ADDIS ABABA UNIVERSITY SCHOOL OF MEDICINE

DEPARTMENT OF EMERGENCY MEDICINE

ASSESSMENT OF THE KNOWLEDGE, ATTITUDE AND PRACTICE ON UNIVERSAL

PRECAUTION AMONG EMERGENCY MEDICINE PROFESSIONALS IN
EMERGENCY ROOM TIKURE ANBESSA SPECIALIZED HOSPITAL, AAU,
ETHIOPIA, 2013 G.C

By: Afework Alemayehu (B.Sc.)

EMAIL abitafewushi@gmail.com mob +251940584198

Advisors: Assefa Seme (MD, MPH, Ass. Professor)

: Aklilu azazh (MD, Internist, Emergency Medicine & Critical Care Physician)

MSC THASIS SUBMITTED TO DEPARTMENT OF EMERGENCY MEDICINE ADDIS

ABABA UNIVERSITY IN PARTIAL FULFILLMENT FOR THE AWARD OF
MASTER’S DEGREE IN EMERGENCY MEDICINE
January, 2013 G.c
Addis Ababa, Ethiopia
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Acknowledgments
I am very grateful to my advisor Dr. Assefa Seme MD, MPH, Ass. professor of the school of
public health, department of reproductive health, Addis Ababa University (AAU), for his
unreserved guidance and constructive suggestions and comments on the stage of proposal
development to final thesis. I would like to mention my respect and cordial to my senior
instructor and advisor Dr. Aklilu azazh (MD, Internist, Emergency Medicine & Critical Care
Physician) of the school of Medicine (SOM), who helped me a lot during the proposal
development including informing me possible organizations, working on universal precaution,
providing guidance and for his solid comments.
My heartfelt thanks extend to Ato sorsa Faltamo (Ministry of Health) w/t Tereza Tadiyos who
helped a lot during proposal writing by being with me in providing material support.
I would take this opportunity to extend my thanks to my friends’ yebeltal kassa (MPH) Degineh
Yohannis(BSc pharm), and my brother Alemyisfa Besufika for their encouragement during the
whole study.
At last but not least I would like to extend my deepest thanks to staffs of emergency medicine
and secretaries (Tigist and Kidist) for their unreserved support during data collection.

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Contents
Acknowledgements…………………..…………………………………………………………….i

Lists of tables and figures ……….....……………………………………………………………iv

List of Acronyms……………………………………………………………………………..…...v

Summery …………………………………………………………………………………………vi

1. Introduction ........................................................................................................................................... 1
Background information ........................................................................................................................... 1
Statement of the problem .......................................................................................................................... 3
Rationale of the study ............................................................................................................................... 4
1 Literature review ................................................................................................................................... 6
Actual Practice .......................................................................................................................................... 7
Safe injection ............................................................................................................................................ 8
Personal Protective Equipment ................................................................................................................. 9
Safe Sharp Waste Management ................................................................................................................ 9
Hand Hygiene ......................................................................................................................................... 10
2 Objective of the study ......................................................................................................................... 13
General objective .................................................................................................................................... 13
Specific objectives .................................................................................................................................. 13
3 Methods and Materials ........................................................................................................................ 14
Study area............................................................................................................................................ 14
Study period ........................................................................................................................................ 15
Study design ........................................................................................................................................ 15
SOURCE AND STUDY POPULATION ............................................................................................... 15
Source and Study populations ............................................................................................................. 15
Inclusion criteria ................................................................................................................................. 15
Exclusion criteria ................................................................................................................................ 15
Data management.................................................................................................................................... 15
Data collection methods ...................................................................................................................... 15

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 Data collectors .................................................................................................................................... 16
Study variables ........................................................................................................................................ 16
Dependent ........................................................................................................................................... 16
Independent ......................................................................................................................................... 16
Data entry and analysis ........................................................................................................................... 16
Ethical consideration ............................................................................................................................... 17
Strength and limitation ............................................................................................................................ 17
Limitations .......................................................................................................................................... 17
Strength of the study ........................................................................................................................... 17
Operational Definitions ........................................................................................................................... 18
4 Result .................................................................................................................................................. 19
Safety of injections ................................................................................................................................. 20
Results of observation ............................................................................................................................. 29
Materials Available (observed) ............................................................................................................... 31
5 Discussion ........................................................................................................................................... 33
6 Conclusions and Recommendations ................................................................................................... 38
7 Recommendations: .............................................................................................................................. 39
8 References ........................................................................................................................................... 40
9 Annexes……………………………………………………………………………………………………………………………………………43

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 Lists of tables and figures
Lists page

1. Fig 1: Years of experience of the emergency medicine professionals in emergency

room, Tikur Anbessa Specialized Hospital, May 2013 G.C ……………………….……19

2. Table 1:-Distribution of respondent by their status of training on infection prevention in
emergency, Tikur Anbessa Specialized Hospital, May 2013 G.C……………………...20
3. Fig 2: Knowledge of emergency medicine professionals about infectious disease
transmitted by needles and sharps in emergency room, Tikur Anbessa Specialized
Hospital, May 2013 G.C…………………………………………………………….......21
4. Table 2: Proportion of emergency medicine professionals who identified types of waste
materials to be discarded in to safety box in emergency room, Tikur Anbessa Specialized
Hospital, May 2013 G.C……………………………….……………………………….22
5. Table 3: Measures to be taken after exposure to blood and body fluid by emergency
medicine professionals in emergency room, TASH, May 2013 G.C……………..…….23
6. Table 4: knowledge of emergency medicine professionals toward the source of infection
in hospital setting, Tikur Anbessa Specialized Hospital, May 2013 G.C………………24

7. Fig 3:- Perception of emergency medicine professionals on the status of needle after use
in emergency room, Tikur Anbessa Specialized Hospital, May 2013 G.c……...............25
8. Fig 4:- showing the practice of emergency medicine professionals on hand washing
before touching the patients in emergency room, TASH, May 2013 G.C……….....…..26
9. Table 5: Reasons cited by emergency medicine professionals for not washing their hands
& washing sometimes in emergency room, TASH, May 2013 G.C………………........27
10. Table 6:-personal protective device utilization by emergency medicine professionals in
emergency room, Tikur Anbessa Specialized Hospital, May 2013 G.C……………….28
11. Fig 6:- shows percentage of procedures observed during data collections in emergency
room, Tikur Anbessa Specialized Hospital, May 2013 G.C……………………………30
12. Table 7: - shows some of the materials used in infection prevention in emergency room
TASH 2014 G.c…………………………...…………………………………………….31

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List of Acronyms
AAU Addis Ababa University
AD Auto disable (syringe)
AIDS Acquired Immune Deficiency Syndrome
CDC Center for Disease Control and Prevention
ER Emergency room

HBV Hepatitis B Virus

HCV Hepatitis C Virus
HIV Human Immunodeficiency Virus
HCW’S Health care workers
HLD High Level Disinfection
IP Infection Prevention
MOH Ministry of Health
NaSH National Surveillance System for Health Care Workers
NSI Needle sticks injury
OPD Out Patient Department
PEP Post Exposure Prophylaxis
PPE Personal Protective Equipment
SIGN Safe Injection Global Network
SNNPR Southern Nation, Nationalities, and Peoples Region
SPSS Statistical Package for Social Science Research
TASH Tikur Anbessa Specialized Hospital

UNAIDS Joint United Nations Program on HIV/AIDS

UP Universal Precautions
WHO World Health Organization

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Summary
Background employing universal precautions means taking precautions with everybody. If
precautions are taken with everyone, health care workers do not have to make assumptions about
people's lifestyles and risk of infection.
Objectives: The main objective of the study was, to assess the knowledge, attitude and practices
about universal precautions among emergency medical professionals and factors associated with
its practice in emergency unit.
Methods: This hospital based cross sectional descriptive survey was conducted in Tikur Anbessa
Specialized hospital, AAU from February through June 2013.
The study was carried out using a structured questionnaire which was self-administered to all
emergency medicine personnel after preliminary introduction at a plenary session. The study was
use both quantitative (which was self-administered) & qualitative(to which an Observation
check-list was used to observe whether or not the staff members involved in patient management
is using an appropriate technique and timing as per the set guideline) methods. Data was entered,
cleaned and analyzed using SPSS for Windows version 16. Frequencies, percentage and graphs
was used for descriptive purposes.

Study period –study period was from February 2013 to June 2013.The total budget for the
accomplishing of this study was 18,465.50 ETB.
Key words: universal precaution, emergency medicine professionals, universal precaution
related practice and hand hygiene.

Results-Only 15(24.6%) of the respondents know the presence of anti HIV prophylaxis after
sustaining needle stick or sharp injuries while 46 (75.4%) didn’t know. The respondents who had
perceived risk of acquiring HIV infection from their health facility waste, when disposed
improperly, 2 said the risk would be for HCW, 3 for supportive staff, 40 (65.6%) for both health
professionals & supportive staff and 8 said would be for Health Professionals, Supportive staff,
the client / patient & the community.
Among the emergency medicine professionals 36(59%) perceived that oxygen delivery materials
like mask, nasal cannula & prong can be reusable whereas 25(41%) perceived as this materials
can’t be reused. Concerning needle recapping after use, 51(83.6%) the respondents perceived

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that it should not be recapped and the remaining 10(16.4%) were said should be recapped after
use.
Discussion-Poor hand washing practice by emergency medicine professionals were found
before and after touching the patients were found. Emergency medicine professionals were not
properly handling, and disposing used Needle/sharp materials in the study area. Personal
protective devices particularly mask and eye goggles, boots etc. were not available during the
survey.

