TYPI CAL OCCUPATI ONAL ACCI DENTS W I TH EMPLOYEES OF A UNI VERSI TY HOSPI TAL I N
THE SOUTH OF BRAZI L: EPI DEMI OLOGY AND PREVENTI ON
I ar a Apar ecida de Oliv eir a Sêcco1 Mar ia Lúcia do Car m o Cr uz Robazzi2 Denise Say ur i Shim izu3 Már cia Mar ia da Silva Rúbio3
Sêcco I AO, Robazzi MLCC, Shim izu DS, Rúbio MMS. Typical occupat ional accident s wit h em ployees of a universit y h ospit al in t h e Sou t h of Br azil: epidem iology an d pr ev en t ion . Rev Lat in am En f er m agem 2 0 0 8 set em br o-out ubr o; 16( 5) : 824- 31.
Descr ipt ive epidem iologic st udy t hat aim ed t o analyze t he t ypical occupat ional accident s not ified by em ployees of a universit y hospit al in t he Sout h of Brazil from 1997 t o 2002, and t o est im at e t heir risk indicat ors. A t ot al of 717 accident s were regist ered; 86% of t hem ( 616) were t ypical and present ed an annual average risk coefficient of 6.0 per 100 em ploy ees. The gr oups t hat pr esent ed m or e r isks for accident s w er e cooks, w oodw or ker s and n u r sin g au x iliar ies, w h ile h an ds w er e t h e m ost af f ect ed ar ea. Regar din g t h e acciden t s n at u r e, t h e gr eat est risks involved biological m at erial. Hence, it is necessary t o orient personnel about t he legal aspect s of occupat ional accident s and r ev iew w or k pr ocesses, especially t hose r elat ed t o em ploy ees w ho per for m act iv it ies at gr eat er r isk of t r ansm issible diseases like AI DS and hepat it is B and C.
DESCRI PTORS: hospit als; accident s, occupat ional; occupat ional r isk s
ACCI DENTES DE TRABAJO TÍ PI COS DE TRABAJADORES DE UN HOSPI TAL
UNI VERSI TARI O DE LA REGI ÓN SUR DE BRASI L: EPI DEMI OLOGÍ A Y PREVENCI ÓN
Se t r at a de un est udio epidem iológico descr ipt iv o que t uv o com o obj et iv o analizar los accident es de t r abaj o t ípicos not ificados por los t rabaj adores de un hospit al universit ario de la región sur de Brasil, de 1997 a 2002 y est im ar indicadores de riesgo. Fueron not ificados 717 accident es, siendo 86% ( 616) t ípicos, cuyo Coeficient e de Riesgo Pr om edio Anual fue igual a 6,0 accident es a cada 100 t r abaj ador es. Los equipos que cor r ier on los m ay or es r iesgos de sufr ir t ales accident es fuer on los de los cociner os, car pint er os y aux iliar es de enfer m er ía, siendo las m anos la part e del cuerpo m ás afect ada. En cuant o a la nat uraleza de los accident es, los de m ayor r iesgo fuer on los r elacionados a m at er iales biológicos. Se const at ó la necesidad de or ient ar al per sonal sobr e los aspect os legales de los accident es y r ev isar los pr ocesos de t r abaj o desar r ollados, especialm ent e par a los que act úan en funciones cuy os r iesgos son m ay or es de cont r aer enfer m edades gr av es com o SI DA y Hepat it is B y C.
DESCRI PTORES: hospit ales; accident es de t r abaj o; r iesgos labor ales
ACI DENTES DE TRABALHO TÍ PI COS ENVOLVENDO TRABALHADORES DE HOSPI TAL
UNI VERSI TÁRI O DA REGI ÃO SUL DO BRASI L: EPI DEMI OLOGI A E PREVENÇÃO
Est u d o e p i d e m i o l ó g i co d e scr i t i v o o b j e t i v o u a n a l i sa r o s a ci d e n t e s d e t r a b a l h o t íp i co s n o t i f i ca d o s p e l o s t r abalhador es de um hospit al univer sit ár io da Região Sul do Br asil, de 1997 a 2002, e est im ar indicador es de risco. Foram not ificados 717 acident es, sendo 86% ( 616) t ípicos, cuj o coeficient e de risco m édio anual foi igual a 6,0 acident es a cada 100 t rabalhadores. As equipes que correram os m aiores riscos de sofrer t ais acident es f or am as de cozin h eir os, m ar cen eir os e au x iliar es de en f er m agem , sen do as m ãos a par t e do cor po m ais at ingida. Quant o à nat ureza dos acident es, aqueles de m aior risco foram os que envolveram m at eriais biológicos. Con st at ou - se a n ecessidade de or ien t ação do pessoal sobr e os aspect os legais dos aciden t es e r ev isão dos pr ocessos de t r abalho desenv olv idos, especialm ent e par a os que at uam em funções cuj os r iscos são m aior es par a cont r air doenças gr aves com o AI DS e hepat it e B e C.
