Despite Progress, More Action Needed To Protect Medical Students From Exposure To Disease Through Accidental Needlesticks, UCSF Study Finds

January 05, 1999

While health workers -- risk of exposure to infectious disease through accidental needlesticks has been greatly reduced through comprehensive training programs and the introduction of new safety devices, a new study by researchers at UC San Francisco finds that medical students remain at high risk of exposure. In the first comprehensive, long-term study of medical students -- risk of needlesticks and other exposures to blood, the UCSF team found that 11.7 percent of the students studied over a seven-year period sustained possible exposure to blood-borne diseases such as HIV and hepatitis. None of the students in the study reported contracting a disease as a result of an accidental exposure.

The study, reported in an article appearing in the January 5 edition of the Annals of Internal Medicine, included 1,022 third and fourth-year medical students from the classes of 1990-1996 who trained at UCSF-affiliated hospitals. Emilie H. Osborn, MD, MPH, the lead author of the study, noted that students in these classes benefited from UCSF's leadership in training and occupational safety programs designed to prevent needlestick injuries. But, the study reveals that they continue to face a higher risk than expected, said Osborn, a physician with the Palo Alto Medical Foundation and former associate dean of student affairs at UCSF.

The results of the study demonstrate the need for greater supervision of medical students, Osborn said. "We have to protect medical students from their own eagerness to learn new things and from pressure from others not to ask for assistance," Osborn said. "Students have to be encouraged to say to their supervisors, 'I can't do that. I want to watch you do it.'"

In an editorial accompanying the study, Daniel D. Federman, MD, of the Harvard Medical School, notes that there is inherent risk in the practice of medicine and, in turn, in the study of medicine. Medical education demands that students participate actively and importantly in the care of patients and, as a result, incur some of the risks of experienced physicians, Federman writes.

The editorial praises UCSF's leadership in developing programs to prevent needlestick exposures. Federman cites as -- outstanding -- a week-long course in needle safety required of all UCSF students and praises UCSF's creation of a confidential hotline for reporting needlestick exposures and obtaining preventive treatment. Despite these efforts, the rate of possible exposure remained at more than 10 percent over the length of the study, a signal that medical students in schools across the country run the same or greater risk of exposure.

The rate of exposures reported in specific years of the study dropped to 6.5 percent of the students in 1996 from a high of 18 percent of the students in 1993.

Most (82 percent) of the needlestick exposures in the study occurred while students worked in one of four services -- obstetrics-gynecology, surgery, medicine, and emergency medicine. The study found no other relationship linked to an increased likelihood of possible exposure. The probability of exposure was not related to the year of graduation, clerkship location, medical school class, prior clerkship experience, or the training site, the authors note.

A subset of the 77 most recent injuries -- those for which more detailed descriptions were obtained -- found that possible exposures occurred most often in operating rooms (26 percent), emergency departments (23 percent), and labor and delivery units (9 percent). Fourteen injuries were inflicted by other health care workers involved in a procedure.

The availability of needle safety devices -- designed to shield the needle after it punctures the skin -- did not prevent injuries in all cases, the study found. In the cases where it was possible to use a safety device, one quarter of the injuries were inflicted by needles equipped with safety devices. Half of the injuries involving needle safety devices occurred before the procedure and half occurred after the needle was used but before the safety shield was put in place.

The authors also noted that in subsequent surveys many students reported that they failed to report possible exposures because they believed them to be too trivial, because they occurred before the hotline was implemented, or because they reported them only to the student health service. Fifty percent or more of possible exposures may go unreported by medical students.

"Supervising attending physicians and senior housestaff [residents] must be charged with the responsibility for ensuring that students are capable of performing procedures safely before expecting them to do so without supervision," the article concludes. "It is our responsibility as medical educators to provide a safe learning environment for students before they face the risks of direct patient care. The era of -- see one, do one, teach one -- is long past."

Data from the study will be used to evaluate steps already taken at UCSF to reduce possible exposures and to guide educators in the next steps to further reduce the rate, said Maxine A. Papadakis, MD, UCSF professor of clinical medicine, associate dean for student affairs in the UCSF School of Medicine, and a co-author of the study.

"UCSF has taken a leadership role in identifying the prevalence of possible exposures and will continue to work with faculty members in the departments with the greatest risk to develop better methods of training and prevention," Papadakis said.

Julie L. Gerberding, MD, formerly a UCSF assistant professor of medicine, is also a co-author of the study. Gerberding now heads the Hospital Infections Program of the National Centers for Infectious Diseases, Centers for Disease Control and Prevention, in Atlanta.

University of California - San Francisco

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