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Introduction
Background information
Universal precautions are the infection control techniques that were recommended following the
AIDS outbreak in the 1980s. Essentially it means that every patient is treated as if they are
infected and therefore precautions are taken to minimize risk. No doubt, universal precautions
are good hygiene habits, such as hand washing and the use of gloves and other barriers, correct
sharps handling, and aseptic techniques.
6
The term Universal Basic Precautions (UBP) was introduced in 1985 by Garner . He defined it
as: “the prevention of transmission of blood borne pathogens like HIV through strict respect by
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health workers of rules concerning care and nursing”. Gerberding et al also defined Universal
pre-caution: “the routine use of appropriate barrier and techniques to reduce the likelihood of
expo-sure to blood, other body fluids and tissues that may contain blood borne pathogens”.
UP assumes that anybody in a hospital, especially patients, is potentially a carrier of blood borne
pathogens, therefore all patients are treated in the same way as though they were infected.
In practical terms it involves the use of gloves, aprons, goggles, suitable care of needles, sharps
and other contaminated instruments, house keeping with appropriate cleaning policies and
ensuring strict adherence to standard practices. This requires the sustained provision of
protective materials, proper training of health care providers and adherence to sterilization and
disinfection protocols. One group of people at a relatively higher risk of exposure is health
workers.
During the 19th century, women in childbirth were dying at alarming rates in Europe and the
United States. Up to 25% of women who delivered their babies in hospitals died as a result of
childbirth fever (puerperal sepsis), which later was found to be caused by Streptococcus
pyogenic bacteria (14). As early as 1843, Dr. Oliver Wendell Holmes advocated hand washing to
prevent childbirth fever (puerperal sepsis).
Perhaps hand washing seemed odd at the time. The lack of indoor plumbing made it difficult to

1
get water. In order to make the water comfortably warm, it would have been heated over a fire.
Besides, contact with water was associated with diseases such as malaria and typhoid fever (14).
In the 1870's in France, one hospital was called the House of Crime because of the alarming
number of new mothers dying of childbirth fever within its confines.
In 1879, a noted speaker at a seminar in Academy of Medicine in Paris, stood at the podium and
cast doubt on the spread of disease through the hands. When an outraged member of the
audience felt compelled to protest, he shouted at the speaker that: "The thing that kills women
with [childbirth fever]...is you doctors that carry deadly microbes from sick women to healthy
ones." That man was Louis Pasteur. Who was a tireless advocate of hygiene, that his efforts were
initially met with skepticism. Skepticism, however, was not the only problem facing advocates of
hygiene. (14).
The HIV/AIDS epidemic is firmly rooted in every country all over the world today. Currently
33.3 million people worldwide are living with HIV. For the health professional, in addition to
contact with infected semen, blood and blood products, HIV infection can also be acquired
through exposure to other contaminated body fluids such as CSF, pericardial/pleural fluids and
amniotic fluids. The risk of HIV infection may appear relatively low but this calls for worry as
4, 5
those infected got it through care of their patients .
The other important component of universal precaution is hand hygiene. Despite its rocky
beginnings, hand washing has become a part of our culture. Hand washing and other hygienic
practices have been taught at every level of school, advocated in the work place, and emphasized
during medical training (14, 15).
In Ethiopia, where the health care services is largely covered by low and mid-level health
professionals, assessing the necessary knowledge, attitude and practice or the skill on universal
precaution and factors in hospitals as early as possible can give way to manage the limited
resource available in the sector. It also improves the quality and safety of health service for the
health providers and consumers. Thus, this survey was conducted to assess the knowledge,
attitude and practice (KAP) of health care workers on universal precaution and determinant
factors for practice in health care facilities in TASH. So that, the health planners, health care
providers, managers and evaluators can use the outcome of this study.

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The world Health organization has announced globally a day for hand-washing by emphasizing
the need to get once hand washed before consuming edible items or before or after completing
procedures particularly that are related with patient care.

The purpose of this study is to assess the universal precaution practices and factors affecting it
among emergency service providers involved in the management of emergency patients seen at
emergency room of Tikur Anbessa Specialized Teaching Hospital (TASTH) in Addis Ababa.

Statement of the problem

Globally, WHO estimated that every year unsafe injections and needle stick injuries cause at
least 8-16 million hepatitis B infections, 2.3-4.7 million hepatitis C infections and 160,000
HIV/AIDS infections (4, 6).
The world health organization (WHO) estimated that at least 50% of the 12 billion injections
administered each year in the developing world are unsafe- posing serious health risk to
recipients, health workers and the public (2,3&4). Injuries from sharp devices have been
associated with the transmission of more than 40 pathogens, including hepatitis B virus (HBV),
hepatitis C virus (HCV), and HIV (3, 5, and 6). These chronic infections lead to a high burden of
morbidity and mortality (6).
In many countries for many years health care workers have been infected with HIV as a result of
their work. The main cause of infection in occupational settings is exposure to HIV infected
blood via a percutaneous injury. Occupational exposure to blood borne pathogens from needle
sticks and other sharps injuries is a serious problem, but it is often preventable. Study done in the
United States (US), showed that more than 800,000 needle stick injuries occur each year despite
continuing education and vigorous efforts aimed at preventing such accidents (8).
Studies have shown the risk of diseases after exposure to HBV from a single needle stick injury
ranges from 27-37%, while the risk following a single needle stick exposure to HIV is much
lower, 0.2-0.4%, and 3-10% for HCV (10, 11, and 12).
The New England Journal of Medicine report reminds us, one of the most effective, simple, and
yet difficult to implement solutions would be for all hospital personnel to wash their hands
between every patient (14)

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Failure to perform appropriate hand hygiene is considered to be the leading cause of nosocomial
infections and the spread of multi resistant microorganisms, and has been recognized as
significant contributor to outbreaks (9). While we are potentially at risk of contracting hand
transmitted illnesses, one-third of our population is especially vulnerable, including pregnant
women, children, old people, and those with weakened immune systems (14, 15, 16)
In health institutions of developing countries like Ethiopia, hand washing practice, though not
strict, is among the components of infection prevention techniques. However, the practice is
affected by such factors like lack of detergents, water, clean wash-room, or carelessness of some
staff working in health institutions. It may also be affected by lack of knowledge about the
importance of hand-washing practice as a component of infection prevention.
Patients that are admitted to emergency department or receiving services on ambulatory basis are
at risk of acquiring infection unless appropriate precautions are taken to prevent infection.
Emergency service workers and other staff working in these settings also are at risk of exposure
to serious and potentially life- threatening infections.
A study done in University of Geneva Hospital in Switzerland revealed that the hand hygiene
compliance rate ranges from 23% to 87%. Overall, doctors practiced proper hand hygiene only
57 percent of the time when opportunities for hand washing arose (16). And a study done by
Nigat project and Engender health in Ethiopia showed that health care workers don’t usually
wash their hands on arrival to work place and before putting on glove; even though, it is well
practiced between clients and before leaving work place (17).
Hospital acquired infections in developing countries has always been there, it is becoming one of
the areas which get attention of health providers, programmers and evaluators. HBV, HCV, HIV
and many of their infectious organisms have been there for many years and continue to be a
common reason for poor and ill health of health care workers and patients or clients (4).

Blood is the single most important source of HIV, HBV and other blood-borne pathogens in the
occupational setting -- prevention of transmission must focus on blood and other body fluids
containing visible blood. Universal precautions also apply to: semen, vaginal secretions, CSF,
synovial, pleural, peritoneal, pericardial and amniotic fluids, tissues, and any body fluids in a
situation where it is difficult to differentiate between types of fluids, such as in emergency
response.
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Rationale of the study
Infection prevention knowledge and technique, as a means to reducing transmission of infections
and avoiding morbidity and mortality related to communicable diseases, is vital particularly in
emergency unit at hospital settings where most infectious substances are ubiquitously distributed.
Hospital acquired infections could emanate from lack of proper applications of techniques of
infection prevention, particularly failure to perform appropriate hand hygiene, beside the
emergence of drug-resistant strains. Healthcare providers, students and other auxiliary staff
(housekeeping, maintenance and laboratory staff) working in health institutions particularly
those working in infectious areas need to have adequate knowledge and skill of applying
techniques required to keep universal precaution in order to prevent transmission of infections.
Universal precaution practice is among the infection prevention techniques that are largely
applied in most developed nations. Proper hand hygiene is the single most important infection
prevention and control practice (1). In countries with limited resource, it is important to develop
the health care staff knowledge, attitude and practice on universal precautions. AS well as, use of
the recommended infection prevention practices to minimize their risk of accidental exposure or
injuries and provide safe service to clients should be a standard practice. a study done by Nigat
project and Engender health in Ethiopia showed that health care workers don’t usually wash their
hands on arrival to work place and before putting on glove; even though, it is well practiced
between clients and before leaving work place (17).
In Ethiopia, where the health care services is largely covered by low and mid-level health
professionals, assessing the necessary knowledge, attitude and practice or the skill on universal
precaution particularly those working in emergency situation life-saving procedures & activities
are prior and factors in hospitals as early as possible can give way to manage the limited resource
available in the sector.

Finally, the result of this will help hospital management and the emergency medicine department
and other concerned departments and units to design an appropriate intervention mechanism of
either availing supplies and equipment or raising awareness among the emergency service
workers. Again this study aims at assessing the knowledge, awareness and practice of emergency
medical personnel on universal precautions so as to forward the results & the effective measures

4
that has to be taken by them was discussed. Finally the result of this study can be used as source
of base line data for other researchers on the same area of study.

Literature review
A study conducted on knowledge, attitude and practices among health care workers on needle
stick injuries revealed that 52 (74%) out of 70 had a history of needle stick injury and. Twenty
subjects (29%) were of the impression that needles should be recapped after use, and only
43(61%) were aware of universal precaution guidelines. The study revealed that 59(84%) of
HCWs were vaccinated (Maqbool Alam, 2002).

One study done in Africa on safety of injection (8) showed that waste disposal was problematic
in Chad, Cameron, Cote-de-voire, Guinea Bissau and Uganda. In these countries there were no
health centers that had a facility for safe disposal of used materials. But in Ethiopia, Rwanda,
Kenya and Zambia, incineration of used syringes was reported to be the common practice.
A study done in Ethiopia at Southern Nation, Nationalities, and Peoples Region (SNNPR)
showed that 32.4% of health care workers (HCW’s) reported as they had sustained at least one
form of accidental injury by needle or other sharps. Among these injuries, both deep and
penetration injuries constitute 63.8%. Nurses and health assistants sustained the highest
proportion of accidental injuries by needles or sharps (p < 0.05). Male HCWs had less chance of
sustaining injury either by needles or by sharps than the female (p < 0.05) (13)

Study on Ghana Accera hospital showed that forty-seven (94%) of the respondents agreed that it
is important to wear gloves when doing invasive procedures but 3 respondents (6%) disagreed.
In spite of this, 22 (44%) persons said every patient going for surgery should be screened for
HIV, 27 (54%) said no to this whilst 1 person (2%) did not give their opinion.
As many as 18 respondents (36%) admitted that they would be reluctant to perform an invasive
procedure on an HIV positive patient but 31 (62%) had no problem with that one (2%)
respondent gave no answer. In the same research done in Ghana showed that twenty four (48%)
of respondents said squeezing of blood from the site of a needle prick reduces the risk of HIV
infection. An equal number disagreed and 2 (4%) did not respond.

