three-year prospective study to improve the management of blood-exposure incidents

Three-Year Prospective Study to Improve the Management of Blood-Exposure IncidentsAuthor(s): By Paul Th. L. van Wijk ;, Marianne Pelk-Jongen; Clementine Wijkmans , MD;Andreas Voss , MD, PhD; Peter M. Schneeberger , MD, PhDSource: Infection Control and Hospital Epidemiology, Vol. 29, No. 9 (September 2008), pp. 871-877Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiologyof AmericaStable URL: http://www.jstor.org/stable/10.1086/590394 .

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o r i g i n a l a r t i c l e

infection control and hospital epidemiology september 2008, vol. 29, no. 9

Three-Year Prospective Study to Improve the Managementof Blood-Exposure Incidents

Paul Th. L. van Wijk; Marianne Pelk-Jongen; Clementine Wijkmans, MD; Andreas Voss, MD, PhD;Peter M. Schneeberger, MD, PhD

objective. Throughout 2003–2005, all blood-exposure incidents registered by an expert counseling center in The Netherlands accessibleby telephone 24 hours a day, 7 days a week, were analyzed to assess quality improvement in the center’s management of such incidents. Theexpert center was established to handle blood-exposure incidents that occur both inside and outside of a hospital. Infection control practitionerscarried out risk assessment, made the practical arrangements associated with managing incidents, and carried out treatment and follow-up, allin accordance with standardized procedures.

design. We analyzed the time it took for exposed individuals to report the incident, the time required to perform a human immunodefi-ciency virus (HIV) test for the source individual when needed, occurrence of injuries, hepatitis B (HBV) vaccination status of exposed individ-uals, and adherence to protocol at the expert center.

results. A mean of 465 incidents was registered during each year of the 3-year study period. Although 698 (50%) of 1,394 reported exposures tookplace in a hospital, 704 (50%) took place outside of a hospital, and 460 (33%) occurred at a time other than regular office hours. HIV tests for sourceindividuals were performed increasingly quickly over the course of the 3-year study period because of earlier reporting and improvements in practicalmatters associated with performing and processing the tests. The percentage of healthcare workers employed outside a hospital who were vaccinatedagainst HBV increased from 34% (52 of 152) to 70% (119 of 170) during the 3-year study period. Consequently, the administration of immunoglobulinand unnecessary laboratory testing were reduced. In assessing the quality of the expert center, flaws in the handling of incidents were identified in 148(37%) of 396 incidents analyzed in 2003, compared with 38 (8%) of 461 incidents analyzed in 2005.

conclusions. The practical matters associated with management of blood-exposure incidents, such as timely reporting and administra-tion of prophylaxis, should be optimized for incidents that occur at times other than regular office hours and outside of hospitals. Theestablishment of a 24-hour centralized counseling facility that was open 7 days a week to manage blood exposures resulted in significantimprovements in incident management and better care.

Infect Control Hosp Epidemiol 2008; 29:871– 877

Despite the fact that the prevalence of infection due to hepatitis Timely reporting of an incident to an experienced health-
B virus (HBV), hepatitis C virus (HCV), or human immuno-deficiency virus (HIV) infection is relatively low in The
care provider will allow the exposed individual to receiveproper preventive treatment and counseling. Assessing the risk

roennbopital

ed Aerved

Netherlands,1-3 blood-exposure incidents still have a great im-pact on the individuals exposed to blood and body fluids, caus-ing anxiety and stress.4,5 Although many healthcare institutionshave guidelines for the management of blood-exposure inci-dents, only a few have established facilities where exposed in-dividuals have instant access to medical care, 24 hours a day, 7days a week.6-8 Instead, exposed individuals are often referredto hospital emergency departments or public health physi-cians. Especially after regular office hours, this approach toincident management may cause unnecessary delay in additionto creating the possibility of inconsistencies in risk assessment.6

From the Department of Medical Microbiology and Infection Control, JeDiseases and Public Health, Hart voor Brabant (P.T.L.v.W., C.W.), ‘s-Hertogeof Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina HosUniversity Medical Centre (A.V.), Nijmegen, The Netherlands.

