ORIGINAL RESEARCH

Risk of exposure to biological material at primary health care facilities

Keyti Cristine Alves Damas Rezende^I; Anaclara Ferreira Veiga Tipple^II; Adenícia Custódia Silva e Souza^III; Karina Machado Siqueira^IV; Sergiane Bisinoto Alves ^V; Thaís de Arvelos Salgado^VI

^I Nurse. Master's Degree in Nursing from the Federal University of Goiás. Nurse of Maternal-Infantile Hospital. Goiania, Goias, Brazil. E-mail: keytidamas@hotmail.com
^II Nurse. PhD Degree in Nursing. Professor at the Federal University of Goias. Goiania, Goias, Brazil. E-mail: anaclara.fen@gmail.com
^III Nurse, PhD Degree in Nursing. Professor at the Catholic University of Goias, Goiania, Goias, Brazil. Email: adeniciafen@gmail.com
^IV Nurse. PhD Degree in Nursing. Professor at the Federal University of Goias, College of Nursing. Goiania, Goias, Brazil. E-mail: karinams.fen@gmail.com
^V Nurse. PhD Degree in Nursing. Nurse at the Hospital das Clínicas of the Federal University of Goias. Brazil. E-mail: sergianebisinoto@yahoo.com.br
^VI Nurse. Master's Degree and Doctoral Candidate at the Federal University of Goias. Brazil. E-mail: thais.arvelos@hotmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2016.6442

ABSTRACT

Objective: to identify modes of exposure to biological material involving nursing professionals at Primary Care Centers in a Health District of Goiânia, Goiás. Method: once ethical requirements were met, data were obtained by questionnaire and direct observa­tion, and recorded on a check list. From January to May 2010, 149 procedures were observed: neonatal and antenatal screening, Papanicolaou test, immunization and dressings. Results: risk of exposure to biological material was found during sharps handling, possible contact with blood, secretions and immunobiologics, aerosol formation, proximity between an accessed limb and nurse's face, and agitation and/or unexpected reaction from user. Conclusion: there is risk of exposure to biological material in procedures performed by primary health care nurses and that risk is heightened by non-observance of standard precautions. There is a need for infection control committees in the health district, to give guidance and supervision on safe procedures.

Keywords: Risk management; primary health care; protective devices; universal precautions.

INTRODUCTION

Healthcare-related infections (HCRI), including those identified in the primary healthcare (PHC) services, have represented a severe problem and various effects in human health context. Under the perspective of worker's health, the biological risk (BR) focuses on the likelihood of occupational exposure to biological agents¹, arising from the presence of pathogens at the workplace. Such an exposure is divided into two categories: exposition with deliberate intention, from the labor activity as a result from directly non-deliberately using or handling the biological agent stemming from the labor activity without the direct handling of this agent. Knowing risks genesis, the protective measures to be implemented can achieve higher electivity¹.

From user perspectives, HCRI represent one of the key indicators for quality of care, because HCRI are among the leading causes for morbidity and mortality and, consequently, cost elevation for the treatment^2. The user, when looking for the health service, is vulnerable to developing infections by microorganisms from exogenous and endogenous sources^3-5.

PHC represents, today, one of the gateways for the Unified Health System (SUS). Thus, the for Integral Healthcare Centers (IHC), which are non-hospital units for urgency and emergency care, and the Basic Health Units (UBS) offer broad service with medium and low complexity. In these units, nursing professionals perform a range of procedures that expose them to occupational hazards, among which the BR stands out.

Accidents involving biological material show risk for infection and may cause emotional and psychological impact on the professional, in addition to the financial costs on the healthcare system with post-exposure prophylaxis and worker's follow-up⁶.

Thus, it is believed that BR characterization, involved in providing cares in PHC, can offer subsidies for managers and employees in developing and implementing a security policy in that context. Thus, this study aimed to identify exposure modes to biological material found in the activities carried out by nursing professionals who work in PHC units of a Health District at the city of Goiania, Goias, Brazil.

LITERATURE REVIEW

PHC is configured as a communication hub with all Healthcare Network and assumes a central role in ensuring access for the population for the services in this network. In this context, special mention deserves to be directed to Family Health Strategy (FHS), adopted by the Ministry of Health in 1994, as an instrument for developing PHC in Brazil, by means of the Family Basic Healthcare Units (FBHCU). PHC qualification and consolidation appears as an expansion strategy, through the reorientation of work processes, increasing the efficaciousness and impact on people's health situation and collectivities⁷.

Significant numbers of health professionals work in the PHC, including in FHS, however, the discussions geared specifically to the risks to which workers are exposed in this scenario are meager. The literature on BR and adopting standard precaution (SP) measures in the hospital area is vast, but it's only recently that this subject has been addressed in the PHC context^8-12.

