College Answer
Immediate Response:
- Stop the procedure
- Ensure patient is safe
- Takeover / delegate patient management as required
Further response:
- 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
Counselling:
- 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.
Additional comments:
Candidates who failed did not give enough detail, e.g. “take bloods” without specifying for which investigations.
Discussion
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
Immediate management:
- 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
Risk assessment:
- 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
Management
- 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