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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 2  |  Issue : 2  |  Page : 47-52

Cost of postexposure management of occupational sharp injuries in an Indian tertiary health care facility: A prospective observational study in a tertiary care hospital


1 Department of Anesthesia, Critical Care, Pain Relief and Infection Control, Fortis Hospitals, Bangalore, Karnataka, India
2 Department of Microbiology, Fortis Hospitals, Bangalore, Karnataka, India
3 Department of Anesthesia, Fortis Hospitals, Bangalore, Karnataka, India
4 Department of Infection Control Nursing, Fortis Hospitals, Bangalore, Karnataka, India

Date of Web Publication19-Jan-2016

Correspondence Address:
Dr. Murali Chakravarthy
Department of Anesthesia, Critical Care, Pain Relief and Infection Control, Fortis Hospitals, Bannerughatta Road, Bangalore - 560 076, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-1880.174349

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  Abstract 

Introduction: Sharp injuries are not uncommon among healthcare workers and costs of post ex-posure management go unmeasured, because a few aspects of it are potential costs due to medi-co-legal and psychological issues which indeed are unmeasurable.Many healthcare institutions even in India are obliged to carry out investigations and provide treatment in the event of sharp injury from an infected patient. These cost the healthcare facility.
Aim: In an attempt to understand the direct cost of post exposure management, we carried out this prospective observational study.
Results: There were two hundred and three sharp injuries at our institution from the year 2007 to 2014. In our study the total cost of post exposure management was INR 423,555/- and approxi-mate mean cost per sharp injury was INR 2100/-. Several workers from developed countries showed that it made economic sense to use safety engineered products rather than manage sharp injuries. This however might not be acceptable verbatim in developing countries counties such India.
Conclusion: Time has come for governments and producers of safety engineered devices to arrive at a formula in making safety engineered devices are available to healthcare workers of India at cost lower than that of developed countries.

Keywords: Health care workers (HCWs), safety-engineered devices (SEDs), sharp injuries (SIs)


How to cite this article:
Chakravarthy M, Rangaswamy S, Harivelam C, Pargaonkar S, Hosur R, Pushparaj L, Anand T, Senthilkumar P, Suganya A. Cost of postexposure management of occupational sharp injuries in an Indian tertiary health care facility: A prospective observational study in a tertiary care hospital. J Nat Accred Board Hosp Healthcare Providers 2015;2:47-52

How to cite this URL:
Chakravarthy M, Rangaswamy S, Harivelam C, Pargaonkar S, Hosur R, Pushparaj L, Anand T, Senthilkumar P, Suganya A. Cost of postexposure management of occupational sharp injuries in an Indian tertiary health care facility: A prospective observational study in a tertiary care hospital. J Nat Accred Board Hosp Healthcare Providers [serial online] 2015 [cited 2019 Apr 26];2:47-52. Available from: http://www.nabh.ind.in/text.asp?2015/2/2/47/174349


  Introduction Top


Sharp injuries (SIs) are avoidable health care-associated hazards; they occur commonly in operation and emergency rooms. Nurses appear to be the most common victims and usually doctors are next on the list. Health care workers (HCWs) unconnected with patient treatment are also exposed to SIs at times due to inappropriate waste disposal by users or by the negligent use of sharps. SIs pose the health hazard of transmitting infections to the victims. The epidemiology and incidence of SIs have been studied. There are only a very few studies about the economic issues involved. The economic burdens from SIs have been defined. [1] They are:

  1. Testing for infection in the injured worker and, if known, the patient on whom the sharp had been used.
  2. Postexposure prophylaxis (PEP) to prevent or manage potential blood-borne virus transmission.
  3. Short- and long-term treatment of chronic blood-borne viral infections that are transmitted to injured workers.
  4. Staff absence and replacement.
  5. Counseling injured workers.
  6. Legal consequences (litigation and compensation claims).


Points 1 and 2 mentioned above include postexposure management while the others are potential and vary from one HCW to another. A burden of amounts varying from €4 million to €7 million is expected to result from SIs due to the abovementioned costs. [2] There are only a few studies assessing this cost from India. This encouraged us to conduct this prospective study.

The protocol of management of SIs in the author's facility is as follows:

  1. First aid.
  2. Report to the emergency room.
  3. Action by nursing supervisor.
  4. Action by the infection control nurse.
  5. Action by the medical staff.


This study aimed at assessing the cost of postexposure management of SIs in health care workers of our institution. The cost of SIs is relatively difficult to study because of the types of costs involved; they are direct, indirect and potential. The costs vary from one part of the world to another and even within the country, the costs vary from one facility to another. The cost of post exposure management of SIs in India has not been studied yet. In this prospective study, we plan to assess the direct costs involved in SIs.


