Keywords
occupational injuries - health care workers - hospital - EPINet - Saudi Arabia
Introduction
The Occupational Safety and Health Administration (OSHA) describes work-related injuries (WRIs) and illnesses as a wide range of incidents, repetitive motion injuries, exposure to hazardous substances, and illnesses induced by work activities.[1]
[2] In the demanding environment of health care, occupational injuries are unfortunately common and varied. Reports identified the health care industry as a major source of workplace injuries, surpassing construction and manufacturing.[3] Common workplace accidents in the health care industry are blood and body fluid exposures (BBFEs), musculoskeletal injuries, needlestick and sharps injuries, violence-related injuries, falling down injuries, and electrical injuries.[4] Health care workers (HCWs) in low- and middle-income countries face biological, psychosocial, ergonomic, and chemical hazards, including bloodborne pathogens, workplace violence, burnout, and musculoskeletal disorders.[5]
Occupational exposure to BBFs poses a considerable risk to HCWs, increasing the risk of infections transmitted by blood such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV), and severe acute respiratory syndrome coronavirus 2.[6]
[7]
[8] These injuries can be caused by mucocutaneous injury (eyes, nose, mouth), nonintact skin exposure, or percutaneous injury via infected needles or sharp objects.[7]
[9]
[10] In addition, HCWs may be exposed to percutaneous injuries or contact with potentially infectious body fluids, such as blood, tissue, or other fluids, which can occur through chapped, abraded, or dermatitis-afflicted skin.[11] HCWs who perform invasive operations utilizing sharp instruments or come into touch with a patient's blood or body fluids have a high risk of BBFE.[12] As per the World Health Organization estimates, 3 million HCWs are exposed to bloodborne pathogens each year, resulting in 170,000 HIV infections, 2 million HBV infections, and 900,000 HCV infections.[13]
Needlestick and sharp injuries (NSIs) are caused when health care personnel mistakenly puncture their skin with needles or sharp items, potentially exposing them to over 20 types of infectious diseases including HBV, HCV, and HIV.[8]
[14]
[15] According to the World Health Organization, there are approximately 2 million sharp injury exposures among 35 million HCWs each year.[16] A global systematic review and meta-analysis revealed a 43% incidence of needlestick injuries, with Africa having the highest rate at 51%, with the highest rates occurring during needle recapping and waste disposal.[15] Health care industry personnel encountered injury rates as high as 16 times than that of the overall U.S. workforce.[17] A study from Saudi Arabia revealed a 52% prevalence of WRIs, with back injuries, eye/mouth splashes, and needlestick injuries being the most common.[18]
Falls, slips, and trips are major causes of injuries among HCWs, often leading to serious consequences. These injuries can be caused by wet floors, uneven surfaces, loose rugs, poor lighting, obstacles like cords or tubing, and cluttered walkways.[19]
[20] They are the second most common cause of occupational fatalities in all industries.[21] Those incidents can lead to lost workdays, reduced productivity, expensive worker compensation claims, and reduced patient care.[22] Work-related musculoskeletal injuries to muscles, bones, and joints in the health sector represent one of the main causes of injury among health professionals.[23]
[24] Repetitive actions such as lifting, pushing, or tugging for patient placement and forward flexion put health care practitioners' spinal columns at risk, resulting in weights that exceed their lifting capacity even in perfect settings.[25] Those injuries are characterized by low back pain, shoulder discomfort, repetitive strain injuries, and joint pain (knees, wrists, and other joints) that restricts body movement.[26]
[27]
Workplace violence is a prevalent occupational hazard with a high rate of injury and disability among workers, but its prevalence is often underreported and challenging to estimate.[28]
[29] It can be categorized into four types: type I (by perpetrators who have no connection to the workplace or the victim), type II (by customers or patients), type III (current or former employees), and type IV (by perpetrators who have personal contacts with employees).[30]
[31] The most common in health care settings is type II, involving patients, their families, or friends.[32] Between 2011 and 2013, the United States had an average of 24,000 workplace assaults and violent actions each year, with roughly 75% occurring in health care and social sector settings.[33]
Occupational injuries negatively impact HCWs' physical health and quality of life, leading to disability.[34] They frequently produce severe discomfort in the musculoskeletal system, making daily tasks difficult, disrupting sleep, and compromising job performance through loss of working days and reduced earnings, resulting in recurring use of health services and medicines.[35]
[36] Moreover, they result in deteriorating quality of services increasing the rate of absenteeism, lack of engagement, teamwork issues, and frequent conflicts at health service delivery points.[37]
Understanding the factors contributing to injury is an important area to investigate as high injury rates translate into substantive costs for the health care industry. Although some studies were conducted in Saudi Arabia,[38]
[39]
[40] they mainly focused on BBFE and there was a dearth of studies that comprehensively assessed diverse occupational injuries utilizing registered data over an extended period. Thus, this study aimed to investigate the burden of WRI in a tertiary care hospital. The study's findings may provide vital details on the extent and types of injuries that health care professionals suffer, allowing for the development of tailored interventions to improve workplace safety. It also informs hospital administrators and local planners on the efficacy of safety standards and potential cost savings in health care. The study contributes to worldwide occupational health knowledge by providing insights into the subject area. Understanding injury patterns can lead to improved training and preventive measures, resulting in greater patient care and job satisfaction.