Given this, it is important to stress out that the employment of safe practices and the use of adequate protective equipment can significantly reduce the risk for occupational accidents, including those related to exposure to biological agents. Biosecurity, in its broader perspective, aims as central objective to provide the professionals and institutions with tools that allow for developing safe activities, whether for health protection or environmental protection¹³.

In 2007, the Centers of Disease Control and Prevention (CDC) published the new practices for preventing and controlling infection, reaffirming the fundamental elements for preventing transmission of infectious agents in healthcare services and bringing updates in relation to the previous publication, which had been disclosed in 1996 and disserted on precautions related to hospital services¹⁴. It is important to note that among the justifications for revising this material is the recognition that healthcare is provided in places that differ from hospital ambience, among which we may refer clinics, long permanence institutions and the domicile, where the professionals perform both administrative activities as well as social ones, such as they have been identified in the investigation¹⁵.

The complications generated by oversights related to infection control in the procedures performed by professionals in the PHC, include: broncho-aspirations, appearance of infected pressure ulcers, infections related to invasive procedures such as vascular catheters, vascular probes, among others ¹⁶. In this sense, it should be noted that infection control should be part of the quality indicators to be followed in the PHC, including homecare, because many complications and user-related inter-occurrences may result from lack of control on the procedures involved in the care.

METHODOLOGY

Cross-sectional, descriptive study, with a quantitative approach, conducted with nursing professionals (nurses, nursing technicians and assistants) working in two BHU, nine FBHCU and three IHCs, belonging to a Health District of the municipality of Goiania-GO.

Considering the limited literature on the subject, some professional nurses, operating in the infection control areas and/or PHC were invited to discuss the study's e proposal. Eight professionals took part in this initial step which purposed to list which procedures developed in the PHC offered to BR to professional and user.

Group consensus was to include procedures involving handling sharps and/or contaminated items, contacts with sterile mucosal sites that offer the possibility to exposure to blood and secretions. Five procedure types were elected: newborn screening tests and pre-natal screenings, Pap smear, vaccinations and dressings. The exposure modes to the biological material were extracted from the observation made when performing the elected procedures.

For data collection, a check list specific for each procedure completed during the direct non-participant observation was prepared. Each check list included the steps on the respective procedures and preventive measures provided for the safety of professionals and users. A questionnaire with closed and open questions for characterizing the professional who performed the procedure was observed and the qualification for the work was applied after this step.

Data collection instruments were evaluated by three experts in infection control for checking their operation capacity. In addition, a pilot test was conducted in PHC service of another municipality. After each unit coordinator's consent, upon presenting the Ethics Committee's approval and authorization by the Municipal Health Secretariat of Goiania, data collection began, which occurred in the period from January to May, 2010. We standardized for each unit, 20 observation hours, divided into shifts according to the schedule and work demand, totaling approximately 280 hours.

The project was approved by the Ethics Committee in Human and Animal Research of the Hospital das Clínicas of the Federal University of Goias - Protocol No. 029/09, according to the Brazilian research recommendations for research with human beings ¹⁷. At the end of the observation period, the subjects were informed about the study objectives and after having access to the records arising from the observation, those who agreed, signed the Free and Clarified Consent Form (FCCF) and responded to the questionnaire.

We used the Statistical Package for Social Sciences (SPSS) software, version 16.0 for Windows for descriptive analysis, using absolute and percentage frequency.

RESULTS AND DISCUSSION

149 comments were made regarding 77 vaccinations, 28 dressings, 28 Pap smears, 11 heel prick tests, and 9 prenatal screenings.

When looking at the exposure modes to biological material in each procedure and the indicated respective personal protective equipment (PPE), it was found that all observation-elected procedures showed the possibility for contact with blood and, in three of the five types of procedures, sharps were used. It has also been observed the possibility for forming splashes and aerosols, accomplishing the dressings; risk related to the level of shaking the child and proximity of punctured member with the professional's face, upon collecting material for the heel prick test and exposure risk due to unexpected response from the pregnant woman in the fingerstick for prenatal screenings, as shown in Figure 1.

(*) The choice of appropriate PPE depends on the dressing evaluation and the planned exposure level.
FIGURE 1: Procedures and situations of possible exposure to biological material and indicated respective personal protective equipment (PPE). Goiânia, Goiás, Brazil, 2010.

Study performed in FBHCU in Sao Carlos-SP, Brazil, 238 procedures were observed involving potential contact risk with biological material, and more than 90% involved the use of needles ¹¹. All actions involving interaction between user and healthcare professional, known to be related to the risk of exposure to biological material, must be surrounded by prudence and require precautionary measures to minimize contamination chance.

