Adesão às precauções-padrão entre profissionais da enfermagem expostos a material biológico

This cross-sectional study, developed at a public teaching hospital with 256 nursing professionals, had the aim to: describe occupational exposure events involving potentially infectious biological material among nursing professionals at a teaching hospital and compare the scores of adherence to Standard Precautions (SP). The first stage of data collection was performed using a form with questions regarding the occupational exposure and the psychometric scale “Adherence to SP”; in the second stage, and upon the participants’ consent, the medical records of the exposed professionals were analyzed. Adherence to SP was assessed as high and intermediate, according to the answers to the scale items. There was no statistically significant difference between those who had been exposed or not to biological material. The results evidence that only the use of the scale of adherence to SP was not enough to contemplate all factors that may be associated with occupational exposure to biological material. Descriptors: Universal Precautions; Occupational Risks; Accidents, Occupational; Occupational Exposure. RESUMEN Estudio transversal, realizado en hospital público de enseñanza, con 256 profesionales de enfermería, objetivando describir las exposiciones laborales a material biológico potencialmente contaminado entre profesionales de un hospital universitario, y comparar los puntajes de adhesión a las medidas de Precauciones-Estándar (PE). Datos recolectados en primera etapa mediante formulario con preguntas referentes a exposición laboral y escala psicométrica “Adhesión a PE”; y en la segunda, con consentimiento de los participantes, se efectuó consulta de historias clínicas de los profesionales expuestos. La adhesión a las PE fue evaluada como alta y media, según las respuestas a los ítems de la escala. No existió diferencia estadísticamente significativa entre los expuestos o no al material biológico. Se evidenció que solamente el uso de la escala de adhesión a las PE no fue suficiente para contemplar todos los factores asociados a la exposición laboral a material biológico. Descriptores: Precauciones Universales; Riesgos Laborales; Accidentes de Trabajo; Exposición Profesional. Malaguti-Toffano SE, Canini SRMS, Reis RK, Pereira FMV, Felix AMS, Ribeiro PHV et al. 132 Rev. Eletr. Enf. [Internet]. 2015 jan./mar.;17(1):131-5. Disponível em: http://dx.doi.org/10.5216/ree.v17i1.29269. doi: 10.5216/ree.v17i1.29269. INTRODUÇÃO A exposição ocupacional envolvendo material biológico potencialmente contaminado constitui um risco para os profissionais da área da saúde, sobretudo àqueles da enfermagem que prestam cuidado direto aos pacientes e manuseiam, frequentemente, objetos cortantes e fluidos corporais. Vários patógenos podem ser transmitidos aos profissionais de saúde, em decorrência de suas atividades laborais, sendo os vírus da Imunodeficiência Humana (HIV), das hepatites B (VHB) e C (VHC) os de maior relevância epidemiológica. No Brasil, o registro do primeiro caso de infecção ocupacional pelo HIV ocorreu em 1994, com uma auxiliar de enfermagem e decorreu da exposição percutânea envolvendo sangue e outros quatro casos de transmissão do HIV relativamente a profissionais de enfermagem foram documentados em pesquisas e tiveram como características comuns a exposição percutânea envolvendo sangue. Profissionais de enfermagem são descritos na literatura como os mais expostos ao acidente envolvendo material biológico, principalmente, em situações de exposições percutâneas, quando da punção venosa e administração de medicamentos Com o intuito de minimizar os riscos de exposição ocupacional a material biológico potencialmente contaminado, várias medidas de segurança vêm sendo estabelecidas nos serviços de saúde, entre elas as Precauções-Padrão (PP), ou seja, um conjunto de medidas de prevenção primária eficaz para reduzir o risco de transmissão de patógenos veiculados pelo sangue e por fluídos corporais. As medidas de PP aplicam-se a qualquer paciente, independentemente, do diagnóstico clínico ou sorológico e equipamentos de proteção individual (EPI), como luvas de procedimento, aventais, máscaras cirúrgicas e protetores oculares são recomendados sempre que o contato com fluidos corporais for previsto. Reforçam, tais medidas, a recomendação de higienização das mãos, antes e após o contato com pacientes e fluidos orgânicos, o descarte de materiais perfurocortantes em recipientes rígidos, cuidados com reprocessamento de materiais e administração de medicamentos injetáveis. Apesar de as medidas de PP serem apontadas, pela comunidade científica, como uma das mais importantes e eficazes medidas preventivas pré-exposição a material biológico, ainda há baixa adesão por parte dos profissionais da área da saúde. Diante deste contexto o presente estudo teve como objetivos comparar os escores de adesão às PP entre os profissionais da equipe de enfermagem que sofreram ou não exposição ocupacional em um hospital de ensino e descrever as características das dessas exposições quanto ao tipo, objeto, fluído