Received December 12, 2007; accepted May 22, 2008; electronically publish© 2008 by The Society for Healthcare Epidemiology of America. All rights res

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of transmission of bloodborne pathogens is a complex matterthat depends on variables such as the type of injury, theamount of blood transmitted, the infectiousness of the sourceindividual, and the exposed individual’s level of protectiveantibodies.9-11 The success of postexposure prophylaxis (PEP)and other treatment depends on the duration of the intervalbetween the incident and the administration of preventivemeasures. Therefore, fast and consistent assessment of ablood-exposure incident is essential, both to prevent infectionwith bloodborne viruses and to deliver proper care while pre-venting unnecessary stress and anxiety.9-11

Bosch Hospital (P.T.L.v.W., M.P.-J., P.M.S.), the Department of Infectioussch, the National Hepatitis Centre, Amersfoort (P.T.L.v.W.), the Department

(A.V.), and Nijmegen University Centre for Infectious Diseases, Radboud

ugust 25, 2008.. 0899-823X/2008/2909-0013$15.00. DOI: 10.1086/590394

29 on Wed, 14 May 2014 21:23:20 PMerms and Conditions


In 2002, we established a 24-hour telephone center in col-laboration with all healthcare providers in our region and thepublic health service. This center was intended to improve the

healthcare officer. Extensive advertising was placed in both re-gional institutions and local papers when the center startedoffering its services, and all healthcare institutions received

872 infection control and hospital epidemiology september 2008, vol. 29, no. 9

management of blood-exposure incidents and the counselingof exposed individuals in our region. The center handles allreports of blood-exposure incidents by telephone. This expertcounseling center was partially funded by the participatinghospitals and regional community health services. For work-related accidents, the cost of managing the incident wascharged to the employer of the injured individual.

During the 3-year study period, we prospectively analyzedfactors that could influence how well blood-exposure incidentswere managed. The major factors we addressed were as follows:adherence to the incident management protocol; effective per-formance of the practical matters associated with managing theincident; the interval between exposure and assessment of theincident; management of exposures that occurred at a timeother than regular office hours (including immediate HIV test-ing); testing the source individual involved in the exposures,for both in-hospital and out-of-hospital exposures; the HBVvaccination status of the exposed individual; and the overallquality of incident handling by the expert center.

methods

Population and Region

The expert counseling center provides service to 2 hospital or-ganizations spread over 5 locations. These facilities have a totalof 1,786 hospital beds, and they employ a total of 2,207 full-time equivalent (FTE) healthcare workers (HCWs). Further-more, the center serves a semirural region (an area of 1,250km2) with 1 major city that has more than 100,000 inhabitantsand an overall population of approximately 500,000 inhabi-tants. The total number of community members employed inhome healthcare settings and nursing homes is estimated at6,500 FTE workers. In addition, there are approximately 260general practitioners, 230 dentists, and 2,350 FTE police work-ers and prison officers.

Logistical Details of Incident Management

All management of in-hospital and out-of-hospital blood-exposure incidents is referred to the regional expert counselingcenter. The call center operates 24 hours a day to allow imme-diate access to reporting and counseling. The center is staffedby infection control practitioners, with backup from infectiousdiseases specialists. It registers all incoming calls, provides riskassessment for incidents, informs and counsels exposed indi-viduals, and provides a plan of action for starting prophylactictreatment. The center initiates laboratory tests, obtains in-formed consent for testing from source individuals, and, ifnecessary, provides medication. Medication can be given inhospital emergency departments, and laboratory tests can beperformed in 1 of the 2 regional hospitals 24 hours a day, 7 daysa week. Reports and written instructions for follow-up are sentto a general practitioner or the appropriate occupational


written instructions that included a short protocol for report-ing a blood-exposure incident.

Protocol

Blood-exposure incidents were classified into 1 of 3 major riskcategories, depending primarily on the severity of the expo-sure. High-risk incidents were defined as those in which therewas a risk of possible exposure to HBV, HCV, and HIV, andthere was significant percutaneous exposure to blood, such asinjuries involving hollow-bore, blood-filled needles. Low-riskincidents were defined as those in which there was a risk ofexposure to HBV only, and there was percutaneous exposureto only a negligible amount of blood. No-risk incidents, inwhich there was no risk for transmission of bloodborne patho-gens, were defined as incidents in which no blood or bodyfluids were involved and/or the skin remained intact.12

Each reported incident was registered in a standardizedfashion. The majority of incidents were analyzed, and incidentmanagement was assessed weekly for adherence to the stan-dard protocol. Flaws in the protocol and violations of protocolwere discussed with the members of the center.