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The level of knowledge of UP among the respondents is high at 92% as compared to the practice.
For instance only 84% of the respondents wear gloves for invasive procedures and an equal
number wear face masks. The least practiced is the wearing of protective eye shields (24%).
Most research indicates that, knowledge of universal precautions does not necessarily impact on
25
compliance. Knight V suggests that not all practitioners are as knowledgeable as they could be.

Recapping of used needles is reported as one way through which health workers sustain needle
pricks and in this study as many as 78% of the respondents do that.26

Actual Practice
Study in Ghana forty-two (88%) of respondents indicated that they wore gloves routinely when
performing invasive procedures on patients but 8 (16%) did not for the reasons that:
• They are careful when performing invasive procedures,
• There is no time to look for gloves in emergency situations
• That sometimes gloves are not readily avail-able,
• They have better control over the IV cannula without gloves and
• They can set intravenous lines without soiling themselves.
Respondents were also asked which precautionary measures they practice in surgical procedures.
In response to the use of other precautionary measures some respondents did not wear some of
the protective gadgets. For example, goggles were not always used because they were not
available in the theatre, were not routinely needed in every operation and the available ones did
not fit or the respondents were not used to wearing goggles for operations.(24)
Observed compliance with universal precautions procedures during practical training ranged
from 95 - 99% for glove use, 76 - 77% for direct sharps disposal without needle recapping, and
56 - 78% for hand washing after glove removal during phlebotomy and intravenous catheter
insertion. The study concluded that such programs were effective in increasing students'
knowledge of universal precautions. Training favorably affects students' willingness to care for
HIV-positive patients and their assessed risk of developing occupational blood borne infection.
(29)
The observed rate of compliance with universal precautions by participants indicates that
individual compliance was inversely related to the years of experience (overall compliance rate

6
of students was 96%; for first-year residents, 92%, second-year residents, 89%, third-year
residents, 84%, fourth-year residents, 78%; r = -0.9918, P = 0.0009). The study concluded that
the knowledge regarding universal precautions was nearly 100%, while overall observed
compliance was only 89%.30
A survey was conducted on standard Precautions: Occupational Exposure and Behavior of
Health Care Workers in Ethiopia. Life time risks of needle stick (30.5%) and sharps injuries
(25.7%) were high. There was a high prevalence of life time 28.8% and one year (20.2%
exposures to blood and body fluids. Taking training was not protective against NSI in the past
one year (Reda et al, 2010). A study conducted on the Assessment of Knowledge, Attitude and
Practice of Health Care Workers on Universal precaution in North wollo zone, Amhara Region,
North Eastern Ethiopia revealed only 45.8% said that they ever had participated in any training
dedicated to infection prevention after their respective pre-service courses on, 2006).
The following universal infection control precautions are advised by the World Health
Organization to help protect health care workers and clients from blood-borne infections
including HIV:
 Washing hands with soap and water before and after procedures.
 Using protective barriers such as gloves, gowns, aprons, masks, goggles for direct contact
with blood and other body fluids.
 Disinfecting instruments and other contaminated equipment.
 Handling properly soiled linen. Gloves and leak proof bags should be used if necessary.
 Cleaning should occur outside patient areas, using detergent and hot water.
 Using a new, auto disable syringe (AD) or single-use disposable injection equipment for
all injections is highly recommended. Sterilizable injection should only be considered if
single use equipment is not available and if the sterility can be documented with Time,
Steam and Temperature (TST) indicators.
 Discarding contaminated sharps immediately and without recapping in puncture and
liquid proof containers that are closed, sealed and destroyed before completely full.
 Document the quality of the sterilization for all medical equipment used for percutaneous
procedures (1, 8, 18, and 19).

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Safe injection
WHO define safe injection as one that does not harm to the recipient, does not expose the
provider to any avoidable risk, and does not result in waste that is dangerous to other people (5).
In transitional and developing countries where unnecessary injections are common, the average
number of health care injections per person was estimated to be 3.7 per year this includes all
health care injections, including those given to diabetics for administering insulin. Many
injections, as well as being unnecessary are also ineffective or inappropriate and unsafe (2, 6).
The WHO estimate that at least 50% of the 12 billion injections administered in the developing
world each year are unsafe- posing serious health risk to recipients, health workers and the public
(2, 3).
Use of new, single use syringe and needle provides high level of safety to the recipient.
However, unreliable and insufficient supplies might lead to the equipment being reused.

Personal Protective Equipment

Protective barriers, now commonly referred to as personal protective equipment (PPE), have
been used for many years to protect patients from microorganisms present on staff working in
the health care setting (8, 18, 19, 22). More recently, with the emergence of HIV/AIDS and HCV
and the resurgence of tuberculosis in many countries, use of PPE now has become important for
protecting staff as well (8, 18, 19, 22)
The type of protective clothing used will depend on the extent of the risk associated with the
health-care waste, so that the following should be made available to all personnel who collect or
handle health-care waste: head cover or caps, face masks, eye protectors, leg protectors or boots
and disposable gloves or heavy-duty gloves (8, 18, 19, and 22).

Safe Sharp Waste Management

It is important to collect and properly contain syringes and needles at the point of use in sharps
container that is puncture and leak proof and that is sealed before it is completely full. Unsafe
sharp waste collection causes between 5% and 28 % of needle stick injuries (18, 23, 24).
Interventions like risk communication, managing sharps waste in efficient, safe and friendly way
can reduce rate of needle stick injury (11, 19, 21, 23, 25) to health care workers, clients and the
community at large.

8
After closing and sealing, sharps containers must not be opened, emptied, reused, or sold (25).
Four commonly used methods to destroy filled safety boxes or to keep them away from people
are: incineration (usually this is the best option), burning in a metal drum (next best option), open
burning (if incineration or burning in a drum or hearth is not possible), and burying without
burning (least safe option unless the burial pit is extremely secure) (19, 25)
A study done in Africa on safety of injection showed that waste disposal was problematic in
Chad, Cameron, Cote-de-voire, Guinea Bissau and Uganda. In these countries there were no
health centers that had a facility for safe disposal of used materials. But in Ethiopia, Rwanda,
Kenya and Zambia, incineration of used syringes was reported to be the common practice (7).
Though there were few studies were done in Ethiopia; one of the study done in SNNPR by W/
Gebreal, Y. revealed that the prevalence of unsafe injection were 74%. Thirty two point four
percent of health care workers sustain sharp or needle stick injuries in one year and 64% of these
injuries were deep or penetrating injuries (14). Another study done in Addis Ababa showed that
84% of health care workers dispose used needles in open plastic bucket and 54% of HCW’s were
observed while they were recap needles and also found that chlorine solutions were prepared and
used in a very weak strength (17).
A study done in Amhara and Oromiya region by Melkamu, Y. and Kumbi, S. revealed that
decontamination solutions were not prepared properly or not changed daily and health care
providers did not consistently use PPE (26). As of the reports of injection safety survey in
Ethiopia lack of supply of syringes, needles and equipment was considered as a reason for few of
the unsafe practices (27).

Hand Hygiene
Despite its rocky beginnings, hand washing has been a part of our culture. Hand washing and
other hygienic practices have been taught at every level of school, advocated in the work place,
and emphasized during medical training (14, 28). According to the United States Centers of
Disease Control and Prevention (CDC), "Hand washing is the single most important means of
preventing the spread of infection." (14, 19) The CDC guidelines specify that hand hygiene
should occur with any patient contact and HCW’s hand should be washed with a non-
antimicrobial soap and water or, an antimicrobial soap and water when hands are visibly soiled,

9
or contaminated. If hands are not visibly soiled, HCW’s can use an alcohol based hand rub for
routinely decontaminating hand in clinical situations as described in literature:
 Before having direct contact with patients
 Before donning sterile gloves when inserting a central intravascular catheter
 Before inserting indwelling urinary catheters, peripheral venous catheters, or other
invasive devices that do not require a surgical procedure
 Before starting work, going for a break and leaving for home
 Before entering and leaving isolation area
 After contact with a patient (such as in taking pulse or blood pressure, or lifting a
patient);
 After contact with body fluids or excretions, mucous membranes, non-intact skin, or
wound dressing
 If moving from a contaminated body site to clean-body site during patient care
 After contact with inanimate objects.
 After using toilet
 After nose blow and
 After removing glove (28, 29)
Yet, recent studies and reports indicate that lack of or improper hand washing still contributes
significantly to disease transmission. While we are all potentially at risk of contracting hand-
transmitted illnesses, one third of our population is especially vulnerable, including pregnant
women, children, old people, and those with weakened immune systems (14, 16). It seems
reasonable to assume that hospitals have come closest to responding to this problem. Modern
surgery, after all, has long since solved many of the early problems of infection. However,
fundamental problems of hygiene still exist. In 1992, The New England Journal of Medicine
reported on a hand washing study in an intensive-care unit.
Despite special education and monitored observation, hand washing rates were as low as 30%
and never went above 48% (14).
A study done in University of Geneva Hospital in Switzerland revealed Anesthesiologists were
the least compliant, washing up only 23 percent of the times than they were expected. Surgeons,
ranking second from the bottom, had only a 36 percent compliance record of practicing proper

10
hand hygiene. Doctors in emergency medicine complied only 50 percent of the time. Doctors in
internal medicine, by contrast, had an 87 percent compliance rate which was the best of the entire
medical specialties in this particular case. Overall, doctors practiced proper hand hygiene only 57
percent of the time when opportunities for hand washing arose (16). Nosocomial infections are
infections acquired by patients while they are in the hospital, unrelated to the condition for which
the patients were hospitalized. CDC estimates that from 5% to 15% of all hospital patients
acquire some type of nosocomial infection. Hospital personnel can also become infected. (14).
The rate of nosocomial infections can be reduced by full-scale infection control programs whose
expense would be recovered by the reduction of the cost involved in treating the nosocomial
infections. But, as The New England Journal of Medicine report reminds us, one of the most
effective, simple, and yet difficult to implement solutions would be for all hospital personnel to
wash their hands between every patient (14).
In Indonesia, UP have been implemented in all major hospitals and health care facilities;
however a survey of 400 HCWs in a referral hospital revealed that 55% reported ≥1 needle-stick
injury per year. (28)
A nation-wide Danish hospital survey revealed that on average 11% of all HCWs sustained a
needle-stick injury every month.11 In a German university hospital 47% of medical staff in
surgery and 19% of HCWs in pediatric department reported at least one needle-stick per
year.(31)
A total of 180/376 (48%) respondents experienced occupational sharps injuries and 233/376
(62%) experienced splash injuries at least once in the last year. 77% of sharps injuries were
sustained during patient handling situations such as giving injection/ IV line and suturing; 32%
were caused by recapping needles with two hands, 15% when cleaning up instruments or
discarding waste and 7% by bending a needle. Occupational sharps injuries happened frequently
(44%) during the night shift, 34% occurred during the morning shift.