DESCRI TORES: hospit ais; acident es de t r abalho; r iscos ocupacionais
1 RN, Ph.D. in Nursing, Facult y, Universit y of Nort hern Paraná, Brazil, e- m ail: iarasecco@sercom t el.com .br; 2 Ph.D. in Nursing, Full Professor, Universit y of
Sao Paulo at Ribeirao Pret o College of Nursing, WHO Collaborat ing Cent er for Nursing Research Developm ent , Brazil, e- m ail: avrm lccr@eerp.usp.br; 3 RN.
I NTRODUCTI ON
R
esear ch on occu p at ion al accid en t s ( OAs) t h at af f ect h ealt h w or k er s r epr esen t s an im por t an t ep id em iolog ical su r v eillan ce t ool an d aim s t o b ase t he planning and m anagem ent of healt h ser v ices in order t o provide decent work condit ions t o t hose who deliv er car e t o societ y.Accor din g t o t h e Br azilian legislat ion , OA is t h e acciden t t h at occu r s du r in g t h e per f or m an ce of w or k and, as a consequence, causes body lesion or funct ional dist ur bance, w it h per m anent or t em por ar y l o ss o r r ed u ced cap aci t y t o w o r k , o r ev en d eat h . Acci d e n t s t h a t o ccu r d u r i n g t h e w o r k p e r se a r e considered t ypical occupat ional accident s ( TOA) , t hose t hat occur dur ing t r anspor t at ion fr om hom e t o w or k are considered com m ut ing accident s, and professional d i sea se i s p r o d u ced o r t r i g g er ed b y t h e ex er ci se inherent t o t he act ivit y it self, and finally, occupat ional disease is acquir ed or t r igger ed by special condit ions t he work is perform ed in and which it is relat ed wit h. All OAs sh ou ld b e r eg ist er ed in t h e social secu r it y aut hor it ies t hr ough t he I nfor m at ion on Occupat ional Accident s ( CAT)( 1 ).
OAs ar e h azar ds t o w or k er s’ h ealt h du e t o labor al act iv it y, env ir on m en t al con dit ion s w h er e t h e w or k is per for m ed, t he w or k er ’s phy sical and m ent al charact erist ics, social, econom ic and polit ical cont ext s. They are caused by an abrupt or insidious rupt ure in t he relat ion healt h- work and int erfere in t he worker’s healt h- disease pr ocess, w it h subst ant ial per sonal and social r eper cu ssion s.
Alt hough appar ent ly cont radict or y, hospit als t hem selves present several risks t o t heir own workers, both in care delivery to patients and in support to health car e ser vices( 2), despit e hospit als’ social obligat ion t o deliver care to workers severely inj ured in accidents.
Hospit al inst it ut ions are insert ed in t he t ert iary econom ic sect or, dir ect ly or indir ect ly com ply ing w it h t he logic of t he capit alist process. While m any privat e h osp it als ar e f ocu sed on t h e sear ch f or p r od u ct ion a n d p r o f i t , w h o se m o d e l r e f l e ct s o n i n a d e q u a t e r e m u n e r a t i o n a n d w o r k co n d i t i o n s, p r o b l e m s o f m a n a g e m e n t , f i n a n c i a l , a n d p e r s o n n e l a r e a l s o frequent ly verified in public hospit als, which event ually r eflect on t heir per sonnel’s w or k pr ocess.
Even if in an unspecific m anner, t he Brazilian labor legislat ion has pr esent ed adv ancem ent s in t he last decades on issues relat ed t o t he safet y and healt h of w or k er s in t he healt h ar ea. On t he posit iv e side,
st andards of adequat e condit ions hospit al work should be per for m ed in, w er e r egulat ed t hr ough Regulat or y St andard 32, of Safet y and Healt h at Work in Healt h Car e I nst it ut ions ( NR- 32)( 3).
Oc c u p a t i o n a l h a z a r d s a r e c l a s s i f i e d i n biological, physical, chem ical, m echanic, physiological and m ent al, and exposur e t o t hese r isks can lead t o OAs. Hospit al w or k er s, especially t h ose w h o deliv er d ir ect car e, ar e ex p osed t o t h ese r isk s b ecau se of t h e i r cl o se co n t a ct w i t h p a t i e n t s w i t h i n f e ct i o u s d i se a se s, t h e n e e d t o m o v e p a t i e n t s a n d h e a v y e q u i p m e n t s, p h y si ca l st r e ss d u e t o t h e r h y t h m , o r g a n i za t i o n a n d d i v i si o n o f w o r k , i n a d d i t i o n t o ex p er ien ces of p ain an d d eat h t h ey sh ar e, am on g ot hers, which lead t o different kinds of st ress. However, t h er e i s a co n si d er ab l e n u m b er o f o t h er w o r k er s, equ ally ex posed t o r isk s, w h o sh ou ld be t ak en in t o account . They w or k in t echnical and logist ic suppor t t o h ospit al car e, lik e lau n dr y, bu ildin g m ain t en an ce a n d e q u i p m e n t , st o r i n g , m a t e r i a l a n d e q u i p m e n t dispensing and j anit or ial ser v ice.