Incident Analysis

In this study, we analyzed the following features for all blood-exposure incidents that involved a risk of transmitting blood-borne virus registered between January 2003 and December2005: (1) the reporting delay, defined as the interval betweenthe incident and the risk assessment; (2) the turnaround timefor HIV testing of the source individual, defined as the timebetween the incident and the availability of the HIV test result(for all incidents between January 2004 and March 2005 thatinvolved the risk of HIV transmission, the time from the expo-sure to completion of the enzyme immunoassay was also re-corded); (3) the level of risk for in-hospital and out-of-hospitalincidents; (4) the percentage of incidents that occurred afterregular office hours; (5) the number of protocol violationsmade at the expert center, which were categorized into thoserelated to incidents that required minimal interventions by thecenter (low-risk incidents) and those related to incidents thatrequired significant interventions by the center (high-risk in-cidents), as outlined in the algorithms in which the handling isdescribed 12; and (6) the HBV vaccination status of the exposedindividual.

Data Analysis and Statistics

Odds ratios (ORs) and 95% confidence intervals (CIs) werecalculated to show the differences in risk between in-hospitaland out-of-hospital incidents. Univariate logistic models wereused to calculate P values, 95% CIs, and ORs for risk assess-ment, violations of protocol, and reporting delay, using the 3years of collected data. A stepwise linear regression model was



table 1. Time Between the Occurrence of Blood-Exposure Incidents and Reporting the Incidents to theExpert Counseling Center, According to Incident Location

Proportion (%) of incidents, by study year

improving management of blood-exposure incidents 873

used to calculate the relationship between the time when theexposure occurred and the time when the HIV test for thesource individual was performed. Possible confounders, suchas whether the exposure occurred in or outside of a hospital,reporting delay, and whether the exposure took place during orafter regular office hours, were taken stepwise into the model.All data were analyzed using SPSS for Windows (SPSS).

results

During the 3-year study period, 1,394 incidents were regis-tered. In 2003, there were 454 incidents; in 2004, there were475; and in 2005, there were 465. A total of 689 incidents oc-curred in a hospital, and 704 occurred outside of a hospital.

Rapidity of Incident Reporting

In 2003, the percentage of in-hospital staff injuries that werereported within 2 hours was 70% (164 of 234); by 2005, thishad increased to 81% (183 of 225). At the beginning of thestudy period, the percentage of out-of-hospital injuries thatwere reported within 2 hours was 50% (109 of 220); by 2005,this had increased to 58% (139 of 240). During the study pe-riod, the percentage of injuries reported within 24 hours in-creased from 78% (183 of 234) to 94% (212 of 225) for in-hospital injuries and from 69% (151 of 220) to 86% (207 of240) for out-of-hospital injuries (Table 1).

HIV Testing for Source Individuals

The Figure shows the change during a 14-month period in thetime interval between a high-risk incident and the availabilityof the HIV test result for the source individual. Between Janu-ary 2004 and March 2005, there were 59 blood-exposure inci-dents registered in which the source individual was tested forHIV. There was a significant decline in the interval between theincident and the availability of the test result during this period(regression coefficient, �0.25 [95% CI, �0.44 to �0.07]; P �

Incident location,time to reporting

2003(n � 454)

2(n �

In-hospital (n � 690)Within 2 h 164/234 (70) 185/Within 4 h 172/234 (74) 198/Within 24 h 183/234 (78) 213/Within 48 h 186/234 (80) 216/

Out-of-hospital (n � 704)Within 2 h 109/220 (50) 136/Within 4 h 121/220 (55) 169/Within 24 h 151/220 (69) 219/Within 48 h 157/220 (71) 229/

note. Not all incidents include time data, so some wea For comparison of 2003 and 2005 data.


.01). Possible confounding factors, such as whether the inci-dent took place in or outside of a hospital, the reporting delay,and whether the incident took place after regular office hours,had no significant influence on this outcome.

Risk Level of Exposure

During the 3-year study period, there were 243 high-risk inci-dents. Of 690 in-hospital injuries, 189 (27%) were high risk; of704 out-of-hospital injuries, 56 (8%) were high risk (OR, 4.25[95% CI, 1.82–9.91]). There were 1,073 low-risk incidents dur-

P a OR (95% CI)a5)2005

(n � 465)

(80) 183/225 (81) .124 1.85 (0.96–3.59)(86) 198/225 (88) .012 2.62 (1.24–5.53)(92) 212/225 (94) .001 4.53 (1.73–11.87)(94) 214/225 (95) �.001 5.01 (1.79–14.01)

(56) 139/240 (58) .449 1.40 (0.80–2.45)(69) 172/240 (72) .026 2.07 (1.15–3.72)(90) 207/240 (86) �.001 2.88 (1.42–5.86)(94) 213/240 (89) �.001 3.18 (1.49–6.78)

cluded. CI, confidence interval; OR, odds ratio.

figure. Time interval between the occurrence of a high-risk blood-exposure incident and the availability of a human immunodeficiencyvirus (HIV) test result for the source individual. Between January 2004and March 2005, there were 59 source individuals tested for HIV.

