TYPICAL OCCUPATIONAL ACCIDENTS WITH EMPLOYEES OF A UNIVERSITY HOSPITAL IN THE SOUTH OF BRAZIL: EPIDEMIOLOGY AND PREVENTION

Estudo epidemiológico descritivo objetivou analisar os acidentes de trabalho típicos notificados pelos trabalhadores de um hospital universitário da Região Sul do Brasil, de 1997 a 2002, e estimar indicadores de risco. Foram notificados 717 acidentes, sendo 86% (616) típicos, cujo coeficiente de risco médio anual foi igual a 6,0 acidentes a cada 100 trabalhadores. As equipes que correram os maiores riscos de sofrer tais acidentes foram as de cozinheiros, marceneiros e auxiliares de enfermagem, sendo as mãos a parte do corpo mais atingida. Quanto à natureza dos acidentes, aqueles de maior risco foram os que envolveram materiais biológicos. Constatou-se a necessidade de orientação do pessoal sobre os aspectos legais dos acidentes e revisão dos processos de trabalho desenvolvidos, especialmente para os que atuam em funções cujos riscos são maiores para contrair doenças graves como AIDS e hepatite B e C.


INTRODUCTION
Research on occupational accidents (OAs) that affect health workers represents an important epidemiological surveillance tool and aims to base the planning and management of health services in order to provide decent work conditions to those who deliver care to society.
According to the Brazilian legislation, OA is the accident that occurs during the performance of work and, as a consequence, causes body lesion or functional disturbance, with permanent or temporary loss or reduced capacity to work, or even death.
Accidents that occur during the work per se are considered typical occupational accidents (TOA), those that occur during transportation from home to work are considered commuting accidents, and professional disease is produced or triggered by the exercise inherent to the activity itself, and finally, occupational disease is acquired or triggered by special conditions the work is performed in and which it is related with.
All OAs should be registered in the social security authorities through the Information on Occupational Accidents (CAT) (1)   .OAs are hazards to workers' health due to laboral activity, environmental conditions where the work is performed, the worker's physical and mental characteristics, social, economic and political contexts.
They are caused by an abrupt or insidious rupture in the relation health-work and interfere in the worker's health-disease process, with substantial personal and social repercussions.
Although apparently contradictory, hospitals themselves present several risks to their own workers, both in care delivery to patients and in support to health care services (2) , despite hospitals' social obligation to deliver care to workers severely injured in accidents.
Hospital institutions are inserted in the tertiary economic sector, directly or indirectly complying with the logic of the capitalist process.While many private hospitals are focused on the search for production and profit, whose model reflects on inadequate remuneration and work conditions, problems of management, financial, and personnel are also frequently verified in public hospitals, which eventually reflect on their personnel's work process.
Even if in an unspecific manner, the Brazilian labor legislation has presented advancements in the last decades on issues related to the safety and health of workers in the health area.On the positive side, standards of adequate conditions hospital work should be performed in, were regulated through Regulatory Standard 32, of Safety and Health at Work in Health Care Institutions (NR-32) (3) .
Occupational hazards are classified in biological, physical, chemical, mechanic, physiological and mental, and exposure to these risks can lead to OAs.Hospital workers, especially those who deliver direct care, are exposed to these risks because of their close contact with patients with infectious diseases, the need to move patients and heavy equipments, physical stress due to the rhythm, organization and division of work, in addition to experiences of pain and death they share, among others, which lead to different kinds of stress.However, there is a considerable number of other workers, equally exposed to risks, who should be taken into account.They work in technical and logistic support to hospital care, like laundry, building maintenance and equipment, storing, material and equipment dispensing and janitorial service.