  Materials and Methods Top


This study was conducted from the year 2007 to 2014. All the SI reports were considered and the tests, prophylaxis and or treatment provided to the HCWs were made note of. The employee category, site of injury, circumstances that led to SI among other parameters were acquired using the Exposure Prevention Information Network (EPINet) format proposed by Jagger et al. [3] All the HCWs reported the circumstances that led to the SI and filled up the EPINet reporting form. As per the institutional protocol, basic tests and follow-up tests were conducted. The flow chart shows the management of sharp injury at our institute [Chart 1]. The testing and treatment following a SI/blood and body fluid exposure in the unit are as follows:

[Additional file 1]

  1. Blood screening: Identifying the source individual or source of the sharps.
  2. Source status (if known).
  3. HCW status:
    1. Check infection control data for hepatitis B antigen and antibody, hepatitis C antibody and human immunodeficiency virus (HIV) antibody results.
    2. Obtain a baseline HIV test for the injured worker at the time for both medical management and baseline infection data. The post exposure prophylaxis regimen is shown in [Table 1].
      Table 1: Postexposure prophylaxis regimen Postexposure prophylaxis regimen PEP-HIV treatment as per the National AIDS Control Organization (NACO)

      Click here to view
    3. The injured worker's hepatitis B antibody status needs to be documented, i.e., whether he/she has received the hepatitis B immunization or not. If he/she has not been vaccinated in the past, hepatitis B immunoglobulin may be given immediately if the risk for hepatitis B exposure is considered significant and the hepatitis B vaccine series should be initiated.
    4. The hepatitis C antibody status of the injured employee must also be documented.


The treatment regimen for postexposure prophylaxis is shown in [Table 1]. The list of all the tests performed is shown in [Table 2]. The costs of the tests and medicines are shown in [Table 3]. The cost due to the absence of staff at work due to the injury and counseling were not included in the study since it was not feasible. Cost of the HCWs who required antiretroviral therapy was included. [Table 4] shows the incidence of SIs among HCWs based on their profession.
Table 2: List of tests to be conducted as per the hospital protocol showing the list of tests conducted after exposure

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Table 3: Showing investigation and treatment of HCWs

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Table 4: Table showing the incidence sharp injuries among HCWs based on their professions

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The cost calculated included the following:

  1. Cost of laboratory tests.
  2. Cost of initial treatment.
  3. Some of the HCWs also required other tests such as complete blood cell count and liver function test in addition to the routine tests.
  4. The cost of additional laboratory tests and vaccinations.
  5. Antiretroviral therapy.



  Results Top


This study was conducted at our facility from the years 2007 to 2014. There were 203 SIs in this period of time. All the SIs were reported on the EPINet form. The list of investigations that were conducted are listed in [Table 3]. The details of the job profile of the HCWs who were injured are mentioned in [Table 4]. Nurses suffered most injuries (43%) in contrast to doctors, who suffered 21% of all injuries and the housekeeping staff (17%). The cost of these therapies and/or investigations changed from time to time. The cost of the tests over the years changed and that is shown in [Table 5]. The cost per SI varied from 1,485 (in 2007) to 2,560 (in 2014). Based on the number of injuries, the total cost of investigation and treatment of SIs is shown in [Table 6]. The follow-up was carried out for 3 years. None of our HCWs seroconverted. Two HCWs were lost to follow-up.
Table 5: Cost of tests

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Table 6: Showing the total cost of sharp injuries

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  Discussion Top


In our prospective observational study during the years 2007 to 2014, we encountered 203 SIs in this period. Occupational SIs among HCWs are not uncommon. In a study of more than 1.4 million patient days, we showed a frequency of 0.43 SIs/1,000 inpatient days. [4] A similar or higher frequency of incidents has been reported by various authors. [5],[6] It is the responsibility of the health care facility to tend to the HCW injured while on duty. Postexposure management of SIs incurs cost. The cost is due to certain laboratory investigations, medications, and follow-up. The cost of SIs is also comprises various other costs arising from investigations and treatment, absence from work, counseling injured workers, and legal consequences. Many of these are potential and may not occur in the same time frame as that of investigations and/or treatment. In this prospective study, we calculated only the cost of investigations and treatment involved in our HCWs from the years 2007 to 2014. Various authors have shown that postexposure management incurs costs for the health care institution. [7] The average costs (in US$) of preventive measures were 168 for hepatitis B virus, 134 for hepatitis C virus, and 146 for HIV [Table 7].
Table 7: Showing the increasing costs of the postexposure management

Click here to view


The actual cost due to SIs and their postexposure management is considerable. In our study, the total cost of postexposure management is 423,555 and average cost per SI is 2,086.5. This method of costing does not take into consideration the probable underestimation of the problem and the cost due to underreporting. Underreporting is a major global problem associated with SI reporting. The incidence of underreporting is to the tune of 50-75%. One could imagine the magnitude of the cost of SIs, which would be grossly underestimated due to underreporting. [8] If one were to expect reporting of all SIs, the cost incurred may be higher.