corporal envolvido e uso de EPI no momento do acidente. MÉTODO Trata-se de um estudo de corte transversal, realizado no período de 2009 a 2010, em um hospital de ensino de grande porte do interior paulista. A população de referência contava com 590 profissionais de enfermagem, lotados nas unidades de Clínica Médica, Cirúrgica, Ginecologia e Centro de Terapia Intensiva (CTI). Por meio de cálculo amostral (α = 0,01; effect size = 0,08, poder do teste igual a 0,99) estimouse 290 sujeitos. Neste estudo, participaram 256 (100%) profissionais, sendo 178 (69,5%) auxiliares de enfermagem, 51 (19,9%) enfermeiros e 27 (10,5%) técnicos de enfermagem, com perda de 11,7%. Considerou-se como critérios de inclusão atuar no mínimo há seis meses na instituição, realizar procedimentos que envolvam fluidos corporais e no caso de enfermeiros, ser enfermeiro assistencial, função descrita para o primeiro nível hierárquico do enfermeiro no hospital de estudo. E como critérios de exclusão, profissionais que realizam, exclusivamente, atividades burocráticas, estar em licença-saúde indeterminada ou afastado por quaisquer outros motivos no período de coleta de dados. Para a primeira etapa da coleta de dados foi aplicado um formulário semiestruturado contendo variáveis demográficas, como sexo, idade, categoria profissional e as seguintes questões fechadas “Sofreu exposição ocupacional com material biológico nos últimos anos? Buscou atendimento médico?” e ainda, a escala psicométrica Escala de “Adesão às Precauções-Padrão” a todos os participantes, durante o turno de trabalho, em momentos mais oportunos. A Escala de “Adesão às Precauções-Padrão” foi traduzida e validada para o Brasil por meio de adaptação transcultural e, mediante autorização dos autores, foi aplicada aos sujeitos desta investigação. Essa escala é do tipo Likert e é composta por 13 itens e cada um com alternativas que variam de 1 a 5 pontos. A escala possui itens específicos quanto ao uso de EPI, como luvas descartáveis, óculos de proteção e avental que são itens avaliados na Escala de “Adesão às PP” e ainda, um escore total onde os níveis de adesão às PP são Malaguti-Toffano SE, Canini SRMS, Reis RK, Pereira FMV, Felix AMS, Ribeiro PHV et al. 133 Rev. Eletr. Enf. [Internet]. 2015 jan./mar.;17(1):131-5. Disponível em: http://dx.doi.org/10.5216/ree.v17i1.29269. doi: 10.5216/ree.v17i1.29269. calculados segundo a média dos escores médios simples de cada item e classificados em: a) alto: para escores médios iguais ou superiores a 4,5; b) intermediário: para escores médios com valores entre 3,5 e 4,49 e c) baixo: para escores médios abaixo de 3,5. A segunda etapa foi composta pela consulta aos prontuários dos profissionais da enfermagem para identificar as variáveis da exposição ocupacional a material biológico, como tipo de exposição, objeto envolvido e uso de EPI no momento do acidente. O estudo piloto foi realizado com 95 profissionais da enfermagem que atuavam em outros setores do hospital, local de realização do estudo. As variáveis do instrumento foram codificadas e catalogadas em um dicionário (codebook). Os dados foram duplamente digitados em planilha Excel for Windows 2003 e após correção dos erros de digitação foram transportados para o Statistical Package for the Social Sciences (SPSS), versão 15.0. Realizou-se análise estatística descritiva para caracterização da amostra e das exposições ocupacionais e os seguintes testes estatísticos: a) alfa de Cronbach; Kolmogorov-Smirnov, para testar a normalidade da distribuição das médias dos escores da escala em grupos com número de sujeitos inferior a 30; c) ANOVA (Analyses of Variance), para analisar a diferença entre os escores médios de adesão às PP entre as categorias profissionais de enfermagem e d) Teste t de Student para comparar os escores de adesão às PP e exposição a material biológico. O projeto de pesquisa foi aprovado pelo Comitê de Ética em Pesquisa do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (Protocolo 4620/2009) e os aspectos éticos foram contemplados. Todos os participantes concordaram em participar das duas etapas de coleta de dados. RESULTADOS Dos 256 profissionais participantes do presente estudo 69,6% eram auxiliares de enfermagem, 10,5% técnicos de enfermagem e 19,9% enfermeiros. Houve predomínio do sexo feminino (78,9%), com idade média de 38,6 anos (variação de 21,3 a 60,4 anos). A maioria possuía ensino médio completo (64,5%). A análise dos escores da escala de adesão às PP apontou que 59,4% dos profissionais apresentaram escores médios altos, ou seja, igual ou acima de 4,5; para 38,3% profissionais o escore médio foi intermediário, entre 3,5 e 4,49 e 2,3% obtiveram escores baixos, ou seja, menores que 3,5. A análise de confiabilidade da escala de adesão às PP teve resultado geral igual a 0,70 e foi considerada satisfatória. Tabela 1: Escore médio, desvio padrão, erro padrão médio da


INTRODUCTION
Occupational exposure involving potentially contaminated biological material constitutes a risk to health professionals, especially those in nursing, who provide direct care to patients, frequently handling sharp objects and body fluids.
