Little has been published on percutaneous injury risks to healthcare workers employed in outpatient surgery settings. And when it comes to implementing regulations that protect the health and safety of employees in these settings, the maxim "no data, no problem" applies in full force. But healthcare workers in ambulatory surgery centers may be more vulnerable to injuries than others if there are no data to support the need for protective measures.

Most published reports on percutaneous injuries to healthcare workers describe exposure risks in inpatient hospital settings. That's mainly because of the convenient access to hospital data. Hospital healthcare workers must report at-risk injuries and blood exposures to a central location, usually the employee health department, that compiles a surveillance database.

Outpatient settings: Different situation
Surveys reveal that percutaneous injury rates for different healthcare worker groups range from a low of 0.15 injuries per year to a high of more than one per year for surgeons, the group with the highest injury risk. In a hypothetical hospital that employs 1,000 healthcare workers, each with an average annual occurrence of 0.2 percutaneous injuries, 200 injuries would occur each year.

But outpatient settings, with far fewer employees, face a different situation. For example, in a facility employing 10 full-time healthcare workers, each with an annual occurrence of 0.2 percutaneous injuries, an average of one injury would occur every five years.

Workers in this kind of setting may erroneously believe that they are at low occupational risk because they rarely observe percutaneous injuries. Small employers use this argument of having few or no recent injuries in their facilities to seek exemption from safety regulations or laws.

But this perspective overlooks the fact the true risk of exposure in an outpatient or office setting isn't determined by the number of injuries per practice, but by the injury rate per device or per at-risk procedure performed. Research on this topic has been hampered by the difficulty in collecting small amounts of data from many clinical sites.

Assessing the risk
Assessing the occupational risk of healthcare workers in outpatient settings should take two factors into consideration:

• whether the workers perform procedures associated with the risk of bloodborne pathogen transmission
• and whether their rate of percutaneous injuries is different from that of inpatient hospital workers performing the same procedures.

The Exposure Prevention Information Network (EPINet) database from the International Healthcare Worker Safety Center provides information on occupational risks in outpatient settings. From 1999 through 2001, 56 hospitals provided EPINet data on percutaneous injuries.

Most of the data were from inpatient settings. But of the 56 hospitals, 29 had affiliated outpatient clinics and/or physicians' offices, and percutaneous injuries from those sites were entered in the EPINet database.

Over three years, inpatient hospital workers reported 5,298 percutaneous injuries, and workers in outpatient clinics and physicians' offices reported 350 injuries. In outpatient settings, proportionately fewer nurses reported injuries (33 percent, compared to 43 percent for hospitals), and more dentists reported injuries (3 percent compared to 0 percent for hospitals). Also reporting more injuries in outpatient settings were students other than medical and nursing students - 15 percent, compared to 1 percent for hospitals. About one-fourth of the "other student" injuries sustained in outpatient settings occurred in dental schools or clinics. echo

Device and procedure
More pertinent to the question of risk is the type of device causing injury and the procedure performed. Blood-filled, hollow-bore devices, such as those used for blood drawing and vascular access, carry a higher rate of pathogen transmission than needles used for injections.

In outpatient settings, proportionately more injuries occur from syringes (34 percent, compared to 31 percent for inpatient hospital settings), butterfly needles, phlebotomy needles and lancets. In hospitals, there were proportionately more injuries from suture needles, scalpel blades and intravenous (I.V.) catheter stylets.

In outpatient settings, proportionately more injuries were associated with injections, blood drawing, and fingersticks or heelsticks; in hospital settings, proportionately more injuries were associated with suturing, I.V. access and injections into I.V. ports. Overall, 25 percent of injuries in outpatient settings were high risk: associated with blood drawing or I.V. access - the same fraction as for hospitals.

Similar risk
When sufficient data are compiled on percutaneous injuries sustained in outpatient settings and are compared with hospital injury data, it is clear that both settings carry a similar spectrum of risk. A comparison of causes of injuries shows that workers in outpatient settings have about the same ratio of injuries from blood-filled needles (those most likely to transmit bloodborne pathogens) as workers in hospital settings. Currently, no data suggest the risks of occupational blood exposures and pathogen transmission are less for healthcare workers in outpatient settings than for those in hospitals.

When healthcare workers must handle sharp medical devices, such as injection equipment, blood-drawing devices and vascular access needles, they need the best protection available from the safest technology, regardless of clinical setting.