The risk of being infect ed by Acquired I m m une Deficiency Syndrom e ( AI DS) and Hepat it is B is am ong t h e m ost f ear ed b y h osp it al w or k er s, esp ecially in consequence of accident s w it h cont am inat ed needles, w h ose in d ices of in f ect ion h av e b een est im at ed at b et w een 0 . 2 5 an d 0 . 4 % f o r t h e Hu m an I m m u n o -d e f i ci e n cy Vi r u s ( H I V) , b e t w e e n 6 a n -d 3 0 % f o r hepat it is B v ir us ( HBV) , and bet w een 0. 4 and 1. 8% hepat it is C virus ( HCV)( 4- 5). The Minist ry of Healt h ( MS) st resses t hat perm anent prevent ive m easures, t hrough t h e adopt ion of Un iv er sal Pr ecau t ion s, ar e t h e best alt ernat ive t o preserve t he healt h of workers exposed t o t hese occupat ional r isk s( 6).
Aim in g t o k n ow an d w or k on t h is issu e, in 1 9 9 8 , t h e St at e of Par an á, in t h e Sou t h of Br azil, i m p l e m e n t e d t h e p r o g r a m o f N o t i f i c a t i o n o f Occu pat ion al Acciden t s in v olv in g Biological Mat er ial ( NATMB) , t h r ou gh t h e u se of a specif ic n ot if icat ion for m , elaborat ed not only in accor dance t o t he CAT ( I n f o r m a t i o n o n o ccu p a t i o n a l a cci d e n t s) b u t a l so a cco r d i n g t o t h e MS r e co m m e n d a t i o n s. Th e MS det er m ined t he use of t w o not ificat ions ( NATMB and CAT) w h en t h is t y p e of accid en t s occu r s, an d f r ee dist ribut ion of ant i- ret roviral drugs for HI V, as well as ot her s t o pr event hepat it is B( 6).
studies focusing on the totality of OAs in hospitals have been carried out in Brazil, possibly because of the diversity of work processes developed in hospitals.
OBJECTI VE
An a l y z e t h e n o t i f i e d TOAs t h a t a f f e c t e d w or ker s at a Teaching Hospit al ( TH) in t he Sout h of Br a zi l b et w een 1 9 9 7 a n d 2 0 0 2 , a cco r d i n g t o t h e variables: t ype of accident , inj ured worker’s funct ion, nature of the accident, part of the body injured, tim e and num ber of hours worked until the m om ent of the accident; and estim ate risk indicators of these occurrences.
MATERI AL AND METHOD
Th i s i s a d e scr i p t i v e e p i d e m i o l o g i ca l a n d c r o s s - s e c t i o n a l s t u d y, b a s e d o n Cl a s s i c a l Epidem iological t heory. The TH under st udy is a facilit y w i t h h o sp i t a l i za t i o n ca p a ct i t y o f 3 3 3 b e d s, f u l l y
av ailab le t h r ou g h t h e SUS ( Br azilian Sin g le Healt h Sy st em ) , an d a st af f of 1 , 7 4 2 collab or at or s( 7 ). Th e st udy was approved by t he Research Et hics Com m it t ee at t he universit y t he hospit al is linked t o.
Dat a collect ion w as car r ied out t hr ough t he o f f i ci a l n o t i f i ca t i o n s o f OAs ( CATs a n d N ATMBs) obt ained fr om t he inst it ut ion’s offices r esponsible for t his inform at ion. For st at ist ical t abulat ion and analysis, Epi- I nfo version 6.04 and Excel elect ronic spreadsheet w er e used. The Coefficient of Risk ( CR) of t he st udy variables was est im at ed, considering t he rat io bet ween t he num ber of OAs t hat occurred at a cert ain m om ent and t he populat ion ex posed t o t he r isk at t he sam e t im e and place.
