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\title{Needle Stick Injury: Inevitable or Avertable}
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             \author[1]{Dr. Abhinav  Wankar}

             \affil[1]{  All India Institute of Medical Sciences}

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\date{\small \em Received: 15 December 2017 Accepted: 4 January 2018 Published: 15 January 2018}

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\begin{abstract}
        


Healthcare workers across the globe are exposed to infectious agents? day in and day out. Increased reliability on diagnostics has increased usage of needles by healthcare personnel while fulfilling their clinical obligations .This has made healthcare personnel prone to injuries. Needle stick injury is an occupational hazard in hospital settings1, 2. Healthcare workers are at great risk of needle stick injury while administering injections, withdrawing blood, disposing needles, handling linen, biomedical waste segregation etc.3, 4,5,6,7. The risk of acquiring HIV through needle stick is 0.3%; while, such risk is 3% for hepatitis C, and 30% for hepatitis B8. These injuries are also seen to induce considerable psychological aftermaths such as phobia, anxiety and stress in affected individuals 9, 10. Needle stick injury are injuries caused by needles such as hypodermic needles, blood collection needles ,intravenous stylets and needles used to connect parts of intravenous delivery systems (National Institute for Occupational Safety and Health). The incidence of needle stick injuries among health-care workers varies in different countries. For instance, its prevalence has been reported to be about 66% in Egypt, 45% in Pakistan, 31.4 % in Germany, 46.8% in Saudi Arabia, 45% in Turkey, 50% in Australia and Taiwan and 79.5% in India. It seems that these injuries are more prevalent in developing countries11. NeedleStcknjurynevitableorAvertableStrictly as per the compliance and regulations of: needles, handling linen, biomedical waste segregation etc. 3,4,5,6,7 . The risk of acquiring HIV injuries. Needle stick injury is an occupational hazard in hospital settings 1,2 . Healthcare workers anxiety and stress in affected individuals 9,10 . injuries are more prevalent in developing countries 11 .