00447

231231231231

244244244244

re ex



table 2. Risk Assessment Characteristics for Blood-Exposure Incidents, 2003–2005

Proportion (%) of incidents, by study year

a


ing the study period. A total of 471 in-hospital injuries (68%)and 602 out-of-hospital injuries (86%) were low risk (OR, 0.35[95% CI, 0.25– 0.77]). There were 30 no-risk in-hospital inju-ries (4%) and 48 no-risk out-of-hospital injuries (7%) (OR,0.55 [95% CI, 0.16 –1.95]).

Risk Assessment

Of 1,394 blood-exposure incidents, 460 (33%) occurred after reg-ular office hours. In 2003, there were 418 incidents in which theexposed individual was at risk of contracting HBV, HCV, and/orHIV; the source individual was known for 352 (84%) of theseincidents. In 2004, the source individual was known for 383(84%) of 457 incidents in which the exposed individual was atrisk; in 2005, the source individual was known for 392 (89%) of442 incidents (P � .72, for comparison of 2003 and 2005 data). Ofthe 85 source individuals tested for HBV in 2003, there were 5 whotested positive; 85 individuals were tested in 2004, and 3 testedpositive; 63 individuals were tested in 2005, and 3 tested positive.Of the 61 source individuals tested for HCV in 2003, there were 6who tested positive; 79 individuals were tested in 2004, and 3tested positive; 71 individuals were tested in 2005, and 1 testedpositive. Of the 67 source individuals tested for HIV in 2003, therewas 1 who tested positive; 79 individuals were tested in 2004, and3 tested positive; 71 individuals were tested in 2005, and 1 testedpositive. PEP was administered once in 2003, once in 2004, and 5times in 2005. Hepatitis B immunoglobulin was administered 85times in 2003, 81 times in 2004, and 59 times in 2005 (Table 2).

Characteristic

Risk levelNo riskLow riskHigh risk

Exposure reported after regular office hoursExposed individual at riskb

Known source individualHBV testing and treatment

Source individual testedSource individual tested positiveHB Ig administered to exposed individual

HCV testingSource individual testedSource individual tested positive

HIV testing and treatmentSource individual testedSource individual tested positivePEP administered to exposed individual

Reference serum taken from exposed individual

note. HBV, hepatitis B virus; HB Ig, hepatitis B immuficiency virus; PEP, postexposure prophylaxis.a For comparison of 2003 and 2005 data.b At risk for contracting HBV, HCV, and/or HIV.


Execution of Protocol

The number of protocol violations made by members of theexpert center decreased significantly during the 3-year studyperiod (P � .001). In 2003, of 396 incidents analyzed, 148(37%) involved a violation; in 2004, of 452 incidents analyzed,78 (17%) involved a violation; and in 2005, of 461 incidentsanalyzed, 38 (8%) involved a violation. More detailed infor-mation about the number of incidents in which the expert cen-ter provided an inappropriate number of interventions is givenin Table 3.

Hepatitis B Vaccination

Although the rate of hepatitis B vaccination among all in-jured hospital employees remained fairly constant duringthe study period (in 2003, the rate was 87% [204 of 234injured employees]; in 2004, it was 94% [217 of 231]; and in2005, it was 92% [206 of 224]), the rate of hepatitis vacci-nation among HCWs injured outside a hospital increasedsignificantly (P � .01). For HCWs involved in blood-exposure incidents outside a hospital, the vaccination ratein 2003 was 34% (52 of 152), in 2004 it was 51% (88 of 173),and in 2005 it was 70% (119 of 170). For all other individ-uals involved in blood-exposure incidents outside a hospital(ie, individuals who were not HCWs), the rate of hepatitis Bvaccination in 2003 was 16% (11 of 68), in 2004 it was 17%(12 of 71), and in 2005 it was 24% (17 of 170).

