Analysis of accidents with organic material in health workers

This retrospective and descriptive study with a quantitative design aimed to evaluate occupational accidents with exposure to biological material, as well as the profile of workers, based on reporting forms sent to the Regional Reference Center of Occupational Health in Florianópolis/SC. Data collection was carried out through a survey of 118 reporting forms in 2007. Data were analyzed electronically. The occurrence of accidents was predominantly among nursing technicians, women and the mean age was 34.5 years. 73% of accidents involved percutaneous exposure, 78% had blood and fluid with blood, 44.91% resulted from invasive procedures. It was concluded that strategies to prevent the occurrence of accidents with biological material should include joint activities between workers and service management and should be directed at improving work conditions and organization.


Introduction
Interest in the theme "Occupational accidents involving exposure to biological material, based on records in reporting forms sent to the Regional Reference Center of Occupational Health (CEREST) in the Macro-Region of Florianópolis" derives from the growing number of notifications involving such accidents.In this context, various factors influence this occurrence and, no matter which factors, awareness raising and changing attitudes are fundamental, among workers as well as health institution managers and administrators, regarding the adoption of standard precautions, with a view to minimizing the number of accidents involving biological material (1) .Health workers' adoption of protection equipment is considered a challenge, as they accept this theoretically, but the equipment still does not permeate daily practice with the same level of intensity (2) .This fact results from a range of factors, such as unavailability/ inappropriateness of Personal Protective Equipment (PPE), work overload, lack of training on the correct use of existing biosafety measures to be taken, as well as the workers' feeling of invulnerability and some workers' wrong habit of recapping contaminated needles (3) .
As a result of the arrival of HIV/aids in the 1980's and, later of epidemiological profile changes, Rev. Latino-Am.Enfermagem 2011 Mar-Apr; 19(2):332-9.
all workers consider themselves vulnerable, including health workers.Considering that, in most cases, they deal with procedures involving biological material, they are more susceptible to these accidents (4) .Given the relevance of the theme, occupational accidents involving biological material cannot be seen as random or casual events, as their understanding and prevention demand a broader approach, which permeates workers, health institutions and social relations (5) .In this perspective, epidemiological research on factors associated with occupational accident occurrence involving biological material, including institutional and individual factors, i.e. related to the workers themselves, can contribute to a greater understanding on the determinant processes for accident occurrence and also offer support for further research and intervention programs in other social contexts (6) .Despite the countless studies on occupational accidents, biological risks and HIV/aids, there is still a lack of research to be used as knowledge and work instruments for professionals and institutions involved in the theme and committed to the formulation of public policies directed at the prevention and health promotion of workers' health (7) .
The results of this study can contribute to knowledge dissemination produced on the theme, as well as to the construction of occupational accident prevention and control strategies involving biological material, through the identification of possible risk factors that may exist during job activities.In view of the entire context and weighing the problem raised -increasing number of reports involving occupational accidents with biological material, the accomplishment of this study is justified, which aims to: Get to know occupational accidents including exposure to biological material which occurred in Greater Florianópolis and; get to know the workers' profile, based on the reporting forms forwarded to the CEREST in the Macro-Region of Florianópolis, between January and December 2007.

Method
This is a retrospective and descriptive study with a quantitative design.Data sources were all 118 accident reporting forms involving biological material occurred in Greater Florianópolis in 2007.Health institutions in this area forwarded these forms to the CEREST, where data were collected.Initially, a survey was carried out and the accidents reported in the forms were investigated.Then, the accidents were analyzed according to the accident victims' profile and accident characteristics, according to the following variables: gender, age, city of residency, work contract, occupation, employer, exposure type, organic material involved, accident circumstance and causal agent, use of Personal Protective Equipment (PPE), as well as information about the victim's vaccination situation and completion of the Occupational Accident Report (CAT).These data were electronically processed and typed in Tabwin, Tabnet and statistics software SPSS 12 for Windows.The research was submitted to the Institutional Review Board of the Florianópolis Health Secretary and, after its approval, data were analyzed (8) .

Profile of workers victims of accidents involving biological material
As for gender, 73% of the accidents involved women, against 27% men.Most of the occupational accidents involving biological material happened among workers in the age range between 20 and 34 years, with 39 cases (56%), against 26 cases (37%) in the age range between 35 and 49 years.

Circumstances of accidents involving biological material among workers
In this context, it is also important to mention that various circumstance predispose to occupational accident occurrence involving biological material.
In this study, in 32.20% of cases, accidents derived from surgical, dental and laboratory procedures, followed by 16.95% originating in intravenous, intramuscular and subcutaneous medication administration; 10.16% due to inappropriate discarding of contaminated material (floor, garbage) and 5.93% during needle recapping.
Besides the above mentioned circumstances, Figure 2 also reveals 22.03% reported as "others".