\end{abstract}


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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
ealthcare workers across the globe are exposed to infectious agents' day in and day out. Increased reliability on diagnostics has increased usage of needles by healthcare personnel while fulfilling their clinical obligations. This has made healthcare personnel prone to injuries. Needle stick injury is an occupational hazard in hospital settings \hyperref[b0]{1,}\hyperref[b1]{2} . Healthcare workers are at great risk of needle stick injury while administering injections, withdrawing blood, disposing needles, handling linen, biomedical waste segregation etc. \hyperref[b2]{3,}\hyperref[b3]{4,}\hyperref[b4]{5,}\hyperref[b5]{6,}\hyperref[b6]{7} . The risk of acquiring HIV through needle stick is 0.3\%; while, such risk is 3\% for hepatitis C, and 30\% for hepatitis B \hyperref[b7]{8} . These injuries are also seen to induce considerable psychological aftermaths such as phobia, anxiety and stress in affected individuals \hyperref[b8]{9,}\hyperref[b9]{10} .\par
Needle stick injury are injuries caused by needles such as hypodermic needles, blood collection needles ,intravenous stylets and needles used to connect parts of intravenous delivery systems (National Institute for Occupational Safety and Health) . The incidence of needle stick injuries among health-care workers varies in different countries. For instance, its prevalence has been reported to be about 66\% in Egypt, 45\% in Pakistan, 31.4 \% in Germany, 46.8\% in Saudi Arabia, 45\% in Turkey, 50\% in Australia and Taiwan and 79.5\% in India. It seems that these injuries are more prevalent in developing countries \hyperref[b10]{11} .\par
Reporting of needle stick injury is a type of secondary prevention which is instrumental in early diagnosis and treatment. It is also required to provide psychological treatment to patients to alleviate anxiety. Even for infection control researchers, the NSIs assessment remains problematic, because official NSIs data are often conservative because of widespread underreporting \hyperref[b11]{12} . It is felt that organizations should have robust needle stick injury reporting mechanism and adequate infrastructure.\par
Despite being aware of the importance of reporting, underreporting of needle stick injuries is a known phenomenon. But little is known about the factors that may be responsible for underreporting. These factors could be individual, organization based on training based. Needle stick injury problem is magnified because of underreporting of Needle stick injuries. Ignorance, lack of understanding gravity of NSI ,lack of Knowledge ,non cooperation of higher staff Author ? ? ? ? ¥: e-mail abhinav.wankar@gmail.com are some of the factors which cause underreporting needle stick injuries . Knowledge of these factors could help organizations take corrective actions and develop a milieu which encourages reporting of needle stick injuries.\par
The present study has been conducted with the objective to determine the frequency of needle stick injuries among nurses, their awareness about the existing reporting mechanism at the organization in went of a needle stick injury and determine factors/barriers amongst nurses for reporting needle stick injuries. 
\section[{II.}]{II.}\par
Material and Methods Stratified random sampling was performed. 6. Methodology: First, the number of staff at each department was assessed. Then, the quota for each department was calculated and selected randomly among the staff at each center. A questionnaire was prepared. The content validity of the questionnaire was determined and modified according to the comments raised by experts. Questionnaire included questions on demographic characteristics (i.e. age, gender, marital status, work experience, job, the highest qualification, working unit and the employment status), the knowledge related to sharps injuries, complications and actions needed to be taken after an injury occurred, the history of exposure to a sharp injury and its causes if occurred, and the actions they have taken after a sharp injury occurred. The characteristics of the occupational exposures including route of exposure and the procedure in which the exposure occurred, place and time of exposure occurrence and viral status of the source patient were also asked. Moreover, data on protective measures used by the HCWs, HBV immunization status and antibody titre, number of injuries reported to the hospital and reasons for not reporting such injuries were also collected. Prior to distribution, the questionnaire was piloted to assess its feasibility and to give more information about the problem. The participants were asked to fill-out the unnamed validated questionnaire and collected by Nursing Infection Control Nurses. 7. Data Analysis: The data were analyzed using SPSS version 17. Chi-square and Fisher Exact tests were used for all the analyses, while p-values < 0.05\% were considered statistically significant. All the participants were free to enter the study or withdraw from it whenever they wished. The questionnaires were coded then; the collected data were entirely kept secret and anonymously reported. 
\section[{III. Observations and Results}]{III. Observations and Results}\par
Total of 193 nurses submitted the questionnaire Following were the observations of study :     The correlation of NSI with policy was strongly significant (P=0.01) j) Needle stick injury with support received from superiors Out of total 112 nurses who had experienced needle stick injury, 48 (42.85\%) had received support from superiors and 74 (66.07\%) had not received support from superiors Correlations of reporting of Needle stick Injury with support of superiors was significant (P=0.000)a) Distribution 
\section[{k) Needle stick injury with years of experience}]{k) Needle stick injury with years of experience}\par
The correlation between needle stick injury and years of experience was not significant (P=0.801) .This indicates that needle stick injury experienced is not dependent on years of experience. 
\section[{IV. Discussion}]{IV. Discussion}\par
Needle stick injuries amongst Nurses working in Tertiary care Hospital in North India. This study attempted to unravel the various factors that hinder reporting of Needle Stick Injury among Nursing Officers in a tertiary care setup. In the present study, 58 \% nursing officer had experienced needle stick injury. This result is similar with results of study conducted by Arman Azadi amongst Iranian nurses which stated that more than one third of nurses have experienced needle stick injury. \hyperref[b12]{13} The similar results may be due to similar hospital setup and similar study population.\par
The study showed correlation between needle stick injuries with years of experience as negative. This result was similar with result conducted by Dr .S. Salelkar and team in tertiary care hospital in Goa. The result is similar as the study was conducted in similar environment . \hyperref[b13]{14} However results were contrary to study findings Telali et al. \hyperref[b14]{15} in their study in south India reported that as work experience increased the incidence of needle stick injuries decreased. The results were contrary as the study conducted by Telali et al comprised of all healthcare workers .Hence the level of knowledge and experience were very varied among study population. As a result increase in experience will increase level of knowledge.\par
In this study, lack of knowledge whether to report NSI was the main cause of undereportng. However lack of awareness of NSI policy, NSI by sterile needle, infrastructure, workload, infrastructure and sero negative patient report, ART side effects were other causes of underreporting. These findings were similar to findings of Arman Azadi \hyperref[b12]{13} . Also studies conducted by Dr Rambha Pathak and team reported that majority of the HCWs who suffered NSI did not report to the hospital administration. \hyperref[b15]{16} The commonest reason cited for this was fear of being considered unskilled followed by not knowing where to report and lack of time. Another author has also reported that 90\% never reported because they were not aware of the importance of postexposure prophylaxis. \hyperref[b17]{17}  In the present study, majority of participants have stated that NSI is experienced during performing any procedure. Other causes stated were due to workload and during BMW segregation. This finding was similar to findings of Dr Rambha Pathak et al in MM Institute of Medical Sciences and Research, Mullana which stated 56.9\% injuries were from a hollow borrow needle and also mentions that 48 \% of needle stick injury occurred during disposal of needles. In study conducted by Ruben et al, long working hours has also been found to be an important risk factor for NSI. \hyperref[b19]{19} The health care environment in a tertiary care hospital is a hectic and stressful one and long duty hours are common. It is important that time management is done appropriately to avoid work stress .Given the dangers of disease transmission through needle stick injuries, the surprising lack of awareness of these dangers and the corrective actions to be taken post injury makes it imperative to address this issue urgently. Healthcare staff needs to be trained in universal precautions, proper sharps disposal and action to be taken in case of injury needs to be given to all categories of health care workers. The hospital needs to have a uniform needle stick injuries policy covering safe work practices, safe disposal of sharps, procedures in event of needle stick injury, training including pre-employment training, monitoring and evaluation of needle stick injuries and procedures for reporting needle stick injuries. \hyperref[b13]{14} Healthcare workers need to be made aware of the needle stick injury policies. 
\section[{V. Conclusion}]{V. Conclusion}\par
Constant education, workshops or life-long short training is an integral to developing awareness amongst health care workers and improving adherence to good clinical practice and concordance with policy and procedures. Efforts should be made to explore alternatives of inventories, devices with safety measures .Ensuring adequate and continuous education and training in safe use and disposal of needles can reduce the incidence to a great extent. NSI surveillance mechanism must be developed in the hospital and preventive practices like vaccinations for hepatitis B, institution of appropriate PEP, psychological support and counseling of affected HCWs and stringent followup must be ensured. Averting NSI is a continuous process and requires a stringent policy to create safe and fair environment for employees.\begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-2.png}
\caption{\label{fig_0}H}\end{figure}
   \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.4594594594594595\textwidth}P{0.25270270270270273\textwidth}P{0.13783783783783785\textwidth}}
Designation\tabcellsep Number of nurses in study\tabcellsep Percent\\
Junior Nursing Officer\tabcellsep 172\tabcellsep 89.1\\
Senior Nursing Officer\tabcellsep 21\tabcellsep 10.9\\
Total\tabcellsep 193\tabcellsep 100\end{longtable} \par
 
