Kobets, Andrew J. MD; Perlotto, James MD; Angoff, Nancy R. MD, MPH, MEd
Although medical students are eager both to learn and participate in invasive procedures in the hospital setting, their inexperience makes them particularly vulnerable to occupational exposures to blood-borne pathogens. Relatively few studies have investigated this trend in medical students, and fewer have identified ways both to provide students with assistance at the time of exposure and to encourage them to report the incident and obtain the appropriate care. A 1999 study at the University of California, San Francisco, School of Medicine indicated that, out of the 1,022 students monitored during a seven-year period, only 119 (11.6%) reported any type of exposure. Yet, the authors concluded that the number of reported incidents of exposure was less than the actual number, likely because students were discouraged from leaving the operating room, were embarrassed by the incident, and could not conveniently obtain care.1 Most concerning, though, was that several students noted that fatigue played a role in the exposure, whereas others reported that another’s actions did so.
The authors of a study from the Johns Hopkins University School of Medicine published in 2009 surveyed surgery residents in 17 U.S. programs about their previous experiences as medical students and asked specifically about needlestick injuries. Of the 699 respondents, 582 (83%) reported a needlestick during their surgical training, and 415 (59%) during medical school. Eighty-nine of these physicians sustained their most recent injury during medical school, 42 (47%) of whom did not report the injury to a health office, stating, among other reasons, that it “took too much time,” that they did not want to experience the “stigma of having had a needlestick,” or even that they “did not want to know the results.”2
An analysis of first-year residents’ knowledge of infection control found that 26% of residents reported not having been formally instructed in proper postexposure management during medical school.3 The authors also found that only 58% of the cohort of residents who experienced an occupational exposure reported it. Another study reported that only 17% of exposed third-year medical students officially reported the incident, 70% of whom subsequently accepted postexposure prophylaxis.4 At the University of Illinois Medical Center, researchers surveyed medical students, residents, and other health care workers about postexposure reporting. Twenty-five percent of surgical residents, 47% of internal medicine residents, and 86% of clinical medical students did not report their exposures.5
These results are not limited to the United States. A study conducted in Israel documented a 50% exposure rate, citing 91 needlesticks in 43 of the 86 surveyed medical students.6 Of the 198 medical students who responded to a Peruvian survey, 47% had been exposed in only the first nine months of 2002.7 Almost 30% of these exposures were deemed “high risk,” and none of the incidents were properly examined. A researcher found 19 exposures in a 15-week period at one South African hospital, half of which occurred while students were on call or in the hospital after hours.8
In our review of the literature, we also found no paucity of analyses documenting similar phenomena among other health care workers. In one French study, incidents occurred at least 3.5 times per 100 health care workers per year; in a Congolese study, incidents occurred in nearly 100% of doctors practicing in rural Congolese hospitals.9,10 These studies strongly recommended that, to address both the high rates of needlestick injuries and the underreporting of such injuries common among medical students and other health care workers, health care leaders must improve reporting systems and create a culture of support and education for all.
Yale University School of Medicine Postexposure Management Initiative
Eleven years ago, one of us (N.R.A.) informally interviewed students who had experienced occupational exposures and learned that they tended to be in denial about such incidents, felt uncertain about what to do, and were reluctant to initiate formal reports.11 For example, one student stated after an exposure that “I didn’t know if I should speak to anyone. I decided then not to do anything. I was a little shell shocked.” These students’ accounts led to the development of a program in 2001 to prevent and manage occupational injuries and exposures in medical students at Yale University School of Medicine.
During orientation, all first-year medical students attend a presentation by one of us (J.P.) on what to do in case of a blood or body fluid exposure. Each student is also given a laminated card to carry with his or her school ID that reiterates these instructions and includes essential phone numbers, such as those for Yale Occupational Health, the Yale emergency department, and a personal phone number for one of us (N.R.A.). Then, in June, before the start of clinical clerkships, the rising third-year students again meet with two of us (J.P., N.R.A.); in small groups of eight or nine students, they sit in a circle to ensure that each student is awake, alert, and attending to the 30-minute discussion. These discussions are meant to empower the students to seek care no matter what the situation is and to reinforce that the expectation of the medical school is that the students leave the procedure to enact the exposure protocol. Topics for these discussions include the circumstances under which most exposures occur, an examination of the types of equipment that students may use to draw blood and start IVs, and explicit instructions about what students should do in case of an exposure, such as washing the exposure site, obtaining testing of the source patient, and seeking immediate counseling regarding the potential use of postexposure prophylaxis. See List 1 for a complete list of the topics covered during these sessions.
To prevent cost from playing a role in students seeking care, the medical school and Yale Health have collaborated to provide the necessary postexposure medications free of charge. Still, because we anticipated that hearing about the experiences of a peer would increase students’ reporting rates and provide a more personal experience for the discussion overall, we asked a student with a serious past exposure to relate his experience to his fellow students in the 2011 session. We also told students that they have the absolute support of the administration to step away from a procedure, after making sure that the patient is safe, should they be exposed. In addition, one of us (J.P.), as the chief of student medicine at Yale Health, has developed a plan for follow-up testing and counseling for students.