RESULTS
Bet w een 1 9 9 7 an d 2 0 0 2 , t h e st u dy per iod, 7 1 7 OAs w er e n ot if ied at t h e TH, accor din g t o t h e classificat ion pr esent ed in Table 1.
f o e p y T
t n e d i c c a
7 9 9
1 1998 1999 2000 2001 2002 Total Totalannualaverage
n % n % n % n % n % n % n % n Nºof
* s r e k r o
w CAAR**
l a c i p y
T 95 84.1 139 93.9 108 91.5 135 88.2 66 88.0 73 66.4 616 85.9 102.7 1709.8 6.0 g
n it u m m o
C 18 15.9 9 6.1 10 8.5 18 11.8 8 10.7 18 16.4 81 11.3 13.5 1709.8 0.8 l
a n o i s s e f o r P
e s a e s i
D 0 0.0 0 0.0 0 0.0 0.0 0.0 1 1.3 19 17.3 20 2.8 3.3 1709.8 0.2 l
a t o
T 113 100 148 100 118 100 153 100 75 100 110 100 717 100 119.5 1709.8 7.0
Table 1 – Annual dist ribut ion of OAs wit h t he TH workers, by t ype of accident , from 1997 t o 2002. Londrina, 2004
n = num ber of OAs; * N of workers: num ber of workers at t he work unit( 7) .; * * CAAR: coefficient of risk – rat io bet ween average annual num ber of OAs and
average num ber of exposed workers. I t provides t he probabilit y of t he accident t o occur
Result s show a higher Coefficient of Annual Average Risk ( CAAR) of t ypical occupat ional accident s ( TOAs) , o f 6 . 0 a cci d e n t s f o r e a ch 1 0 0 w o r k e r s, f ollow ed b y t h e coef f icien t of com m u t in g accid en t s ( CAAR equal t o 0.8) and t he coefficient of professional diseases, wit h m uch lower levels ( CAAR equal t o 0.2) . The lat t er pr esent ed a consider able incr ease in 2002 d u e t o a p a t i e n t h o sp i t a l i z e d w i t h sca b i e s m i t e ( S a r c o p t e s s c a b i e i ) i n t h e e m e r g e n c y c a r e . H e infect ed w or ker s w hom he had had cont act w it h and t hose w ho had handled cont am inat ed m at er ial used in dir ect car e ( Table 1) .
I n t h e y e a r - b y - y e a r a n a l y s i s o f CR, a n expressive reduct ion in t he TOA indicat or was verified in t h e last t w o y ear s ( Fig u r e 1 ) . I t can b e d u e t o p r ev en t iv e m easu r es im p lem en t ed in t h e h osp it al,
u n d er - n ot if icat ion of cases, or y et , t h e st r ik e t h at o ccu r r ed b et w een Sep t em b er 2 0 0 1 a n d Feb r u a r y 2002. The st rike affect ed only t he out pat ient services, w h i l e h o sp i t a l i za t i o n , e m e r g e n cy ca r e a n d o t h e r ser v ices of high com plex it y w er e not int er r upt ed.
0,0 2,0 4,0 6,0 8,0 10,0
Typical 5.6 8.1 6.5 7.9 3.9 4.2
Commuting 1.1 0.5 0.6 1.1 0.5 1.0
Profissional disease 0.0 0.0 0.0 0.0 0.1 1.1 1997 1998 1999 2000 2001 2002
Ano CR
Funct ions in which t here were higher risks of t y pical accident s at t he TH w er e: cook , w oodw or ker, nur sing aux iliar y, laborat or y aux iliar y and j anit or. I t ev i d en ces t h e n eed f o r sp eci al at t en t i o n t o t h ese w o r k e r s a n d t o t h e w a y w o r k i s o r g a n i z e d a n d p er f or m ed . Man y t im es, cook s w er e in j u r ed w h en u sin g k n iv es, h an d lin g m ach in es t o cu t v eg et ab les and by elect rical shocks due t o lit t le room in t he work ar ea or f alls on w et f loor s. Wood w or k er s su f f er ed acciden t s, especially w h en u sin g t h e elect r ical saw , which caused cuts on their hands. The nursing personnel
n o i t c n u F R
C CRannual
e g a r e v a 7 9 9
1 1998 1999 2000 2001 2002
k o o
C 38.5 42.9 35.7 35.7 9.1 22.2 32.0 r e k r o w d o o
W 16.7 14.3 28.6 14.3 0.0 16.7 15.0 y r a il i x u A g n i s r u
N 10.0 16.5 10.4 14.3 6.0 5.7 10.4 y r a il i x u A y r o t a r o b a
L 6.3 11.1 0.0 16.7 5.6 15.8 9.3 l a r e n e G / d i A l a r e n e G / r o t i n a J y r a il i x u A s e c i v r e
S 9.8 9.2 8.8 11.2 7.9 6.0 8.8 r e m m u l