11
Objective of the study
General objective
To assess the knowledge, attitude and practices on universal precautions among emergency
medicine professional in emergency unit, TASTH from January 2013 to June 2013 G.C

Specific objectives

1. To describe the knowledge of universal precaution among emergency medicine

professional involved in emergency patient management in TASTH
2. To assess the attitude of emergency medicine professionals involved in emergency
patient management towards universal precaution in TASTH
3. To assess the practice of universal precaution by emergency medicine professional
involved in emergency patient management in TASTH
4. To determine factors associated with the practice of universal precaution at emergency
unit in TASTH

12
Methods and Materials
Study area
The study was conducted in Tikur Anbessa Specialized Teaching Hospital (TASTH) which is
located in the capital of Ethiopia, Addis Ababa City, Kirkos Sub City. It was established in
1973 EC; during the reign of Emperor Haile Selassie as part of the national effort for
providing quality health care to the community. The hospital totally holds 12, 3000 m. sq. area
of land and the building has settled on 45000 m sq. area. There are 1262 various rooms from
the basement to the eighth floor. The hospital is currently functioning as teaching hospitals
under AAU and it is the country’s biggest specialized referral hospitals containing 800 total
numbers of beds. This hospital sees approximately 370,000- 400,000 patients per year but the
exact number is not known.

The hospital was the biggest in Ethiopia during establishment period and was regarded as an
exemplary hospital without any other superior one in the continent of Africa. Even at the
moment it is renowned and famed as service rendering, training providing and research
conducting institution equipped and facilitated with modern medical equipment and highly
skilled medical specialists.

The hospital had five major clinical departments which include department of internal medicine
(B8, C8, D8 and B5), department of surgery (B4, C4, D4 and D5), department of gynecology and
obstetrics (C6 and D6), department of pediatrics including Neonatology (B6, B7, C7 and D7),
and department of orthopedics (B3 and D3). In addition to these major clinical departments, the
hospital has other departments such as department of radiology it has seven x-ray rooms, nine
surgical and two laboratory diagnostic rooms, a currently established emergency unit (pediatrics
and adult emergency with critical care units), different diagnostic laboratories, radiotherapy unit,
pharmacy sections and Medical and Surgical ICUs. Currently the hospital has about 850 beds
that give service to adults and pediatric patients. The number of patients being served in the
hospital increased over time with 363, 623 patients seen in 2006 alone. In terms of human
resource, the hospitals had in 2007, 119 senior physicians, 267 graduate study students and 85
undergraduate students who participate directly on the hospital activities. The hospital had, in the
same physical year, 1234 employees among which 444 were medical professionals (3).

13
Study period
The study period was from February, 2013 to June, 2013 G.C

Study design
Hospital based cross sectional descriptive survey with both quantitative and qualitative
(observation using check-list) components was used.
To fully incarcerate the universal precaution practice among the emergency medicine
professionals, an Observation check-list was used to observe whether or not the staff members
involved in patient management is using an appropriate technique and timing as per the set
guideline.

SOURCE AND STUDY POPULATION

Source and Study populations

All emergency medicine professionals who are working in adult emergency unit in TASTH
during the study period consists of 17 residents, 3 salaried senior staff MSC emergency
medicine professionals & 47 MSC Emergency medicine students, totally 67 .

Inclusion criteria
 Salaried senior staff members, emergency medicine residents & emergency medicine
MSC students working in emergency room
 All the above who are willing to participate in the study

Exclusion criteria

 Those who are not working in the adult emergency rooms

 Those who are not willing to participate in the study
 Those who is assigned to work during night time

Data management

Data collection methods

A structured and pretested self-administrated questionnaire was used for the quantitative data
collection. Data was collected during the working hour and morning sessions. Self-administered
questionnaire was distributed to all seniors’ residents and MSC students on morning sessions. All
14
volunteer seniors & students are requested to fill in the questionnaire following the morning
session. For the qualitative part, observation by using check list by two MSC students who are
not involved in quantitative data collection of this study was used for 5 consecutive days during
working hours in emergency rooms.

Students and residents working in emergency unit are carefully observed whether or not they
follow the techniques of universal precaution.

Data collectors

Data collectors were five MSC students who have no clinical attachment to emergency unit were
used. Of which 3 was used for quantitative data collection & 2 was used for qualitative
data collection. Those who involved in quantitative data collection will not be used for
qualitative data collection.

Study variables

Dependent
The dependent variables of interest were knowledge, attitude and practice of universal precaution
among emergency medicine professionals in TASTH.

Independent
The independent variables include the socio-demographic variables (sex, level of education),
perceived risk/benefit of universal precaution, work experience, training (types, years of
training), and qualifications.

Data entry and analysis

Data was entered, cleaned and analyzed using SPSS for Windows version 16. Frequencies,
percentage and graphs were used for descriptive purposes.

Data quality assurance

Data collection instruments was designed carefully after referring appropriate literatures and 5%
of the questionnaires was pre-tested in pediatric emergency unit in TASH. Data collectors and
supervisor was adequately trained on the objective of the study, procedure of data collection and
15
organization. Data collectors and supervisor will make sure that all questionnaires are complete.
Any ambiguity was solved on the spot.

Data entry was done by well-trained data clerks who have previous experience. The entered data
was counter checked by principal investigator before further analysis.

Ethical consideration
Ethical clearance was obtained from school of graduate study. Permission was sought from head
of emergency medicine department. Staff was asked for verbal informed consent. Only
individuals who consented to be involved in the study are finally selected for the interview.
Confidentiality was kept at all level. No participant is requested to write his/her identity such as
name or ID number on the questionnaire. There is no physical or psychological harm related to
this study. However, staff may sacrifice 15-20 minutes of their study/work time to fill in the
questionnaire. The hospital workers, emergency medical professionals and ER staff will be
benefited from interventions/measures to be taken by the faculty/departments on the identified
gaps in improving universal precaution knowledge, attitude and practice.

Strength and limitation

Limitations
This study has limitations but is also a good starting point for more extensive future research
with the aim of giving our patients optimum care whilst being careful not to compromise our
own health in the process as it is lifesaving activity.
1. The study population was small making it difficult to generalize the findings
2. There was no known literature available on previous studies involving emergency medicine
professionals.

Strength of the study

1. Study includes only emergency medicine professionals that may decreases confounding
factors.
2. Use of observation as data collection method w/c increases the validity of the result.

16
Operational Definitions
Emergency medicine professionals –those who are attended the department of emergency
Medicine for their MSc or specialty education, including the MSc holders in the ER.
Antimicrobial soap - Soap (detergent) containing an antiseptic agent.
Antiseptic agent - Antiseptics are antimicrobial substances that are applied to the skin to
reduce the number of microbial flora.
Antiseptic hand rub - Applying an antiseptic hand rub product to all surfaces of the hands to
reduce the number of microorganisms present.
Colonization – pathogenic (illness or disease causing) organism are present in person but are
not causing symptom or clinical finding.
Hand hygiene care - A general term that applies to hand washing, antiseptic hand wash,
antiseptic hand rub, or surgical hand antisepsis
Health care workers - those health workers, who do have contact with syringes, needles,
sharp materials, blood and body fluids by the virtue of their duties.
Visibly soiled hands - Hands showing visible dirt or visibly contaminated with proteinaceous
body substances (e.g., blood, fecal material, urine)
Multi-drug resistant pathogens - Bacteria that cause serious infections that are very difficult
to treat due to the pathogens' resistance to many commonly- prescribed antibiotics.
Safe injection- one that doesn’t cause harm to the recipient, does not expose the provider to
any avoidable risk, and does not result in waste that is dangerous to other people.
Confounding factors-factors that can affect directly or indirectly the dependent variables

17
 Result
A total of 67 emergency medicine professionals with a response rate of 91% were found valid
and included in the analysis for quantitative data and 10 (15%) emergency medicine
professionals in emergency room were included in qualitative data compilation. Among the
respondents 42 (68.9%) were males and 19 (31.1%) were females. Concerning the professional
categories of the respondents, 12 (19.7%) were emergency medicine residents, 3 were
emergency medicine MSc holders and 46(75.4%) were MSc students. Theirwork experience in
their current profession or job title after last graduation is presented in fig 1 as follows.
Concerning the experience of the respondents 18(29.5%) served for two years, 14(23%) have
served for five and above five years, 11(18%) had four years’ experience, 10(16.4%) served for
three years and 8(13.1%) had only one year experience since last graduation.

Fig 1: Years of experience of the emergency medicine professionals in emergency

room, Tikur Anbessa Specialized Hospital, May 2013 G.C

18
Table 1:-Distribution of respondent by their status of training on infection prevention in
emergency room, Tikur Anbessa Specialized Hospital, May 2013 G.C

profession of the respondent Did you take training on

infection prevention? Total

NO yes

Residents 6 6 12

Emergency medicine MSc holders 3 0 3

MSc student 22 24 46

Total 31 30 61

Among the respondents, half of them 30(49.2%) had training on infection prevention which were
directly related with universal precaution, of which 24(80%) were MSc students whereas the
remaining 6 were residents. But more than half of respondents 31(50.8%) had no training on
infection prevention at all. Of the respondents 24(39.3%) were know the presence of infection
prevention office in TASH, 21(34.4%) were said that there was no infection prevention & waste
management office in Tikure Anbessa specialized hospital and 16(26.2%) didn’t know the
presence of the office. Concerning the infection prevention guideline 15(24.6%) of the
respondents were know the presence of infection prevention guideline in TASH, whereas
32(52.5%) or more than half of them said no guideline at TASH and 14(23%) didn’t know the
presence or absence of the guideline.

Safety of injections
Among the respondents 31(50.7%) of emergency medicine professionals ever had participated in
any training program dedicated to infection prevention after their respective pre-service courses
and 30(49.2%) were never participated on infection prevention training. All respondents know
that dirty needles and sharp materials could transmit disease-causing agents. Some of the
common diseases known by the respondents were HIV only 3, HBV, HCV & HIV were

19
27(44.3%), HBV, HCV,HIV & malaria were 8 , HBV, HCV, HIV, Tetanus & Malaria 8, HBV,
HCV, HIV & Tetanus 13(21.3%), HBV,HCV,HIV & TB were 2 (fig 2).

