A cross-sectional study on awareness and practice of universal precautions among laboratory technicians of a tertiary health care facility

INTRODUCTION

Universal precautions (UPs) are a set of precautions or actions designed to prevent HCWs from being exposed to blood and deep body fluids by applying the basic principles of infection control through hand washing, utilization of appropriate protective barriers such as gloves, masks, gowns, and eye shields, safe handling and disposal of needles, and safe decontamination of instruments and other contaminated equipment.¹ The term standard precaution is replacing universal precautions, as it expands the coverage of universal precautions by recognizing that anybody fluid may contain contagious and harmful microorganisms.²

UPs are important because any health care organization has a responsibility to protect its staff from potential dangers and itself from loss of manpower due to occupational injuries or illnesses.³ Patients may be harmed if staff are uninformed about safe handling of blood or body fluids, and they may be deprived of appropriate care due to HCWs’ inappropriate fears or misunderstandings^4,5 Surveys have shown that the use of UPs significantly decreases the number of incidents of occupational exposure to blood.^6,7 Nevertheless, the level of compliance with UPs has been reported to be generally low.^8,9

According to WHO, Standard precautions are meant to reduce the risk of transmission of blood borne and other pathogens from both recognized and unrecognized sources. They are the basic level of infection control precautions which are to be used, as a minimum, in the care of all patients in all settings. These precautions apply when there is a risk of potential exposure to blood, body fluids, secretions, and excretions especially encountered in laboratory workers.

Biological hazards and health safety issues are therefore a special concern in laboratory technicians who are at risk of exposure to: blood borne pathogens while handling contaminated lab samples such as blood or other body fluids, i.e. cerebrospinal fluid, and semen, to M. tuberculosis from working with specimens(e.g., acid fast bacilli smears), to hazardous laboratory chemicals and to needle stick injuries or cuts from sharp objects when working with specimens, centrifuge tubes or overfilled sharps containers.¹⁰

Standard laboratory safety practices can minimize such accidental exposure and ensure that each blood sample would be treated carefully with the assumption that all specimens are potentially infectious.¹¹ Occupational exposure resulting in nosocomial infections and further transmission of these pathogens is an area of increasing concern due to spread of resistance and increasing resource use.

The aim of the study was to assess the baseline knowledge and practices regarding standard precautions followed by laboratory workers from different departments of a tertiary health care facility in Hyderabad, Telangana. It is observed that knowledge influences the practice and compliance of these precautions, therefore an assessment of knowledge and practices can help us visualize the extent to which these practices are followed and any gaps between knowledge and practice can be identified.

METHODS

Cross sectional study was conducted in Osmania general hospital, which is a tertiary level health care facility in Hyderabad district of Telangana for a period of one month from 1 November 2018 to 20 November 2018.

Sampling technique

Osmania general hospital has 5 departments concerned with laboratory workers, these include: microbiology, biochemistry, pathology, ICTC center and TB clinic. Each department had on an average 20 lab workers posted in different shifts of morning, afternoon and night. To achieve a sample size of 70, department register of each department was taken and 14 individuals from each department were selected by random method. After taking consent, 70 respondents were administered the questionnaire in total.

Sample size

Assuming the knowledge and awareness of laboratory workers regarding standard precautions as 50% and taking absolute error as 12%.A sample size of 70 was taken for the study.

Inclusion/exclusion criteria

Inclusion criteria included those workers who were working for a period of >1 month in the facility and who had given consent for the study. Exclusion criteria included students with BSc, MLT degree.

Study tool

Self-administered structured questionnaire was used consisting of two parts-the first part contained information on socio demographic characteristics such as age, sex, duration of working, experience and second part included knowledge-type questions addressing knowledge of the concept in general and hand hygiene and practices related to them. Knowledge type questions included identifying fluids to which SP are applicable and fluids to which they are not applicable, and appropriate precautions followed for different procedures like handling paperwork, collecting and transporting specimens, centrifuging and likewise. Practice wise questions included how frequently (always, sometimes, never, not applicable) was SP practiced like, hand hygiene, use of personal protective equipment (PPE), disposal of waste, and cleaning of spills.

Statistical method/tool

Data was entered and Statistical analyses were performed using Microsoft excel 07. Descriptive analysis was done and Chi-square tests were used for establishing association.

