Cases & Commentaries
Bloody BP Cuff
Approach to Improving SafetySafety TargetResource TypeSetting of CareTarget AudienceError Types
Patient #1, a 28-year-old male, was a trauma patient following a motor vehicle collision into a cement pillar. Patient #1 was in the trauma bay with massive injuries and profuse bleeding. The blood pressure cuff (which was partly fabric and partly nylon) was saturated with so much blood that it could be wrung out. Patient #1 was taken to surgery where he coded and died about an hour later.
Patient #2, a 24-year-old female, was also in a motor vehicle collision and had cuts over her upper body from glass shattered in the crash. Patient #2 was placed into the same trauma bay vacated by patient #1. The same blood-saturated cuff was placed onto her arm, with no regard for universal precautions.
A nurse noted that the same bloody cuff was used from patient to patient. This observation was received by other staff members with a shoulder shrug. Several weeks later, a letter from the medical examiner revealed that Patient #1 was HIV and Hepatitis B Virus (HBV) positive and that the collision was a suicide.
The early days of the AIDS epidemic saw first responders trying to literally guess which patients might be harboring a potentially lethal blood-borne agent. In addition to the obvious problems of profiling and stigma, these “eyeball tests” proved highly inaccurate, sometimes with serious consequences. Ultimately, the healthcare system embraced a strategy of universal precautions—in essence, assuming that any patient might be harboring a blood-borne infectious agent and acting accordingly.
Unfortunately, as with many sensible infection control practices, universal precautions are sometimes neglected, as in this case. Blood-borne pathogens represent a significant concern to all individuals in emergency settings,(1,2) including health care personnel and patients. The reported prevalence of HIV infection in emergency department patient populations ranges from 0.15% to 7.8%,(3-5) with even higher values reported from centers with particularly high-risk patient populations.(6) Since the prevalence of HIV is lower than that of most other blood-borne pathogens, the risk of hepatitis and other bacterial pathogens is even higher. In fact, two studies—one in emergency department patients (3) and one limited to trauma patients (4)—demonstrated that roughly 25% of patients exhibited seropositivity for at least one important transmissible agent such as HIV, Hepatitis B, or Hepatitis C.
It is not known how often medical equipment becomes contaminated during trauma resuscitations, but anecdotal reports and the clear increased exposure to blood and other body fluids suggest that this case represents a common and serious hazard. However, poor compliance with barrier precautions in emergency and trauma settings remains widespread.(7-11) It may be tempting to attribute the error in this case to the hectic conditions, but such circumstances typically surround trauma situations and thus cannot be regarded as acceptable mitigating factors.
General factors influencing compliance with barrier precautions include time pressures and concerns about impact on dexterity.(7,8,12,13) Paradoxically, health care workers have shown lower rates of gown utilization in resuscitations involving bleeding,(7) when the risk of exposure is clearly greater. There is no reason to assume that health care workers comply with recommended barrier precautions to any greater extent when patients are the ones being exposed to blood (as in this case) than when they themselves are at risk.
While rates of nosocomial transmission from equipment to patient remain unknown, cases of such transmission have been documented in various settings.(14-17) Importantly, blood and body fluid exposure has been occult in these settings. By contrast, the case at hand and other trauma situations involve exposure to grossly bloody equipment.
The rate of HIV infection from health care worker to patient is thought to be low if not zero in the absence of percutaneous or mucosal exposure. One study utilized computer modeling to estimate HIV transmission during invasive radiological procedures.(18) When the physician's HIV status was not known, the risk of transmission of HIV to a patient during a procedure was estimated to be 0.03 per million procedures. When the physician was HIV-positive, the risk of transmission to a patient was estimated to be 7.5 per million procedures.
While the risk for patients and surgeons may be low in controlled settings (operating rooms and invasive radiology suites), it is higher in trauma situations especially when hemorrhage is present. The cost of changing obviously contaminated equipment may seem high for such a relatively small risk. Considering the liability that a hospital may incur, cleansing or disposing of this equipment may result in cost savings and better patient care. To ensure proper cleansing or disposing of contaminated equipment, processes should be in place in all emergency departments. These processes should be managed by the nursing supervisor, the emergency room physician, as well as the trauma surgeon. Proper education and knowledge may help create a safer environment for both health care workers and patients. A list of suggestions is displayed in the Table.
