Jen L. is an RN working a 12-hour shift three nights a week in a busy labor and delivery unit of a major metropolitan hospital. She relates that in her practice she starts peripheral I.V.s on anywhere from 2 to 10 patients each night. “Actually, I'm pretty good at sticking patients,” Jen says. “So I'm often called upon to help my coworkers if they have a problem with an I.V. start.” When asked if blood exposure is a concern, Jen's answer is immediate and strongly stated. “Of course it is! With every I.V. start, I'm at risk for blood exposure. Yes, I wear gloves and follow all my hospital's policies. But the truth is, every time I place a needle into a patient's vein and remove the stylet, I'm at risk of being exposed to blood. I've had several occasions where blood that leaked onto the protective pad beneath the patient's arm later ended up on my arm as I cleaned up. A few times blood has also splashed out of the I.V. during stylet removal. I'm always careful, but with all my care, blood exposure seems almost inevitable.”
Short peripheral intravenous catheters (SPIVCs) are the most frequently utilized vascular access devices. Over 300 million are used every year in the United States.1,2 The insertion of an SPIVC predisposes the nurse to certain occupational hazards, such as a needlestick injury and exposure to blood. According to the CDC, approximately 384,325 healthcare professionals in the United States are exposed to blood and other bodily fluids due to needlestick and mucocutaneous exposures every year.3 The Needlestick Safety and Prevention Act, signed into law in November 2000, made a difference in providing needlestick protection for healthcare workers.4 Today the vast majority of U.S. hospitals have converted to safety catheters.
Needlestick prevention is just one part of the story in healthcare worker protection. There's also the potential daily risk of mucocutaneous (hands, eyes, face, and skin) blood exposure due to leakage or splash when starting an SPIVC. Anytime there's blood leakage, the nurse is at risk for exposure to various bloodborne pathogen infections including, but not limited to, HIV, hepatitis B (HBV), and hepatitis C (HCV).5–7 HCV is the most common chronic bloodborne pathogen infection, followed by HBV.8 Frequently, the nurse is unaware of any organisms or pathogens a patient may harbor. Patients may themselves be uninformed of any infection, or they chose not to disclose diseases to the healthcare team. Each time an SPIVC is placed, the nurse is at risk. Therefore, all blood and bodily fluids should be considered potentially infected with some type of bloodborne pathogen.9
Who's at risk?
The percentage of healthcare workers who experienced a sharps exposure is almost equal to those who experienced a mucocutaneous exposure (22.6% versus 23.1%).10 According to published surveys, up to 35.9% of healthcare workers report having experienced at least one blood or body fluid exposure in the previous year.11 Unfortunately, a much higher percentage of mucocutaneous exposures go unreported, when compared with sharps exposures (82.9% versus 33%).10 Personnel in clinical areas such as the OR, pediatrics, medical units, labs, and the ED have a higher rate of blood and body fluid exposure.7 Nurses are at the greatest risk based on a reported total exposure rate of 48.6%.12 This risk increases when an SPIVC placement is required on an uncooperative, noncompliant, or combative patient.13
The inserting nurse may be the primary person exposed to the blood leakage, spill, or splash from an SPIVC insertion, but others, such as personnel in housekeeping, laundry, biohazard waste disposal, and, potentially, even visiting family members, can be secondarily exposed. Healthcare workers have a responsibility to implement safe work practices, and utilize standard precautions and personal protective equipment (PPE) in an effort to protect themselves, colleagues, patients, and others who could be inadvertently exposed to blood. Using the appropriate PPE and taking proper precautions is critical in limiting blood exposure risk and providing a level of protection. These precautions should be implemented before, during, and after the SPIVC procedure. However, PPE is only beneficial if it's taken out of the box and used as directed.