Patients and Methods
Study Setting
This study examined data collected from January 2017 to December 2020 at Johns Hopkins Aramco Healthcare (JHAH), a tertiary care hospital located in Dhahran, in the Eastern Province of Saudi Arabia. The Health, Safety, and Environment Department at JHAH oversees the health, wellness, occupational safety, and environmental aspects of its employees to maintain a safe working environment and adhere to best evidence-based practices. Incident, accident, and injury reports are systematically recorded using the Datix reporting system.
Study Population
There was no active selection of study participants. The data have been provided by facility-based occupational health specialists who have been utilizing Exposure Prevention Information Network (EPINet) for several years, some since 2012. This study investigated a 4-year data aggregate of 187 health care providers who had a prior history of any occupational accident and were enrolled in the system.
Data Collection
The EPINet is a Microsoft Access-based surveillance system, developed by the International Safety Center, to standardize the recording and tracking of BBFEs in health care facilities.[41] The Ministry of Health (MOH) of the Kingdom of Saudi Arabia has adopted the EPINet program in 52 MOH federal hospitals by the year 2012.[42] Datix is the reporting system in which each incident, accident, and injuries sustained by HCWs are recorded. Then, each exposed individual was assessed at the staff clinic or emergency room (for after-hours exposures), where blood tests were asked for, counseling was given, and postexposure prophylactic therapy was commenced if necessary. The infection control team operates a root-cause analysis to prevent future recurrence of the event. Occupational health contacts the injured employee to discuss the injury and treatment, implementing measures to prevent seroconversion; when applicable, staff blood tests are repeated at 3 and 6 months. A clinical assessment by an occupational medicine specialist is conducted, if necessary, to evaluate job fitness and design a progressive return-to-work plan, if needed. All the details such as job category of the exposed worker, department or facility, injury location and time, type and purpose of the sharp item, contamination status, source patient details, original user of the sharp item, and the injury's place and severity were recorded using EPINet ver 1.5. Furthermore, the program can gather more details about the exposure, such as the device and technique used, and then provide detailed feedback on which areas are most vulnerable to exposure.[43]
Data Quality
The above three-decade participatory development and modification of the instrument have substantiated evidence for both content and face validity. The exposure patterns are consistent among organizations and throughout the year, reinforcing the instrument's reliability.[44]
Outcome Measurements
Occupational injuries or illnesses among JHAH workers are systematically categorized to effectively record and address various types of incidents. This approach ensures that appropriate care and preventive measures are implemented, promoting a safer and healthier work environment. The following categories were used: (1) loss time injury refers to any injury that necessitates taking time off work, (2) restricted duty injury involves injuries that require modifications to duties or working hours. (3) medical treatment case includes injuries that need medical treatment by a physician, such as medication, injections, or radiological investigations, and (4) first aid (FA) covers injuries that only require FA without medical intervention by a physician such as BBFEs and needlestick injuries, provided there is no seroconversion.
Furthermore, EPINet categorized the exposures into two categories, BBFEs and NSIs. According to the classification, needlestick injuries encompass all reported incidents where a needle or any other sharp object exposed to a patient's body fluid pierces the skin of a health care provider. Whereas BBFE includes all instances where a patient's blood or body fluid comes into contact with nonintact skin or mucous membranes (such as the eyes and mouth) of a health care provider; these are classified as mucosal exposures and human bites.[38]
Data Analysis
Data for this study were extracted from the Datix system of EPINet and exported to SPSS version 16.0 for analysis. The data set included variables such as the type of injury, cause, department, and time of occurrence. Descriptive statistics such as frequency, percent, mean, and median were used to summarize the distribution of different types of injuries. The results were presented in text, table, and figure forms.
