Learning objectives
After completing this chapter, the reader will be able to:
- 1.
Review practical suggestions on maintaining personal safety when on clinical rotations.
- 2.
Summarize the Centers for Disease Control and Prevention (CDC) recommendations on universal precautions associated with patient care.
- 3.
Describe various personal and environmental safety risks that could impact the clinical phase student.
- 4.
Distinguish various forms of student mistreatment and harassment that may occur during clinical experiences.
- 5.
Formulate plans for reporting student mistreatment and harassment to the appropriate officials at their respective institutions and programs.
Introduction
Maintaining the personal safety of each student when on clinical rotations is a top priority and requirement of physician assistant (PA) programs. This chapter will review basic safety recommendations to arm students with tools to practice safely, review common threats to student safety, and explore the issues of student mistreatment during clinical experiences. Health profession students typically hone their skills by working with patients in busy offices, hospitals, and other facilities. Students are sometimes placed in “educational” situations with minimal supervision and asked to perform procedures for which they are not adequately trained. Such circumstances place students at risk for injuries ranging from needlesticks to more substantial injuries. All students must be equipped with basic safety practices to protect themselves and the patients they serve.
PA programs require students to provide basic health information upon admission. The only confidential student health information that can be disclosed to the program involves immunizations and results of tuberculosis (TB) screening. Programs should not have access to other types of health information on students. Students usually complete a health status form describing any medical concerns or significant items in their medical history that may put them or patients at risk. In addition, programs require documentation that all students have current institution-required immunizations, such as rubeola, rubella, and tetanus booster. Programs are required to base their immunization policy and recommendations on current Centers for Disease Control and Prevention (CDC) recommendations for health professionals. TB testing is also performed on entry into the program and is repeated annually.
Before enrollment or at orientation, many programs require students to undergo background checks, drug screenings, or both. These procedures help ensure a safe environment within the educational institution.
Students should receive required information on sexual harassment, bloodborne pathogens, general personal safety, and the Health Insurance Portability and Accountability Act (HIPAA). PA programs cover these topics to ensure a basic level of student health and safety. The greatest potential for risk exposure starts when students begin working with patients. Possible exposures may include infectious agents (e.g., hepatitis, human immunodeficiency virus [HIV], TB), physical injury (e.g., needlesticks, lacerations, latex allergies, physical attacks by a patient), and emotional abuse (e.g., verbal abuse, belittlement, sexual harassment). Programs differ in the ways they educate students, prevent exposures, and protect everyone. In the following sections, safety issues important to the clinical portion of a PA training program are explored.
Rotation safety
To maintain your safety on clinical rotations, common sense is the rule. Be aware of your surroundings at all times, especially when at a new location. Ask your preceptor to review clerkship safety policies. Ask questions regarding who has access to the clinic space, whether chaperones are required for male and female examinations, what to do in case of an emergency, how to work with disgruntled patients, and what to do if you sustain an injury. Remember to have your needlestick injury protocol readily available on rotations.
The issue of violence in the health care workplace is ever present, under-reported, and a persistent concern of which PA students must be aware. In the health care arena, the most common scenario is where the perpetrator is associated with the medical practice/facility and becomes violent while receiving care. In general, clinicians are more likely to experience workplace violence in the emergency department or psychiatric settings; however, violence can occur in any setting at any time. , , Episodes of workplace violence across all categories are under-reported for various reasons. For example, in one study, among physicians, the reporting rate was 26%. The difficulty is knowing what exactly constitutes workplace violence. Types of workplace violence that have been reported in the literature include verbal assault, spitting, threats, physical assault, and battery. As a PA student, it is imperative that you report any incident of violence to your supervisor and program officials.