The risk of being infected by Acquired Immune
Deficiency Syndrome (AIDS) and Hepatitis B is among the most feared by hospital workers, especially in consequence of accidents with contaminated needles, whose indices of infection have been estimated at between 0.25 and 0.4% for the Human Immunodeficiency Virus (HIV), between 6 and 30% for hepatitis B virus (HBV), and between 0.4 and 1.8% hepatitis C virus (HCV) (4)(5) .The Ministry of Health (MS) stresses that permanent preventive measures, through the adoption of Universal Precautions, are the best alternative to preserve the health of workers exposed to these occupational risks (6) .
Aiming to know and work on this issue, in 1998, the State of Paraná, in the South of Brazil, implemented the program of Notification of Occupational Accidents involving Biological Material (NATMB), through the use of a specific notification form, elaborated not only in accordance to the CAT (Information on occupational accidents) but also according to the MS recommendations.The MS determined the use of two notifications (NATMB and CAT) when this type of accidents occurs, and free distribution of anti-retroviral drugs for HIV, as well as others to prevent hepatitis B (6) .
As from the 1990's, several authors have focused on this issue, especially in studies on OAs due to the handling of piercing-cutting material and potentially contaminated biological material.Nevertheless, few   System), and a staff of 1,742 collaborators (7) .The study was approved by the Research Ethics Committee at the university the hospital is linked to.

MATERIAL AND METHOD
Table 1 -Annual distribution of OAs with the TH workers, by type of accident, from 1997 to 2002.Londrina, 2004 n = number of OAs;*N of workers: number of workers at the work unit (7).; ** CAAR: coefficient of risk -ratio between average annual number of OAs and average number of exposed workers.It provides the probability of the accident to occur

Results show a higher Coefficient of Annual
Average Risk (CAAR) of typical occupational accidents (TOAs), of 6.0 accidents for each 100 workers, followed by the coefficient of commuting accidents (CAAR equal to 0.8) and the coefficient of professional diseases, with much lower levels (CAAR equal to 0.2).
The latter presented a considerable increase in 2002 due to a patient hospitalized with scabies mite (Sarcoptes scabiei) in the emergency care.He infected workers whom he had had contact with and those who had handled contaminated material used in direct care (Table 1).
In the year-by-year analysis of CR, an expressive reduction in the TOA indicator was verified in the last two years (Figure 1).were mainly injured in the handling of piercing-cutting material, in the performance of venous puncture and medication administration.In addition to accidents caused by needles in venous puncture procedures, laboratory auxiliaries suffered accidents during the exams themselves, handling materials under examination, and during the cleaning process of glass containers, especially containing blood.The janitorial personnel were injured by piercing-cutting materials inadequately disposed in the trash and in inappropriate places, whose source of contamination was invariably unknown.

Londrina, 2004
The relevance of accidents that involved exposure to biological material in the hospital context was confirmed when analyzing the nature of accidents.These accidents were the most frequent in all years and totalized 314 cases, presenting a CAAR of 3.1, followed by accidents with medical-hospital material (102 cases and CAAR equal to 1.0), especially needles, which presented risks to a great number of workers  and to technical-scientific education, besides humanistic and ethical aspects of future professionals.
In the analysis of all accidents registered by workers at the study hospital, a higher ratio of TOAs was found when compared to cases of commuting accidents and professional disease.This leads to the conclusion that the events mostly occurred in the work (26,645) informed as occupational diseases.A fact worth mentioning is that these accidents resulted in 2,717 deaths (8) .
It was verified in this study that the hospital workers who exert predominantly manual activities and those in the smaller income range are the ones most affected by accidents, which is in accordance with the investigations of other Latin-American authors (9)(10)(11)(12) .Higher exposure does not seem to be linked to lower professional qualification, but to the type of activities these workers perform.
In fact, exposure to workloads characterizes social division and work technique, by the way activities are divided and organized, by the great volume of tasks and repetitiveness of procedures, which can make the team feel the burden of activities and physical and emotional exhaustion in their own body (13) .
Several Latin-American authors have discussed the specific exposure of nursing workers to such occurrences.In fact, these professionals, especially technicians and auxiliaries, are the ones most involved in severe accidents, due to their increased occupational exposure to potentially infectious body fluids like blood, due to their physical proximity to the patient, typical of the nursing care activity, and interrupted tasks of higienization, medication administration, handling and preparation of surgical instruments after use, handling of contaminated excretions and fomites, hectic rhythm required to perform tasks in time, the way the work is divided and organized, making them more vulnerable to occupational risks and OAs, as well as hazards due to exposure (2,9,(11)(12)(14)(15)(16)(17)(18) .
The high level of TOA notifications caused by biological material found in studies on OAs with hospital workers reveals renewed attention in relation to AIDS, especially from nursing personnel.This is possibly due to the discrimination stigma this disease carries, which makes health professionals apprehensive.
Although the hepatitis B virus has been known much longer and represents a higher risk of infection than HIV, with repercussions to health as significant as those from HIV, it does not provoke so great concern among professionals and society itself as AIDS does.
An occupational case of AIDS was notified in São Paulo in 1996.Since the beginning of the epidemic, from 1981 to 1999, 100 proved cases and 213 probable cases of contamination of health professionals by HIV were identified worldwide due to OAs, and the United States is responsible for the largest number of investigated cases (15) .

