台灣醫療人員的針扎問題 - 流行病學、國際經驗與防治現況 台大醫學院護理學系所 醫療人員安全衛生中心 蕭淑銖 (RN; PhD) 台灣醫學教育學會 2010.04.24

Healthcare workers Working in healthcare environment But not necessarily in healthy environment

針扎後的感染機率 醫護人員針扎傷害 HBV: 30% HCV: 1.8 HIV: 0.3% 醫療人員最常見之職業傷害之一 後果可小可大

Occupational infections following percutaneous exposures Bacterial Brucellosis 1966 Diphteritis 1923 Gonhorrea 1947 Leptospirosis 1937 Mycobacteriosis 1977 Mycoplasmosis 1971 Rocky Mountain Spotted Fever 1967 Scrub typhus 1945 Staph.aureus 1983 Strept.pyogenes 1980 - necrotizing fasciitis 1997 Syphilis 1913 Tuberculosis 1931 - from HIV+ 1998 Viral Haemorragic fevers (Ebola/Marburg) 1974 HIV 1984 Herpes Simplex 1962 Simian Immunodeficiency virus 1994 Herpesvirus simiae 1991 Dengue 1998 Creutzfeldt-Jakob 1988 Herpes Zoster 1976 Hepatitis nAnB 1987 Hepatitis B 1982 Hepatitis C 1992 Hepatitis G 1998 Fungal Protozoal Blastomycosis 1903 Malaria 1972 Cryptococcosis 1985 - from HIV+ 1994 Toxoplasmosis 1951 Sporotrichosis 1977 Leishmaniasis 1997 Tumors Human colonic adenocarcinoma 1986 Sarcoma 1996 Cases of occupational infection following a percutaneous exposure have been reported in the literature since the first years of 20th century. However, these cases were sporadic and mainly occurring during laboratory activities. It was towards the end of the 1940s, that reports of serum hepatitis in health care workers alerted the investigators to the risk of occupational exposures to blood. Subsequent studies confirmed the risk to be significant in the health care setting, and recommendations on the use of precautions to prevent exposure to blood and on vaccination against hepatitis B in health care workers were first issued in 1982. As of today, we are aware of more than 30 pathogens or diseases that have been transmitted through needlestick or cuts, alone or in combination, including agents used in animal models and even tumors. However, the three pathogens that pose the greatest risk to health care workers and are responsible for most documented cases of occupationally acquired bloodborne disease are hepatitis B virus, hepatitis C virus, and human immunodeficiency virus. Jagger J, De Carli G, Perry J et al. In Wenzel RP: Prevention and Control of Nosocomial Infections, 2003. Updated. CMESH-醫療人員安全衛生中心

臺灣針頭與銳物扎傷，體液、血液暴觸長期研究架構 全國性針扎調查 1996~1998 不同族群之針扎調查 1998~1999 陽轉個案數之推估 2000 建立追蹤系統之準備 2001~2002 針頭與銳物扎傷追蹤 2003 ~ 體液、血液暴觸追蹤

Chinese EPINet 醫護人員針扎傷害 – 與國際同步之通報系統 Center for Medical Employee Safety & Health (C-MESH)

Center for Medical Employees’ Safety and Health Standardized surveillance system by Reporting to C-MESH 網址： http：// epinet.cmesh.org.tw C-MESH: Center for Medical Employees’ Safety and Health Many times of modifications and LOTS of COMMUNICATION!!

截至2009年12月09日為止，通報了2,924件針頭或尖銳物扎傷意外事件，154件血液體液暴觸事件，共3,078件醫療工作意外事件。 合作醫院之職業類別人數分佈 職業類別 加入系統工作人員數 醫師 5,220 (16.7) 護理人員 18,204 (58.1) 醫技人員 5,914 (18.9) 清潔人員 2,001 (6.4) 總計 31,339 (100)

Annual number of percutaneous injuries by number of healthcare workers #NSI = 6.9 + 0.034 * #HCWs. R2 = 0.67. P=0.0003

Annual number of percutaneous injuries by patient-days cared #NSI = 8.5 + 2.2 * #[10,000 patient-days cared]. R2 = 0.79. P<0.0001