Fig 2: Knowledge of emergency medicine professionals about infectious disease transmitted

by needles and sharps in emergency room, Tikur Anbessa Specialized Hospital, May 2013
G.C

Only 15(24.6%) of the respondents know the presence of anti HIV prophylaxis after sustaining
needle stick or sharp injuries while 46 (75.4%) didn’t know. The respondents who had perceived
risk of acquiring HIV infection from their health facility waste, when disposed improperly, 2 said
the risk would be for HCW, 3 for supportive staff, 40 (65.6%) for both health professionals &
supportive staff and 8 said would be for Health Professionals, Supportive staff, the client /
patient & the community.
Majority 54(88.5%) of the respondents knows the benefits of proper waste disposal as it is
important to reduce the risks of spreading infections to staff, clients, visitors provides clean
working compounds and rooms, and decreases odors.
Twenty-eight (45.9%) of the respondents were washing their hands sometimes, 19(31.1%)
washes always, 8 washes often, and 6 never wash their hands after touching surfaces near
patients in emergency room.
Those who washed their hands after touching intact skin of the patients in emergency room on
sometime bases 10(16.4%), on always bases 31(50.8%), often bases 10(16.4%) and never were
20
10(16.4%). Concerning the blood or body fluid splash to body parts in emergency room who said
no were 41(67.2%), who said yes 15(24.5) and those who did not remember were 5 respondents.
Among those who had blood or body fluid splash 14(93.3%) were MSC students whereas the
remaining were residents.
Table 2: Proportion of emergency medicine professionals who identified types of waste
materials to be discarded in to safety box in emergency room, Tikur Anbessa Specialized
Hospital, May 2013 G.C

Types of waste materials to be discarded to safety

box Frequency Percent

Syringe, Needle, Needle from IV bags, Lancets &

29 47.5
other contaminant sharps

Needle, Needle from IV bags, Lancets & other

17 27.9
contaminant sharps

Syringe, Needle, Needle from IV bags & Lancets 8 13.1

syringe & needles 3 4.9

needles & needle from IV bags 4 6.6

Total 61 100.0

With regard to the measures to be taken after exposure to blood and body fluid by emergency
medicine professionals in emergency room only 8 respondents were able to respond correctly
four answers out of four exact choices as washing with soap and water, Visiting VCT, Seek PEP
& Report to the head person.

21
Table 3: Measures to be taken after exposure to blood and body fluid by emergency
medicine professionals in emergency room, Tikur Anbessa Specialized Hospital, May 2013
G.C

Measures taken after exposure to blood and body fluid Frequency Percent

washing with soap & water 1 1.6

wash with alcohol, iodine, chlorine 4 6.6

seek PEP 3 4.9

washing with soap & water & visiting VCT 1 1.6

Wash with alcohol, iodine & chlorine, Visiting VCT, Seek

3 4.9
PEP & Report to the head person

Washing with soap and water, Wash with alcohol, iodine

2 3.3
& chlorine, Seek PEP & Report to the head person

Washing with soap and water, Visiting VCT, Seek PEP &
8 13.1
Report to the head person

Washing with soap and water, Wash with alcohol, iodine

6 9.8
& chlorine & Seek PEP

Washing with soap and water, Seek PEP & Report to the
3 4.9
head person

Washing with soap and water & Seek PEP 3 4.9

washing with soap & water and washing with alcohol,

6 9.8
iodine chlorine

washing with soap & water, seeking VCT & seek PEP 10 16.4

All 11 1.8

Total 61 100.0

22
Table 4: knowledge of emergency medicine professionals toward the source of infection in
hospital setting, Tikur Anbessa Specialized Hospital, May 2013 G.C

Sources of infection Frequency Percent

health personnel 1 1.6

contaminated equipment 5 8.2

Contaminated equipment, polluted air & other patients 7 11.5

Health personnel, Contaminated equipment & Other patients 9 14.8

Health personnel, Contaminated equipment & polluted air 1 1.6

contaminated equipment & polluted air 5 8.2

Health personnel, Contaminated equipment, polluted air & other

33 54.1
patients

Total 61 100.0

Among the respondents 29(47.5%) were commonly using savalon, iodine and alcohol as
antiseptic/decontaminant in emergency room, 8 were using savalon & alcohol.

Those who were using Savalon only 3 and those who were using chlorine 3, while those who
reported using alcohol were 10 (16.4%). Fifteen (24.6%) were experienced blood or body fluid
splash to eyes, mouth or nose and 41(67.2%) were not faced any splash to their eyes, mouth or
nose 5 were not remember.

Forty-seven (77%) the respondents were checking patients for those infectious diseases like
HCV, HEP-B & HIV in emergency room when patients suspected of the diseases, 10(16.4%)
were checking on admission and 4(6.6%) were not check at all. 48(78.7%) of the respondents
were strongly agreed and 13(21.3%) were agreed that in absence of infection prevention/UP
hospital setting can be the source of infection. Among the respondents 46(75.4%) were given BP
cuff for decontamination after using it for bleeding patients but the remaining 15(24.6%) were
not given it for decontamination.

23
Among the emergency medicine professionals 36(59%) perceived that oxygen delivery materials
like mask, nasal cannula & prong can be reusable whereas 25(41%) perceived as this materials
can’t be reused. Concerning needle recapping after use, 51(83.6%) the respondents perceived
that it should not be recapped and the remaining 10(16.4%) were said should be recapped after
use. On use of laryngoscope in emergency room 17(27.9%) strongly agreed as they were used it
after decontamination, 41(67.2%) agreed and 3 were disagreed.

All the emergency medicine professionals perceived toward contribution of displaying infection
prevention posters in hospitals to universal precaution and 23(37.7%) washing their hands before
touching the patients and 38(62.3%) were not washing their hands before touching the patient.

Fig 3:- Perception of emergency medicine professionals on the status of needle after use in
emergency room, Tikur Anbessa Specialized Hospital, May 2013 G.c

24
Fig 4:- showing the practice of emergency medicine professionals on hand washing before
touching the patients in emergency room, Tikur Anbessa Specialized Hospital, May 2013
G.C
Among the respondents only 23(37.7%) were washing their hands before touching their patients
whereas 38(62.3%) were not washing their hands before touching the patients in emergency
room at Tikur Anbessa Specialized Hospital.

25
Table 5: Reasons cited by emergency medicine professionals for not washing their hands &
washing sometimes in emergency room, Tikur Anbessa Specialized Hospital, May 2013
G.C

Reasons for not washing their hands or

washing some times Frequency Percent

Inaccessibility of hand washing materials 22 36.1

emergency condition 9 14.8

absence of hand washing materials in ER 1 1.6

I am using glove 5 8.2

Other 1 1.6

Inaccessibility of hand washing materials,

9 14.8
Emergency condition & I use glove

Emergency condition & I use glove 1 1.6

Not always necessary & I use glove 1 1.6

inaccessibility & emergency condition 7 11.5

Total 56 91.8

Forty-nine (80.3%) were wearing personal protective equipment before touching the patients and
12(19.7%) were not wearing personal protective equipment before touching the patients in
emergency room. Reason of the respondents for not using personal protective device were 4
because of inaccessibility of the equipment’s, 16.7% said absence of PPE in ER,25% it is
emergency situation & Inaccessibility of equipment’s and 25% said because of inaccessibility of
equipment’s & absence of PPE in ER.

26
Table 6:-personal protective device utilization by emergency medicine professionals in
emergency room, Tikur Anbessa Specialized Hospital, May 2013 G.C

Frequency Percent

Valid double glove 3 4.9

Gown 2 3.3

double glove, Boots/shoes & Gown 26 42.6

double glove, Boots/shoes, Masks & Gowns 9 14.8

double glove, Boots/shoes, goggle & Gown 7 11.5

apron, double glove, Boots/shoes, Masks & Gown 2 3.3

Total 49 80.3

Missing System 12 19.7

Total 61 100.0

Concerning needle prick injury 22(36.1) had sustained needle prick injury whereas 39(63.9) had
no needle prick injury. From those sustained needle prick injury 14(23%) were sustained once a
year and 8 were sustained twice within a year. of the total respondents 45(73.8%) were properly
discard used materials as universal precaution guideline and 15(24.6) were not using as per the
guideline. Among the emergency medical professionals 53(86.9%) do not use and throw
materials like nasal cannula, prong and face mask and 8 were use and throw nasal cannula/prong
and face mask. Concerning laryngoscope decontamination after using it for intubation 46(75.4%)
was giving it for decontamination, 14(23%) was not giving it for decontamination and 1 had
never used laryngoscope to incubate the patients. Of those respondents who don’t give
laryngoscope for decontamination 12(19.7%) were putting it there on the trolley.

27
Results of observation
Out of the 10 observed emergency professionals 6 were males. Among them 5 were residents
and the remaining were emergency MSC students. Among the respondents 6 have explained the
procedures to the patients since this is ethics of any health professionals.
A total of 24 hand washing opportunities were observed. Of these all or 3 opportunities were
observed while properly washing their hands with alcohol hand rub, medicated soap and water
after completing the procedures. The highest hand washing practiced in the emergency room
were 2 emergency medicine MSc students and followed by 1 resident.
From the actual observation of ten (10) respondents 7 had not washed their hands. From Socio
demographic characteristics, male (70%) had better hand hygiene adherence than female.
Among 10 of the respondents were observed as they ever wore at least one type of personal
protective device. Among respondents who wore personal protective devices during observation
were all observed emergency professionals wore utility glove, 3 wore masks, 2 wore used apron,
2 wore boots or shoes which cover toes, no one had wore head cover and eye protectors. Some
of the reasons for not wearing any of the stated personal protective devices specially head cover
and goggle were stock out of the desired PPE.

Among the observed emergency professionals 5 have disposed off after recapping the needles.
Of these, 4 used two hand recapping method. Despite providing 30(49.2%) had training on
infection prevention which were directly related with universal precaution, of which 24(80%)
were MSc students whereas the remaining 6 were residents. still two hand recapping technique
continued. Seven observed emergency care providers do not wash their hands after removing the
gloves. Almost all observed emergency medicine professionals discarded used needles properly
in the safety box.