P2003 2004 2005

. . .454 (8) 18/475 (4) 24/465 (5)454 (77) 363/475 (76) 359/465 (77)454 (15) 94/475 (20) 82/465 (18)454 (28) 151/475 (36) 158/465 (34) . . .454 (92) 457/475 (96) 442/465 (95) . . .418 (84) 383/457 (84) 392/442 (89) .72

418 (20) 83/457 (18) 63/442 (14) .58/85 (6) 3/83 (4) 3/63 (5)418 (21) 81/457 (18) 59/442 (13) .18

418 (15) 79/457 (17) 71/442 (16) .555/61 (10) 3/79 (4) 1/71 (1)

418 (16) 74/457 (16) 71/442 (16) .998/67 (2) 2/74 (3) 1/71 (1)/67 (2) 1/94 (1) 5/82 (6)418 (8) 27/457 (6) 13/442 (3) .004

lobulin; HCV, hepatitis C virus; HIV, human immunode-

36/351/

67/127/418/352/

85/5

86/

61/6

67/11

34/

nog



table 3. Violations of Protocol for Management of Blood-Exposure Incidents at the Expert Counseling Center, 2003–2005

No. of incidents in which protocol was violated,by study year


discussion

The number of incidents reported each year during the 3 yearssince the center opened has remained constant. The constantnumber of incidents is surprising; one might have expected anincreased number as a result of increased awareness. Duringthe year before this study, information about the new centerwas extensively communicated to HCWs and others likely tobe involved in blood-exposure incidents. Although the litera-ture suggests that one must consider an average underreport-ing rate of 30%–50%,9,13,14 we did not further assess possibleunderreporting as a reason for the constant number of inci-dents reported because we presumed that the service was easilyaccessible. The increase in the HBV vaccination rate during thestudy may have masked the effect of increased awareness cre-ated by the center.

Efficient Practical Management of Blood-ExposureIncidents

Immediate reporting of incidents makes the handling ofpractical matters associated with a blood-exposure incidenteasier for the counselor. If an incident is reported promptly,

Variable 2003 (n �

Total no. of violations 148Type of violation

Too few interventions: testing notperformed or advice not providedwhen indicated

For exposed individualAnti-HBs not tested 3No reference serum taken 5No advice on HB Ig 5No advice HBV vaccination 38

For source individualHbsAg not testedb 56Anti-HCV not testedb 12Anti-HIV not testedb 4

Total 123Too many interventions: testing performed when

not indicatedFor exposed individual

Reference serum taken 20For source individual

HBsAg tested 2Anti-HCV tested 2Anti-HIV tested 1

Total 25

note. There were a total of 454 incidents in 2003, 475 incidents in 2004, aimmunodeficiency virus antibodies; anti-HCV, hepatitis C virus antibodies ;surface antigen; HBV, hepatitis B virus; OR, odds ratio.a For comparison of 2003 and 2005 data.b When the source individual was known.


more time is available to obtain blood from the source in-dividual, perform testing, and administer preventive mea-sures before the deadline for their effectiveness has passed.Guidelines advise that prophylactic medications should beadministered as soon as possible after the incident if they areto be the most effective.15-17 Therefore, an expert counselingcenter should be well known and easily accessible to all pro-fessionals at occupational risk for bloodborne diseases. Forincidents that occur outside a hospital, the management ofthese practical matters is even more complex than it is in ahospital, where all necessary resources are at hand. For thisreason, those who employ at-risk individuals outside hos-pital settings should instruct their employees adequately.Our study shows that instructions are helpful in reducingreporting delay.

Analysis showed that the turnaround time for HIV testingdecreased significantly during the 14 months that the centercollected data on this procedure. We did not find any sig-nificant effect from possible confounders such as location,reporting delay, or the time the exposure occurred. Decreas-ing the turnaround time for HIV testing gave counselors

P a OR (95% CI)a2004 (n � 452) 2005 (n � 461)

78 38 �.001 0.15 (0.10–0.22)

�.001 0.12 (0.08–0.19)

2 01 10 1

19 17

32 25 17 2

66 24.025 0.47 (0.24–0.91)

8 5

4 50 20 2

12 14

5 incidents in 2005. Anti-HBs, hepatitis B virus antibodies; anti-HIV, humanconfidence interval; HB Ig, hepatitis B immunoglobulin; HbsAg, hepatitis B

396)

nd 46CI,



more time to collect the test results necessary for assessingwhether PEP should be administered.9-11 A rapid HIV testcould potentially decrease turnaround time further18,19;

HBV Vaccination Rates

The increase of the HBV vaccination rate from 34% to 70%


however, such a test would need to be available 24 hours aday, 7 days a week, at multiple sites, and it would need to beable to be performed by laypeople. Currently, we do not seeany advantages to using a test other than the conventionalimmunoassay.