Results
Background Characteristics of HCWs
Data from 187 HCWs were considered for this study. More than half (51.8%) of the HCWs were nurses followed by physicians (20.8%) ([Fig. 1]).
Fig. 1 Distribution of health care workers by their profession, in Johns Hopkins Aramco Healthcare (JHAH) from 2017 to 2020, Saudi Arabia.
The Magnitude of Occupational Injuries by HCWs
Between January 2017 and December 2020, a total of 187 workplace injuries were recorded in the JHAH. BBFEs were the primary categories of reported occupational injuries through Datix, accounting for 56.7% (95% confidence interval [CI]: 52.34, 59.89) of all injuries. Falls, slips, trips, and collisions constituted the second most prevalent cause of occupational injuries, representing 15% (95% CI: 12.47, 18.73) of the total injuries (19/187) and the most significant reason for lost workday injuries. Other sharp injuries account for 10.2% (95% CI: 7.89, 13.01), while injuries resulting from physical or mental strain make up 6.4% (95% CI: 4.88, 8.79). Nine health care providers were victims of workplace violence or assaults with an annual average of two reported incidents. These violent incidents were reported by the behavioral health unit and emergency unit. Musculoskeletal disorder or pain was reported by four staff members within 4 years. Only three instances of dermatitis were reported, all related to using of hand sanitizer. The highest number of each injury was recorded in the year 2019 ([Table 1]).
Table 1
Occupational injuries recorded in JHAH from 2017 to 2020, Saudi Arabia
|
Categories of occupational injuries
|
Number of injuries in each year
|
|
2017 (%)
|
2018 (%)
|
2019 (%)
|
2020 (%)
|
Total (%)
|
|
Blood and body fluid exposure
|
21
|
25
|
29
|
31
|
106 (56.7)
|
|
Slips, trips, and collisions
|
4
|
6
|
11
|
7
|
28 (15.0)
|
|
Other sharps injury
|
1
|
7
|
8
|
3
|
19 (10.2)
|
|
Injury caused by physical or mental strain
|
3
|
0
|
4
|
5
|
12 (6.4)
|
|
Injury caused by workplace violence or assaults
|
2
|
1
|
5
|
1
|
9 (4.8)
|
|
Traffic accident (outside the organization performing organizational duty)
|
0
|
0
|
3
|
3
|
6 (3.2)
|
|
Manual handling
|
2
|
0
|
2
|
0
|
4 (2.1)
|
|
Dermatitis
|
0
|
0
|
2
|
1
|
3 (1.6)
|
|
Contact with hazardous substance
|
0
|
0
|
0
|
0
|
0 (0.0)
|
|
Total
|
33
|
39
|
64
|
51
|
187
|
Abbreviation: JHAH, Johns Hopkins Aramco Healthcare.
Blood and Body Fluids Exposures
Over the past 4 years, the cumulative incidence of BBFEs reported was 7.05 BBFE per 100 occupied beds. The highest number of health care professionals with BBFEs was documented in 2019 and 2020, at 36 and 48 events, respectively. In the specified category, needlestick injuries surpassed both mucosal and human bite injuries over all four consecutive years. The rate of needlestick injuries was 3.2 per 100 occupied hospital beds. Human bite injuries experienced the lowest incidence over the years, with no reports in 2018 ([Fig. 2]).
Fig. 2 The distribution of blood and body fluid exposures among health care workers in Johns Hopkins Aramco Healthcare (JHAH) from 2017 to 2020, Saudi Arabia.
Locations for BBFE
The analysis of data on BBFE indicated that the majority (38.7%) of BBFE happened at the operating theaters, followed by the emergency room (28.3%). Comparative number of incidents was recorded in the supportive lab and medical inpatient units ([Table 2]).
Table 2
Locations of BBFE service delivery points (locations) in JHAH from 2017 to 2020, Saudi Arabia (n = 106)
|
Locations/Departments
|
Human bite
|
Mucosa
|
Needlestick
|
Total (%)
|
|
Operating room
|
0
|
6
|
35
|
41 (38.7)
|
|
Emergency department
|
0
|
3
|
27
|
30 (28.3)
|
|
Supportive lab
|
0
|
2
|
6
|
8 (7.5)
|
|
Medical inpatient
|
0
|
1
|
6
|
7 (6.6)
|
|
Pediatric ICU
|
1
|
0
|
2
|
2 (1.9)
|
|
Pediatrics (0–5 y)
|
1
|
0
|
4
|
5 (4.7)
|
|
Orthopedic/Surgical inpatient
|
1
|
1
|
2
|
4 (3.8)
|
|
Dental
|
0
|
0
|
5
|
5 (4.7)
|
|
Surgical unit
|
0
|
0
|
3
|
3 (2.8)
|
|
Total
|
3
|
13
|
90
|
100 (100.0)
|
Abbreviations: BBFE, blood and body fluid exposure; ICU, intensive care unit; JHAH, Johns Hopkins Aramco Healthcare.