Using PPE is considered a SP, so that it is recommended in care for all users, regardless of presumed infection state, in situations where there is a risk for contact with blood, body fluids, organic-origin secretions and excretions ¹⁴. Indicating a certain PPE is also based on the presumed exposure risk for professionals and users in a procedure.

The gloves are designed to prevent hand contamination of the professionals, but also protect users from exposure to microorganisms found in outer sources. Short coats are used to protect your arms and body exposed areas, also avoiding a possible contamination of the own clothes. Masks and goggles should be used given the possibility for contact with respiratory secretions a blood d aerosols or body fluids¹³. The Regulatory Norm - NR 32¹ includes closed footwear as mandatory PPE for healthcare professionals.

In relation to situations where the exposure to biological material was found during the Pap smears performed by nurses and dressings made by technicians in nursing, in 11 (45.8%) and 13 (46.4%), respectively, there was noted the risk for blood splashes and secretions, situations in which all professionals had possibility for ocular mucosa exposure as shown in Table 1, where the goggles do not appear, because no professional has used them.

TABLE 1: Situations related with exposure risk to biological material for bloodspot tests and dressings in basic healthcare units of a health district. Goiânia, Goiás, 2010.

It is noteworthy that there are evidences where the eyes rank second as most affected body region during an accident^18,19.

Exposure risk for oral mucosa was also observed and adherence to masks in Pap smears and dressings was 4 (16.6%) and 19 (67.8%), respectively. In fact, for all the Pap smears and dressings, there were 100.0% adherence to the recommended PPE, which allows to infer that there occurred potentiation for the exposure risk to biological material for the workers and users.

Visible surface contamination was observed in 12 (50.0%) Pap smears and 5 (17.8%) in dressings, however, decontamination cares for these surfaces were done in smaller periodicities. Just after 9 (32.1%) dressings, one conducted friction with 70% alcohol with no prior cleaning. A procedure considered to be inappropriate, once that 1%sodium hypochlorite germicides and 70% alcohol, available for surface disinfection in the units, have low action under the presence of organic matter^20,21.

It was observed that both for the Pap smear, as well as for dressings, there was no recommended adhesion to SP. It is interesting to stress out that the professional technicians in nursing had demonstrated greater care in minimizing the BR involved in accomplishing the dressings, when compared with the nurses, when accomplishing the Pap smears. Situation that compromises the autonomy being necessary for the nurses to guide, supervise and encourage adherence to SP on the part of their team, functions expected from this professional^22-24, in addition to encouraging a patient safety culture^25,26.

Sheet exchange did not occur during the Pap smears. Sheets were overlaid with Kraft paper, exchanged for each user. Although a little uncomfortable, this paper fulfills the function of protecting the gynecological litter surface from splashes and secretions. In carrying out dressings, one just proceeded to exchange sheets in the presence of visible filthiness.

In addition to environmental contamination issue, the low hygiene levels on the hands for the Pap steams and dressings, both before the procedures, 4 (16.6%) and 14 (50.0%), respectively, as well as after, what occurred in only 3 (12.0%) of tests and after dressings there was no adherence. It is noteworthy that all sites intended for implementing the procedures had sink with manually-operated tap, paper towels, and liquid soap and that in half of these sites, the 70% alcohol was available. Still, at most opportunities, summing up the moments before and after, nurses and technicians in nursing did not accomplish their hand hygiene, disregarding the importance on this simple and low-cost practice^22,27,28.

The low adhesion of health professionals to hand hygiene is repeatedly documented^28-32. The non-observance on this measure exposes professional and users for exposure risk to biological material.

Data from this study allow us to infer that the professionals are replacing the hand hygiene by using gloves, which had adherence in accomplishing 21 (87.5%) Pap smears and 23 (82.1%) dressings. However, this practice consolidates a misconception, because using gloves does not replace hand hygiene and it must occur before and after using this PPE¹.

In situations related to exposure risk to biological material during vaccinations, heel prick tests and prenatal screenings, one observed the directing of sharps for the professional's hand that was acting, as shown in Table 2.

TABLE 2: Situations that configured exposure risk to biological material in procedures with the use of sharp articles, in basic healthcare units of a health district. Goiânia, Goiás, 2010.

It was found that in all heel prick tests and prenatal screenings, lancet targeting occurred towards the healthcare professional's hand. In these procedures, involving fingerstick, or heel puncture, in order to obtain blood sample for examinations, there is always the direction of the lancet or needle towards the professional's fingers, since they are required to firmly hold the place, pressing it with their fingers in order to proceed to puncture. It is necessary to consider that the risk observed in this context takes place on the occurrence of accident before the puncture, which would not be accident with biological material, since that it would anticipate the contact with the user. However, the physical injury appears as a gateway to biological agents.

