The Effectiveness of Intervention to Reduce Blood-Borne Pathogen Exposure Incidents in Healthcare Workers in the Largest Clinical Setting in Slovenia

Healthcare workers (HCWs) are at high risk of developing infections caused by blood-borne pathogens, due to injuries with sharp medical devices (sharps), and skin and mucous membrane contacts with blood or other potentially infectious materials (1–6). Accidental occupational exposure to blood-borne pathogens, particularly to blood-borne viruses such as hepatitis B, hepatitis C and HIV, can affect an HCW’s health and lead to debilitating or even fatal consequences (1, 2, 4). Additionally, the HCWs may experience significant emotional distress, fear and anxiety that may sometimes result in behavioural and occupational changes (3, 5, 7, 8). The infection is not only health damaging, but could also destroy the HCW’s career and impact the hospital costs (3, 8).

Therefore, early reporting of blood-borne pathogen exposure incidents (BBIs) is crucial for immediate medical evaluation and follow-up. The beginning of immediate intervention is very important to address possible infection of the HCW and it can also help to avoid spreading blood-borne infection to others (9). Unfortunately, numerous studies show that underreporting of BBIs is considerable (10–12).

BBIs may occur in various health occupations (6, 7) as many medical procedures require the use of sharps that may penetrate the skin and cause an injury (1, 2, 6, 13). The responsible services at the University Medical Centre Ljubljana (UMCL), the largest medical centre in Slovenia, have recognized the problem and already faced it - since 1998, HCWs have been monitored and treated for incidents. However, the period 2016-2017 represents a major milestone, when intensified organised intervention - health promotion and administrative measures for reducing BBIs - was introduced.

Aimed at evaluating the effectiveness of this intervention, the objective was to analyse the incidence of reported BBIs (RBBIs) over a 15-year period in different HCW groups.

The study results showed that intervention was in general effective, as there was a statistically significant trend of decreasing AIR of RBBIs in the post-intervention period.

Unfortunately, the comparison of the results of our study with the results of similar studies was limited, since we have not found any very similar study in the literature. We were able to compare, for example, AIR of RBBIs, and the comparison showed that the incidence of RBBIs at UMCL was lower than in other studies (1, 14), which could mean underreporting, especially because even in studies with a higher incidence, underreporting is exposed as a problem (4, 11, 13, 15).

In terms of gender, the study showed that the intervention had a positive effect on female HCWs. Unfortunately, a linear trend could not be assessed in men. Interestingly, our study did not find a significant difference in BBIs between males and females, which is in contrast to some other studies, some of which reported a higher incidence in women (7, 16–18) and others in men (14).

Among the different occupational groups of HCWs, the effect of the intervention was greatest in the MD/DMD group, especially because this group recorded a significant increase of RBBIs before the intervention, and after it the strongest decline among all occupational groups. Despite the fact that the group of nurses in general has the lowest values, the intervention seems to have resulted in a further decrease of the problem. This may be due to the fact that the educational programmes on preventive measures were most intensively performed in this occupational group. On the other hand, RBBIs were most frequent in NUAs. This result is consistent with the findings of some other studies reporting a substantial risk of incidents among NUAs especially with sharps (1, 19). The reason was mostly sharps laid wrongly or placed in overfilled containers, inappropriate placing or emptying sharps containers. However, there is no evidence of effectiveness of intervention in this occupational group. It was similar in the other HCWs group.

The study also provided some important results related to divisions/departments. First, the most notable result was the high AIR of RBBIs in the Stomatology Division. However, this is consistent with some other studies which indicate that dental HCWs are at highest risk of BBIs (20, 21). On one hand percutaneous injuries prove to be a substantial risk (22), while on the other, exposure to blood and body fluids due to the nature of the occupation also represents a common problem (23). Unfortunately, the intervention did not achieve its goal in this division. Second, a significant decrease in AIR in the period 2017-2022 was recorded in the Surgery Division, where, due to the nature of the work, there is a lot of contact with sharps and, as a result, exposure to injuries is high (16, 24). This result suggests that the intervention was successful in this division. Finally, a significant decrease in AIR of RBBIs was also recorded in the Ophthalmology Department and the Neurology Division. However, this decline began before the observed intervention (in 2014 and 2015 respectively), which could be explained by the intensive trainings that took place in both units at that time.

Regarding the causes of BBIs, the intervention resulted in a significant decrease in BBIs only in sharps. However, this is actually the most important result, since this cause is by far the most common, as reported also in many other studies (1, 4, 7, 8, 25–27). It is even more important because in the pre-intervention period there was an increasing trend of BBIs with sharps. It seems that HCWs generally started to follow precautions more strictly after the intervention.

The current study has some limitations. First, only reported incidents were included, which were certainly not all. However, we believe that this gap does not represent a significant problem. Second, one can argue that participants from only one health institution were included. However, this institution is one of the largest healthcare facilities in Central Europe (28). Next, the increase in BBIs in the pre-intervention period could also be influenced to some extent by UMCL’s efforts to increase the reporting of incidents, which had been going on for several years before the observed intervention. However, we believe that these activities did not have a major impact on the presented results. Next, within the post-intervention period, the Covid-19 pandemic was included, which could represent a source of bias. However, we believe that the pandemic in fact resulted in greater awareness of the importance of reporting BBIs along with a much greater consideration of precautionary measures, so the effect of the decrease shown by the results can be attributed mainly to the intervention. Finally, one might argue that the study provides no comparison with data from other hospitals in the country. However, such a comparison was out of the scope of this study, as it was a UMCL project. On the other hand, this study has an important strength - according to the available literature, it is the first to systematically investigate the data on RBBIs in a large clinical setting over a longer period of time, which also included an intervention to reduce the problem.

Despite the limitations, the study provides important implications for occupational medicine. The findings could serve in development of improved programmes for better prevention, and earlier and more accurate reporting of BBIs.

Among the promotional activities in UMCL, the most effective measures were training of HCWs, activities that promoted BBIs reporting, and preventive procedures that included proper use of safety devices. On the other hand, the protocol for reporting and treatment of BBIs proved to be less appropriate and needs to be further upgraded. Accordingly, the findings suggest that additional health promotion and/or supervisory work-related interventions are needed. At UMCL, it will definitely be necessary to pay more attention to the education of the male section of HCWs, those HCWs who are not MD/DMDs or nurses, especially to the education of NUAs, and among the departments/divisions to the Stomatology Division, which should be supported by regular periodic surveys, as is already the case with nosocomial infections (29).

Although the findings of the current study make a significant contribution, further research is needed to elucidate the situation. First, additional data on subjects who have experienced BBIs in the UMCL, will enable more extensive statistical analysis and provide more data necessary for the development of even more reliable programmes for the management of BBIs. Next, it would be very reasonable to extend the UMCL project to at least other hospitals in Slovenia, to highlight whether the trends at UMCL are consistent with broader patterns or unique to this institution, and it would be even better if it could be extended to similar hospitals in neighbouring countries.

The results of the study showed that intervention introduced at the UMCL was partially effective; however, at the same time the study showed in which HCW groups it was less effective. The findings could serve as a basis for development of improved prevention programmes and BBIs reporting among the HCWs, not only in Slovenia, but also more widely.