P 0.0 25.0 0.0 0.0 0.0 25.0 8.3 t s i p a r e h t o i s y h
P 0.0 0.0 25.0 0.0 0.0 20.0 8.0 y s p o r c e N d n a y m o t a n A n a i c i n h c e
T 20.0 0.0 0.0 0.0 25.0 0.0 8.0 y r a il i x u A n e h c t i K d n a n o it i r t u
N 2.1 6.3 12.9 11.1 1.6 4.7 6.6 y r a il i x u A y r d n u a
L 5.8 2.0 6.0 3.9 5.8 11.5 5.9 y s p o r c e N d n a y m o t a n A y r a il i x u
A 0.0 33.3 0.0 0.0 0.0 0.0 5.6 s s e r t s m a e
S 0.0 16.7 16.7 0.0 0.0 0.0 5.6 t n a d n e t t A g n i s r u
N 5.9 6.7 6.7 7.7 0.0 0.0 5.1
y o b -e c if f
O 5.0 0.0 6.3 6.7 6.7 6.3 5.1 n a i c i n h c e T y r o t a r o b a
L 4.8 6.5 6.8 5.7 0.0 4.8 4.8 r e c if f O e c n a n e t n i a
M 12.5 0.0 0.0 12.5 0.0 0.0 4.2 n a i c i s y h
P 0.0 1.5 7.6 8.5 4.8 1.0 3.8 r
e v i r
D 0.0 7.1 0.0 0.0 0.0 14.3 3.6
e s r u
N 0.0 6.2 3.1 4.1 4.2 0.0 3.0 e c n a n e t n i a M t n e m p i u q E n a i c i n h c e
T 0.0 0.0 0.0 12.5 0.0 0.0 2.1 t s i n o i c i r t u
N 12.5 0.0 0.0 0.0 0.0 0.0 2.0 l a c i m e h c o i
B 0.0 0.0 0.0 10.0 0.0 0.0 1.7 e v it a r t s i n i m d A y r a il i x u a / n a i c i n h c e
t 1.1 0.7 1.5 0.0 0.4 1.2 0.8 r
e t r o
P 0.0 0.0 0.0 0.0 0.0 4.3 0.7 n a i c i n h c e T y g o l o i d a
R 0.0 0.0 0.0 0.0 4.0 0.0 0.7 l
a t o
T 5.6 8.1 6.5 7.9 3.9 4.2 6.0
were m ainly inj ured in t he handling of piercing- cut t ing m at erial, in t he perform ance of venous punct ure and m edication adm inistration. I n addition to accidents caused by needles in venous punct ure procedures, laborat ory au x i l i ar i es su f f er ed acci d en t s d u r i n g t h e ex am s t hem selves, handling m at erials under exam inat ion, and during the cleaning process of glass containers, especially cont aining blood. The j anit orial personnel were inj ured by piercing-cutting m aterials inadequately disposed in the t r ash an d in in appr opr iat e places, w h ose sou r ce of cont am inat ion was invariably unknown.
Table 2 – Dist r ibut ion of CR of OAs t hat occur r ed w it h TH w or ker s, accor ding t o funct ion, fr om 1997 t o 2002. Londr ina, 2004
Th e r e l e v a n ce o f a cci d e n t s t h a t i n v o l v e d exposure t o biological m at erial in t he hospit al cont ext was confirm ed when analyzing t he nat ure of accident s. These accident s w er e t he m ost fr equent in all y ear s
at t h e h ospit al. Cases of f alls, im pact s an d lesion s d u e t o e x c e s s i v e e f f o r t e x e r t e d a t w o r k w e r e r espon sible f or 1 6 3 OAs, pr esen t in g CAAR equ al t o 1.6 accident s for each 100 w or k er s.
Hands are t he m ost affect ed body part ( CAAR of 3.9) . Cont am inat ed hy poder m ic needles pr esent ed t h e h ig h est occu p at ion al r isk an d w er e r esp on sib le for 41.9% ( 258) of t he 616 cases de TOAs, t ot aling a CAAR of 2.5 ( Figur e 2) .
I t is h ig h lig h t ed t h at , in 3 . 4 % ( 2 1 ) of t h e ca se s, a cci d e n t s o ccu r r e d w i t h H I V se r o p o si t i v e pat ient s wit h t he following charact erist ics: one of t hem w as also ser oposit iv e for Hepat it is C; 57.1% ( 12) of accident s occur r ed due t o pier cing- cut t ing m at er ials, and in 4.8% ( 1) t he inj ured person cut herself. There w e r e n o n o t i f i ca t i o n s, t h r o u g h CAT, o f a cci d e n t s involving cut s, and of seven of t he 12 accident s caused b y p i e r ci n g - cu t t i n g m a t e r i a l s. Fa i l i n g t o r e g i st e r accident s leav es w or k er s legally unpr ot ect ed in case o f co n t a m i n a t i o n . I n o n e ca se , t h e p a t i e n t w a s sim ult aneously infect ed by HCV and HI V, and anot her pat ient w as infect ed by HCB.