3.19 8,286 CMESH-醫療人員安全衛生中心

Percutaneous Injuries (PCIs) Among the Participating Hospitals and the Estimated PCIs for Taiwan (Shiao et al., RINAH 2008)

Incidence of individual kinds of needles in Taiwan NSI per 10,000 patient-days Estimated annual NSI Rate (95% CI) Disposable needles 1.55 (1.24-1.87) 4,036 (3,222-4,850) IV catheter (stylet) 0.15 (0.12-0.19) 402 (321-483) Needle on IV line/ tubing 0.12 (0.10-0.15) 316 (252-380) Vacuum tube blood collection needle 0.10 (0.08-0.13) 273 (218-328) Blood gas syringe 0.06 (0.04-0.07) 144 (115-173) Winged needle IV set 0.04 (0.04-0.05) 115 (92-138) Central line catheter introducer needle 0.03 (0.02-0.03) 72 (57-86) Hypodermic needle 0.02 (0.02-0.03) 57 (46-69) Other catheter needle 0.01 (0.00-0.01) 14 (11-17) Pre-filled cartridge syringe Other needles 0.23 (0.18-0.27) 589 (469-706) Total 2.32 (1.85-2.79) 6,032 (4,815-7,249)

回函 一、醫療人員安全衛生中心之中文版EPINet針扎監控系統所得資料，可統計醫療院所各項針型之扎傷率，亦可推算全國各項醫療人員針扎及血液體液暴觸之危險性。以一年期間參與通報之15家醫院，總員工數8714位，被靜脈留置針扎傷而通報者共計13件。若以全國醫療人員總數192,611員推算，則全國一年間有287次醫療人員被靜脈留置針扎傷。 二、由於通報率難以逹到百分之一百，以上估計的扎傷率為低估，亦即全國真正扎傷率，應遠高於每年287次。 三、靜脈留置針是直接與血液接觸的醫療器材，均為患者血液污染性針頭，因此其傳染病毒性肝炎、AIDS等經血液傳染疾病之風險高。以國內可經血液傳染疾病盛行率而言，住院患者16.7%有B型肝炎之帶原(其中感染性特強的HBeAg陽性血液1.7%)；且有12.7%之C肝帶原率。因此推算全國每年有超過84位之醫療人員被具傳染性之靜脈留置針扎傷

全民健康保險特殊材料給付規定 E301-4 N-C- 精密輸液套(免針頭加藥) Precision administration set 免針頭加藥精密輸液套（Needle free IV BAG）適用範圍如下：一、具感染高危險性病人：(一)經診斷為血清(液)傳染性疾病者，如肝炎病人、梅毒、愛滋病人等。(二) 血清(液)有傳染性疾病帶原者，如肝炎病毒帶原者、VDRL(+)、HIV(+)等。(三) 潛在性易感染血清(液)傳染性疾病者，如藥物毒癮者、曾大量輸血者等。二、以單位考量:(一) 急診。(二) 加護單位。(三) 腫瘤單位。(四) 感染科病房。(五) 手術房。 G301-2 C-E- 安全護套空針Disposable plastic needle syringe 附安全護套空針適應症限：急救室、急診、愛滋病、肝炎或其他血液傳染性疾病患者使用。 G301-4 N-D- 安全性靜脈導管 限愛滋病患者使用(93/10/01)適應症修訂(950501)1、具感染高危險性病人：愛滋病、病毒性肝炎、SARS、血液傳染性疾病及藥物濫用之病患。2、以單位考量:急診。 I301-1 輸液延長管附安全護套Safety extension tube 限急救室、急診、愛滋病、肝炎、或其他血液傳染性疾病患者，作點滴輸液且頇延長輸液管患者使用。 I301-3 無針式注射用連接頭、延長管 限愛滋病患者使用。適應症限(92/11/01)：無針式接頭、無針式接頭附輸液延長管適應症限：愛滋病、病毒性肝炎、SARS、血液傳染性疾病、其他不確定傳染途徑之新興疾病。

Mechanisms of Percutaneous Injuries (Shiao et al., RINAH 2008)