Once again, these instructions are given to students on a laminated plastic card along with our phone numbers (J.P., N.R.A.) and those for Yale Health, Yale Occupational Health, the Yale emergency department, etc. The students are encouraged to carry this card at all times with their school ID and to call one of us (J.P. or N.R.A.) at any time in case of an exposure. Finally, we have a policy that students may not perform any invasive procedures on patients known to be positive for HIV or hepatitis C during the first six months of their clinical rotations.
In April of their graduation year, we surveyed the classes of 2010 (110 students) and 2011 (135 students) about their occupational exposures and reporting in an anonymous online survey. We developed the survey questions in 2010 to analyze student exposures and reporting behaviors based on N.R.A.’s findings during her informal interviews with students,11 as well as our literature review on the topic. We then e-mailed the survey as an attachment to a letter written by the dean of students encouraging strong participation from the class. See Appendix 1 for this letter and our survey. Students were given two weeks to respond.
Survey of Graduating...Image Tools
The survey included 29 questions, the majority of which required a yes or no response. If a responder answered yes to a question asking about a specific experience, he or she would then be directed to an additional set of free-text response questions, to allow for a more detailed description of the student’s experience. We also asked respondents for their year of graduation and gender, as well as about how to improve our postexposure reporting and management systems.
We collected deidentified survey responses, aggregated them in a database, and performed quantitative analyses on the yes/no questions and qualitative analyses on the free-text responses to identify core concepts. While we analyzed the data for both classes together, we also recorded the individual class data to determine the effect of the student describing his exposure experience for the majority of the 2011 class. The Yale Human Investigation Committee reviewed our survey and found it to be exempt from institutional board review.
See Table 1 for a summary of our results, both in aggregate and separated by graduation year. One hundred six of 110 eligible students in 2010 and 119 of 135 in 2011 returned our survey, for a combined response rate of 92%. Of the 225 survey respondents, 211 (94%) recalled the discussions and 215 (96%) rated them as either “good” or “great.” Forty-one of 106 (39%) students in the class of 2010 and 41 of 119 (35%) in the class of 2011 experienced an exposure of any type; males and females experienced an equal number of exposures in both classes. Of those students, 10 of 41 (24%) in 2010 and 7 of 41 (17%) in 2011 experienced multiple exposures. Of those students who experienced an exposure, 22 of 41 (54%) in 2010 and 25 of 41 (61%) in 2011 reported either an individual or multiple incidents, demonstrating a combined reporting rate of 57% for all sharp and nonsharp exposures. Although 35 of 82 (43%) students did not report their exposure, 12 of those 35 (34%) experienced a low-risk exposure of a nonsharp nature. Twice as many students from the class of 2011 started postexposure prophylaxis compared with the class of 2010, doubling from 5 of 41 (12%) exposed students to 10 of 41 (24%).
Importantly, 63 of the 82 (77%) students who experienced at least one exposure indicated that their exposure occurred in the operating room, and 20 (24%) indicated that it occurred as the result of another’s actions. Twenty-one (26%) also stated that overcrowding was a factor. Suture needle exposures accounted for 19 of the 55 (35%) incidents in 2010 and 27 of the 48 (56%) incidents in 2011. Overall, 45% (46/103) of all exposures were the result of mishandled suture needles in the operating room.
Fifty-two of the 82 (56%) students who experienced an exposure had the laminated card on them at the time of the incident. When asked if they knew what to do immediately after their exposure, 54 of 82 (66%) students said yes. In 2010, 17 of 41 (41%) students who experienced exposures did not know what to do, but in 2011, after the introduction of the student describing his exposure experience to the class, that number fell to 11 of 41 (27%).
In their free-text responses, students described their experiences in vivid detail. One student reported:
[N.R.A. and J.P.] made a very positive experience out of what could have been a very demoralizing one. My exposure came early in my medical training, at a time when I did not want to “rock the boat.” Had I not already known [N.R.A. and J.P.] to be supportive of students in general and very serious about this issue, I would not have taken any action…. I had no problem saying it’s school policy to follow up on this event.
Another student relayed:
I could not help but think of all the potential consequences. It is cliché, but one doesn’t think this is likely to happen to them until it does. I was angry that I had been stuck largely due to the actions of another person and that it had been largely minimized by that person. I did feel the resident and nurse were quite supportive and I felt as though I should follow through with the recommended procedure. In fact, in retrospect, having followed the procedures was invaluable to my peace of mind—invaluable.
From most to least common, students cited the following reasons for not reporting their exposures: intact skin; minimal, if any, mucous membrane exposure; knowledge of the source patient’s seronegativity for HIV and hepatitis C; hassle with reporting; and feeling embarrassment or guilt for doing so. Students stated that if they had been encouraged by the resident or attending physician to report the incident, they would have done so; instead, some felt that they were discouraged from doing so.