Needlestick Injuries
Overall, needlestick injuries accounted for 84.9% of BBFE and 48.1% of all occupational injuries. Furthermore, the analysis was done to show the distribution of needlestick injury by type of needle. Throughout the period, injuries caused by suture needles emerged as the predominant cause of needlestick injuries, closely followed by hypodermic needles and cannulas ([Table 3]).
Table 3
The distribution of needlestick injuries by type of needles in JHAH from 2017 to 2020, Saudi Arabia
|
Type of needles
|
2017
|
2018
|
2019
|
2020
|
Total (%)
|
|
Suture needle
|
2
|
2
|
9
|
14
|
27 (30.0)
|
|
Hypodermic needle (Butterfly) for intravenous infusion or venipuncture
|
1
|
1
|
9
|
10
|
21 (23.3)
|
|
Cannulas (various products)
|
4
|
2
|
5
|
8
|
19 (21.1)
|
|
Hypodermic needle attached to a disposable syringe
|
2
|
1
|
2
|
1
|
6 (6.7)
|
|
Insulin syringe needle
|
0
|
1
|
2
|
1
|
4 (4.4)
|
|
Biopsy needle
|
0
|
0
|
1
|
2
|
3 (3.3)
|
|
Blood gas syringe
|
0
|
1
|
0
|
1
|
2 (2.2)
|
|
IV catheter
|
0
|
0
|
0
|
2
|
2 (2.2)
|
|
Recapper and syringe holder
|
0
|
0
|
0
|
1
|
1 (1.1)
|
|
Port-a-cath access needle
|
0
|
0
|
1
|
1
|
2 (2.2)
|
|
Central venous line
|
0
|
0
|
0
|
1
|
1 (1.1)
|
|
Hypodermic needle on blood collection device (Vacutainer)
|
0
|
0
|
1
|
0
|
1 (1.1)
|
|
Spinal needle
|
0
|
0
|
1
|
0
|
1 (1.1)
|
|
Total
|
9
|
8
|
31
|
42
|
90 (100.0)
|
Abbreviation: JHAH, Johns Hopkins Aramco Healthcare.
BBFEs by Health Care Workers
Occupational injuries were further assessed by the profession of health care provider reporting the injury. Accordingly, 113/187 (60.4%) of all injuries and 57.3% of BBFEs were experienced by nurses, followed by physicians and allied health care providers ([Table 4]).
Table 4
The distribution of blood and body fluid exposures by health care workers category in JHAH from 2017 to 2020, Saudi Arabia
|
HCWs categories (n = 106)
|
Number of BBFEs per year
|
|
2017
|
2018
|
2019
|
2020
|
Total (%)
|
|
Nurse
|
13
|
6
|
23
|
15
|
57 (53.8)
|
|
Physician
|
5
|
3
|
7
|
4
|
19 (17.9)
|
|
Allied health
|
2
|
2
|
4
|
5
|
13 (12.3)
|
|
Housekeeping
|
1
|
0
|
1
|
2
|
4 (3.8)
|
|
Student/Trainee (physician)
|
0
|
1
|
1
|
1
|
3 (2.8)
|
|
Student/Trainee (nurse)
|
1
|
1
|
2
|
2
|
6 (5.6)
|
|
Others
|
1
|
0
|
1
|
2
|
4 (3.8)
|
|
Total
|
23
|
13
|
39
|
31
|
106 (100%)
|
Abbreviations: BBFE, blood and body fluid exposure; HCW, health care worker; JHAH, Johns Hopkins Aramco Healthcare.
Reportable Injuries
Reportable injuries were grouped according to the OSHA standards, with loss time injuries being the majority of reports, followed by cases requiring medical attention. Restricted work injury accounted for the lowest report. There was no report for other categories: work-related fatality, medical treatment beyond FA, loss of consciousness, and significant injuries or illnesses ([Fig. 3]).