An SPIVC procedure places the nurse at risk for blood exposure during the insertion component of the procedure and during the handling and disposal of the contaminated materials following completion of the process. The insertion of an SPIVC requires access to a vein, thus blood exposure risk is inherent within this procedure. The actual cannulation of the vein may allow blood to leak out of the insertion site, and when the stylet is removed blood can flow out of the open end of a traditional catheter. Any blood that leaks, splashes, or spills during an SPIVC insertion can end up on the bed, floor, shoes, clothing, unprotected skin, or gloves. Once this initial contamination occurs, the nurse can cross-contaminate other items in or outside the patient's room such as the bed rail, infusion pump, linen hamper, doorknobs, items in the nurses' station, and the like. Many times, the gloves used to start the SPIVC have blood drops on them that are difficult to spot; the nurse then touches other items and contaminates surfaces, potentially exposing others to the patient's blood.
For the purpose of this study, SPIVC devices were defined as follows:
—Traditional SPIVC: A traditional SPIVC is defined as a current stand alone open-ended catheter. Blood could leak out of the catheter hub if vein occlusion isn't properly applied during the insertion process.
—Blood-contained SPIVC: A blood-contained SPIVC is defined as a catheter system with a preassembled extension set and clamps that prevent blood from leaking during the insertion process and subsequent access. Blood-contained SPIVCs don't require clinicians to occlude the vessel during the insertion process.
The study reports findings from a random group of nurses, purchasing agents, and material(s) managers. The purpose of the study was to (1) determine attitudes toward and experiences concerning blood exposure, (2) assess the potential cleanup cost when blood leakage occurs from the catheter hub during insertion of an SPIVC, and (3) compare frequency of blood leakage and costs among hospitals that use blood-contained versus traditional SPIVCs.
Study design and sample
Telephone interviews were conducted with a total of 104 nurses and nurse managers nationwide from 30 hospitals of various types and sizes who place SPIVCs. Nurses were selected from the following hospital areas: the ED, preoperative unit, same-day surgery, labor and delivery unit, medical-surgical units, and the ICU. Nurses were categorized into groups based on the type of SPIVC (blood-contained versus traditional) primarily used in their department. The sample size was evenly divided between these two groups.
An online survey was conducted with a total of 28 purchasing agents and material(s) managers in hospitals throughout the country. To qualify to participate in the study, purchasing agents were required to know the current price they pay for supplies used during insertion of SPIVCs and cleanup.
Nine in 10 nurses reported that absence of blood leakage during SPIVC insertion is important. Most nurses reported blood exposure as being a concern for their own safety, as well as for patients' safety. Approximately half the respondents cited additional reasons for concern, including patient comfort, the mess that results, and the time it takes to clean up blood leakage due to the insertion of an SPIVC.
The study shows the average number of SPIVC placements by nurses hospital-wide in a typical week was 17.5. Nurses in the ED and preoperative/same-day surgery units are likely to place more (33 and 29 on an average week, respectively).
The most commonly used materials during insertion of an SPIVC include:
1. gloves (89%)
2. alcohol wipes (60%)
3. gauze (59%)
4. tourniquets (38%)
5. dressings (34%)
6. tape (33%)
7. I.V. start kit (32%)
8. antiseptic wipes (31%)
9. absorbent drapes, towels, and sheets (38%).
Almost 11% of the nurses surveyed didn't mention wearing gloves. Other research uncovered that only two-thirds of healthcare workers reported wearing gloves routinely during an invasive procedure.11
Over half of the respondents (52%) stated that while placing an SPIVC they used absorbent drapes, gauze, towels, or sheets for safety reasons—identified as infection prevention, sanitation, or disinfection purposes. These materials don't prevent or stop the risk of blood exposure.
Blood leakage: Comparative analysis
Respondents were asked how often they experience blood leakage from the catheter hub during insertion of the SPIVC. Nurses from the traditional group were compared with nurses from the blood-contained group.
—Traditional group: 49% of the respondents who used only traditional SPIVCs stated they experienced blood leakage up to 50% of the time; 20% stated they experienced blood leakage 100% of the time; 10% stated they never experienced blood leakage.
—Blood-contained group: The blood-contained group reported experiencing blood leakage only 11% of the time, on average, which significantly reduces their blood exposure risk. Approximately 89% of the time nurses who used blood-contained SPIVCs experienced no blood exposure.