This study has not taken into consideration other measurable and immeasurable costs of other tests such as complete blood cell count and liver function test in addition to the routine tests. The cost of additional laboratory tests and vaccinations and antiretroviral therapy has also not been taken into consideration, as none of our HCWs seroconverted.

The increasing cost of investigation of SIs is also a matter of concern and it also indicates the economic burden on the health care institutions, which may not be completely offset by adopting SEDs. It is a matter of interest if use of safety-engineered devices (SEDs) would reduce the health care cost considering their high procurement cost. The question is - is the practice of using SEDs cost-effective? In a developing country such as India, it is difficult to justify the use of SEDs. In several European studies, the cost-effectiveness of use of SEDs has been shown. Considering the high cost of postexposure management in those countries, the cost of procurement of SEDs might be justified. But in our country, the only way one could facilitate the process of using SEDs is by reducing the procurement cost. The manufacturers of SEDs in India have to address this issue. The society might expect the manufacturers to reduce the cost of these morbidity-preventing products under their corporate social responsibilities. It is also this authors' opinion, that HCW safety is not only the responsibility of the health care institutions, but also of the society, state and central governments. Since SEDs which have been shown to reduce the SIs considerably, they must be subsidized by governmental participation, thus making it available at lower cost to these unaffordable healthcare institutions. HCW safety must be prioritized by the health department of the Government of India and endeavors such as cost reduction of SEDs must figure at the top of the pecking order of "must dos" in the care of HCWs.


  Conclusion Top


Postexposure management costs of SIs are significant and increasing every year. It is time that both health care providers and manufacturers of SEDs address the Indian challenge - health care providers by allocating funds for the purchase of SEDs and manufacturers by reducing the cost of SEDs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Scotland NH. Safer Sharps Devices: An Evaluation of Utility in NHS Scotland. Edinburgh, UK: Scottish Executive Health Department; 2005.  Back to cited text no. 1
    
2.
Saia M, Hofmann F, Sharman J, Abiteboul D, Campins M, Burkowitz J, et al. Needlestick injuries: Incidence and cost in the United States, United Kingdom, Germany, France, Italy, and Spain. Biomed Int 2010;1:41-9.  Back to cited text no. 2
    
3.
Jagger J, Perry J. Power in numbers: Using EPINet data to promote protective policies for healthcare workers. J Infus Nurs 2002;25(Suppl):S15-20.  Back to cited text no. 3
    
4.
Chakravarthy M, Singh S, Arora A, Sengupta S, Munshi N, RangaswamyS, et al. Epidemiology of sharp injuries - prospective EPINet data from five tertiary care hospitals in India - Data for 144 cumulated months, 1.5 million inpatient days. Clin Epidemiol Glob Health 2014;2:121-6.  Back to cited text no. 4
    
5.
Ghasemzadeh I, Kazerooni M, Davoodian P, Hamedi Y, Sadeghi P. Sharp injuries among medical students. Glob J Health Sci 2015; 30;7:47047.  Back to cited text no. 5
    
6.
Floret N, Ali-Brandmeyer O, L′HOriteau F, Bervas C, Barquins-Guichard S, Pelissier G, et al.; Working Group AES-RAISIN. Sharp Decrease of Reported Occupational Blood and Body Fluid Exposures in French Hospitals, 2003-2012: Results of the French National Network Survey, AES-RAISIN. Infect Control Hosp Epidemiol 2015;36:963-8.  Back to cited text no. 6
    
7.
Oh HS, Yoon Chang SW, Choi JS, Park ES, Jin HY. Costs of postexposure management of occupational sharps injuries in health care workers in the Republic of Korea. Am J Infect Control 2013;41:61-5.  Back to cited text no. 7
    
8.
Rajkumari N, Thanbuana BT, John NV, Gunjiyal J, Mathur P, Misra MC. A prospective look at the burden of sharps injuries and splashes among trauma health care workers in developing countries: True picture or tip of iceberg. Injury 2014;45:1470-8.  Back to cited text no. 8
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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