RESULTS

The mean age of the respondents was 32.37 years, all of them were graduates by education and the mean length of experience was 5.45 years. Males amounted to 53% and females amounted to 47% of the total respondents. The respondents worked in the following departments: biochemistry, microbiology, pathology, ICTC center, and DOTS clinic (Table 1).

Respondents were scored out of 34 questions, in the domain of knowledge. Each correct answer allotted one mark with no negative marking for wrong answers. The mean score for knowledge was 14 (41.1%). Majority correctly identified which fluids to apply SP (mean score=3.5) when compared to which fluids do not come under SP (mean score=1.5), eight questions were asked on procedure and the appropriate precaution to be followed for each one (washing hands/wearing gloves/wearing gown), lastly four questions were asked on previous training and handling of laboratory equipment (Table 2). 25% (n=17) of them had undergone any sort of training on universal precautions in the previous 12 months, 68% answered correctly on shielding machines which emit splash/splatter, 75 % answered yes on using capped tubes while centrifuging specimens and 62% choose yes on whether to decontaminate the container of specimens.

Knowledge regarding procedure precautions was low and the respondents had nil knowledge on when to use disposable gowns for safety, however majority had correct knowledge on appropriate use of gloves while performing procedures when compared to washing hands. Collecting blood, filtering specimens and transferring specimens were the procedures where maximum knowledge was seen (82%), whereas removing rubber stoppers was the procedure where least knowledge was found (62%). In the area of practice, questions were asked regarding frequency of practicing (always/sometimes/ never/not applicable) standard precautions (Table 3).

Maximum practice was seen on promptly wiping contaminated spills, followed by disposal of sharp objects into a container, least practices was reported in wearing eye shields and disposal of waste into a plastic bag.

DISCUSSION

The level of awareness of SPs is only about 41% in this study which is similar to a study conducted by Goswami et al. among interns in tertiary care facility in western India¹² and a similar level of knowledge on the basic concepts of SP 37.0% was observed in a study on healthcare workers in the Lower Manya Krobo District, Ghana.¹³

The area of concern is the knowledge about fluids to which the SPs are applicable /not; majority of the candidates had very poor knowledge (22%) about fluids to which SPs are not applicable compared to fluids to which the SPs are applicable (44%) which was similar to a study conducted by Motamed et al.¹⁴ among health care workers(HCWs) and medical students in Mazandaran province where many of them had the misconception that the universal precautions should be applied when in contact with sweat(80.8%). This being a very basic element of SPs is a red flag for practice.

In the area of knowledge regarding procedures maximum knowledge was found on wearing gloves, and zero knowledge was seen in wearing gowns, this might be due to frequency of usage of gloves commonly in day to day practice and thereby having maximum knowledge regarding the same and least use of gowns in regular practice amounting to nil knowledge., a similar pattern was observed among Interns of a Medical College in West Bengal, India conducted by Mukherjee, et al.¹⁵ where 62.4% respondents had correct knowledge regarding usage of gloves.

In the domain of practice, the responses were quite satisfactory with majority of the responses being “always” for all the practices, wearing eye shields & face masks was only “sometimes” followed and majority of “not applicable” were for disposing potentially contaminated material into labeled bags. The results were similar to a study conducted by Wilson E. Sadoh¹⁶ where a high proportion (94.6%) of the HCWs always washed their hands after handling patients and over half of the respondents (63.8%) always wore gloves, aprons and gowns during surgeries and deliveries and 56.5% never wore eye glasses during the procedures. Another study conducted on cross-sectional study was conducted among Kazakh medical students revealed similar results where only half (51.5%) of the students reported that they always use gloves, and even fewer reported that they always use masks or eye protection.¹⁷ Results were similar to another study done among health care workers in four national hospitals in Kabul, Afghanistan where 90.3% of the respondents reported that they adhered to safe disposal of used needles and sharps and other blood contaminated items, and 92.6% of them reported wearing gloves when they were exposed to deep body fluids or blood products.¹⁸ A similar study in rural northern India also found that HCWs had a low level of overall practice of UP.¹⁹

According to the current study, professional experience does not add to knowledge regarding precautions; no significant association was found between years of experience and knowledge.

Limitation of the study

The study was conducted in a single tertiary care hospital, so the study cannot be generalized to the whole population. The sample size was less thus furthering the notion of non applicability to whole population.

