You are supervising a registrar who suffers a needle stick injury during the insertion of a central line in a patient with a history of intravenous drug use.
Outline your approach to this problem.
- Stop the procedure
- Ensure patient is safe
- Takeover / delegate patient management as required
- Wash the registrar’s wound immediately with soap and water
- Express any blood from the wound
- Initiate injury-reporting system used in the workplace
- Patient may need to be consented and then tested for HIV, hepatitis B, Hepatitis C
- Refer registrar to designated treatment facility: Emergency Department / Infectious Disease Physician / Immunology as per hospital protocol
- With consent, registrar to be tested immediately and confidentially for HIV, hepatitis B and C
- Document the exposure in detail for your own record and for the employer
- If the patient is HIV positive, post exposure prophylaxis needs to be started within two hours of the exposure.
- For possible Hepatitis C exposure, no treatment is recommended but advice must be obtained from Infectious Disease Specialist
- If the source patient tests positive for HIV, hepatitis B, hepatitis C, get post-exposure prophylaxis in accordance with CDC guidelines and as per recommendations from Infectious Disease Specialist or other expert.
- Registrar to have follow up with post exposure testing
- Advise re: taking precautions (including safe sex) to prevent exposing others until follow up testing is complete.
- If exposed to blood borne pathogen, he/she should not donate blood for six months until cleared
- While definitive testing is essential, counsel the registrar that the risk factors for infection are: deep injury, visible blood on devices, and needle placement in a vein or artery, lower risk with solid suture needle.
Related to procedure:
- Review of registrar’s technique, equipment used, unit policy for procedural training, assessment of competency, etc.
Candidates who failed did not give enough detail, e.g. “take bloods” without specifying for which investigations.
This question is near-identical to Question 25 from the first paper of 2007. LITFL have an approach to staff needlestick injuries. David Tripp's notes for the fellowship exam are also a source of a nice point-form algorithm. A list of definitive sources for this information would include the 2017 NSW Health Policy Directive: HIV, Hepatitis B and Hepatitis C - Management of Health CareWorkers Potentially Exposed, as well as the Westmead Children's Hospital procedure "Needlestick and Blood Exposure Injuries: Health Care Worker". A NM
- Abort the procedure
- Ensure the patient is safe:
- Take over the procedure and finish it yourself; or
- Delegate the task to a competent staff member
- Ask the registrar to express blood from the wound
- Wash the punctured area with soap and water
- Report the incident
- Is the patient known to have Hpe B, C, or HIV?
The following are associated with an increased risk of transmission:
- Hollow needle
- Large needle diameter
- Needle was previously in an artery or vein
- Absence of gloves
- Depth of wound
- Into artery or vein
- Exposed to a large volume of blood
- High blood titre of HIV, Hep B or C
- Document the Hep B immunisation status of the staff member
- Perform antibody tests of both the staff member and the patient, with written consent
- If the source is known to be Hep B C or HIV positive,
- Solicit advice from infectious diseases authorities
- Arrange appropriate vaccinations, antiretroviral prophylaxis and councelling
- Arrange follow-up for the patient and staff member
- Possible management strategies:
- For Hep B, IV immunoglobulin may be appropriate
- For Hep C, there is nothing.
- For HIV, postexposure antiretroviral therapy is helpful (and needs to be commenced within 2 hours!)
- Safe sex for 6 months
- Follow-up testing: 6 weeks and 6 months
- Review unit guidelines and compliance
- Some health districts include mandatory central notification of all health care worker exposure events
- Offer emotional support to the staff member, and get help from infectious diseases authorities to aid post-exposure councelling
Wicker, Sabine, et al. "Determination of risk of infection with blood-borne pathogens following a needlestick injury in hospital workers." Annals of occupational hygiene 52.7 (2008): 615-622.
McGovern, Patricia. "Needlestick injuries among health care workers: a literature review." AAOHN Journal 47 (1999): 237-244.
2017 NSW Health Policy Directive: HIV, Hepatitis B and Hepatitis C - Management of Health CareWorkers Potentially Exposed
Westmead Children's Hospital procedure: "NEEDLESTICK AND BLOOD EXPOSURE INJURIES: HEALTH CARE WORKER"