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Needle Stick Injury Dr. Deepak Gupta
Part I
Occupational Exposures and Sharps Management
Sharps Management
What is an occupational exposure? A blood or body fluid exposure that occurs
as a consequence of a work-related activity There are two types of blood and body fluid
exposure:▪ Percutaneous exposure (penetrates the skin) e.g.
needlestick injury (NSI) or cut with a sharp object such as a scalpel blade
▪ Non-percutaneous or mucocutaneous exposure (contact of mucous membrane or non-intact skin with blood or body fluids) e.g. blood splash to the eye
Sharps Management
What about human bites and scratches that break the skin? For human bites, clinical evaluation must
include the possibility that both the person bitten and the person who inflicted the bite were exposed to blood borne pathogens▪ Transmission of HIV infection by this route has
been reported rarely, but not after an occupational exposure.
The risk of transmission of a blood borne virus via a scratch is highly unlikely
Sharps Management
Why do I need to be concerned if I have an occupational exposure? An occupational exposure potentially
exposes healthcare workers to blood and other body fluids (except sweat), that may contain blood borne viruses▪ Human Immunodeficiency Virus (HIV)▪ Hepatitis B Virus (HBV)▪ Hepatitis C Virus (HCV)
Contaminated sharps pose the greatest risk to healthcare workers of occupational exposure to blood borne viruses
Sharps Management
How does transmission of a blood borne virus occur from a contaminated sharp? Transmission requires transfer of blood-
containing material by injection or via sharp instruments through unbroken skin
The risk of transmission is influenced by: ▪ Organism▪ Volume of blood▪ Status of source▪ Status of staff member
Sharps Management
What is the risk of transmission following a NSI to a positive source?
HIV▪ 0.3%
HBVIf healthcare worker susceptible (i.e. non-immune)▪ 1% - 6% if the source is hepatitis B surface antigen
(HBsAg)-positive▪ 22% - 31% if the source is HBsAg- and HBeAg-positive
HCV▪ 1.8% (range: 0% - 7%)
Sharps Management
Who is at risk of an occupational exposure? All healthcare workers who have the potential for exposure
to infectious materials (e.g. blood, tissue, and specific body fluids, as well as medical supplies, equipment or environmental surfaces contaminated with these substances) e.g:▪ Nurses▪ Doctors▪ Laboratory staff▪ Technicians▪ Therapists▪ Support personnel e.g. housekeeping, maintenance▪ Dental staff▪ Contractual staff▪ Students
Sharps Management
Where, when and how do NSI occur? Where?▪ Inpatient units▪ Operating rooms▪ Emergency Department▪ Procedure Room
When and How?▪ During use▪ After use and before disposal (including recapping)▪ During or after disposal▪ After appropriate disposal ▪ After inappropriate disposal
Sharps Management
What types of devices are involved in NSI? Analysis of the results of a 10-year study at a large
Queensland tertiary referral hospital revealed that two hollow-bore devices were implicated in over 90% of NSI
1
▪ Disposable needle/syringes▪ Steel-winged (butterfly) needles
Other types of hollow-bore needles include:▪ Intravenous (IV) catheter stylets▪ Multi-sample blood collection (‘vacutainer’) needles▪ Arterial blood collection syringe needles▪ Aspiration needles▪ Injector pen needles
Sharps Management -General Principles
Policies and procedures including NSI management Standard Precautions including personal protective
equipment (PPE) Hepatitis B vaccination Education programs Modifications to work practices including
alternatives to using needles Safe handling of sharps Sharps disposal systems i.e. puncture-resistant
containers Injury prevention features/safety devices
Active Passive
Sharps Management -General Principles
The person who has used the sharp is responsible for its immediate safe disposal following use, preferably at the point of use.
Sharps Management -General Principles
Needles should not be recapped, bent or broken by hand, removed from disposable syringes or otherwise manipulated by hand.
Sharps Management -General Principles
In the case of inappropriately disposed sharps, a sharps container should be taken to the location, the sharp handled and disposed of in a manner to avoid injury, and hands washed following disposal. Report inappropriate disposal
Needlestick and other sharps injuries
A Percutaneous piercing wound;
typically set by a needle point but possibly also by other sharp
instruments or objects.
Needlestick and other sharps injuries
An occupational exposure is defined as:
a needle stick, sharp puncture wound or a splash to mucous membranes (i.e.,
mouth or eye) with blood or body fluids while caring
for your clients.
Needlestick and other sharps injuries
High-risk procedures All invasive procedures Blood taking Suturing Giving injections Inappropriate disposal of sharps.