CONCLUSION

In the domain of knowledge, only 25% had undergone training on standard precautions and Knowledge regarding procedure precautions was low with a mean of 41%, thus highlighting the importance of conduct regular training sessions and reinforcing knowledge and practices for the same among lab workers. In addition to regular contact sessions and trainings, ensuring availability of equipment at the appropriate place and time for the lab workers will definitely prove to be a reminder for adequately following the procedural precautions. Ultimately the organizations policies and rules will decide adherence of standard precautions among the workers and ensure their implementation.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Review Committee.

REFERENCES

1. 1. Center for disease control and prevention, recommendations for prevention of HIV transmission in health-care settings. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/00014845.htm. Accessed on 25 May 2020.
2. 2. Sadoh WE, Fawole AO, Sadoh AE, Oladimeji AO, Sotiloye OS. Practice of universal precautions among healthcare workers. J Natl Med Assoc. 2006;98:722-6.
3. 3. Chan R, Molassiotis A, Chan E, Chan V, Ho B, Lai CY, et al. Nurses’ knowledge of and compliance with universal precautions in an acute care hospital. Int J Nursing Stud. 2002;39:157-63.
4. 4. Van Servellen GM, Lewis CE, Leake B. Nurses’ responses to the AIDS crisis: implications for continuing education programs. J Contin Edu Nurs. 1988;19:4-8.
5. 5. Walsh G. AIDS: fear of contagion among nurses. Br J Nurs. 1992;1:66-8.
6. 6. Beckmann SE, Vlahov D, Koziol DE, McShalley ED, Schmitt JM, Henderson DK. Temporal association between implementation of universal precautions and a sustained, progressive decrease in percutaneous exposures to blood. Clin Infect Dis. 1994;18:562-9.
7. 7. Wong ES, Stotka JL, Chinchilli VM, Williams DS, Stuart CG, Markowitz SM. Are universal precautions effective in reducing the number of occupational exposures among health care workers? A prospective study of physicians on a medical service. JAMA. 1991;265:1123-8.
8. 8. Gershon RR, Vlahov D, Felknor SA, Vesley D, Johnson PC, Delclos GL, et al. Compliance with universal precautions among health care workers at three regional hospitals. Am J infect Control. 1995;23:225-36.
9. 9. Gershon RR, Karkashian C, Felknor S. Universal precautions: an update. Heart Lung. 1994;23:352-8.
10. 10. OSHA-Occupational Safety & Health Administration, Hospital e-tool: healthcare wide hazards-laboratory. Available at: https://www.osha.gov/SLTC/etools/hospital/hazards/hazards.html. Accessed on 20 November 2019.
11. 11. Universal infection control and control precautions-AIDS/STD section, Ministry of health, Malaysia. Available at: https://www.ppukm.ukm.my//jpmd/wp-content/uploads/2015/03/Policies-Procedures-On-infection_control.pdf. Accessed on 16 November 2018.
12. 12. Hansa MG, Sumeeta TS, Sachin MP, Mitesh KP. A study on knowledge, attitude and practice of laboratory safety measures among paramedical staff of laboratory services. National J Community Medicine. 2011;2(3):470-3.
13. 13. Akagbo SE, Nortey P, Ackumey MM. Knowledge of standard precautions and barriers to compliance among healthcare workers in the Lower Manya Krobo District, Ghana. BMC Research Notes. 2007;10(1):432.
14. 14. Baba N, Mahmoodi F, Khalilian A, Peykanheirati M, Nozari M. Knowledge and practices of health care workers and medical students towards universal precautions in hospitals in Mazandaran Province. Eastern Mediterranean Health Journal. 2006;12(5): 653-61.
15. 15. Sadoh WE, Fawole AO, Sadoh AE, Oladimeji AO, Sotiloye OS. Practice of universal precautions among healthcare workers. J Natl Med Assoc. 2006;98(5):722-6.
16. 16. Nugmanova Z, Patel N, Nurbakhytc A, Akhmetovaad GM, Kovtunenkoa N, Trumovaa Z, et al. Universal precautions in Central Asia: the need for multiple strategies in this window of opportunity. J Hospital Infection. 2015;89(3):197-201.
17. 17. Said HF, Michiyo H, Tomoya H, Mohammad ABS, Zakhro D, Nobuyuki H. Knowledge and practice of universal precautions among health care workers in four national hospitals in Kabul, Afghanistan. J Infect Dev Ctries. 2014;4(8):535-42.
18. 18. Kermode M, Jolley D, Langkham B, Thomas MS, Holmes W, Gifford SM. Compliance with Universal/Standard Precautions among health care works in rural north India. Am J Infect Control. 2005;33:27-33.