Current practice in the management of high-risk orthopaedic trauma patients in Scotland

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1 Injury Extra (2005) 36, Current practice in the management of high-risk orthopaedic trauma patients in Scotland S.A. Suttie, S. Robinson, G.P. Ashcroft*, J.D. Hutchison Department of Orthopaedic Surgery, Aberdeen Universit Medical School, Foresterhill, Aberdeen, Scotland AB9 2ZB, UK KEYWORDS Orthopaedics; Universal precautions; Blood-born pathogens; Trauma Summary Surgeons are exposed to bodily fluids on a daily basis with the inherent risk of contracting a blood-borne pathogen. This is especially so in orthopaedic trauma due to prolonged contact with open wounds, manipulation of sharp instruments and bone spikes, frequency of high-risk patients and the possibility of aerosolised virus particles. We aimed to identify what preventative measures orthopaedic trauma theatres in Scotland use to reduce potential transmission of blood-borne pathogens from patients to staff, routinely and in the case of high-risk patients (e.g. hepatitis B + C patients). The 25 orthopaedic trauma units in Scotland were surveyed by telephone questionnaire on their precautions to prevent transmission of blood-born pathogens during exposure prone procedures. All 25 units participated in the study. All units utilised the double gloving technique with one unit using protective under gloves. Only one unit wore enclosure suits on identifying high-risk patients. In only 10 units was eye protection (goggles/visors) mandatory. Simple and effective precautions were taken in all 25 units surveyed to reduce the risk of patient-to-surgeon transmission of blood-borne pathogens. However, facial protection from aerosolised particles was not routine practice in the majority of units. # 2004 Elsevier Ltd. Open access under CC BY-NC-ND license. Introduction Surgical teams are exposed to bodily fluids and tissues on a daily basis, which pose a risk of infection with blood-borne pathogens, mainly viral (hepatitis B + C and HIV). Transmission of these diseases from patients to health care workers and vice versa has been documented. 1,2 The risk of exposure to such bodily fluids and tissues increases in trauma surgery, * Corresponding author. Tel.: address: g.p.ashcroft@abdn.ac.uk (G.P. Ashcroft). especially orthopaedic trauma operations due to prolonged contact with open wounds, manipulation of sharp instruments and tissues, the frequency of and difficulty in identifying high-risk patients, and the presence of relatively large quantities of blood. 6,8,15 Aim To identify what preventative measures orthopaedic trauma theatre staff in Scotland use to reduce potential transmission of blood-born pathogens # 2004 Elsevier Ltd. Open access under CC BY-NC-ND license. doi: /j.injury

2 60 S.A. Suttie et al. from patients to staff, routinely and in the case of high-risk patients (e.g. hepatitis B + C patients). Twenty-six units in Scotland undertake orthopaedic surgery and of these, 25 units perform orthopaedic trauma surgery. We performed a telephone questionnaire of the 25 units performing orthopaedic trauma work. The questionnaire was directed to either the theatre manager or the nurse in charge of orthopaedic theatres. A sample questionnaire is shown in Fig. 1. The study was undertaken between 15/1/04 and 1/4/04. All of the 25 units performing orthopaedic trauma surgery (156 consultant orthopaedic surgeons at 1/2/04) participated in the study (100% recruitment). Methods Results In 12/25 units, the point of contact was the senior nurse in charge of orthopaedic theatres and in the remaining 13/25, this was the theatre manager. All 25 units within the study undertook orthopaedic trauma surgery that involved the use of power instruments (drills and saws). Fourteen units had a theatre allocated solely for orthopaedic trauma with one of these utilising the general on-call theatre out of hours. Eight units used the general orthopaedic theatre for their trauma work, with three of these utilising the general on-call theatre out of hours. Three units used Figure 1 Questionnaire.