Suggestions for improving the exposure reporting system included “it would be great to have your comprehensive [postexposure prophylaxis] guide (the one you pass out at orientation) easily accessible from a computer. I would consider an email to the students that is quick and easy to locate immediately after an exposure”; “continue to educate faculty and house staff about the expectations of the administration regarding exposures”; and “even though I did not have to pay for the testing, [I] was worried that I would, because I did not go to the health plan.”
Students remembered and highly rated our discussions. Over 50% of them had the laminated card outlining the necessary steps to take after an exposure on their person at the time of the incident. Most students were confident about what they needed to do and took the necessary steps to get counseling and/or treatment.
Our data showed fewer students experienced occupational exposures overall (36%) as compared with other studies (59% and 50%).2,6 We believe that the strong encouragement by the associate dean for student affairs for students to speak up and seek care likely impacted the number of students who reported an incident. Possibly, hearing a classmate speak about his or her personal experience with an exposure convinced more students to report their exposures and seek care in 2011 than 2010, but we cannot prove a clear causal relationship. Overall, 57% of students reported their exposures, and 33% of all incidents were of a nonsharp nature. Of the 43% of students who did not report an exposure, it is possible that some experienced low-risk, nonsharp exposures.
Limitations of our study include the lack of randomization regarding our survey analysis as well as the absence of a control group who did not participate in our postexposure management sessions. In addition, although we divided our students into two groups based on graduation year, these groups were in fact heterogeneous and included a few members from other classes who had pursued combined degree programs or had taken time to complete research fellowships. Additionally, recall bias may have caused some students not to document exposures about which they may have forgotten, and even though the survey was anonymous, some students may still have been apprehensive about describing their exposure or unwilling to take the time to describe it for us. Finally, although we would like to draw inferences from our interventions to increased reporting rates, we cannot state with certainty that our interventions made a definitive impact on the number of students who sought care after their exposure. Although some of these interventions make intuitive sense and are qualitatively reported by students to have had an impact, there may be other barriers to reporting an exposure that we have yet to identify and understand.
In our study, the majority of incidents occurred in the operating room, and suture needlesticks accounted for the greatest number of exposures. A quarter of students cited overcrowding, and a quarter cited “another’s actions” as the reason for their exposure. Despite these reasons, students also noted that a barrier to their reporting the incident was the discouragement that they perceived from other members of the team. Although our data represent only student testimonials and not necessarily the exact accounts of the incidents that occurred, we find it unfortunate that students perceived this atmosphere. We hope that interventions, such as ours to empower students, will reduce this mentality. We are currently working with the surgery clerkship director to address these issues specific to the operating room environment. Ultimately, however, we are reassured to learn that the most common reasons for not reporting an exposure include previous knowledge of the patient’s seronegativity and the student’s judgment that contact occurring with unbroken skin represented minimal risk.
We learned a great deal about our students’ experiences with exposures from this study, including that a small population is still unwilling to report an incident because they perceive an environment that propagates feelings of embarrassment or guilt in spite of empowerment initiatives by the administration. In addition, access to the appropriate care still must be streamlined to make it easier for students to follow up after their exposures so that difficulty in identifying treatment plans is never a reason for a student not to report an incident. The protocol for postexposure management is now available online, making this information readily accessible even if students are not carrying the laminated card on their person at the time of exposure.12 In addition, we are considering sending e-mail reminders to access the protocol in the event of an incident to increase students’ adherence to the policy. Most important, we are focusing further preventive strategies and interventions on students’ experiences in their surgical rotations, including educating surgical residents and faculty in addition to medical students. For example, we may institute a quarterly session on postexposure management at the start of each surgical rotation and a yearly surgical grand rounds on the topic. Finally, a focused session like ours, given at a key point during students’ training when they are statistically more likely to experience an exposure, is a targeted intervention that other medical schools can institute to empower students to reverse the mentality that reporting an exposure and seeking care is discouraged.
We must continue to educate faculty and residents new to our institution each year about our student empowerment policy because physicians must work closely with students to encourage the proper management of occupational exposures. Medical students, with their limited experience, are particularly susceptible to occupational exposures, especially in a crowded operating room. Physicians thus must play a role in creating a safer environment, including the introduction of a universally acceptable word that physicians and students could use to indicate that sharps are close to others’ hands in the operating room, in much the same way that golfers shout “fore” to warn of an incoming golf ball on the course.
Clinicians, both physicians and medical students, must care for their own well-being to best care for their patients. In today’s multiprofessional environment, members of the health care team are responsible for the health and safety of each other and for reducing the perception among students that seeking care after an exposure is a sign of weakness or cause for embarrassment. By doing so, we are both protecting our students from undue harm and promoting an environment to the next generation of physicians, who will see reporting and seeking care as the necessary next steps after an exposure.
Acknowledgments: The authors thank Shana Criscione and Linda Halle-Smith for their efforts in facilitating this project and Annie Engberg for composing the online PowerPoint presentation outlining proper postexposure management steps.
Other disclosures: None.
Ethical approval: The Yale Human Investigation Committee reviewed this study and found it to be exempt under 45 CFR 46.101 (b)(1).
Previous presentations: The findings of this study were presented at the Society for General Internal Medicine regional meeting, Boston, Massachusetts, March 2011.