9,3%(57);CAAR=0,6
Eyes
6,09%(37);CAAR–0,4
Torso
64,9%(400);CAAR=3,9
Hands
8,9%(55);CAAR=0,5
LowerLimbs
10,9%(67);CAAR=0,6
Otheraffectedareas
Figur e 2 – Dist r ibut ion of OAs t hat occur r ed w it h TH workers, according t o body area inj ured in t he accident from 1997 t o 2002. Londrina, 2005
Regarding t he t im e t he OAs occurred and t he n u m b er of h ou r s w or k ed u n t il t h e m om en t of t h e accident , t he event s m ost ly occurred in t he m orning, possibly becau se of t h e h igh er in t en sit y of t ask s in t h i s p e r i o d , w i t h a g r e a t v o l u m e o f s u r g i c a l p r oced u r es, ex am s, t r an sp or t at ion of p at ien t s an d differ en t k in ds of for w ar din g. Th e t h ir d h ou r seem s t o indicat e a peak of act ivit y for professionals working
six - h ou r sh if t s. Th e sam e can be said of t h e n igh t period, during t he organizat ion of work in which m ore com plex pr ocedur es ar e per for m ed in or der t o allow pat ient s t o r est fur t her ahead.
Time of the accident
0 10 20 30 40 50 60 70
n = 595 15 36 62 60 45 45 26 31 50 30 31 41 12 8 17 26 10 7 7 11 5 4 5 11
7 8 9 1
0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2
4 1 2 3 4 5 6
Figur e 3 – Dist r ibut ion of OAs t hat occur r ed w it h TH w or k er s, accor d in g t o t h e t im e of occu r r en ce an d num ber of hours worked unt il t he accident event from 1997 t o 2002. Londrina, 2005
DI SCUSSI ON
A t t e n t i o n t o h e a l t h i n t h e h o s p i t a l en v i r o n m en t i s a co l l ect i v e a ct i v i t y t h a t i n v o l v es pr ofessionals w it h specific k now ledge and pr act ice in healt h sciences and r elat ed ar eas, because m any of t he int er dependent w or k pr ocesses r equir e t his k ind of j oint work. There are few st udies report ing on t he whole range of OAs, possibly because of t he diversit y of act iv it ies and w or k pr ocesses dev eloped at t hese inst it ut ions.
Addit ional difficult ies are found when t he st udy focuses on THs. The peculiarit ies of t hese inst it ut ions need t o be account ed for because, in addit ion t o t he ser v i ces o f f er ed t o t h e p o p u l a t i o n , t h ey a r e a l so com m it t ed t o r esear ch on n ew h ealt h t ech n olog ies
Number of hours worked until the accident
0 20 40 60 80 100 120
a n d t o t e c h n i c a l - s c i e n t i f i c e d u c a t i o n , b e s i d e s hum anist ic and et hical aspect s of fut ure professionals. I n t he analysis of all accident s r egist er ed by workers at t he st udy hospit al, a higher rat io of TOAs w as f ou n d w h en com p ar ed t o cases of com m u t in g accident s and pr ofessional disease. This leads t o t he conclusion t hat t he event s m ost ly occurred in t he work en v ir on m en t an d ar e r elat ed t o t h e w or k p r ocess. Th e sam e is ob ser v ed in ot h er st u d ies f ocu sed on t his issue in hospit als, r epr oducing w hat also occur s in t h e r em ain in g sect or s of societ y. On ly in 2 0 0 6 , 503.890 OAs were regist ered in t he Brazilian I nst it ut e of Social Securit y, wit h 80.0% ( 403,264) of TOA cases, 1 4 . 7 % ( 7 3 , 9 8 1 ) co m m u t i n g a cci d e n t s a n d 5 . 3 % ( 2 6 , 6 4 5 ) in f or m ed as occu pat ion al diseases. A f act w or t h m ent ioning is t hat t hese accident s r esult ed in 2,717 deat hs( 8).
I t was verified in t his st udy t hat t he hospit al w or k er s w h o ex er t pr edom in an t ly m an u al act iv it ies and t hose in t he sm aller incom e r ange ar e t he ones m ost af f ect ed by acciden t s, w h ich is in accor dan ce w i t h t h e i n v e st i g a t i o n s o f o t h e r La t i n - Am e r i c a n au t h or s( 9 - 1 2 ). High er ex posu r e does n ot seem t o be link ed t o low er pr ofessional qualificat ion, but t o t he t y pe of act iv it ies t hese w or k er s per for m .