# source patient with positive test Estimated annual exposure Incidence of contact with contaminated sharps, by infectious patients and estimated total injuries per year # source patient with positive test NSI per 10,000 patient-days of care Estimated annual exposure Rate (95% CI) HBsAg (+) 73 (13.9%) 0.45 (0.36-0.54) 1168 (932-1403) Anti-Hepatitis C 87 (16.6%) 0.49 (0.39-0.58) 1263 (1008-1517) HIV 4 (0.8%) 0.023 (0.018-0.027) 59 (47-71) VDRL 16 (3.0%) 0.091 (0.072-0.109) 236 (188-284) (Shiao et al., RINH 2008)

Previous studies on seroprevalence In-patients in a tertiary referral center (1998) HBsAg (+) 16.7% Anti-HCV (+) 12.7% Anti-HIV (+) 0.8% 13.9% 16.6% (this study, 2006) 0.8% (Shiao et al., Am J Infect Control 2002)

Seroprevalence of hep B among source patients Not tested 陽性 抽血中心 41.7 12 產房 10.0 40.0 10 檢驗室 16.7 25.0 24 急診室 6.4 21.1 109 檢查室 18.2 33 血液透析室 4.4 15.2 46 開刀房／恢復室 7.7 14.4 299 病房外（走廊／護理站） 3.6 14.3 56 加護病房 7.1 13.1 267 病房 7.0 12.4 573 門診 10.6 85 總數 119 219 1,553

Seroprevalence of hep C among source patients Not tested 陽性 血液透析室 32.7 85 檢驗室 13.0 26.1 33 加護病房 1.1 19.8 299 病房 3.5 17.5 573 抽血中心 16.7 10 開刀房／恢復室 4.1 15.2 267 急診室 15.0 109 檢查室 11.8 14.7 24 病房外（走廊／護理站） 3.6 14.3 46 門診 5.6 11.1 56 總數 119 219 1,553

Seroprevalence of HIV among source patients Not tested 陽性 檢查室 12.5 3.1 32 開刀房／恢復室 3.6 2.0 305 急診室 4.7 0.9 109 病房 3.7 0.7 565 加護病房 2.9 0.4 277 總數 119 219 1,553

醫療人員B型肝炎免疫/感染情形： 醫療人員有42.1%的人員沒有接種過B型肝炎疫苗 31.8%對B型肝炎有抵抗力 6.1% B型肝炎carriers 26.8%的人不確定自己有沒有接種過B型肝炎疫苗

在醫療人員當中，有10位接受B型肝炎免疫球蛋白的治療，15位接受干擾素治療。 病人源中有38筆Anti-HIV呈陽性反應，投予預防性用藥的醫療工作人員有26人次；病人源中VDRL陽性者有59位，接受Penicillin預防或治療的醫療工作人員有25人次，施打破傷風類毒素者共8人次。 目前在中文版EPINet通報系統中，因針扎事件所花費的醫療人員及病人源檢驗費已累積達新台幣5,399,800元(尚未包含預防性藥物費用)，平均每次事件之費用為2,353元。 2017/3/18

不同職業別之引起扎傷之尖銳物前三名 排名順序 醫師 護理人員 清潔人員 醫技人員 1 縫合針 拋棄式注射器 2 靜脈留置針 不確定針型 3 35.1 (154) 拋棄式注射器 54.3 (1,044) 45.5 (56) 35.9 (189) 2 22.8 (100) 靜脈留置針 7.8 (150) 不確定針型 21.1 (26) 13.5 (59) 3 不確定類型的尖銳物 7.3 (32) 其他針型 6.6 (127) 採血針 8.1 (10) 採血針&其他針型

不同職業別引起扎傷尖銳物是否受到污染

Not every percutaneous injury was reported to the hospital Under-reporting was 1/2 ~ 4/5 in previous studies We compare reporting and a retrospective survey (12 month recall of injuries) to determine the under-reporting rates

