Healthcare Workers Still Vulnerable to 'Splash and Splatter'

Caroline Helwick

December 02, 2014

NEW ORLEANS — In spite of protections, mucocutaneous splash and splatter incidents still occur frequently, often in hospital areas that are considered to be low risk and in the absence of appropriate personal protective equipment, according to the largest study of its kind.

Infection after occupational exposure to blood and body fluids has the potential for serious consequences, particularly from diseases like HIV and, more recently, the Ebola virus.

"What's interesting is that the Centers for Disease Control has said that mucocutaneous splash and splatter events are not occurring frequently. These data show that they are," said Amber Mitchell, DrPH, from Vestagen Technical Textiles, in Orlando, Florida. "And they are not occurring only in high-risk settings, but in low-risk settings as well," she said here at the American Public Health Association 142nd Annual Meeting.

Dr Mitchell analyzed more than 32,000 exposure incidents from 68 hospitals in the United States that report to the Exposure Prevention Information Network. She examined the use of face protective equipment, looked at the impact of the national policy on mucocutaneous splash and splatter incidents, and assessed differences in hospital risk areas, equipment use and type.

Dr Mitchell evaluated incidents during three time periods: 1995 to 1999, before the Needlestick Safety and Prevention Act was passed; 2000 to 2002, during the updating of the Occupational Safety and Health Administration Bloodborne Pathogens Standard; and 2003 to 2007, after these policies were fully implemented.

No Impact of National Policy

There was no substantial difference in needlestick exposures or splash and splatter incidents between the 5 years before the needlestick act was passed and the 5 years after.

"The national policy made no difference to a healthcare worker's risk for needlestick or splash and splatter," Dr Mitchell reported.

What was interesting was that 79% of these exposures were happening to the eyes.

"Because that analysis showed no differences, I spent more time on the data, looking for compliance to protective equipment. I wanted to know, if exposures are happening, why?" she explained.

"I looked at where people were wearing equipment when exposed and, if exposed, were they wearing it appropriately? For instance, if the exposure was to the eye, were they wearing goggles? If to the nose, were they wearing a surgical mask or respirator?" she said.

Dr Mitchell identified 5038 mucocutaneous splash and splatter incidents to the eyes, nose, and mouth from 1995 to 2007, 66% of which occurred in high-risk hospital areas and 34% of which occurred in low-risk areas.

This finding contradicts current thinking that areas in the hospital considered lower in risk, such as areas outside of patient's rooms, convey a low risk for occupational exposure, she explained.

"While it is not surprising that most exposures were in high-risk areas, what was interesting was that 79% of these exposures were happening to the eyes," she continued.

Healthcare workers in these cases were wearing masks (39%), face shields (10%), goggles (10%), side shields (2%), or eyeglasses (39%).

It is concerning that 39% of these workers were wearing eyeglasses, she said. Although eyeglasses provide a physical barrier to splash and splatter, "to an industrial hygienist, eyeglasses would not be considered protective equipment," she said.

Appropriate Protection Rare

Mucocutaneous splash and splatter incidents very often occurred in the absence of appropriate protection.

"If you got a splash or splatter to the eyes, nose, or mouth, were you wearing the right equipment? The answer is no," said Dr Mitchell.

Only 2% of people in low-risk areas and 3% in high-risk areas who experienced an exposure to the nose or mouth were wearing the appropriate protective gear.

"For people with exposure to the eyes, only 22% in low-risk areas were wearing the right protection during this time period," she added. "This is worse than the rates of hand hygiene."

Table. Splash and Splatter Incidents by Protective Equipment Use

Risk Area Eyeglasses Side Shield Goggles Face Shield Mask All
   Low 149 5 27 28 N/A 209 (22%)
   High 360 23 101 116 N/A 579 (65%)
   Low N/A N/A N/A 5 9 14 (2%)
   High N/A N/A N/A 9 15 24 (3%)
   Low N/A N/A N/A 4 6 10 (2%)
   High N/A N/A N/A 12 18 30 (3%)


"This is 32,000 exposures over almost 13 years, before and after Needlestick Safety and Prevention Act and the incorporation of that act into the Bloodborne Pathogen Standard. I thought the heightened awareness of blood exposures over that time would be more meaningful," Dr Mitchell said.

The use of eyeglasses is especially interesting, said Dean Baker, MD, from the Center for Occupational and Environmental Health at the University of California, Irvine.

"As a practice issue, getting people aware of protective equipment, especially face masks, is difficult because of the impression that this alienates patients," he explained during the discussion period. "You've shown that a substantial majority of contacts occur in the eye. Given what you have shown, eyeglasses — while they are less than perfect protection — might be acceptable on a facility-wide basis."

"It's also true that if you had some special type of eyeglasses, perhaps oversized, as a requirement, it would be clear whether people were wearing them or not," he added. "They are not as good as face masks, but this might be a way to address a problem that occurs in 79% of these experiences."

Dr Mitchell said she agrees, and reported that she is in conversation with industry about designing an apparatus that is somewhere between standard eyeglasses and goggles "that would be more acceptable" as part of personal protective equipment.

Dr Mitchell and Dr Baker have disclosed no relevant financial relationships.

American Public Health Association (APHA) 142nd Annual Meeting: Abstract 299069. Presented November 17, 2014.


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