At least one study has shown that implementation of policies like these can improve compliance with universal precautions.(19) This case raises the specific issue of whether disposable blood pressure cuffs (or disposable covers) should be added to universal precautions, at least in settings such as trauma care. One study from the operating room revealed blood contamination of approximately 30% of surfaces tested.(20) Unrecognized blood contamination would almost certainly have a higher prevalence in trauma rooms. Blood pressure cuffs are already known to be reservoirs of bacterial pathogens such as Clostridium difficile.(21,22) Contamination with blood and blood-borne viruses is likely a significant (albeit under-recognized) patient safety problem. Until the cost-effectiveness of disposable blood pressure cuffs has been established, we can at least recommend explicit attention to the cleaning and disinfection of blood pressure cuffs between patients, even in hectic settings such as trauma resuscitations.
Reinforcement of universal precautions must be continued for everyone involved in patient care, especially in trauma care. While the risk of blood-borne pathogen transmission to both patient and health care worker is low, such transmission can be deadly and can be decreased by the standard use of universal precautions.
Atul K. Madan, MD Director, Bariatric Program, UT Medical Group, Inc. Chief, Section of Minimally Invasive Surgery Division of General Surgery, Department of Surgery, University of Tennessee
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7. Madan AK, Raafat A, Hunt JP, Rentz D, Wahle MJ, Flint LM. Barrier precautions in trauma: is knowledge enough? J Trauma. 2002;52:540-3.[ go to PubMed ]
8. Madan AK, Rentz DE, Wahle MJ, Flint LM. Noncompliance of health care workers with universal precautions during trauma resuscitations. South Med J. 2001;94:277-80.[ go to PubMed ]
9. Madan AK, McKinell KJ, Posner SJ, Gaines CG, Flint LM. Higher risk of HIV transmission during trauma resuscitations. J La State Med Soc. 2000;152:567-71.[ go to PubMed ]
10. Henry K, Campbell S, Maki M. A comparison of observed and self-reported compliance with universal precautions among emergency department personnel at a Minnesota public teaching hospital: implications for assessing infection control programs. Ann Emerg Med. 1992;21:940-6.[ go to PubMed ]
11. Evanoff B, Kim L, Mutha S, et al. Compliance with universal precautions among emergency department personnel caring for trauma patients. Ann Emerg Med. 1999;33:160-5.[ go to PubMed ]
12. Williams CO, Campbell S, Henry K, Collier P. Variables influencing worker compliance with universal precautions in the emergency department. Am J Infect Control. 1994;22:138-48.[ go to PubMed ]
13. Henry K, Campbell S, Collier P, Williams CO. Compliance with universal precautions and needle handling and disposal practices among emergency department staff at two community hospitals. Am J Infect Control. 1994;22: 129-37.[ go to PubMed ]
14. Bronowicki JP, Venard V, Botte C, et al. Patient-to-patient transmission of hepatitis C virus during colonoscopy. N Engl J Med. 1997;337:237-40.[ go to PubMed ]
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17. Ramos-Gomez F, Ellison J, Greenspan D, Bird W, Lowe S, Gerberding JL. Accidental exposures to blood and body fluids among health care workers in dental teaching clinics: a prospective study. J Am Dent Assoc. 1997;128:1253-61.[ go to PubMed ]
18. Hansen ME, McIntire DD. HIV transmission during invasive radiologic procedures: estimate based on computer modeling. AJR Am J Roentgenol. 1996;166:263-7.[ go to PubMed ]
19. Kelen GD, Green GB, Hexter DA, et al. Substantial improvement in compliance with universal precautions in an emergency department following institution of policy. Arch Intern Med. 1991;151:2051-6.[ go to PubMed ]
20. Hall JR. Blood contamination of anesthesia equipment and monitoring equipment. Anesth Analg. 1994;78:1136-9.[ go to PubMed ]
21. Manian FA, Meyer L, Jenne J. Clostridium difficile contamination of blood pressure cuffs: a call for a closer look at gloving practices in the era of universal precautions. Infect Control Hosp Epidemiol. 1996;17:180-2.[ go to PubMed ]
22. Base-Smith V. Nondisposable sphygmomanometer cuffs harbor frequent bacterial colonization and significant contamination by organic and inorganic matter. AANA J. 1996;64:141-5.[ go to PubMed ]
Table. Suggestions to Decrease the Chance of Blood-Borne Pathogen Transmission