Fig. 3 Distribution of reported injuries in Johns Hopkins Aramco Healthcare (JHAH) from 2017 to 2020, Saudi Arabia.
Discussion
Occupational injuries in the health care sector provide considerable issues, affecting the welfare of health care professionals and the overall efficacy of health care facilities. This study aims to provide a thorough examination of occupational injuries documented over 4 years at a tertiary care hospital in Saudi Arabia. Accordingly, 56.7% of occupational injuries were BBFEs, followed by falls, slips, trips, and collisions (15.0%), sharp injuries (10.2%), and strain-related injuries (6.4%). The cumulative incidence of BBFEs was 7.05 BBFE per 100 occupied beds per year. Needlestick injuries represent nearly half (48.1%) of all injuries recorded. The majority of the reported BBFEs were by nurses, followed by physicians and allied health care providers.
The cumulative number of BBFE (7.05 BBFE per 100 occupied beds) reported in this study was higher than reports from the Duke Health and Safety Surveillance System (5.5 per 100 occupied beds).[45] Another study in France reported an incidence rate of exposures of 8.9 per 100 hospital beds.[46] The overall magnitude of BBFE in this study (56.7%) was consistent with the report from the United States (58.0%),[44] higher than studies from France (39.1 and 23.8%)[46]
[47] but lower than a report from Turkey (64%).[48] The incidence of needlestick injury in this study (3.2 incidents per 100 beds) was lower than the reports from Japan (4.8 per 100 occupied beds)[49] and Saudi Arabia (25.43 per 100 occupied beds).[40] A study done in Australia reported 3.23 per 100 full-time equivalent employees.[50] The diverse occurrence and proportions of workplace injuries among health care providers across different countries could be ascribed to variations in safety regulations, health care infrastructure, training and education, cultural attitudes, workload, staffing levels, economic factors, and reporting practices.
Falls, slips, trips, and collisions were the second leading cause of occupational injury, accounting for 15%, which is consistent with a study conducted in the United States, where 18% of HCWs experienced this sort of injury in the previous 12 months.[51] A study in South Africa showed that 20% of HCWs experienced fall, slip, and trip injuries.[52] This finding shows the need for developing mitigation strategies such as improving lighting, maintaining clean and dry floors, using slip-resistant flooring, clearing walkways, marking hazardous areas, providing proper footwear, conducting regular training, implementing safety protocols, and using assistive devices.[53]
[54]
The highest proportion of BBFE was sustained by nurses (53.8%), which was supported by studies from India (45.7%), Saudi Arabia (59.4%),[38]
[42] Serbia (68.6%),[55] Greece (65.1%),[56] and France (60%).[57] Another study found that surgeons had a higher prevalence (64.0%) than scrub nurses (36.0%).[58] This might be due to several factors. The physical demands of their profession, such as regularly moving, lifting, and repositioning patients, commonly result in musculoskeletal injuries, and long shifts and extended hours contribute to weariness, increasing the risk of accidents.[59]
[60] In addition, nurses are frequently exposed to hazardous materials such as medications, infections, and cleaning chemicals, which can cause a variety of injuries and illnesses.[61]
[62] The high amount of direct patient care they offer increases the likelihood of needlestick injuries, slips, stumbles, and falls.[59]
[62] Furthermore, nurses are more likely to experience workplace violence, such as physical and verbal abuse from patients or visitors.[62]
[63] However, the prevalence among nurses is slightly lower in this specific study as compared to other countries, and this might be due to variations in the sample size, stricter implementation of safety protocols, better access to ergonomic training, and cultural factors that emphasize compliance with workplace safety regulations.
This study has both strengths and limitations. The study utilizes an extensive data set covering 4 years, providing substantial and practical insights regarding workplace injuries in hospitals. Nonetheless, the study encounters limitations, including possible concerns over data quality and completeness, as we lack control over the initial data collection procedure, which may create biases. The study is constrained by the variables present in the secondary data, potentially excluding pertinent elements. Moreover, the historical context of the data may restrict its relevance to contemporary actions and circumstances.
Conclusion
The study reveals that BBFEs are the most prevalent occupational injuries among HCWs, with nurses being the most affected group. Needlestick injuries constitute nearly half of these incidents, highlighting a critical area for intervention. To mitigate these risks, it is essential to implement stringent safety protocols, including regular training on handling sharp instruments, use of personal protective equipment, safe patient handling protocols, and adherence to standard precautions. Enhancing workplace ergonomics and implementing environmental safety measures can help reduce occupational injuries.
