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The risk and cost of hepatitis B exposure in the lab.

Despite the best precautions, a blood collection tube shatters in the lab, lacerating a technologist's fingertip. At bedside, an errant needle jabs a phlebotomist's palm. The wounds may be minor, but the accidents trigger immediate action to protect these employees from hepatitis B.

Until 1982, passive hepatitis B immunoprophylaxis was the only recourse when environmental safeguards, such as needle-disposal containers, failed. Since then, however, the availability of a vaccine for active immunization has changed the picture. Hospitals must consider this new alternative and reevaluate the costs and benefits of preventive measures -- especially for clinical laboratory employees, who run a greater risk of exposure to the disease than colleagues in other hospital departments.

Toward this goal, our research team undertook a study in 1981 to gauge the extent and financial impact of potential exposures to hepatitis B in all services of six metropolitan Phoenix community hospitals. Our aim was to help administrators understand the risks and develop the most cost-effective and useful programs to protect personnel.

The collected data point clearly to one conclusion: Hepatitis B exposure in the clinical laboratory is such a serious and costly problem that lab directors and supervisors should become involved in their hospitals' planning concerning use of the hepatitis B vaccine.

Our study differs from previous research in four important ways:

* It focuses on community hospitals, where most hospital-based laboratory personnel work. Earlier studies demonstrated the risk of hepatitis B to laboratory personnel in teaching hospitals and major medical centers, county hospitals that serve indigent population, and Veterans Administration hospitals.

* It is a one-year prospective study with case finding and follow-up--not s retrospective analysis of reported exposures.

* it is a multihospital study using standardized methodology--not an examination of one institution.

* It includes a detailed cost analysis of each potential exposure.

We randomly selected the six Phoenix area community hospitals and invited them to participate. All agreed.

First we met with each hospital's infection control and employee health nurses to explain the study. Then our research staff visited each hospital weekly to collect data on every potential exposure to hepatitis B. We defined "potential exposure" as any reported employee incident resulting in indirect or direct percutaneous or mucosal surface exposure to a patient's blood or secretions. This included needle puncture wounds from sharp instruments and broken glassware, pipetting accidents, blood and secretion spills, and human bites.

We constructed a survey to record employee information, including the kind and duration of medical intervention following each accident. Source documents included supervisors' reports of employee injuries; employees' health, medical, and incident/accident records; safety committee minutes; personnel records; and logs that the Federal Government requires for occupational injuries and illnesses.

For our cost analysis, we collected data on charges for passive immunization with immune globulin, laboratory tests, and medical care given employees; workers' compensation payments to employees for hepatitis B; and salary ranges for specific employee groups. More salary data came from the 1982 salary survey of the Arizona Hospital Association. Finally, we culled statistics on typical charges for laboratory tests, medical procedures, and treatment related to hepatitis B from two rate review packages submitted by Arizona hospitals to the Bureau of Economics and Planning of the Arizona Department of Health Services in 1982.

Employees pay billed charges through their insurers or hospitals for hepatitis B exposure treatment. Therefore, we used data on billed charges to represent the hospitals' costs for every test, procedure, and treatment needed after potential exposures.

Costs of emergency room or other treatment site vists were assigned as treatment costs, using average charges. We excluded first aid, treatment at the accident site, physical exam, and history costs because they were difficult to calculate. These costs exist, however, so our dollar estimates for postexposure treatment were conservative.

Once we assigned costs, we multiplied them by the number of times each medical service was given to each exposed employee and then calculated a total sum. From this, we derived an average cost per exposure. To measure the cost of lost work hours, including time required for first aid, we used the average wage rate for each employee's job class, multiplied by known or estimated time lost for diagnosis or treatment.

Finally, to calculate annual rates of exposure by type of employee and other parameters, we amassed data on positions, assignments, age, tenure, and sex for all individuals in the study group.

The six hospitals employes 387 laboratory personnel. When the research team finished its year-long task of gathering reports from all six sites, we found that three types of personnel--technicians, medical technologists, and phlebotomists--were potentially exposed to hepatitis B a total of 111 times. That's 28.7 exposures per 100 lab employees every year.

In other words, a typical year finds two out of every seven laboratory staff members involved in on-the-job incidents that potentially expose them to hepatitis B.

We classified exposures by the kind of incident (Figure I). Two-thirds were needle puncture wounds. When we separated the exposures by hospital location (Figure II), we found that fewer than half occurred in the lab. Specimen collection accounted for many of the incidents--31 per cent occurred in the adult medical-surgical nursing unit; 10 per cent in the intensive and cardiac care units; and 9 per cent in the emergency room.

The likelihood of potential exposure to hepatitis B varied with job title, tenure, and age (Figure III). Medical technologists were less likely to be involved in incidents (15.5 exposures per 100 MTs) than were laboratory technicians (23.7 exposures per 100) or phlebotomists (87.5 exposures per 100). Surgical technicians had a 24.7 per 100 exposure rate, but such other hospital personnel as nurses, clinicians, x-ray technicians, and respiratory therapists were well below the lab exposure rates.

Laboratory staff members in their first two years of work had a lower rate of potential exposure than those with more seniority, a trend that may reflect the selective assignment of tasks to new employees in these hospitals.

There was a strong inverse relationship between exposure risk and age. Before age 30, the rate was markedly higher. It declined with subsequent 10-year brackets, mirroring the movement of experienced personnel into management positions.

Ten of the 111 exposures involved patients who were known to be hepatitis B antigen-positive. The hospital staffs conducted chart reviews or serologic testing on 39 of the remaining 101 patients who were identified as sources for the incidents. None had hepatitis B.

Even if we make the conservative estimate that the 62 patients not followed were free of hepatitis B, then 9 per cent of the recorded incidents were exposures to the disease. That estimate jumps to 22.4 per cent if we restrict our analysis to source patients who were followed--the 10 with hepatitis B and the other 39. In either case, the data show a substantial risk that exposure to patient blood or secretions also means exposure to hepatitis B.

Our cost analysis revealed that the six hospitals spent $9.039 on testing and treatment for potential exposures involving lab personnel. Lost work time cost $564. Total costs equaled $9,603, or $86.51 per exposure.

Some interventions performed in response to these 111 incidents, of course, have nothing to do with hepatitis B prevention: eye irrigation, suturing, antibiotics, tetanus toxoid, VDRL testing, and follow-up doctor's visits, for example. These "continuing costs," as we call them, are associated with potential hepatitis B exposures but unrelated to the disease itself.

Hepatitis-related costs, on the other hand, are those interventions aimed specifically at the potential exposure--costs that could have been eliminated had employees been protected by immunization. In the six hospitals, 83 per cent, or $71.74, of costs associated with an exposure incident are directly related to preventing hepatitis B. This includes administration of immune globulin and serologic and liver function tests. We did not count work time lost because of a doctor's visit or the basic visit charge. While such care might include both hepatitis-related and continuing costs, we assigned it entirely to the latter because it was impossible to determine a generally applicable breakdown.

It's important to note that the risk and cost of receiving the hapatitis B vaccine were not considered in this study, although we are analyzing them at the present time.

Our study shows that laboratory personnel in community hospitals are at substantial risk of exposure to hepatitis B. It also shows that a potential exposure costs community hospitals an average of $86.51--and that hospitals can avoid $71.74 of this cost by immunizing laboratory personnel with hepatitis B vaccine.
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Copyright 1984 Gale, Cengage Learning. All rights reserved.

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Author:Kirkman-Liff, Bradford L.; Dandoy, Suzanne E.
Publication:Medical Laboratory Observer
Date:Oct 1, 1984
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