Risk Level

Throughout the study, the majority of high-risk incidents oc-curred in a hospital, whereas the majority of out-of-hospitalincidents were low risk. Hospitals have to be well prepared tohandle high-risk incidents, and they should preferably have allnecessary laboratory tests and PEP available at all times. On theother hand, a high hepatitis B vaccination rate makes handlinglow-risk incidents easier, and increasing the HBV vaccinationrate is the best method for preventing transmission of HBV inlow-risk incidents. The improvement in the HBV vaccinationrate during the study period—the result of a national cam-paign that coincided with the opening of the expert counselingcenter, and partly created by feedback from our center— didindeed facilitate the handling of low-risk incidents by reducingthe need to administer immunoglobulin.

Risk Assessment

More than one-third of the incidents registered in this study werereported after regular office hours, which shows the need for con-tinuous service to guarantee quality in care. We confirm that a24-hour service is essential, as has been shown by Patel et al.6 Dur-ing the study period, the percentage of incidents in which thesource individual could not be identified ranged from 11% to16% (66 of 418 incidents in 2003; 74 of 457 in 2004; and 50 of 442in 2005). These incidents were mostly caused by discarded needlesfrom sharp device containers and needles or other blood-contaminated sharp devices that had been left lying out (an injurythat primarily affected cleaning staff). Targeted feedback of thisinformation to the departments involved can actually help to re-duce the incidence of this problem.

Assessing risk from incidents in which the source individ-ual cannot be identified is challenging. No definite risk es-timation can be given in such cases, and serologic follow-upis required, leading to more anxiety for the exposed individ-ual. Although PEP was administered more often in 2005than in the 2 previous years, this difference was not signifi-cant. However, one reason for the increased administrationof PEP might be that unidentified source individuals couldnot be tested after high-risk exposures. On the other hand,significantly less immunoglobulin was administered in 2005than in previous years, because the source individuals forlow-risk exposures were tested more appropriately.


among HCWs employed outside a hospital obviously directlydecreased the risk for HBV transmission. In 2003, hepatitis Bimmunoglobulin had to be administered to 86 exposed indi-viduals, whereas in 2005, this number decreased to 59. Thismade the handling of low-risk incidents far simpler. The Dutchgovernment only advises HBV vaccination for limited riskgroups. Institutions that employ HCWs should actively pro-mote and provide HBV vaccination, to prevent infection. Also,the Dutch labor inspectorate could play an active role in stim-ulating healthcare institutions to set up hepatitis B vaccinationprograms.20

Quality Control

During the 3 years of the study, the number of incidents that in-volved protocol violations committed by members of the expertcenter decreased significantly, thereby improving the way inwhich blood-exposure incidents were handled. Although inade-quate handling of these incidents is potentially harmful to HCWs,overly careful management may lead to unnecessary laboratorytesting and/or the administration of unnecessary medication.Counseling and support for the exposed individual can be done ina uniform way. However, it is not easy to achieve and maintain ahigh level of expertise. Each new expert center will require timeand experience to gain knowledge about how to apply the proto-col appropriately. In addition to medical knowledge, the mem-bers of each expert center will also require training and experiencein the psychosocial skills needed to handle various situations asthey arise.

In conclusion, the counseling center improved several as-pects of the management of blood-exposure incidents. Thecenter was accessible by telephone 24 hours a day, 7 days aweek, which provided an easy and less time-consuming way toreport blood-exposure incidents. We were able to reduce thereporting delay, improve the handling of practical matters as-sociated with an incident (especially after regular office hours),improve the quality of incident management, and, by increas-ing HBV vaccination rates, reduce the administration of im-munoglobulin.

acknowledgmentsPotential conflicts of interest. All authors report no conflicts of interest rele-vant to this article.

Address reprint requests to Paul Th. L. van Wijk, Jeroen Bosch Hospital,Department of Medical Microbiology and Infection Control, POB 90153, 5200ME ‘s-Hertogenbosch, The Netherlands ([email protected]).

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three-year prospective study to improve the management of blood-exposure incidents

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