\caption{\label{tab_1}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.15283911671924288\textwidth}P{0.0804416403785489\textwidth}P{0.6167192429022083\textwidth}}
\tabcellsep \tabcellsep d) Needle Stick Injury experienced during course of\\
\tabcellsep \tabcellsep career\\
\tabcellsep \tabcellsep Out of total 193 nurses, 112 nurses (58\%) had\\
\tabcellsep \tabcellsep experienced needle stick injury while 81 nurses (42\%)\\
\tabcellsep \tabcellsep had not experienced needle stick injury.\\
Area Posted\tabcellsep Number of Nurses\tabcellsep Percentage\\
General Ward\tabcellsep 49\tabcellsep 25.4\\
Private Ward\tabcellsep 2\tabcellsep 1\\
Emergency\tabcellsep 65\tabcellsep 33.7\\
ICU\tabcellsep 15\tabcellsep 7.8\\
OT\tabcellsep 27\tabcellsep 14.0\\
OPD\tabcellsep 35\tabcellsep 18.1\\
Total\tabcellsep 193\tabcellsep 100\end{longtable} \par
 
\caption{\label{tab_2}Table 2 :}\end{figure}
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\noindent\textbf{3} \par 
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\tabcellsep \tabcellsep \tabcellsep f) Frequency of needle stick injury reported\\
\tabcellsep \tabcellsep \tabcellsep Out of 112 nurses who had needle stick injury,\\
\tabcellsep \tabcellsep \tabcellsep 63 nurses reported needle stick injury. Out of these 60\\
\tabcellsep \tabcellsep \tabcellsep nurses (95.23\%) had reported it 1-3 times and 3 nurses\\
Frequency of needle stick injury\tabcellsep Number of nurses\tabcellsep Percentage\tabcellsep (4.7\%) had reported it 3-5 times. 3 nurses did not give any response\\
1-3 times\tabcellsep 85\tabcellsep 75.89\tabcellsep \\
3-5 times\tabcellsep 26\tabcellsep 23.21\tabcellsep \\
Total\tabcellsep 111\tabcellsep 100\tabcellsep \end{longtable} \par
 