We still emphasize that during fingerstick or heel puncture, the user can become affected by the pain and collapse the hand or foot. In this case, there is the possibility of occurring accidents with biological material, because the professional may cause an accident with the already-used lancet.

It is noteworthy that, with the mandatory use of safety devices, established in Brazil by Decree No. 1748 of the Ministry of Labor and Employment ³³, one expects a positive impact on workers' safety, but that cannot yet be measured in the described situations, using the lancet with a security device would diminish this risk, offering more security to the professional and the user.

While conducting vaccinations, it was also noted that at every opportunity the needle pointed towards the professional hand, because it holds the member where injectable vaccine will be applied. In this case, the risk for accidental needlestick injury is potentiated against unexpected user reactions, especially children.

Study in public health units in Ribeirão Preto - SP, found that among 155 work accidents, 40% involved worker's exposure to potentially contaminated material, which occurred predominantly with needles in the presence of blood ⁸, a reality similar to hospital ambience ³⁴.

The non-immediate discard of sharps occurred while accomplishing 2 (22.2%) prenatal screenings and in 10 (90.9%) heel prick tests. On these occasions, after heel puncturing, the used lancet has been deposited on a kidney-type vat, along with the cotton. In one heel prick tests (9.0%), it was observed that the amount of blood which flowed was insufficient requiring a new puncture, which was performed with the same lancet. This procedure has exposed the newborn at risk of contamination, since that the same lancet was used, previously deposited in a non-sterile vat. In this situation there also was a risk for exposure to the professional, both by contact with blood-stained cotton, as well as with the already-used lancet.

Opposing this practical, one observed that upon vaccination the sharp was an immediately discarded.

It is important to stress out that, many times, PHC units do not count on the necessary infrastructure for discarding, and preserving health service wastes, what potentiate the BR for the involved professionals ³⁵ . Within the hospital there are evidences that accidents occur more often after use and before disposal of a sharp ^36,37.

It is stressed out that all the rooms, where procedures were performed involving the handling of sharps, had rigid container, resistant to puncture, rupture and leak, with lid and properly labeled, suitable for packaging these materials, as recommended by the Brazilian legislation ^38,39. It was noted, however, that sharp collectors were not prepared in appropriate brackets and were exposed to moisture, accessible to children and distant from the procedure site.

There was no possibility for contact with blood in 7 (63.6%) heel prick tests. On these occasions, the amount of blood which flowed from the puncture was extensive, soaking the cotton ball with which the professional pressured the site. The observed risk was potentiated by the moderate child's agitation state, present in 5 (45.5%) collections, enabling the occurrence of blood splashes in oral and ocular mucous membranes, because in this situation the professional's face is close to the child's heel. However, safety goggles not even appear in Table 2 as PPE because the professionals that performed the procedure did not use them.

Upon prenatal screenings, the possibility for contact with blood at every opportunity is due to the proximity between the professional and the puncture site, because it is necessary for the professional to press the user's finger. In this procedure it is also noted that, in one of the collection opportunities, there was an unexpected reaction of a pregnant woman to puncturing, (11.1%) increasing the risk of accidents with sharps. It is stressed out that, unlike what happens with vaccination, held in a proper room for material's safekeeping and administration, heel prick tests and prenatal screenings were carried out in different rooms, spaces available for procedures. These situations hampered the correct disposal of used lancets in these tests, sometimes requiring their transport, contrary to the recommendations³⁸.

CONCLUSION

This work made it possible to characterize BR in the activities developed in the PHC for professionals and users. This characterization is firmed on the developed procedure nature, being that the exposure was related to the handling of sharps, possibility for contact with blood, secretions and immunobiological agents, possibility for aerosol formation, proximity of punctured member and professional's face, restlessness and/or unexpected response from the user. Failures related to adherence to SP also contributed to for the professionals and users to provide greater exposure to the BR.

The BR is therefore inherent to health practices, regardless of the place where this practice occurs. Further studies are needed for knowledge on BR specifics, seeking for applied alternatives and solutions.

As limitation for this study is the absence of data concerning vaccination situation for the professional participants, which would contribute to understanding the situation for professional's risk in case of exposure. We suggest that new researches directed to controlling infections in the PHC should be carried out so that this theme wins the deserved importance, both in academic ambience as well as in the professional sphere. Efforts should be directed to orienting the nursing professionals for reaching a greater adherence to SP. The nurse, as the leader of this team, should be encouraged to develop actions with respect to security and the commitment to minimize the BR inherent to their practice, still acting with educational actions in this context.

Another important aspect relates to social control possibility to collaborate for adopting safer practices during healthcare. It is suggested that the user population for health services be informed on the risk to which they are exposed, especially in situations where the professionals do not follow proper preventive measures.

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