Organic material involved in accidents with biological material
Another extremely important variable during postaccident assessment, besides the type of exposure, is the organic material involved, which is characterized by the presence of blood, fluid with blood, liquor, among other secretions and body fluids.
Figure 3 demonstrates that 82 accidents involving biological material (69.49%) contained blood; 9.32% fluid with blood; 14.41% were reported as others, including organic material like liquor, serous fluids, sputum and 6.78% were reported as ignored and/or left blank.

Workers' use of Personal Protective Equipment in view of accidents involving biological material
Regarding the health workers' adoption of PPE in their professional activities, although the present study data revealed that a majority uses these biosafety measures, the workers do not always mention these in practice.It was verified that, in 83 records (71%), the workers affirm that they were using some kind of PPE, such as gloves, gown, mask, glasses, among others, at Rev. Latino-Am.Enfermagem 2011 Mar-Apr;19(2):332-9.
the time of the accident.Twenty-six percent of them answered that they were not using the PPE and only 3% left this question blank and/or ignored it.
As for the vaccination situation against Hepatitis B, among the accident victims involving biological material, the study data reveal that, although the large majority informed on the reporting forms that they underwent the recommended vaccination scheme, 37 records were taken into account, that is, 31% of workers had not been vaccinated or their vaccination status was ignored and/or left blank.
With respect to the completion and issuing of the Occupational Accident Report after the accidents involving biological material, out of 118 analyzed reporting forms, only 26 (22%) issued the CAT, while 88 (75%) did not, ignored and/or left this question blank.

Discussion
Based on the presented results, occupational accidents involving biological material predominated among women and nursing professionals, including nurses, nursing technicians and auxiliaries.These results are expected as, according to data by the Federal Nursing Council, today, the nursing profession in Brazil comprises 88.26% women.This fact is also justified as nursing team professionals are not only the biggest group, but are also acknowledged as the largest workforce in health institutions, who have direct contact with the patient, administering medication, doing wound dressings, among other invasive procedures that entail a constant risk of accidents involving biological material (9- 10) .
As opposed to other categories of health professionals, nursing workers spend most of the time with the patient, performing "care" from the perspective of "doing" and, consequently, exposing themselves to different risk, as they can acquire occupational illnesses and injuries due to work (11) .As an aggravating factor for accidents involving this professional category, double work journeys should also be reminded, often leading to mental illness, lack of attention and stress (12) .Also regarding accident susceptibility, students follow nursing professionals.This incidence is due to the large number of technical schools and colleges in the Macro-region of Florianópolis, with many students taking their curricular and/or extra-curricular practicum at different health institutions, sometimes without technical conditions or without direct supervision from the schools or even indirect supervision from the services, as a result of the high demand for existing health actions (13) .
Regarding types of exposure to accidents involving biological material, this study highlighted piercing-cutting objects, such as scalpel blades and needles, mainly in recurring recapping.Studies confirm the high incidence level of accidents involving perforations, underlining the urgent need for surveillance and continuous training for care when handling these objects (14) .
In Brazil, occupational accidents involving piercingcutting material at hospital institutions started to be mentioned in research in the 1970's , although still incipiently.As from the 1980's, due to the alarm raised in publications and debates about aids, many health professionals got terrified by the possibility of catching the disease through accidents involving material contaminated with secretions and fluids, which are common in piercing and cutting material (15) .This increased the interest in investigating this issue more in-depth, particularly in the hospital context, observing that, since then, it has been the target of further speculations, debates, studies and research (16) .