FINAL CONSIDERATIONS
The evaluation of variables that compose the It is necessary to reorient all workers regarding the current legislation, with a view to preventing undernotification cases, for their own safety, with adequate provision of legal support.
Meticulous evaluation of work processes developed in hospitals, the way the work is divided and organized, is essential in this task, especially for workers who develop functions subject to higher professional risks.It is necessary to know how the worker is inserted in the social group and the history of work processes that cause exhaustion, due to the specificities of the worker's -way of living and working (13) .
The range of variables that compose the hospital work requires more detailed studies, to allow for the development of sound actions of health preservation and promotion to those who dedicate themselves to care for others' health.

OBJECTIVE
Analyze the notified TOAs that affected workers at a Teaching Hospital (TH) in the South of Brazil between 1997 and 2002, according to the variables: type of accident, injured worker's function, nature of the accident, part of the body injured, time and number of hours worked until the moment of the accident; and estimate risk indicators of these occurrences.

Figure 1 -
Figure 1 -Annual distribution of CR of OAs that occurred among TH workers, according to their type

Figure 2 -Figure 3 -
Figure 2 -Distribution of OAs that occurred with TH workers, according to body area injured in the accident from 1997 to 2002.Londrina, 2005 environment and are related to the work process.The same is observed in other studies focused on this issue in hospitals, reproducing what also occurs in the remaining sectors of society.Only in 2006, 503.890OAs were registered in the Brazilian Institute of Social Security, with 80.0% (403,264) of TOA cases, 14.7% (73,981) commuting accidents and 5.3% daily work processes hospital workers are involved in, and especially the search for preventive measures that can be implemented to improve this reality, aiming to reach the human dimension in the work activity, are shown as alternatives for health promotion of this professional group, as recommended by the SUS.The highest risk indicators were verified in this study for typical accidents, which affect mainly cooks, woodworkers and nursing auxiliaries.Hands were the most affected part of the body, exposed to biological material in the handling of piercing-cutting materials.The highest frequency of events happens in the morning and at the third hour.In this perspective, all potential preventive measures able to contribute to OA prevention and health promotion of workers in hospital units should be searched for and institutionalized with the support of the Service of Engineering, Medicine and Safety at work, the hospitals' internal comissions on accident prevention, as well as all other organizational structures responsible for health education and surveillance in the institutions.Preventive and educative actions aimingd to avoid new occurrences should be a concern of all those involved, and require intense effort to inform and educate professionals and students in the area, especially to prevent OAs, which always culminate in professionals' emotional exhaustion, health risks, economic and social problems, financial investments and ethical and legal problems that involve professionals, patients and institutions, among others.

Table 2 -
Distribution of CR of OAs that occurred with TH workers, according to function, from 1997 to 2002.
the body part affected in the TOAs,