey, the reason most commonly cited (31%) was the amount of time involved in making a report. Whereas just over half of the 89 needlestick injuries were reported to the employee health office, a greater proportion of needlestick injuries involving high-risk patients were reported: 92% (11 of 12) of injuries involving high-risk patients were reported, compared with 47% (36 of 77) of injuries involving low-risk patients. Another person was aware of the needlestick injury in only 40% (17 of 42) of the injuries that were not reported to an employee health service.
In univariate logistic regression analysis, factors that were significantly associated with a failure to report the most recent medical school injury to employee health services were that the patient involved was a low-risk patient and that no other person knew about the injury (Table 4). Low-risk patients were involved in 77 (87%) of the 89 injuries that occurred during medical school and that were reported, for each of the 89 respondents, as being that person's most recent injury. Univariate analyses showed that medical students were more likely not to report their most recent needlestick injury if a low-risk patient was involved (odds ratio [OR]: 12.53; 95% CI: 1.54, 101.84) or if no other person knew of the injury (OR: 21.57; 95% CI: 5.75, 80.89). We found no statistically significant differences in reporting behavior between the sexes, between types of injuries (self-induced or non-self-induced), between the types of needles (solid or hollow), or between the operating room and other locations of the injury; in addition, the type of clinical task performed during injury and what was perceived as the cause of the needlestick injury had no significant effect.
We used a stepwise logistic regression model to determine the association between nonreporting of the most recent medical school needlestick injury to an employee health service, after adjustment for the variables listed in Table 4. The only statistically significant predictor of reporting was the fact that no other person knew about the needlestick injury (OR: 21.57; 95% CI: 5.75, 80.89). Injury involving a low-risk patient was added to the model, but it did not statistically improve the model, and so it was removed.
We report a high incidence among surgery residents of having sustained needlestick injuries during medical school (59%). We closely analyzed data from these respondents to ascertain possible associations with events during residency. Compared with those who had not received a needlestick injury during medical school, respondents who did sustain a needlestick injury during medical school were more likely to have received a needlestick injury during residency, to have received a needlestick injury in circumstances involving a high-risk patient, and not to have reported the most recent needlestick injury to an employee health service. Nearly half of the respondents whose most recent needlestick injury occurred during medical school did not report the injury to employee health services.
Although one cannot ascertain the exact “cause” of the aforementioned associations, a few possibilities can be suggested. First, the personal attributes of the surgeon-in-training, such as inferior manual dexterity and carelessness, could be a risk factor for needlestick injury during surgery residency. Second, the surgery residents in our sample went to various medical schools, each offering its own skills-training program and structure. The skills training at individual medical schools is a key variable, as is discussed in some detail below. Third, psychological attributes of the respondent, such as confidence and efficacy, may correlate with a higher risk of needlestick injury during both medical school and surgery residency.
Our findings suggest that needlestick injuries during medical school may be more prevalent among current surgery residents than has previously been reported for other medical school students.2,3,9–11 Published reports estimate the global incidence of needlestick injuries among medical students as between 12%9 and 50%.3 A seven-year longitudinal study at the University of California, San Francisco, found that 119 (12%) of 1,022 medical students had sustained at least one needlestick injury during their medical training.9 A 2005 study at the University of Toronto reported that 35% of medical students had sustained at least one needlestick injury; this is the highest reported incidence of needlestick injury among medical students in the past 10 years.2 On the basis of our findings, we can state that needlestick injuries during medical school among students who go on to surgery residencies are highly prevalent and likely are underreported.
Our data corroborate previous reports of extensive underreporting of needlestick injuries among medical students. Studies have shown that between 22% and 59% of needlestick injuries to medical students are reported to health offices or hospital personnel.4,11–14 A 1999 study in French medical students noted that 20% of students who had sustained a needlestick injury were advised not to report the injury to their health service.11 We found that if no one but the injured party knew about the injury, the needlestick was less likely to be reported to an employee health service. This lack of reporting may be due to fears about poor clinical evaluations, fear of stigmatization by other medical students, senior residents, and physicians, or embarrassment about the mishap.10 In addition, we found that injuries involving low-risk patients were less likely than injuries involving high-risk patients to be reported to employee health services (OR: 12.53; 95% CI: 1.54, 101.84). However, prompt reporting of all needlestick injuries, not just those involving high-risk patients, is critical to ensuring proper medical prophylaxis, counseling, and legal precautions.8,9 HBV, HCV, and HIV infections have serious implications for long-term health, social and professional relationships, and future employment.6 Reporting of needlestick injuries involving patients with HCV infection is of particular importance to medical students and health care workers alike. Although no effective postexposure prophylaxis is available for HCV, early-stage detection by HCV RNA testing is crucial to preventing chronicity.15 Further education on blood-borne pathogen prevalence and transmission rates is necessary to improve needlestick-reporting rates among medical students.
We found that most medical students selected “feeling rushed” as a possible cause of the needlestick injury. This finding is consistent with the fact that most of the injuries were self-inflicted. Given a medical student's skill sets and authorized duties, these injuries were unlikely to occur during true emergency settings, although 13% of the injuries were judged by the surgeon- in-training not to be preventable. The most commonly cited reason for nonreporting of a needlestick injury was the lack of time, but more than half of the respondents cited “other” as their reason for their nonreporting.