Survey findings show that the average cost per cleanup (when there's blood leakage from the catheter hub) is $0.30 for the gauze, absorbent drapes, towels, and sheets used per event.
Clinicians were asked how many of each material they used per cleanup. Purchasing agents were asked how much they pay for sanitary items and the cost of laundering linens. Results showed the average number of materials used per cleanup as:
* absorbent drapes–0.16
Cost was calculated based on the average price for each item per the purchasing agents, then multiplied by the average number of items used per event.
The average cost of $0.30 per blood leakage cleanup may not seem expensive but is significant. For example, say that an institution has approximately 4,000 SPIVC insertions each month. Now, calculate the overall cleanup costs: 4,000 ($0.30) = $1,200 each month, or $14,400 each year. This calculation assumes nurses have prepared the necessary material before insertion, in case there's a leakage, and the material, once set out in the patient's room, can't be used elsewhere. $14,400 is just for cleanup costs related to SPIVC insertion in one institution.
In addition, approximately 28% of nurses reported blood leaking onto the patient's bed, requiring a change in linens 23% of the time. It isn't possible to include the cost of changing bed linens into the cleanup cost. This is because nurses reported the percent of the time they changed sheets based on the number of leakages they experienced overall, not per incident. This type of blood leakage episode incurs an additional cost of lost nursing time (an average of 4 minutes) and cost of laundering the linens.
All nurses were asked whether they reported instances of blood contact with their unprotected skin during SPIVC insertion. Half of the nurses who had blood leak onto their scrubs stated that they changed immediately; the other half attempted to clean up the blood from their scrubs.
The underreporting of blood exposure has been discussed and highlighted in medical literature.5–7,11,14,15 In a survey of German hospitals on reporting blood exposures, the underreporting rate was 45%.6 In the United States, researchers found this rate to be 82%.10 Clinicians gave many reasons for not reporting exposure, including time required, confidentiality issues, not understanding the importance of reporting, and concern about negative repercussions.14 Some clinicians have been instructed to report only “significant” exposures, and others mentioned that it's only necessary to report the exposure if the source patient is known to have an HBV, HCV, or HIV infection.14,5 Nurses tend to minimize the risk of blood exposure, considering it to be part of the job. Although it's part of the job, exposure should be limited by implementing safe practices, technology, and standard precaution measures. Mucocutaneous exposures subject the nurse to the risk of an occupational infection or the adverse effects from prophylactic treatment. Reporting blood exposure provides better understanding of the circumstances and factors surrounding the event, an opportunity to look at compliance issues, and the ability to lead prevention improve ments and identify educational trends and strategies.
Based on study results, it's clear that nurses and other healthcare workers are concerned with the risks associated with blood leakage. Regardless of the level of experience a nurse may have with inserting SPIVCs, inadvertent exposure is a reality that can't be ignored. The type of SPIVC used can play a role in reducing the risk of exposure, along with cutting hospital expenses, which is critical in today's cost-conscious healthcare environment.
Results of this study suggest that nurses who use blood-contained SPIVCs are less likely to experience blood exposures, if they experience any at all. They're also likely to decrease utilization of materials such as gauze, absorbent drapes, towels, and sheets during insertion.
The type of SPIVC used can reduce or prevent blood leakage. At the time of this study, blood control SPIVC—defined as a traditional SPIVC with an internal mechanism designed to control blood leakage from the catheter hub during insertion—weren't available in the United States. Blood control and blood contained SPIVCs don't require clinicians to occlude the vessel during insertion; ultimately, they reduce cleanup costs, nursing time, and any additional costs should an exposure occur. Each clinician is responsible to implement all appropriate protective measures while performing an SPIVC insertion. According to the Infusion Nurses Society Standards of Practice, primary prevention measures, such as PPE, engineering controls, and standard precautions can improve safety, decrease exposure, and decrease the potential for transmission of a bloodborne pathogens.16 Each institution should have policies and procedures developed on the safe handling and disposal of hazardous materials and waste.16 In addition, educational programs must also be available to provide employees with the training to appropriately implement safety practices and procedures.
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