3 Current practice in the management of high-risk orthopaedic trauma patients in Scotland 61 Table 1 Results from questionnaire Precautions taken Number of units (n/24) Protocol for exposure prone procedures Standard 25 Extra precautions 14 (Table 2) Face protection Masks 25 Eye protection (goggles/glasses/visors) Mandatory 10 Optional 15 Gowns Single use, disposable, synthetic 24 Reusable armoured 1 Space suit 1 (when high-risk patient) Gloves Double glove technique 25 Protective undergloves (cloth) 1 Footwear Boots/clogs personal choice 19 Boots alone 1 Clogs alone 5 Protective overshoes 1 (when high-risk patient) the general on-call theatre for all orthopaedic trauma. Table 1 displays the results of the questionnaire (excluding theatre utilised). Discussion Exposure to blood and therefore blood-borne pathogens is a daily event for all those working in a surgical theatre, whether scrubbed or not. The theatre environment increases the risk compared to other health care workers due to the handling of sharp instruments and constant exposure to open wounds and bodily fluids. It is therefore essential that theatre staff should be taking the appropriate protective measures to reduce this risk. This is especially so in surgical specialties thought to be at high risk of bodily contamination, such as orthopaedics, trauma, cardiothoracic and gynaecology. 6,8,15 Other variables include amount of irrigation fluid used, duration of procedure, blood loss and working position (i.e. surgeon, first assistant). 15 Previous studies have identified relatively higher rates of HIV and hepatitis C in trauma patients than the general population. 3,5,7 One German study conducted HIV studies on patients with open wounds in the trauma emergency room of a university hospital and found six HIV infections in 220 patients tested, corresponding to a prevalence of 2.7%. 5 Chambers and Lord 3 documented a prevalence of HIV (1.3%) and hepatitis C (5.4%) in penetrating injuries in one hospital in Sydney, Australia. These rates were higher than the general population. This emphasises the risk to healthcare workers treating these patients, and should highlight the necessity of practising universal precautions against body fluid exposure when managing trauma victims. One of the most important methods for reducing risk is the establishment of protocols for managing exposure-prone procedures and the spillages and contaminations that can occur with these. In this study, all 25 units had a protocol (universal protocol for all departments in that hospital), whilst some took further precautions on identifying a high-risk patient (Table 2). Studies have shown that certain areas of the body are more exposed to contamination than others; Table 2 Extra precautions taken when notified of high-risk patient Precautions taken Patient on end of theatre list Minimal staff in theatre Single use anaesthetic equipment Single use saws and drills Disposable drapes Empty surplus equipment from theatre Wear overshoes Plastic aprons under gowns

4 62 S.A. Suttie et al. those at greatest risk include the fingers, face, neck and lower limbs. 6,8,15 However, these sites vary according to surgical specialty. Jagger et al. 8 found the face (especially eyes) was the most likely area to be affected by exposure to blood followed by hands, irrespective of the type of surgery carried out. Quebbeman et al. 15 found that orthopaedic surgeons were at an increased risk of facial contamination, due to spray from the use of power tools and irrigation fluids. Our study revealed that in all 25 units, all theatre staff was required to wear face masks. Further facial protection was made available to scrubbed staff in the form of glasses, goggles or visors but was not mandatory attire in 15 units. Jagger et al. 8 found that 74% of their study population were not wearing eye protection and even in those that did the eye protection was sometimes inadequate. The same authors advocated the use of protective eye wear for all personnel in theatre due to the fact that circulating nurses had nearly the same number of eye exposures as scrubbed staff. 8 Eye and facial protection is especially important in the orthopaedic setting due to the theoretical risk of aerosolised transmission of HIV/hepatitis C due to aerosolised particles from power saws and drills 4 and studies have revealed that HIV particles can survive after being aerosolised by power tools. 9,10 The standard face mask and visor worn by theatre staff in this study is not protective against such aerosolised particles and therefore, it is essential that all personnel in orthopaedic theatres, most of all those who are scrubbed, should be aware of this risk. One solution is for those affected to wear a hood/space suit in the presence of a high-risk patient. Quebbeman et al. 15 demonstrated that in orthopaedic surgical practice the face, neck and lower limbs were the most at risk of exposure to blood rather than the fingers and hands. They attributed this to the orthopaedic surgical team wearing double gloves. In all 25 units in this study, all personnel scrubbed in theatre wore double gloves and one unit wore protective cloth under gloves. Double gloving seems to be standard practice for orthopaedic surgeons in the western world. 14,15 The risk of transmission of hepatitis B + C following a hollow needle injury is approximately 30 and 1.8%, respectively, while the risk of acquiring HIV is 0.3%. 19,20 The technique of double gloving has been shown to reduce the risk of contamination of the surgeon s hands in multiple studies (either due to tears or perforations). 6,18 Based on this, Nystrom and Wittmann 13 have calculated the risk of a surgeon operating on HIV patients actually contracting HIV from hollow needles whilst double gloved; from their calculations a surgeon can expect to acquire HIV infection at rate of 1 in every 800 hollow needle stick injuries. Lemaire et al. 11 argue that the annual rate of a surgeon, irrespective of discipline, in Europe contracting HIV from occupational exposure is between and 3%. This is an optimistic picture. However, the risk of needle stick injury can be greatly reduced with the aid of cut-resistant inner gloves. Sutton et al. 17 on testing an inner protective glove (paraderm made of knitted fibres of extended chain polyethylene) found it to significantly reduce the number of inner glove perforations. This was confirmed by the findings of Salkin et al. 16 on analysing cut-resistant inner liners. They discovered that 100% more force was required to penetrate these inner liners with a scalpel and that 50% more force was required to penetrate these with a needle compared to double gloving with no protective liner. Waterproof synthetic (non-woven) gowns were worn by the majority of scrubbed staff in this study. One unit consistently used armoured, reusable gowns. Although the make of gown was not surveyed in this study, single-use non-woven gowns have been shown to be more effective in limiting liquid strikethrough and bacterial transmission than non-synthetic gowns. 12 With regards to footwear, 19 units used either clogs or Wellington boots, but this was a personal choice. One unit used autoclavable clogs with each new wearer required to insert a clean insole prior to use. Although this may reduce transmission of infection between wearers, it does not in itself offer any further protection from spillage of blood. Quebbeman et al. 15 have shown that orthopaedic surgeons had high rates of contamination of their legs and feet which could be prevented by wearing Wellington boots and longer impermeable gowns. Conclusion Orthopaedic trauma admissions inevitably contain a disproportionate number of individuals with hepatitis B, C and HIV. All the surveyed units in Scotland were using simple and effective measures to reduce the risk to theatre staff during orthopaedic cases. There were however areas of deficiency which need to be addressed, namely lack of eye protection. In addition, further thought should also be given to footwear made available for orthopaedic surgeons, such as Wellington boots, which would greatly reduce contamination of the feet with blood. It must be recognised however that the standard precautions appropriate to general surgery require alteration when applied to orthopaedic surgery. The dangers inherent from additional sharp instruments