Country Japan 4 79-85% Canada 21 60% US Nash 24 42% US-EPINet 33 40% 4th ICOH - HCWs, Montréal, Canada - 1999 Studies on occupational risk in the world - Workshop Country Percutaneous exposures rate x 100 beds Estimated under-reporting rate Japan 4 79-85% Canada 21 60% US Nash 24 42% US-EPINet 33 40% France 12 50-57% SIROH Spain Taiwan 13 ? 30% 50% 82% However, these results, like the others coming from studies based on surveillance of reported exposures, are biased by underreporting, a major problem which has been extensively studied. Healthcare workers do not report all of the exposures they sustain, mainly because of a low risk perception, difficulties with the reporting system, lack of time and fear of the consequences of a misbehavior. In 1999, during a workshop of the coordinators of the studies on occupational risk in the world, the rates of percutaneous exposure estimated within these studies were compared and discussed. As you can see, these rates varied greatly between the different countries, and also within the same country between the different studies. One of the main variables affecting these rates was underreporting; therefore, also the underreporting rates, estimated through surveys, were included in the analysis. Correcting for underreporting, the exposure rates are definitely higher, and in the different countries, 20 to 55 percutaneous exposures per 100 beds could be sustained every year by healthcare workers. During the same workshop, it was evidenced that among other factors, differences in the average length of hospital stay could account for the variations between these rates. In the US, for example, there is considerable pressure to minimize the length of patients’ hospital stays and to discharge them as quickly as possible. Probably more diagnostic and invasive procedures are performed in a shorter time period in those countries with lower average stays, thus exposing healthcare workers to more sharp medical devices in a given time interval. CMESH-醫療人員安全衛生中心

Incidence of PI 10/2004 to 09/2005: Compaing EPINet with recall survey (Shiao et al., 2009) CMESH-醫療人員安全衛生中心

Reason for not-reporting % 通報太過於麻煩、通報後的審查過程太消耗時間 47.0 認為病人源屬於低危險性族群 36.7 我已有B型肝炎抗原、抗體 27.7 太忙了 我想我不會那麼倒楣的 27.1 我不知道如何報告或向誰報告 13.3 太沮喪了以致於不想報告 9.6 扎傷事件發生多次且已通報過 3.6 我的同事及醫師們說：放心，不會有問題的 3.0 認為醫院沒有權利知道我的情況 2.4 通報了也沒什麼用 CMESH-醫療人員安全衛生中心

True rate of PCIs…  33,600 per year in Taiwan, Or 4 PCIs every hour! CMESH-醫療人員安全衛生中心

What happens to healthcare workers sustaining percutaneous injury Long process of follow-up Risk of seroconversion Mentally stressed

Impact Understanding of the true severity of percutaneous injuries Safer healthcare environment Regulations Reporting International exchanges International comparisons of surveillance Assisting development of the reporting system

勞工安全衛生設施規則修正條款 規範雇主為防止工作環境或作業活動引起之物理性、化學性、生物性及人因性危害，應採取危害辨識、評估及控制之措施。（修正條文第19條之二） 增訂雇主對於供勞工使用之呼吸防護具之選擇、使用及維護方法，應依國家標準規定辦理。（修正條文第277條） 增訂雇主對於使勞工從事遭生物病原體污染之廢棄物處理時，應優先採用機械器具處理，以避免勞工感染疾病。(修正條文第296條) 增訂雇主對於生物病原體或受其污染物品之儲存，為避免污染物質洩漏或尖銳物品穿刺之情形，應使用防止洩漏或不易穿透材質之容器盛裝。（修正條文第297條） 規範雇主對於工作場所有生物病原體危害之虞者，應訂定生物病原體危害暴露控制計畫，據以落實執行。（修正條文第297條之一） 規範雇主對於作業中遭受生物病原體污染之針具或尖銳物品扎傷之勞工，應建立扎傷感染災害調查制度並採取必要之防治措施。(修正條文第297條之二）

And, some things “Untold” but hold great Impacts…

受針扎護理師 那時候是我幫同事扶病人的腳，可是她可能硬針抽出來的時候不知道我手在那，就直接往我手扎下去。 扎第一刻就是眼淚快掉出來，問學姊，學姊也是很冷的跟你說就針去急診，其實那時候心情真的是很低落，覺得就是因為沒有人要理你。 過了兩三天，我放完假回來，那個病人他檢查出來VDRL(+)又有C肝這樣子，那剛好我又上到那一team，那一交班，學姊她們不敢跟我講，就畫一朵梅花這樣子，那一看就知道，心情就更低落。 學姊又在旁邊開玩笑，以後妳先生阿，如果你被感染梅毒阿，不能怪妳先生怎樣怎樣。就會更害怕。那種，那時候的想法是覺得說那我真的被感染到了怎麼辦？ 因為有allergy的經驗，所以那時候掛急診，醫生建議要打，說那就再做penicillin test，結果是negative，那他說要打。