Many pathogens can be transmitted to health professionals (1) as a result of their work activities, and the human immunodeficiency virus (HIV), and hepatitis B (HBV) and C (HCV) have the greatest epidemiological relevance.
In Brazil registration of the first case of occupational HIV infection was diagnosed in a nursing assistant in 1994 and was the result of percutaneous exposure involving blood (2) .Four other cases of HIV transmission in relation to nursing professionals have been documented in research and had common characteristics where percutaneous exposure to blood was involved (3)(4) .
In order to minimize the risk of occupational exposure to potentially contaminated biological material, various security measures have been established in health services, including the Standard Precautions (SP), i.e., a set of effective primary prevention measures to reduce the risk of transmission of blood-borne pathogens and body fluids (11) .
SP measures apply to any patient, regardless of the clinical or serological diagnosis, and personal protective equipment (PPE) such as medical gloves, aprons, surgical masks, and eye protection are recommended whenever contact with body fluids is anticipated.To reinforce these measures, hand washing before and after contact with patients and organic fluids, disposal of sharp materials in rigid containers, and using caution when reprocessing materials and administering injectable drugs are recommended (11)(12) .
Although SP measures are identified by the scientific community as one of the most important and effective pre-exposure preventive measures for biological material, there is still poor compliance by health professionals (13)(14) .
Given The psychometric scale "Adherence to Standard Precautions" was also included (15) .
The "Adherence to Standard Precautions" scale was translated and validated in Brazil (15) by means of crosscultural adaptation, and was applied to the subjects of this investigation with the permission of the authors.This scale is a type of Likert scale and is composed of 13 items, each with alternatives ranging from 1 to 5 points.
The scale has specific items in relation to the use of PPE, such as disposable gloves, goggles, and aprons, that are evaluated items on the "Adherence to SP" scale, and also a total score where the SP membership levels are calculated according to the average of the simple average scores for each item.These are classified as: a) highaverage scores equal to or greater than 4.5; b) intermediate -for average scores with values between 3.5 and 4.49; and c) low -for average scores below 3.5 (15) .
The second step was composed of consulting the  Professionals who were exposed or not to potentially contaminated biological material were categorized according to their answers and notes in the medical records, and then the analysis of the scores between the groups was performed.

Of
The participants were initially divided into two groups (exposed or not to the biological material), but were subsequently divided into four groups: A -professionals who responded as having suffered occupational exposure in the past two years when answering the questionnaire and who also had such notes in medical records (n=18); B -professionals who mentioned in the questionnaire that they had suffered exposure but did not have such notes in their medical records (n=26); Cprofessionals who did not report exposure in the questionnaire but were registered in the medical records as having had exposure (n=25); and D -professionals who did not report exposure and had no such notes in the medical records (n=187).
In the comparison between groups A and B, normal 3.8% in the exchange of saline/drip; and 3.8% in the handling of surgical instruments.Regarding the use of personal protective equipment, in 53.8% of exposures professionals did not wear gloves at the time of the accident.In 88.4% of exposures, professionals did not wear goggles.We found no information on the use of an apron in the medical records.