Needlestick and other sharps injuries
High-risk procedures
Recapping needles (Most important) Transferring a body fluid between
containers. Poor healthcare waste management
practices
Needlestick and other sharps injuries
Risk factors for occupational exposure to body fluids include the following:
Failure to adhere to universal precautions
Using equipment designed without appropriate safety features
Performance of exposure-prone procedures
GIUDELINES FOR PEP
Post exposure prophylaxis
Guidelines The post-exposure guidelines should
address: Immediate action Follow-up action Record keeping with standardized
codes Confidentiality
Post exposure prophylaxis
Guidelines Bleed area for 3 – 5
minutes(controversial) Wash site immediately with soap and
running water Disinfect area for 3 – 5 minutes with
10% iodized polyvidone (povidone iodine) diluted with 3 volumes of water or with a 0.5% chlorine bleach solution.
Post exposure prophylaxis
Guidelines
1:10 dilution of a 5% chlorine bleach solution or 1:6 dilution of a 3% chlorine bleach solution
Take a blood sample for baseline HIV, Hepatitis B surface antigen and Hepatitis C antibody status.
Post exposure prophylaxis
Guidelines Pretest confidential counseling
should be offered to the health care worker
If health care worker have not had Hepatitis B immunoglobulin vaccination, it should be considered
Post exposure prophylaxis
Guidelines
Generally PEP works best the first 3-24 hrs after the accident occurred.
It can also be started up to 72 hrs after the accident, but not effective after that.
Post exposure prophylaxis
Guidelines
Immediately encourage site bleeding while washing the wound and skin sites exposed to blood or body fluids.
Wash with soap and water or other antiseptics
CDC guidelines
The need for tetanus and/or hepatitis B prophylaxis is based on medical history.
Health care workers should have been immunized against hepatitis B.
Hepatitis A prophylaxis may (rarely) need to be considered depending on the source-patient situation.
CDC guidelines
The need for HIV or chemoprophylaxis (antiretrovirals) is based on an assessment of the risk by using the 3-step process developed by the Centers for Disease Control and Prevention (CDC)
CDC guidelines
Step 1: Determine exposure code. Is the source material blood, bloody
fluid, other potentially infectious material, or an instrument contaminated with one of these substances? If not, there is no risk of HIV transmission? If yes, what type of exposure occurred?
If the exposure was to intact skin only, there is no risk of HIV transmission.
CDC guidelines
Step 1: Determine exposure code.
If the exposure was to mucous membrane or integrity-compromised skin, was the volume of fluid small (few drops, short duration) or large (several drops or major splash, long duration)? If small, the category is exposure code 1. If large, the category is exposure code 2.
CDC guidelines
Step 1: Determine exposure code
If the exposure was percutaneous, was it a solid needle or a superficial scratch (ie, less severe)?
If yes, the category is exposure code 2.
CDC guidelines
Step 1: Determine exposure code
Was it from a large-bore hollow needle, a device with visible blood, or
a needle used in a source patient's artery or vein (ie, more severe)?
If yes, the category is exposure code 3.
CDC guidelines
Step 2: Determine HIV status code.
What is the HIV status of the exposure source?
If HIV negative, no post exposure prophylaxis is needed.
If HIV positive, was the exposure low titer or high titer?
CDC guidelines
Step 2: Determine HIV status code.
Low-titer exposures are asymptomatic patients with high CD4 counts
These are HIV status code 1.
CDC guidelines
Step 2: Determine HIV status code.
High-titer exposures are patients with primary HIV infection, high or increasing viral load or low CD4 counts, or
Advanced Acquired Immunodeficiency Syndrome (AIDS)
CDC guidelines
Step 2: Determine HIV status code
These are HIV status code 2.
If HIV status is unknown or the source is unknown, the HIV status code is unknown.
CDC guidelines
Step 3: Match exposure code with HIV status code
To determine if any post exposure prophylaxis is indicated.
Post exposure prophylaxis recommendation are as follows:
CDC guidelines
Exposure code 1 and HIV status code 1:
Post exposure prophylaxis may not be warranted.
Exposure type does not pose a known risk.
The exposed health care worker and the treating clinician should decide whether the risk for drug toxicity outweighs the benefit of post exposure prophylaxis
CDC guidelines
Exposure code 1 and HIV status code 2:
Consider the basic regimen. Exposure type poses a negligible risk
for HIV transmission. A high HIV titer in the source may
justify consideration of post exposure prophylaxis.
CDC guidelines
Exposure code 1 and HIV status code 2
The exposed health care worker and the treating clinician should decide whether the risk for drug toxicity outweighs the benefit of post exposure prophylaxis.
CDC guidelines
Exposure code 2 and HIV status code 1:
Recommend the basic regimen. Most HIV exposures are in this
category. No increased risk for HIV
transmission has been observed, But use of post exposure prophylaxis
is appropriate.
Created for benefit of Health care workers