\caption{\label{tab_3}Table 3 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.36428571428571427\textwidth}P{0.48571428571428565\textwidth}}
Needle Stick Injury: Inevitable or Avertable\tabcellsep \\
\tabcellsep Year 2018\\
\tabcellsep 9\\
\tabcellsep Volume XVIII Issue VI Version I\\
\tabcellsep D D D D )\\
\tabcellsep (\\
\tabcellsep Medical Research\\
1-3 times 3-5 times\tabcellsep Global Journal of\end{longtable} \par
  {\small\itshape [Note: K © 2018 Global Journals e) Out of nurses who had experience needle stick injury, frequency of needle stick injury experiences g) Reasons the Needle Stick Injury have not been reported]} 
\caption{\label{tab_4}Number of times Needle stick injury reported}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{4} \par 
\begin{longtable}{P{0.10874673629242819\textwidth}P{0.3817232375979112\textwidth}P{0.1464751958224543\textwidth}P{0.21305483028720623\textwidth}}
\multicolumn{2}{l}{Sr No. Reasons the Needle Stick Injury has}\tabcellsep Number of Nurses reporting\tabcellsep Percentage of nurses among who\\
\tabcellsep not been reported\tabcellsep the reason of not reporting\tabcellsep had experienced needle stick injury\\
1\tabcellsep Needle stick injury by sterile needle\tabcellsep 32\tabcellsep 28.57\\
2\tabcellsep Lack of awareness about policy\tabcellsep 39\tabcellsep 34.82\\
3\tabcellsep Lack of knowledge about NSI\tabcellsep 84\tabcellsep 75\\
4\tabcellsep Workload\tabcellsep 24\tabcellsep 21.42\\
5\tabcellsep ART side effects\tabcellsep 7\tabcellsep 6.25\\
6\tabcellsep Infrastructure\tabcellsep 30\tabcellsep 26.78\\
7\tabcellsep Patient report negative\tabcellsep 13\tabcellsep 11.60\end{longtable} \par
  {\small\itshape [Note: Figure 4: Reasons the Needle Stick Injury have not been reported h) Factors responsible for occurrence of NSI According to nurses, factors responsible for occurrence of NSI]} 
\caption{\label{tab_5}Table 4 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{5} \par 
\begin{longtable}{P{0.5971794871794871\textwidth}P{0.2037820512820513\textwidth}P{0.04903846153846154\textwidth}}
\multicolumn{2}{l}{Factors Responsible for occurrence of NSI Number of nurses}\tabcellsep Percentage of nurses\\
NSI while Performing Procedure\tabcellsep 148\tabcellsep 76.66\\
Work Overload\tabcellsep 115\tabcellsep 59.58\\
Improper Handling during Procedure\tabcellsep 109\tabcellsep 56.47\\
Negligence during procedure\tabcellsep 105\tabcellsep 54.40\\
During BMW segregation\tabcellsep 112\tabcellsep 58.03\\
i) Study population who are vaccinated for Hepatitis B\tabcellsep \multicolumn{2}{l}{Out of total 193 nurses, 75 (38.9 \%) nurses were aware}\\
Out of the total study population 160 (82.90 \%)\tabcellsep \multicolumn{2}{l}{of existing policy on Needle Stick Injury in the institute}\\
nurses were previously vaccinated for Hepatitis B and\tabcellsep \multicolumn{2}{l}{while 118 (61.1\%) nurses were not aware of existing}\\
33 (17.10\%) population were not vaccinated for\tabcellsep policy.\tabcellsep \\
Hepatitis B\tabcellsep \tabcellsep \\
Correlation of NSI with vaccination is not\tabcellsep \tabcellsep \\
significant (P= 0.9)\tabcellsep \tabcellsep \\
Study Population Who Were Aware Of Existing\tabcellsep \tabcellsep \\
Policy On Needle Stick Injury In The Institute\tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_6}Table 5 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{6} \par 
\begin{longtable}{P{0.39285714285714285\textwidth}P{0.3214285714285714\textwidth}P{0.1357142857142857\textwidth}}
Sr No.\tabcellsep Number of nurses who are aware of policy\tabcellsep Percentage\\
Aware of\tabcellsep \tabcellsep \\
existing\tabcellsep 75\tabcellsep 38.9\\
policy\tabcellsep \tabcellsep \\
Not aware of existing\tabcellsep 118\tabcellsep 61.10\\
policy\tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_7}Table 6 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.85\textwidth}}
Support from\\
superiors\\
42.85 \%\\
superiors 66.07\\
\%\end{longtable} \par
 
\caption{\label{tab_8}}\end{figure}
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