Among the exposures, 42.3% involved needles with a lumen containing blood, and 23% of professionals were not following the use of gloves procedures.
Chemoprophylaxis was indicated in 34.6% of exposures.
It is noteworthy that any instances of saline conversion, according to data obtained in the record sheets of specialized clinics, were not verified.

DISCUSSION
Analysis of the scale of adherence to SP scores showed that 59.4% of subjects reported high mean scores; for 38.3% of professionals the average score was intermediate; and only 2.3% were low scores.On average the analysis of individual scale items identified that 87.9% of professionals said they "always" use gloves in procedures involving biological material, but it was observed in exposure records that PPE was not used at the time of the accident.
A study performed with nursing professionals in the intensive care units of the same institution obtained an average score for the intermediate "Adherence to SP" scale; however, the authors observed that important items on the scale did not have total adherence, such as proper disposal of sharp materials, hand hygiene after removing disposable gloves, and protective eye wear (14) .
In the present study, most of the exposures were percutaneous (80.7%), during venipuncture and performance of the glucose testing.Research conducted in Brazil showed that such needles were involved in percutaneous exposure occurring in a hospital; however, with the introduction of a disposable and retractable lancet, there was a significant lowering of percutaneous exposures for small-gauge needles among nursing professionals (16) .
Of the total percutaneous exposures, 3.8% occurred at the time of disposal and 9.5% when recapping needles with a lumen or peripheral catheter introducer.Such occurrences were also observed in other investigations involving nursing professionals (17)(18)(19)(20) .
According to data from 62,970 reports of exposures to biological material in the state of São Paulo, the use glove procedures during the time of the accident occurred 74.4% of the time (7) .In the same study it was observed that gloves were used in only 35.4% of cases of drug administration and venipuncture for blood collection, and in 18.9% of cases involving the collection of blood (7) .
Regarding protective eyewear, the records note that they were not used in any mucocutaneous exposures.
In the present study, some professionals reported in the questionnaire that they had suffered exposures but did not seek medical attention; this is also confirmed by the medical records.Other Brazilian studies also found that exposed nurses did not seek medical attention or did not report accidents (21)(22) .Research conducted at the same institution showed that 29.2% of the accidents were not officially reported and that many professionals seeking care at the clinic did not seek engineering, safety, and occupational health services for official notification of the occurrence.

CONCLUSION
Nursing professionals suffered percutaneous and mucocutaneous exposures.Exposure underreporting was identified to verify that professionals who responded as having suffered occupational exposure to biological material had no accident reports in their medical records.
The data showed high and intermediate adherence for total scores of adherence to SP scale; however, there were no differences among participants exposed or not to the biological material.
It was demonstrated in this study that the use of only adherence to the SP scale was not enough to cover all factors that may be associated with occupational exposure to biological material.The need exists therefore for further research, such as observational studies that can compare the adherence to SP scores obtained by applying the adherence to SP scale with the adherence of professionals in care practice.
records of nursing professionals to identify the variables of occupational exposure to biological material, such as type of exposure, object involved, and use of PPE at the time of the accident.The pilot study was conducted with 95 nursing professionals working in various sectors of the hospital where the study was performed.The variables of the instrument were coded and cataloged in a dictionary (codebook).Data were doubleentered into an Excel spreadsheet for Windows 2003 and, after correcting typing errors, were transported to the Statistical Package for Social Sciences (SPSS), version 15.0.A descriptive statistical analysis to characterize the sample and occupational exposures was performed, including the following statistical tests: a) Cronbach's alpha; b) the Kolmogorov-Smirnov test for normal distribution of the average scale scores in groups where the number of subjects is less than 30; c) ANOVA (Analyses of Variance), to analyze the difference between the average scores of adherence to SP between professional nursing categories; and, d) Student's t test to compare the adherence to SP scores and exposure to biological material.The research project was approved by the Research Ethics Committee of the Clinical Hospital of the Faculty of Medicine of Ribeirão Preto, University of São Paulo (Protocol 4620/2009), and the ethical aspects were covered.All participants agreed to participate in the two data collection stages.

Table 1 :
the 256 professionals in the present study, 69.6% Mean score, standard deviation, standard mean error of adherence to SP scale* of nursing professionals who reported not having suffered occupational exposure to biological material and who had exposure records.Ribeirão Preto, SP, 2009-2010.