28
 Fig 6:- shows percentage of procedures observed during qualitative data collections in
emergency room, Tikur Anbessa Specialized Hospital, May 2013 G.C

29
 Materials Available (observed) in Emergency Room, TASH 2013 G.c
The presence of adequate infection prevention materials including PPE is some of the factors that
directly affect the practice of infection prevention. Therefore the main aim of observation of
materials in emergency room is to assess why emergency medicine professionals not utilizing
some of the materials that are important for infection prevention.

Table 7: - shows some of the materials used in infection prevention in emergency room
TASH 2014 G.c

Available material Unit of measure Amount (number)

Chlorine Liter Not available
Utility glove Pk/box 4
Examination glove number 10pairs
Mask number Not available
Apron and goggle number Not available
Boots number Not available
Safety boxes number 8
Syringe 5cc 10/day
10cc 5/day
20cc 2/day
Dressing set number 4/day
Nasal cannula number 4
Oxygen mask number 7

According to observation of the materials used in emergency room utility glove, examination
glove, safety boxes, dressing set, nasal cannula, oxygen mask alcohol swab and different types of
Syringes were available. The emergency room was observed for storage of soiled/socked linen, it
is stored in hamper bag and the dressing/suturing materials were autoclaved and packed with
cloths in emergency room. The sharp/needle collection boxes (safety boxes) which were
available in all emergency rooms i.e. at the back, front and resuscitation rooms in which sharps

30
mixed with other wastes in some boxes at resuscitation room during observation. Again there
was plastic waste container in all rooms i.e. at the back, front and resuscitation rooms but the
waste were not properly disposed.

However, anti-septic solution (especially chlorine), , some of personal protective devices like
mask, goggle and boots were not available in emergency room also functional water sources,
written or infection prevention pictures not available in all emergency rooms. Windows were
observed in all emergency rooms; most of the windows in back and front were not open during
observation and absent in back orthopedics (ward B) and procedure room which ends the rooms
with poor ventilation.

31
 Discussion
In Ethiopia, there are few studies on universal precaution and related topics. This study
contributes to determine the knowledge, attitude, and practices of emergency medicine
professionals toward infection prevention in adult emergency room and other related factors in
Tikur Anbessa Specialized Hospital, Ethiopia.
According to this study 30(49.2%) had training on infection prevention which was directly
related to infection prevention of which 24(80%) were MSc students whereas the remaining 6
were residents. This is similar with the study conducted in North Wollo zone, Amhara Region,
North eastern Ethiopia among health professionals which was 45.8% of the respondents said that
they ever had participated in training dedicated to infection prevention after their respective pre-
service courses. Though there is a national guideline on infection prevention, almost all
participants agreed on lack of teaching and learning materials in local language for health care
workers, clients and communities on infection prevention. On top of these there was no
continuous support and supervision to improve the universal precaution. The in-service training
given for health care workers also had complaints of short in duration ending with poor skill. The
short duration might compromise the qualities and contents of the training.
Also, only provision of a lot of information at a time may not convince staff about the duty of
care to client/patient, environment and safe practice of health care workers. As to the knowledge
of respondents about diseases transmitted via blood or body fluid from contaminated needles and
sharps were HIV only 3(4.9%), HBV, HCV & HIV were 27(44.3%), HBV, HCV,HIV & malaria
were 8, HBV, HCV, HIV, Tetanus & Malaria 8, HBV, HCV, HIV & Tetanus 13(21.3%),
HBV,HCV,HIV & TB were 2 (Fig 2).
According to this study the knowledge of respondents about diseases transmitted via blood or
body fluid from contaminated needles and sharps were, those who said only HIV were 3 but all
the respondents 100% said HIV, 48(95.1%) said HepB virus, 48(95.1%) said HCV, malaria
16(26.2%), tetanus 13(21.3%) and TB were 2. This study showed that the emergency medicine
professionals had better knowledge on diseases transmitted via blood or body fluid from
contaminated needles and sharps than similar study done on health professionals who were BSc
and lower in their profession by W/Gebreal, Y. in SNNPR where 197 (92.9%) HIV, 65 (30.7%)

32
HBV, 55(25.9) tetanus, and 19 (9.0%) HCV. (13) This might be difference in professions and
level of education of the respondents.
In this study only 15(24.6%) of the respondents know the presence of anti HIV prophylaxis after
sustaining needle stick or sharp injuries. This finding is lower than the result of the study
conducted in North Wollo zone, Amhara Region, North eastern Ethiopia among health
professionals (32) was One hundred ten (31.3%) of the respondents know the presence of anti
HIV prophylaxis after sustaining needle stick or sharp injuries. This difference could be
explained by lack of information among the students and lack of orientation before assigning the
students to emergency rooms from the very beginning of their attachment to this hospital.

According to this study among emergency medicine professionals 22(36.1%) had sustained
needle prick injury. This is much better than a study conducted on knowledge, attitude and
practices among health care workers on needle stick injuries revealed that 52 (74%) out of 70
had a history of needle stick injury. This difference could be most of the respondents were
university instructors so that they were not spent their time mostly with hospital patient care that
may reduce their time of exposure to needle prick injury. But this study is higher than the study
done in Ethiopia at Southern Nation, Nationalities, and Peoples Region (SNNPR) showed that
32.4% of health care workers (HCW’s) reported as they had sustained at least one form of
accidental injury by needle or other sharps this could be lack of training and less exposure to
patient care that can give more experience to the study subjects particularly for those on teaching
duties since most of they are from university.

Based on this study which was on knowledge attitude and practice among emergency medicine
professionals showed that 16.4% of the respondents perceived that needle should be recapped
after use. However, similar study conducted on knowledge, attitude and practices among health
care workers on needle stick injury revealed that twenty subjects (29%) were of the impression
that needles should be recapped after use. This could be explained on the bases of their
professions and the level of their education because my study subjects were MSc students and
residents.

33
According to this study which showed that almost all (100%) of the respondents were wearing
gloves during invasive procedures similar study on Ghana Accera hospital showed that forty-two
(88%) of respondents indicated that they wore gloves routinely when performing invasive
procedures on patients. This showed that the emergency medicine professionals have better
practiced the use of gloves in emergency rooms than the practice of Ghana Accera hospital
health professionals. This could be fear of the infectiousness of diseases like HIV and HEP-B
virus due to the higher prevalence of infectious disease in Ethiopia.

Even though, the following universal infection control precautions are advised by the World
Health Organization to help protect health care workers and clients from blood-borne infections
including HIV: - Using protective barriers such as gloves, gowns, aprons, masks, goggles for
direct contact with blood and other body fluids. In this study the 100% wear gown as hospital
protocol despite this 77% of the respondents were wear gloves, 22.4% wear mask, for invasive
procedures and those who put on goggle were 14.3%. But study done in Perceptions and Practice
of universal blood and body fluid precautions by registered nurses at a major Sydney Teaching
Hospital showed that84% of the respondents wear gloves for invasive procedures and an equal
number wear face masks. The least practiced is the wearing of protective eye shields (24%).this
shows significant difference because of inaccessibility and absence of personal protective device
particularly goggle and face masks in emergency room.

According to this study measures to be taken after needle stick or sharp injury among emergency
medicine professionals were 40(65.6%) said washing with soap& water, 38(62.3%) were seeking
post exposure prophylaxis, 22(36%) were testing for HIV, 21(34.4%) were washing with alcohol
and chlorine and 16(26.2%) were reporting to the head person. This study has revealed that
emergency medicine professionals have comparatively a better knowledge on counseling &
testing for HIV, taking post exposure prophylaxis and reporting to head personal after needle
stick injury than the previous study done on knowledge, attitude and practice of health care
workers on universal precaution in north Wollo zone, Amhara region, north eastern Ethiopia(32),
showed that measures HCW’s had taken after needle stick or sharp injury includes 171 (91.9%)
washing with water and soap, 145 (78.0%) washing with alcohol or chlorine solution,37 (19.9%)

34
counseling and testing for HIV, 6(3.2%) taking post exposure prophylaxis and 34(18.3%)
reporting to their supervisors. This may be the difference in the level of their knowledge and
educational status MSC and residents’ vs. BSC nurses and diploma health professionals.
Despite this the emergency medicine professionals have less preferred to use washing the site
with soap, water, washing with chlorine & alcohol after needle stick injury as compared to the
previous study. (32) This may be explained by their preference to use the other methods
mentioned above rather than soap, water, washing with chlorine & alcohol.

According to this study,47(77%) the respondents were checking patients for those infectious
diseases like HCV,HEP-B &HIV in emergency room when patients suspected of the diseases,
10(16.4%) were checking on admission and 4 were not check at all. In the setting of above
results that can be good opportunity which may exposes the respondents to infectious diseases
like HCV, HEP-B &HIV. Fifteen (24.6%) were experienced blood or body fluid splash to mucus
membrane. This indicates few number of respondents experienced blood or body fluid splash as
compared to similar study done at SNNPR in which splash of blood or body fluid on the mucus
membrane 32.4%. (18) This difference is because of the time that they cover on duty, since my
study subjects were students they may have vacation within a year and more off-duty days and
because of shortage of personal protective equipment’s supplies in emergency room.

Based on this study among the respondents only 23(37.7%) were washing their hands before
touching their patients. This is consistent with similar study done in university of Geneva
hospital on practice of the hand washing rate range 23 to 87% (22) and According to the Access
Excellence Collection publications, hand-washing rates were as low as 30% and never exceed
above 48% .(20)

According to this study the respondents who had perceived risk of acquiring infection from their
health facility waste when disposed improperly were 58(93%) for emergency /health care
worker, 59(96.7%) were supportive staffs ,16(26.2%) were the community and 16(26.2%) were
for clients/patients. This shows significant difference in knowledge of the respondents because of

35
their educational level as compared with similar study done by Mesele Damte which was
260(74.1%) for health professionals and 247 (70.4%) for supportive workers.(32)
Among the observed emergency professionals (50%) were disposed off used needles after
recapping of it. Of these, (80%) used two hands recapping method. Despite providing 30(49.2%)
of the respondents in Tikur Anbessa Specialized Hospital had training on infection prevention
which were directly related with universal precaution, among the respondents who had taken
infection prevention training 24(80%) were MSc students whereas the remaining (20%) were
residents still two hand recapping technique continued. This indicates majority/large number of
the respondents was using two handed method which was higher as compared to similar study
done in Addis Ababa, two hands recapping of 53.8% was found. (23) This could be explained by
the small sample size of this study and the respondents might be from those who were not taken
infection prevention training at all. The finding in this study on recapping of used needles were
lower than another study conducted in north Wollo out of the 90 observed injections, 55 (61.1%)
were disposed off after recapping of needles. This could be because of difference in the number
of observations by the studies.