打到第四次之後就開始allergy，那時候我只是覺得頭整個是昏的，眼睛一直冒星星這樣子，沒過多久就倒了，對，就是整個就是allergy shock這樣子。之後她們就把我放在那個ICU裡面，其實那時候又加了ambu，如果我那時候我沒有醒來的話阿，可能endo就插上去了。 她們是說反正我就一路被抬到ICU的床上，ㄏㄟˋ，她們說我好像有一點黑，就cyanosis這樣子，那就開始擠ambu，可是之後我可能就醒了，那醒來可能因為shock的關係，可能血管在收縮吧，就一直chillness這樣子，反正那時候就覺得，糟了如果當下沒醒的話怎麼辦？整個就是快要憂鬱症發生了。 就還蠻擔心自己之後有什麼事情的話，對，因為其實爸爸年紀也大了，那時候是覺得說 (流淚)，如果我今天有什麼事的話，那他們要怎麼辦？那時候是這樣覺得，妳又會看到我爸這樣子，又看到我媽在旁邊就是狂掉眼淚，就是那時候其實還在用氧氣，對，那時候還在用氧氣，那沒什麼力氣，然後看到她們這樣，我會覺得說我怎麼會這麼不孝，我怎麼讓這種事情發生。」

Nov 6, 2000 “This morning at 11:00am President Clinton signed the Needlestick Safety and Prevention Act into law in an Oval Office ceremony in the White House. The U.S. is the first country to pass a law guaranteeing the safest protective technology to prevent occupational infection from bloodborne pathogens. The next frontier is the rest of the world. “

The Needlestick Safety and Prevention Act November 6, 2000 2007/5/24

Needlestick Safety and Prevention Act 2001  Health care employers must evaluate and implement safer medical devices designed to minimize occupational exposure. The safety feature must be integrated into the device and not a separate accessory Health care workers must be involved in the product evaluation process  Health care facilities must maintain a sharps injury log

CMESH-醫療人員安全衛生中心

CMESH-醫療人員安全衛生中心

（木戸内清：医学・医療における安全衛生， 医事新報，3954：47-61.2000.） The first civil suit case about occupational hepatitis in Japan (Courtesy of Dr. Toru Yoshikawa) Mar.1999, OSAKA A nurse who was infected to HCV from a needlestick Injury filed a suit for 30 million yen against the hospital. 原告主張：安全配慮義務違反 針刺し事故防止の遵守事項の説明なし 患者がC型肝炎であると説明なし 針刺し後の処置方法について説明なし civil suite 通常のやり方をしておらず， 病院主張：針刺しは本人の過失 Osaka District Court sentenced the hospital to pay 27 million yen ($10,000,000). （木戸内清：医学・医療における安全衛生， 医事新報，3954：47-61.2000.） 2006/09-10 CMESH-醫療人員安全衛生中心 March 9, 1999. Asahi news paper

安全針具品項與 醫療院所層級分佈狀況 醫療院所層級 真空採血針 安全性靜脈留置針 安全性注射空針 全院都沒有 醫學中心 2/2 0/2 0/2 (0%) 區域教學醫院 11/14 13/14 1/14 1/14 (7%) 地區教學醫院 0/7 5/7 1/7 (14%) 區域醫院 6/10 4/10 (40%) 地區醫院 9/32 10/32 21/32 (66%) 專科醫院 2/13 3/13 10/13 (77%) 洗腎中心 1/1 0/1 護理之家 總數 31/80 39/80 1/80 38/80 CMESH-醫療人員安全衛生中心

Needlestick injuries among to healthcare workers They are truly happening Consequences Long process of follow-up Risk of seroconversion Mentally stressed Patient safety? Something has to be done

C-MESH: Center for Medical Employees’ Safety and Health Appreciations The 100 Participating hospitals who report PCIs to C-MESH C-MESH: Center for Medical Employees’ Safety and Health