I n fact , ex posur e t o w or k loads char act er izes so ci a l d i v i si o n a n d w o r k t e ch n i q u e , b y t h e w a y act iv it ies ar e d iv id ed an d or g an ized , b y t h e g r eat v olu m e of t ask s an d r ep et it iv en ess of p r oced u r es, which can m ake t he t eam feel t he burden of act ivit ies and phy sical and em ot ional ex haust ion in t heir ow n body( 13).
S e v e r a l La t i n - A m e r i c a n a u t h o r s h a v e discu ssed t h e specif ic ex posu r e of n u r sin g w or k er s t o su ch o ccu r r en ces. I n f act , t h ese p r o f essi o n al s, especially t ech n ician s an d au x iliar ies, ar e t h e on es m o st i n v o l v e d i n se v e r e a cci d e n t s, d u e t o t h e i r i n c r e a s e d o c c u p a t i o n a l e x p o s u r e t o p o t e n t i a l l y infect ious body fluids like blood, due t o t heir physical pr ox im it y t o t he pat ient , t y pical of t he nur sing car e a c t i v i t y, a n d i n t e r r u p t e d t a s k s o f h i g i e n i z a t i o n , m edicat ion adm inist r at ion, handling and pr epar at ion o f s u r g i c a l i n s t r u m e n t s a f t e r u s e , h a n d l i n g o f cont am inat ed ex cr et ions and fom it es, hect ic r hy t hm r equir ed t o per for m t ask s in t im e, t he w ay t he w or k i s d i v i d e d a n d o r g a n i z e d , m a k i n g t h e m m o r e v ulner able t o occupat ional r isk s and OAs, as w ell as hazards due t o exposure( 2,9,11- 12,14- 18).
The high level of TOA not ificat ions caused by biological m at erial found in st udies on OAs wit h hospit al
workers reveals renewed at t ent ion in relat ion t o AI DS, esp ecially f r om n u r sin g p er son n el. Th is is p ossib ly due t o t he discr im inat ion st igm a t his disease car r ies, w h i ch m a k e s h e a l t h p r o f e ssi o n a l s a p p r e h e n si v e . Alt hough t he hepat it is B virus has been known m uch longer and r epr esent s a higher r isk of infect ion t han HI V, wit h repercussions t o healt h as significant as t hose from HI V, it does not provoke so great concern am ong pr ofessionals and societ y it self as AI DS does.
An occupat ional case of AI DS was not ified in São Paulo in 1996. Since t he beginning of t he epidem ic, f r o m 1 9 8 1 t o 1 9 9 9 , 1 0 0 p r o v e d ca se s a n d 2 1 3 p r o b a b l e c a s e s o f c o n t a m i n a t i o n o f h e a l t h pr of ession als by HI V w er e iden t if ied w or ldw ide du e t o OAs, and t he Unit ed St at es is r esponsible for t he lar gest num ber of inv est igat ed cases( 15).
Regarding t he body part affect ed in t he TOAs, hands w er e, as ex pect ed, inj ur ed in 64.9% ( 400) of TOAs, w it h a CAAR of 3 . 9 accid en t s f or each 1 0 0 w o r k er s a t t h e TH. Ey es w er e a n o t h er so u r ce o f concern, m ainly because of t he exposure t o biological m at erial. This st udy showed ocular exposure t o t hese elem ent s in 85. 4% ( 35) of cases; in 42. 9% ( 15) of cases, t h e sou r ce p at ien t w as ser op osit iv e f or HI V an d / or h ep at it is B. Th is is r elev an t b ecau se t h ese accid en t s ar e av oid ab le t h r ou g h sim p le p r oced u r es lik e t h e u se of goggles du r in g secr et ion aspir at ion , su r gical in st r u m en t at ion , in bir t h car e, collect ion of cont am inat ed ex cr et ions and fluids, am ong ot her s.
The findings of t his st udy regarding t he m ost affect ed body par t in OAs ar e ev en higher t han t he g en er a l d a t a p r esen t ed b y t h e Mi n i st r y o f So ci a l Secu r it y, w h ich f ou n d t h at h an d s w er e af f ect ed in 3 2 . 6 % ( 4 0 7 , 3 5 9 ) o f a l l ca ses b et w een 2 0 0 2 a n d 2005( 8).
Mu scu losk elet al p r ob lem s cau sed b y TOAs pr esen t ed in t h e n ot if icat ion s w er e: 2 8 con t u sion s, one fract ure, seven t orsions, four luxat ions, and four m uscular dist ensions, t ot aling 12.6% ( 44) of OA cases, w hose CR w as est im at ed at 1.1.