Among 10 of the respondents observed almost all were ever wore at least one type of personal
protective device. Among respondents who ever worn personal protective devices during
observation was 10 wore utility glove in emergency room, as glove use for all patient care
contacts is a useful strategy for reducing risk of transmission of organism. Similar study done on
the use of personal protective device in provision of cares ever wore were 98.9% only for gown
and also low as 59 (16.9%) goggle and shoe/boot 107 (30.7%) could be related to absence of this
materials in emergency room as confirmed by observation during qualitative data collection.(32)

36
Conclusions and Recommendations
 Poor hand washing practice by emergency medicine professionals were found before and
after touching the patients were found.
 Emergency medicine professionals were not properly handling, and disposing used
needle/sharp materials in the study area.
 Personal protective devices particularly mask and eye goggles, boots etc were not
available during the survey.
 All emergency professionals were wear gloves during invasive procedures
 Inaccessibility of hand washing materials and absence particularly water in all emergency
rooms
 Emergency medicine professionals have comparatively better knowledge on counseling
&testing for HIV, taking post exposure prophylaxis and reporting to head personal after
needle stick injury.
 Only 3/4 of the respondents were know the presence of anti HIV prophylaxis after
sustaining needle stick or sharp injuries.
 All the emergency medicine professionals perceived toward contribution of displaying
infection prevention posters in hospitals to universal precaution
 The risk of health institution acquired infection to heath care workers, clients, patients,
children and the communities were very high.
 Majority of the emergency medical professionals do not use and throw materials like
nasal cannula, prong and face mask in emergency room was observed.
 In emergency room utility glove, examination glove, safety boxes, alcohol swab and
different types of Syringes were available during observation of the materials used.
 Infection prevention indicators like posters were not displayed in all emergency rooms.
 Two handed recapping of the used needles were observed.
 Windows were observed in all emergency rooms; most of the windows in back and front
were not open during observation and absent in back orthopedics (ward B) and procedure
room which ends the rooms with poor ventilation.

37
Recommendations:
1. Emergency department should provide early orientation regarding infection prevention
for emergency professionals at the time of commencement of their training and before
they assigned to the emergency practice.
2. The involvement of emergency medicine professionals in different activities regarding
infection prevention should be encouraged and events such as exhibitions, poster making,
quizzes, debates and other competitions regarding infection prevention should be
organized consistently.
3. Emergency directorate should try to provide personal protective devices to the emergency
rooms particularly eye goggles, masks and boots.
4. Emergency directorate should facilitate the maintenance of the non-functional water
system and hand washing materials in emergency rooms.
5. The emergency care providers should be encouraged to open windows and discouraged
for recapping of used needles in emergency rooms
6. Administration should initiate in increasing the knowledge and understanding of
emergency medicine professionals and emergency care workers regarding infection
prevention by providing adequate trainings.

38
References
1. Guideline of Infection prevention
2. The standard of care. Infection prevention and control. College of Nurses of Ontario,
2009
3. The Addis Ababa University Medical faculty, Tikur Anbessa specialized Hospital: A 34
years of Journey /from 1973-2008/, March 2009
4. Marcus, R. Surveillance of Health Care Workers exposed to blood from patients’
infected with HIV. New England J of Med 1988; 319, 1118-1123.
5. Vlahov D, Polk DF, Transmission of human immunodeficiency virus within the health
care setting. Occup Med 1987; 2(3): 429-450.
6. Garner JB. What is in a name? Today’s Surgi-cal Nurse 1997; 19(1): 14-21, 46-47.
7. Gerberding JL, Lewis FR, Schecter WP. Are Universal Precautions realistic? Surg Clin
of North America 1995; 75(6): 1091-1104.
8. L. Simonsen, A. Kane, J. Lioyd, M. Zaffran, and M. Kane. Unsafe injections in the
developing world and transmission of blood borne pathogens: a review. BWHO 1999;
77(10): 789-800
9. Giving safe injections using Auto-disable syringes for immunization. 2001:1-10.
Available online at: http://path.org/resources/safe-injpdf.htm
10. Panlilio AL, Cardo DM, Campbell S, Srivastava PU, Jagger H, Orelien JG et al. Estimate
of the annual number of percutaneous injuries in U.S. health care workers [Abstract S-
T2- 01]. In: Program and abstracts of the 4th International Conference on Nosocomial
and Healthcare-Associated Infections; Atlanta, March 5-9, 2000:61.
11. Collins CH, Kennedy DA. Microbiological hazards of occupational needle stick and
other sharps’ injuries. J Appl Bacteriol 1987; 62: 385-402.
12. Hutin, Y. et al. Best injection practices for intradermal, subcutaneous and intramuscular
needle injection. Bulletin of World Health Organization (WHO), 2003;81: 491-500
13. Linda T., Debora B., Noel M. Infection prevention: Guidelines for Healthcare Facilities
with Limited Resource: JHPIEGO March 2003.
14. Yalcin AN. Socioeconomic burden of nosocomial infections. Indian J Med Sci [serial
online] 2003 [cited 2005 Dec 30]; 57:450-6. Available on line at:
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 http://www.indianjmedsci.org/article.asp?issn=0019
5359;year=2003;volume=57;issue=10;spage=450;epage=6;aulast=Yalcin
15. CDC. ALERT: Preventing needle stick injuries in Health care settings. (NIOSH): 2000
(108): 1-23.
16. Pike AM. Laboratory-associated infections: summary and analysis of 3921 cases. Health
Lab Sci 1976; 13:105-14.
17. Sharps Injury Prevention Workbook: (Available on line at:
http://www.med.virginia.edu/epinet/soi01.htm1)
18. W/ Gebreal, Y. Assessment of safety of injection and related medical practie in health
institutions at Sidama Zone, SNNPR. 2004. (Unpublished MPH thesis).
19. Christine L. Case, Ed.D. Microbiology Professor at Skyline College.
20. Biography, In: Access Excellence collection, Hand washing. Available online at:
http://www.accessexcellence.org/LC/SS/ferm_biography.html
21. Hand washing: A simple way to prevent infection. Hand washing is a simple habit that
can help keep you healthy. Learn about the benefits of good hand hygiene, as well as
when to wash your hands and how to clean them properly. December 30, 2005. Available
on line: Advertising and sponsorship policy.
22. Karen Pallarito. Doctors Skimp on Hand Hygiene. Health on network foundation. 09-
JUL-2004. Available online at http://www.cdc.gov/od/oc/media/pressrel/fs021025.htm
23. Nigat project and Engenderhealth. Stigma or discrimination and infection prevention
practices in health care settings. 2003 (Unpublished).
24. Ghana medical journal A.A.J. HESSE, N.A. ADU-ARYEE, K. ENTSUA-MENSAH
AND L. WU June 2006 Volume 40, Number 2

25. Knight V. Perceptions and Practice of univer-sal blood and body fluid precautions by
regis-tered nurses at a major Sydney Teaching Hos-pital. J of Advan Nurs 1998; 27(4):
746-751.
26. .Danchaivijitr S, Tantiwatanapaiboon Y, Chokloikaew S, Tangtrakool T, Suttisanon L,
Chitreechuer L. Universal precautions: knowledge, compliance and attitudes of doc-tors
and nurses in Thailand. J Med Assoc Thai 1995; 78(Suppl 2): S112-S117.

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27. Panlilio AL, Cardo DM, Campbell S, Srivastava PU, Jagger H, Orelien JG et al. Estimate
of the annual number of percutaneous injuries in U.S. health care workers [Abstract S-
T2- 01]. In: Program and abstracts of the 4th International Conference on Nosocomial
and Healthcare Associated Infections; Atlanta, March 5-9, 2000:61.
28. Antono SK. Internal report from the Quality and Occupational Safety Committee of Dr.
Hasan Sadikin Hospital, Bandung, 2006.
29. Diekema DJ, Schuldt SS, Albanese MA, Doebbeling BN. Universal precautions training
of preclinical students: impact on knowledge, attitudes, and compliance. Journal of
Preventive medicine 1995 Nov;24(6):580-5. Available from URL: -
http://www.ncbi.nlm.nih.gov/pubmed/ 8610081? ordinalpos=4 & itool = Entrez System
PEntrez. Pubmed. Pubmed_Results Panel. Pubmed_RVDocSum
30. Helfgott AW, Taylor-Burton J, Garcini FJ, Eriksen NL, Grimes R. Compliance with
universal precautions: knowledge and behavior of residents and students in a department
of obstetrics and gynecology. Available fromURL:-
http://www.ncbi.nlm.nih.gov/pubmed/
31. Wicker S, Jung J, Allwinn R, Gottschalk R, Rabenau HF. Prevalence and prevention of
needle stick injuries among health care workers in a German university hospital. Int Arch
Occup Environ Health 2008; 81: 347-354. http.dx.doi.org/10.1007/s00420-007-0219-7

41
Annex I: Conceptual framework
Figure 1: modified Conceptual framework to study the KAP of health care workers
on universal precaution, July 2006

42
 ADDIS ABABA UNIVERSITY SCHOOL OF MEDICINE
DEPARTMENT OF EMERGENCY MEDICINE

Annex II
Informed Consent Form for Quantitative survey questionnaires:
Date_____________ Code number of the checklist--------------

Hallo! Good morning?

My name is Sr. / Ato ----------------- and my friend is Sr. / Ato-----------------------. We are a research team
member of AAU, Department of Emergency medicine. Today we are here to collect data on the assessment of
knowledge attitude & practice of emergency medicine professionals on universal precaution which will be
done by Afework Alemayehu who is the member of emergency medicine MSc students.

The objective of this questionnaire is to assess the knowledge, attitude and practice of emergency medicine
professionals on universal precaution in the emergency room, TASH.

We would like to assure you that the study is confidential. We will not keep a record of your name and
address. You have a right to skip any question that you do not want to answer. Your correct answer can make
the study to achieve the goals. Therefore, you are kindly requested to respond genuinely and voluntarily with
patience. The questions may take about 10-15 minutes.

Do you have any question?

Are you willing to participate in the interview?

If Yes, Go to the next page

If No, Thank them and interrupt it.