Universal precautions
One area often neglected by students is the consistent use of universal precautions. Universal precautions are infection control guidelines designed to protect health care providers from exposure to diseases spread by blood and certain body fluids. Implemented in the 1980s as HIV infection became more prominent, universal precautions eliminated concerns about which patients might require precautions because of infection and which patients were not infected. Simply put, universal precautions require that you assume everyone may be able to transmit hepatitis B, HIV, or other infectious agents, and therefore the same precautions are used for all patients. The types of exposures for which universal precautions should be used and for which they are not necessary can be found in Table 19.1 .
| Universal Precautions Required | Universal Precautions Do Not Apply |
|---|---|
| Semen | Feces |
| Vaginal secretions | Nasal secretions |
| Synovial fluid | Sputum |
| Cerebrospinal fluid | Sweat |
| Pleural fluid | Tears |
| Peritoneal fluid | Urine |
| Pericardial fluid | Vomitus unless contaminated with blood |
| Amniotic fluid | Saliva unless contaminated with blood |
Universal precautions involve the use of personal protective equipment such as gloves, gowns, masks, and protective eyewear, which can reduce the risk of bloodborne pathogen exposure to the health care student’s skin or mucous membranes. In Figure 19.1 , the provider is using a face shield and gloves that are appropriate for the procedure he is performing. The use of a gown would only protect his clothing and is not otherwise indicated (and is likely wasteful) in this situation. Each situation is different, and students should be thoughtful about selecting the correct personal protective equipment required for each situation. As a student and future professional, it is incumbent on you to use universal precautions whenever appropriate. If you are performing a phlebotomy, suturing a laceration, or performing a punch biopsy, these precautions are in place to protect you from exposure to infectious agents, but they are effective only if you use them correctly and consistently.
Needlestick and sharps injuries
Needlestick and sharps injuries are the most common method of transmitting bloodborne pathogens between patients and health care providers; therefore they pose a significant risk to health care workers and students. According to the CDC, approximately 385,000 needlestick and other sharps-related injuries occur in hospital-based situations each year. In a single large American medical center, over a 13-year period, 18,000 occupational injuries occurred. Needlesticks, lacerations, and splash injuries made up nearly 13,000 of those reported injuries. Needlestick and sharps injuries are primarily associated with transmission of hepatitis B, hepatitis C, and HIV, but other types of infections can also result. Health care students are at especially high risk for needlestick injuries because of their relative inexperience; exposure rates have been reported between 11% and 50% of students. One PA program found that 22% of its students had some type of exposure, 60% of which were percutaneous injuries. PA programs are expected to define, publish, and make readily available to students information addressing “exposure to infectious and environmental hazards.”
The most important points of this discussion on student safety are prevention of needlestick injuries and reporting an injury if one occurs. Prevention of needlestick and sharps injuries has improved significantly through the adoption of safer needles, protocols on handling sharps, and improved provider education on safety techniques. It is incumbent on PA educational programs to train their students in safe procedures and to establish a comprehensive response process for handling expected injuries.
PA students must take advantage of their programs’ training opportunities in the areas of phlebotomy, initiation of IV lines, suturing, and other procedures that involve needles and sharps. Usually, training in these techniques takes place far in advance of actual clinical experience. Students should be closely supervised to ensure that they are performing the appropriate procedures for which they have been trained and that they are doing so correctly. It is natural to want to impress the supervisor or preceptor, which can lead students to perform procedures for which they are not yet qualified. To remain safe, students must be aware of these behaviors and understand their roles in caring for patients.
PA programs are required to provide students with a process for reporting and seeking medical care in the unfortunate event of a needlestick injury. Current recommendations call for the student to be evaluated and given appropriate postexposure prophylaxis within hours after an exposure. PA programs or institutions provide this information; however, it is imperative that you keep it readily available so that you can make appropriate contacts when the need arises. Exposures that occur in a training hospital are usually handled quickly, but injuries in a rural site without access to appropriate prophylactic medications can be a challenge. Any student who will be in a rural clinical location needs to be familiar with the program’s needlestick reporting process.