Wort h m ent ioning is t he fact t hat , as opposed t o piercing- cut t ing inj uries, which are oft en considered less im por t ant , back pains ar e v er y significant . They ar e caused by abr upt m ov em ent s, phy sical effor t or even by support ing a pat ient so as not t o fall, by falls, im pact s and m ovem ent s required t o lift a bin of dirt y cl o t h es. Th e h i g h er r el ev an ce o f acci d en t s m ak es pr of ession als r egist er t h e f act becau se, of t en t im es, acciden t s pr ev en t t h em f r om con t in u in g t o per f or m t heir w or k .
As expect ed, in t he evaluat ion of t he OAs t hat occu r r ed at t h e h osp it al, it w as ob ser v ed t h at t h e lar gest num ber of occur r ences happened dur ing t he day, especially in t he m orning. I t seem s t o be relat ed t o t he t im e w hen t her e is an int ense lev el of w or k , especially car e pr ocedur es. I n t er m s of t he num ber of h ou r s w or k ed u n t il t h e m om en t of t h e acciden t , t he m aj orit y of cases occurred bet ween t he t hird and f if t h h ou r w or k ed , w h ich is p ossib ly r elat ed t o t h e higher volum e and rhyt hm of work in t his period and int ense w or k in six - hour shift s, w hich is t he sy st em em ployed by t he st udy inst it ut ion. ( Figur e 3) .
FI NAL CONSI DERATI ONS
The evaluat ion of variables t hat com pose t he daily w or k pr ocesses h ospit al w or k er s ar e in v olv ed in, and especially t he search for prevent ive m easures t hat can be im plem ent ed t o im prove t his realit y, aim ing t o r each t he hum an dim ension in t he w or k act iv it y, are shown as alt ernat ives for healt h prom ot ion of t his pr ofessional gr oup, as r ecom m ended by t he SUS.
Th e h igh est r isk in dicat or s w er e v er if ied in t his st udy for t y pical accident s, w hich affect m ainly cook s, w oodw or k er s an d n u r sin g au x iliar ies. Han ds w er e t he m ost affect ed par t of t he body, exposed t o biological m at er ial in t he handling of pier cing- cut t ing
m at er ials. The highest fr equency of ev ent s happens i n t h e m o r n i n g a n d a t t h e t h i r d h o u r. I n t h i s per spect iv e, all pot en t ial pr ev en t iv e m easu r es able t o cont r ibut e t o OA pr ev ent ion and healt h pr om ot ion of w or k er s in h ospit al u n it s sh ou ld be sear ch ed f or and inst it ut ionalized w it h t he suppor t of t he Ser v ice o f En g i n eer i n g , Med i ci n e an d Saf et y at w o r k , t h e hospit als’ int er nal com issions on accident pr ev ent ion, a s w e l l a s a l l o t h e r o r g a n i z a t i o n a l s t r u c t u r e s r espon sible for h ealt h edu cat ion an d su r v eillan ce in t he inst it ut ions.
Pr ev ent iv e and educat iv e act ions aim ingd t o avoid new occurrences should be a concern of all t hose in v olv ed , an d r eq u ir e in t en se ef f or t t o in f or m an d e d u ca t e p r o f e ssi o n a l s a n d st u d e n t s i n t h e a r e a , especially t o pr event OAs, w hich alw ays culm inat e in p r o f essi o n al s’ em o t i o n al ex h au st i o n , h eal t h r i sk s, econom ic and social pr oblem s, financial inv est m ent s a n d e t h i c a l a n d l e g a l p r o b l e m s t h a t i n v o l v e professionals, pat ient s and inst it ut ions, am ong ot hers. I t is necessar y t o r eor ient all w or k er s r egar ding t he c u r r e n t l e g i s l a t i o n , w i t h a v i e w t o p r e v e n t i n g u n d er n ot if icat ion cases, f or t h eir ow n saf et y, w it h adequat e pr ov ision of legal suppor t .
Me t i cu l o u s e v a l u a t i o n o f w o r k p r o ce sse s dev eloped in hospit als, t he w ay t he w or k is div ided and organized, is essent ial in t his t ask, especially for w o r k er s w h o d ev el o p f u n ct i o n s su b j ect t o h i g h er pr of ession al r isk s. I t is n ecessar y t o k n ow h ow t h e worker is insert ed in t he social group and t he hist ory of w or k pr ocesses t hat cause ex haust ion, due t o t he sp e ci f i ci t i e s o f t h e w o r k e r ’ s - w a y o f l i v i n g a n d w or k ing( 13).
Th e r a n g e o f v a r i a b l es t h a t co m p o se t h e hospit al work requires m ore det ailed st udies, t o allow f o r t h e d e v e l o p m e n t o f so u n d a ct i o n s o f h e a l t h p r eser v at ion an d p r om ot ion t o t h ose w h o d ed icat e t hem selv es t o car e for ot her s’ healt h.
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