Occupational accidents involving piercing-cutting material deserve further research in comparison with
other types of accidents (deriving from exposure of mucous tissue, intact and/or non-intact skin), as they result from needle pricks, cuts by blades or shards of glass, objects that may be contaminated by the presence of blood, among other body fluids that frighten workers regarding the possible risk of contamination by HIV and hepatitis viruses (17) .In this contact, rigorous assessment of the accident type is needed, that is, the type of exposure needs to be investigated and registered, as well as the body part in contact with the organic material, as the contamination risk degrees vary for certain diseases, consequently entailing different recommended post-accident conducts (18) .
In accident assessment, besides knowing the type present (19) .The most severe accidents involve a larger blood volume, marked by: profound injuries caused by piercing-cutting material, visible presence of blood on the invasive device, accidents involving needles previously used in source patients' veins or arteries and accidents involving large caliber needles, as well as accidents that involve enhanced budded virus involving an HIV-positive source patient (18) .The most important is to avoid these accidents, through permanent education, making workers familiar with the adoption of standard precautions and raising their awareness about the need for adequate use, as an effective measure to reduce infection risks by blood-borne diseases, as post-exposure prophylactic measures are not totally effective (13) .
Various circumstances predisposing to occupational accidents involving biological material were mentioned in the study.In this context, there are individual conditioning factors, such as non-adherence to personal protective equipment use, contaminated needle recapping, inappropriate discarding of contaminated material, as well as double work journeys, which in turn lead to fatigue, tiredness and lack of attention (2,7) .Also, institutional conditioning factors exist, such as lack of training offered by institutional managers, the agitation of the health service, lack of human resources, inadequacy of recipients for discarding contaminated materials, among others (2,7) .In the circumstances mentioned, the workers handled piercing-cutting objects while performing the activity.Hence, the high number of accidents involving piercing-cutting objects as causal agents is not a coincidence.In the same line of thought, the occurrence of occupational accidents involving biological material is also related to the discarding of contaminated material in inappropriate places, loaded containers, transportation/handling of unprotected needles, medication administration without the use of proper protective equipment, disconnection between needle and syringe, as well as contaminated needle recapping.The containers used for discarding piercing-cutting material are not always adequate for this purpose.Sometimes, adaptations are made, using containers like medication boxes and cleaning product packages (11,13) .
As for contaminated needle recapping, 15 to 35% of occupational accidents appoint this error in the needle care procedure.These data were evidenced in a study carried out at a Brazilian teaching hospital, which analyzed accident occurrence situations and trends involving needles (14) .In this line of thought, other studies also ratified the occurrence of these accidents among workers, through the disconnection of the uncapped needle from the syringe, as well as needle recapping, procedures that are no longer recommended according to the Standard Precautions (14)(15)17,20) . Althouh health institutions are entities aiming for care, treatment and care delivery to patients affected by diseases, the latter can also be responsible for illnesses among professionals who are part of the workforce at those institutions (12) .
Regarding the use of PPE, although figures still reveal that some workers do not adopt this equipment, in this study, based on data completed on the reporting forms, the importance managers and workers attribute to PPE use in their job activities is observed when in contact with blood and/or body fluids.Countless efforts have been made to seek ways to minimize accidents involving biological material and possible infection acquisition, such as HIV and hepatitis viruses (1,4) .Just supplying PPE is not sufficient though.Instead, workers need to be sensitized, trained and their anxiety and doubts about the adoption and correct use of biosafety measures need to be listened to.Moreover, it is highlighted that, to enhance health workers' protection in their daily activities involving patients, using common sense, adequate work conditions, availability of PPE and mainly permanent education are necessary and fundamental, with a view to occupational safety and health promotion (12) .
As for the vaccination situation against hepatitis B among accident victims involving biological material, despite the free recommended doses the Health Secretary offers health professionals, unfortunately, the latter still are not totally immune to the hepatitis B virus, as observed in this study.In this sense, constant vaccination campaigns against hepatitis B and onthe-job orientations are opportune and necessary, as transmission occurs despite very small quantities of blood or fluids coming from chronic patients, when in contact with the eye surface or other exposed mucous tissues (21)(22) .
Another important finding revealed in this study refers to underreporting, due to the non-completion and issuing of the CAT after the occupational accident involving biological material.Despite the great importance of this action, in most cases, it is still ignored and/or not completed.There are several reasons for this occurrence, ranging from mere lack of knowledge about the compulsoriness of this procedure to the noncharacterization of the episode as an accident and victims' fear of reporting (23) .It is highlighted that, no matter the occupational accident category, reporting is compulsory, Rev. Latino-Am.Enfermagem 2011 Mar-Apr;19(2):332-9.
including CAT issuing, so as to contribute to the planning of disease and/or health problem prevention actions, as well as occupational health promotion.

Conclusion
This study provided knowledge about the profile of accident victims involving biological material, as well as the peculiar characteristics of these accidents in Greater Florianópolis.Regarding the profile, nursing workers were the most exposed to occupational accidents involving biological material and piercing-cutting objects, with the presence of blood and/or fluid with blood.This is in line with research ratifying the high incidence level of these accidents among nursing workers, as these are not only the main group, but also have direct contact with the patient, handling piercing-cutting objects.
In view of this context, research is needed about accidents involving biological material, so as grant managers, institutions and workers the possibility to (re)plan strategies that go beyond the mere avoidance of accidents and aim to promote workers' health and quality of life in their job activities.
of exposure, it is fundamental to know what biological material was involved, characterized by the presence of blood, fluid with blood, liquor, among other secretions/ body fluids.Investigating the presence of biological material is extremely important, and attention should be even greater when this material is blood and/or fluids with blood, like in the present study.Occupational accidents involving blood and other potentially contaminated fluids should be treated as emergency cases, as interventions for HIV and hepatitis B prophylaxis, when indicated, need to start soon after the accident with a view to greater efficacy.Severity criteria in accident risk assessment consider the blood volume, as well as the virus quantity Vieira M, Padilha MI, Pinheiro RDC.

Finally, it is
concluded that the data collected in this study indicate that strategies to prevent occupational accidents involving biological material should include joint actions, established between workers and service management, aiming to improve job conditions, especially directed at work organization, supply of materials with safety devices, establishment of educative programs, as well as sensitization with a view to behavioral change among workers and managers, as isolated actions are considered ineffective to minimize these problems.