5 Current practice in the management of high-risk orthopaedic trauma patients in Scotland 63 and bone spikes indicate the need for armoured gloves in high-risk cases. Consideration also needs to be given to the regular use of enclosure suits in view of the additional risk posed by aerosols from powered tools for which standard eye protection and masks give only limited protection. There is also a need for an observational study of these orthopaedic units to audit their compliance with protocols (e.g. wearing of eye protection) and to assess other preventative measures (notouch technique, use of blunt needles) commonly in use. References 1. Bell DM. Human immunodeficiency virus transmission in health care settings: risk and reduction. Am J Med 1991;91 (Suppl 3B): Centers for Disease Control and Prevention, CDC HIV/AIDS Surveillance Report Atlanta; p Chambers AJ, Lord RSA. Documented prevalence of HIV and hepatitis C infection in patients with penetrating trauma. ANZ J Surg 2001;71(1): Chou L, Reynolds MR, Esterhai JL. Hazards to the orthopaedic trauma surgeon: occupational exposure to HIV and viral hepatitis A. J Orthop Trauma 1996;10(4): Froschle G, Uner AB, Wening JV. Prevalence of human immunodeficiency virus in the trauma emergency room. Arch Orthop Trauma Surg 1996;115: Geberding JL, Littell C, Tarkington A, et al. Risk of exposure of surgical personnel to patients blood during surgery at San Francisco General Hospital. N Engl J Med 1990;322(25): Henein MN, Lloyd L. HIV, hepatitis B and hepatitis C in the code one trauma population. Am J Surg 1997;63: Jagger J, Bentley M, Tereskerz P. A study of patterns and prevention of blood exposure in OR personnel. AORN J 1998; 67(5): Johnson GK, Robinson WS. Human immunodeficiency virus (HIV-1) in the vapours of surgical power instruments. J Med Virol 1991;33(1): Joint Working Party of the Hospital Infection Society and the Surgical Infection Study Group: risks to surgeons and patients from HIV and hepatitis: guidelines on precautions and management of exposure to blood or body fluids. BMJ 1992;305: Lemaire R, Masson J. Risk of transmission of blood-borne viral infection in orthopaedic and trauma surgery. J Bone Joint Surg Br 2000;82(3): Leonas KK, Jinkins RS. The relationship of selected fabric characteristics and the barrier effectiveness of surgical gown fabrics. Am J Infect Control 1997;25(1): Nystrom PO, Wittmann D. Patient to surgeon infections fact or fiction. Br J Surg 2003;90(11): Patterson J, Megan M, Novak CB, et al. Surgeons concern and practices of protection against blood-borne pathogens. Ann Surg 1998;228(2): Quebbeman EJ, Telford GL, Hubbard S, et al. Risk of blood contamination and injury to operating room personnel. Ann Surg 1991;214(5): Salkin JA, Stuchin SA, Kummer FJ, Reininger R. The effectiveness of cut-proof glove liners: cut and puncture resistance, dexterity, and sensibility. Orthopedics 1995;18(11): Sutton PM, Greene T, Howell FR. The protective effect of a cut-resistant glove liner: a prospective, randomised trial. J Bone Joint Surg Br 1998;80(3): Thanni LO, Yinusa W. Incidence of glove failure during orthopaedic operations and protective effect of double gloves. J Natl Med Assoc 2003;95(12): Wall SD, Howe JM, Sawhney R. Human immunodeficiency virus infection and hepatitis: biosafety in radiology. Radiology 1997;205: Wittmann MM, Wittmann A, Wittmann DH. AIDS, emergency operations, and infection control. Infect Control Hosp Epidemiol 1996;17:532 8.