Signature of the consenting interviewer-------------------------------------------

A. Questionnaires responded 1. Completed 2. Partially completed

3. The interviewee refused 4. Others--------------
Data collector’s Name: 1. ----------------------------- Signature ----------- 2. ---------- -------- Signature ------------

Supervisor’s name-------------------------------- Signature -----------------

i
ANNEX III
KNOWLEDGE, ATTITUDE AND PRACTICE QUESTIONNAIRES
SECTION I: MARK √ IF THE ANSWER IS RIGHT & × IF THE ANSWER IS WRONG
A. Socio-demographic characteristics

Sex 1. Male
2. Female
B. Respondents background /qualification

Profession: 1. Resident 2. Emergency medicine MSc holder 3. MSc student

Years of experience after last gradation-----------

Did you taken any training on infection prevention/IP? 1. YES 2. NO

If yes, which type of training ? Specify----------------------------------------------------------------------------

----------------------------------------------------------------------------

Do you have waste management and infection control officer in TASH? 1. YES 2. NO

Do you have infection prevention guideline in your emergency room? 1. YES 2. NO

Part I: knowledge:

1. Which of the following disease(s) is/ are transmitted by dirty needles and sharp? Circle all that apply
1. HBV 2. HCV 3.HIV 4. Tetanus 5. Malaria 6. TB
2. Do you know whether there is Post Exposure Prophylaxis (PEP) in your hospital? 1. YES 2. NO
3. Who could be at risk of infection from your hospital waste if not disposed properly in ER?
1. Health Professionals 2. Supportive staff 3. The client / patient
4. The community 5.Children 6. Other specify--------------------
4. What is/are benefits of proper waste disposal?
1. Reduces the risks of spreading infections to staff, clients, visitors
2. Reduces the risk of accidents to both client and staff
3. Provides clean working compounds and rooms
4. Decreases odors
5. Others specify -------------------------------------
5. How often do you clean your hands after touching an environment surface near to the patient (for
example, table wall or bed rail?
1. Always 2. Often 3. Sometime 4. Never

6. How often do you clean your hand after touching a patient’s intact skin (for example, when measuring
a pulse, or blood pressure? 1. Always 2.Often 3.Sometime 4.Never

ii
7. What goes in to the safety box? Please, circle all that apply
1. Syringe 2. Needle 3. Needle from IV bags
4. Lancets 5. Their plastic materials 6. Empty vials
7. Cotton pads 8. Dressing materials 9. Bag or extension tubes
10. Latex gloves 11. Other contaminate sharps

8. What do you think are the main reasons for reuse of syringe and needles?
1. Shortage of supply 2. Knowledge deficit 3. Carelessness
4. To reduce the cost of treatment 5. Other specify
9. After exposure to blood or body fluid what measures did you take? Circle all that apply.
1. Washing with soap and water 2. Wash with alcohol, iodine, chlorine
3. Visiting VCT 4. Seek PEP
5. Report to the head person 6. Other specify----------------------

10. What is the chemical you use to decontaminate? Circle all that apply. 1. Chlorine 2. Savalon
3. Formaldehyde 4. Iodine 5.Alcohol 6. Other specify---------------
11. Do you know decontaminant available in your ER at this time? 1. Yes 2.NO

12. Have you ever had blood or body fluid splashed to your eye, mouth and/or nose?

1. Yes 2. No 3. Don’t remember

13. When do you check patients for those infectious pathogens like HIV & Hep B in ER?

1. When patient suspected for it 2. During admission in all patients 3. Not at all

14. What are the sources of infection in hospital setting? Circle all that apply.
1. Health personnel 2. Contaminated equipment 3. Contaminated air
4. Other patients 5.others specify----------------------------------------------
PART II Attitude

1. Do you agree that, in the absence of universal precaution hospital facilities can be the source of
infection and epidemic diseases?
1. Strongly agree 2. Agree 3. Don’t know 4. Disagree 5. Strongly disagree
2. Have you ever given BP cuff for decontamination after using it for bleeding patients in ER?
1. Yes 2. No
3. Do you think that oxygen delivery materials like mask, nasal cannula & prong reusable?
1. YES 2. NO
4. Do you think that needles should be recapped after use? 1. Yes 2. No
5. Do you think that recapping is the cause for needle prick injury 1. Yes 2. No
6. Do you agree the reuse of laryngoscope in ER after decontamination? 1.agree 2.disagree
7. How do you estimate the importance of hand washing in ER? 1. High 2. Medium 3.minimum

iii
 8. Do you think the recognitions and support of ER heads is important for successfulness of universal
precaution practice? 1.yes 2.NO
9. Do you agree, distribution of infection prevention materials in ER is important for successfulness of
universal precaution practice? 1.yes 2.NO
10. Does displaying of infection prevention postures in hospitals can contribute to universal precaution?
1. Yes 2.NO
Part III Practice
1. Did you wash your hands before touching the patients? 1. YES 2. NO
2. If yes Q 1 how often does you wash your hands? 1. Always 2. Sometimes
3. If your answer is NO or some times for Q 1, what were the reasons?
1. Inaccessibility of hand washing materials 2. Not always necessary 3. Emergency condition
4. Absence of hand washing materials 5. I use glove 6. Other -------------------------------
4. Did you wear PPE before touching the patients? 1. YES 2. NO
5. If yes in Q 4 Which device did you use in bleeding patients in ER?
1. Apron 2. Utility gloves (double glove) 3. Boots/shoes
4. Eye protectors/ Goggle 5. Masks 6. Gowns
6. If NO Q 4 why? 1. It is emergency situation 2. Inaccessibility of equipment 3. Absence of PPE in ER
7. Do you wear gloves during invasive procedure? 1. Yes 2. NO
8. Have you ever had needle stick injury? 1. Yes 2. No
9. If yes how many times? 1. One / 1year 2. 2times/year 3. >3 times
10. Did you properly discard used materials per UP guideline? 1. Yes 2. No
11. If NO for Q 10 why? 1. Absence of waste container 2.inaccessablity to waste container
3. I don’t know where to discard 4. Other specify ---------------------
12. Have you ever reused needle or syringe? 1. Yes 2. No
13. did you use & throw nasal cannula/prong & mask per patient in ER? Yes No
14. If NO for Q 13 why? 1. Few in number 2. It is reused in ER
3. Decontaminated always 4.Doesn’t harm p’ts
15. When reusing it Q 13, did you check whether it is decontaminated or not? 1. Yes 2. No
16. Do you give laryngoscope for decontamination after intubation? 1. Yes 2.NO
17. If NO for Q 16 why? b/c 1. I simply put it there after use 2.I have never used it 3.it is re-usable
Do you have any suggestions for improving universal precaution in ER? ---------------------------------------------
------------------------------------------------------------------------------------------------------

iv
SECTION II
Observation checklist
A. Materials available in ER
1. Amount of chlorine available in the store or department ( ) in liter
2. Amount of utility glove available in the store or department ( ) in number
3. Amount of examination glove available in the store or department ( ) PK of 100
4. Amount of mask available in the store or department ( ) in number
5. Amount of apron available in the store or department ( ) in number
6. Amount of boots available in the store or department ( ) in number
7. Amount of safety box available in the store or department ( ) Pk
8. Amount of Syringe and needle available in the store or department
I. 5 ml II. 10ml III. 50 ml IV. Others ---------
( ) Pk of 100 ( ) Pks of 100 ( ) Pks of 100
( ) Pks of 100 ( ) Pks of 100
1. How much prepared dressing set observed? ( )number
2. Is there alcohol swab in the emergency room? Yes No
3. Is there functional water source in ER facility? Yes No
4. Is there nasal cannula in ER? Yes(# ) No
5. Is there oxygen mask in ER? Yes((# ) No
6. Is the water available in all ER rooms?
7. Where is the soiled linen stored? I. On the ground II. In the drum III. Hamper bag
8. How are dressing sets stored? I.Socked in chlorine solution
II.Socked in savalon solution
III.In the boiler with water
IV.Boiled/autoclaved and packed with clothes

v. Other specify-------------------------------------------------

9. Is there any sharp /needle collection box? I .Yes II. No

10. If yes in which rooms? mark I all II front III back IV critical room

IV. procedure room

11. Type of sharp collection material I. Safety box/ card box/ II. Plastic pail with lid

III. Plastic pail without lid I V. Other specify ---------

12. In which rooms? mark I all II front III back IV resuscitation room

V. procedure room

v
13. How was the condition of the safety box or sharp container in ER?
I. Over filled
II .Torn and needles seen through the hole
III. Empty or few dirty syringed and needles
IV. Sharps mixed with other waste

14. In which rooms? mark I all II front III back IV resuscitation room

IV. Procedure room

15. Is there waste container in ER? I .Yes II. No III. Not available

16. In w/c rooms? mark I. all II front III back IV resuscitation room

IV. Procedure room

17. Is there a written material or picture for risk Communication in ER/ working room? I. Yes II. No
18. Are there adequate windows for ventilation in ER? YES NO other conditions -------
---------------------------------------------------------------------------------------------------------------------------

vi
SECTION III
B. OBSERVATION OF ACTIVITIES
1. Sex of observed health professional? I. Male
II. Female
2. Qualification /Profession: 1. Resident 2. Emergency medicine Msc holder 3. MSC student
3. Does the emergency professional explain the procedure to the patient?
I. Yes II. No

4. When did the health care provider wash his or her hand?
I. Before commencing the procedure
II. After completing the procedure
5. At the time of observation does the emergency care provider wear personal protective
Equipment /PPE? I.YES II.No III.Not available
6. Does the health professional checks weather the beds are decontaminated or not before admission of
the patients? I.YES II. NO
7. Which one of the PPE was witnessed? Mark when observed
I. Apron I.YES II.No III.Not available
II. Utility gloves (double glove) I.YES II.No III.Not available
III. Head cover I.YES II.No III.Not available
IV. Boots/shoes I.YES II.No III.Not available
V. Eye protectors/ Goggle I.YES II.No III.Not available
VI. Masks I.Yes II.No III.Not available
VII. Gowns I .Yes II.No III.Not available
8. Have you observed when recapping of the needle occurring?
I. Yes II. No
9. How was the technique of recapping?
I. Single hand scoop technique II. Two hand technique III. Not recapping
10. Does the health care provider swab the vial tops?
I. Yes II. No
11. Does the health care provider decontaminate medical instrument /equipment after procedure?
I.YES II No
12. The decontamination solutions is prepared properly or changed daily? I. Yes II. No
13. At the time of observation was the examination/procedure coach decontaminated after procedure?
I. Yes II. No
14. Did he/she discard the needle without recapping? I. Yes II. NO
15. Did the emergency professional wash his/her hand after removing the gloves? I. Yes II. No
16. The professionals discard the used needles properly in safety box? I. Yes II.No
17. Procedure observed during data collection? specify ------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------
vii