Implications for educators
Implementing mandatory disability insurance for medical students and an increase in the amount of education on needlestick-reporting measures may help protect medical students and decrease the rates of nonreporting.2 It may be premature to cite the classic mantra of “see one, do one, teach one” to medical students, given their inadequate technical skills and heightened anxiety levels, but a system of testing and certification of basic techniques such as phlebotomy, suturing, and passing or recapping needles, implemented before the clinical rotations begin, may ensure training and basic competency and, thereby, reduce injuries from “sharps” and increase skill and confidence.
Medical school programs should emphasize safe operating room techniques and promote the use of new safe-needle technologies, such as syringes with a built-in auto-disabling capability, retractable needle devices, and needleless intravenous delivery systems.16,17 Unfortunately, it is not uncommon for medical students to learn a new skill set directly on a patient. The use of video trainers, human patient simulators, and virtual reality computer-based trainers has been shown to teach and improve surgical skill sets, and, accordingly, those techniques should be incorporated into the training curriculum for medical students.18–20 Specifically, with regard to the occupational risk of blood-borne pathogen transmission, simulators allow for a safe and controlled learning environment for physicians-in-training to master proper “sharps”-handling techniques. Numerous medical schools have already incorporated the use of surgical simulators into the standard clerkship curriculum to prevent students from having to learn new skill sets on real patients.21
Efforts for reducing the incidence of needlestick injury among medical students could include the use of blunt-tip needles and the practice of double-gloving when handling sharp instruments in the operating room, inserting intravenous catheters, or working in emergency situations. Studies indicate that the risk of blood contamination can be reduced to one seventh or one eighth of prior levels by the adoption of double-gloving, without impairment of tactile sensation.22,23 A review of four randomized clinical trials24 found that blunt-tip needles were shown to reduce and even eliminate needlestick injuries. As a result of such findings, the American College of Surgeons issued a consensus statement in 2002 supporting the use of blunt-tip needles to decrease the risk of needlestick injury.25 Although their widespread implementation is gradual, blunt-tip needles are increasingly being adopted for routine closure of the abdominal fascia. In our study, most needlestick injuries occurred when solid-bore needles are used during suturing in the operating room, a finding that strongly supports the use of blunt-tip needles to reduce the rate of needlestick injuries.
A systems approach
A systems approach to safety views each injury as a product of an environment that allows for its repeated occurrence. Strategies aimed at addressing the problem of needlestick injuries should include improving reporting systems and creating a culture of safety. Another study, which used focus groups, found that trainees often feel a strong sense of obligation to their patients and are concerned that their leaving the patient's side to report an injury may jeopardize the continuity of care.26 To address this point, we emphasize that temporary coverage by other providers and the presence of accessible and efficient reporting systems are essential to a culture of safety. At Johns Hopkins Hospital, a “5-STIX” hotline has been instituted for reporting all occupational blood exposures; after such a report is received, a rapid response team is activated to deliver appropriate care, with attention to preserving confidentiality. Improved hospital reporting systems not only promote appropriate care for the injured provider but also enable an institution to better measure the problem in a detailed manner, so as to guide local occupational health strategies.
“Sharpless” surgery is a new protocol that promotes the use of nonsharp alternatives instead of sharp instrumentation when feasible. Using this protocol on a general surgery university service, we found that up to 28% of a general surgeon's practice can be completed without any sharp instruments. Adjustments such as using electrocautery cutting frequencies instead of a knife and applying skin glue rather than using suture closure further minimize the risk of injury in the operating room.6 Because traditional preventive strategies for minimizing needlestick injuries in the operating room have not had a substantial impact, the advantages—and, indeed, the feasibility—of sharpless procedures in specific cases should be evaluated. A procedure assessment has shown that cases commonly involving blood-borne pathogens (e.g., soft-tissue abscess, lymph node biopsies, and laparoscopic procedures) are especially suitable for sharpless surgery. Conversion to sharpless technique in select surgical procedures will ultimately reduce the risk of percutaneous injury to medical students, surgical residents, and operating room personnel.6
While our results show a considerably higher prevalence of needlestick injury in medical school than has been shown by other published data, we recognize a few potential limitations to our study. Our needlestick survey was presented to current surgery residents, a population that is more likely to have handled needles in medical school than are medical students in general. In addition, reporting of needlestick injuries could be subject to recall bias, which would be a notable limitation of this study. Recall bias could be exaggerated among senior surgery residents who graduated from medical school up to five years before the study and who had sustained multiple injuries in the course of their surgery training. Furthermore, the likelihood that medical students actively pursuing a career in surgery would be more proactive in an operating room could have resulted in higher prevalence rates among our sample than would be expected in medical students not choosing a surgery residency. The natural consequence of frequent handling of sharp instruments and of additional elective rotations in surgical subspecialties is a greater risk of needlestick injury. Our survey did not elucidate the specific type of rotation in medical school (e.g., clerkship or subinternship) when these injuries were sustained. Data on outcomes of the needlestick injury, including serologic testing for HIV and hepatitis infection, are also unavailable. Further investigation of needlestick injuries in medical school would benefit from a survey of residents in all specialties.
We conclude that needlestick injuries are common among medical students and often go unreported to employee health services. These findings, coupled with advances in postexposure prophylaxis in preventing infection, call attention to the urgency of addressing this preventable problem. Medical students incur a significant risk of personal injury during their clinical training; medical centers should do more to implement novel prevention strategies and improved reporting systems for medical students.
The study was supported by the Mr. and Mrs. Chad Richison Foundation and the Lotus Global Health Foundation.
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