A troubling concern identified in the medical literature is the failure of health care workers and students to report needlestick and sharps injuries. Reasons for not reporting include fear of losing insurance or employment, concerns about the effectiveness of postexposure prophylaxis, and a tendency to deny personal risk. , , Failure to report even what is considered an inconsequential exposure can have a significant impact on future ability to practice. Although it may seem inconvenient, reporting provides several benefits for both the student and the health care entity. Reporting an incident may be useful for future insurance and disability claims. It typically results in the student being evaluated medically and helps the institution assess internal systems that may prevent similar exposures for other health care workers.
During a busy Saturday morning in the emergency department (ED) of a rural community hospital, a senior PA student was busy suturing a laceration on the scalp of a male patient. The patient was being held by local law enforcement on a drug-related charge. He had been in a fight at the jail, resulting in his laceration. The patient was somewhat uncooperative, and as the PA student was placing a suture, the patient moved suddenly, causing the bloody needle to deeply puncture the student’s gloved right middle finger. The student called for a nurse to assist him and to monitor the patient as he spoke with the family physician covering the ED. He asked the physician what he should do and was told to thoroughly clean the puncture site and then contact his program for advice. The student remembered he had been given a needlestick emergency contact card with a toll-free telephone number to call in case of an injury. After cleaning the site, he called the appropriate number and was given information about testing, follow-up, and postexposure prophylaxis, as well as points to discuss with the patient about having his blood tested for infectious diseases. The patient refused to consent to testing for HIV and hepatitis B and C. The student underwent baseline testing and decided to begin HIV prophylaxis medication. He was counseled on the risk for developing HIV, the need for safe sexual practices, and length of time for follow-up. He completed the postexposure prophylaxis without incident, and his HIV test result remained negative 1 year later.
Latex allergy
Latex is ubiquitous in the health care system. It has been used in all facets of medicine for several decades. The use of latex soared during the 1980s and 1990s because latex gloves were recommended as protection against bloodborne pathogens, including HIV. As use of latex products increased, so did the incidence of allergic reactions associated with latex proteins. Commonly, latex gloves are coated with cornstarch powder as a dry lubricant. The latex protein particles easily stick to the powder and aerosolize when the gloves are removed, resulting in latex allergy reactions, which can be local (skin), respiratory, or both ( Table 19.2 ).
| Latex in the medical setting | Latex in the nonmedical setting |
|---|---|
| Catheters | Baby pacifiers |
| Endotracheal tubes | Balloons |
| Enema kits | Bracers |
| Gastroscopic tubes | Condoms |
| Gloves | Dental rubber dams |
| Incubator | Door/window isolations |
| Nasogastric tubes | Elastic bands |
| Operation room masks, hats, shoe covers | Hot water bottle |
| Orthodontic elastics | Rubber bands |
| Oxygen masks | Sailing equipment |
| Pulmonary resuscitation bags | Shower curtain |
| Reflex hammer | Stamps |
| Stethoscope tubing | Toys |
| Syringes | Sports equipment |
| Tracheal tubing |
The actual prevalence of latex allergy is difficult to pinpoint. Data on occupational health care subgroups range from 0.5% to 24%. This wide range can be attributed to several issues related to the quality of the research studies and inconsistencies in the definition of “latex allergy.”
Three types of clinical syndromes are associated with latex exposures. The majority of reactions involve an irritant dermatitis caused by the rubbing of gloves on the skin. This type is not immune mediated and is not associated with allergic symptoms.
A second form is the result of a delayed (type IV) hypersensitivity reaction, causing a contact dermatitis within 24 to 48 hours after exposure. Individuals with a history of atopic disease are at greater risk for this type of reaction. The most serious and least common presentation is the immediate (type I) hypersensitivity reaction. This is mediated by an immunoglobulin E response specific to latex proteins. As the process escalates, histamine and other systemic mediators are released, possibly resulting in anaphylaxis ( Table 19.3 ).
