Posts tagged #procedures

Needlestick Injuries

needlestick image.png

Written by: Logan Wedel, MD (NUEM PGY-2) Edited by: Hashim Zaidi, MD (NUEM ‘18) Expert commentary by: Tim Loftus, MD, MBA


So You Just Sustained A Needlestick Injury… Now What?

A Brief Guide For Healthcare Professionals


Needlestick injuries continue to be a common source of work related injury among health care professionals.

Since the Needle-Stick Safety and Prevent act of 2000, non-surgical needle sticks have decreased by 31.6% (2001-2006). Over this same time period, incidents within the surgical setting have increased 6.5%.

However the most recent data from the CDC still estimates 385,000 injuries a year, which equates to more than 1,000 needle stick injuries per day amongst health care professionals. Unfortunately, this is believed to be a gross under-estimation secondary to the vast amount of incidents that go un-reported.

So I Got Stuck… What Is My Actual Risk?

High Risk

  • Inoculation from deep or open wound

  • Stick with a hallow bore needle / Needle used for blood draw

Low Risk

  • Suturing needle

  • Discarded needle

No Risk

  • Unused needle

  • No break in the skin

Good News! The risk of occupational transmission is low!

Transmission Rates by Disease - From a Source Positive Patient

Hepatitis B: 1% - 62% (Depending on exposure type and infectivity of source patient)

  • Risk of developing clinical evidence of infection ranges from 1% - 31%

  • Risk of developing serologic evidence of infection ranges from 23% - 62%

  • Fortunately, this disease is the most easily prevented. Staying up to date on vaccines is the #1 way to prevent HBV infection!

Hepatitis C: 1.8%

  • Has ranged from 0% - 7% in some studies

  • Extremely low transmission rates from mucous membrane exposure

Human Immunodeficiency Virus (HIV): 0.3%

  • Rates drop to 0.09% with mucous membrane exposure

Immediately After Exposure

Safely cease the procedure. Have another operator take over if available.

  • The best way to prevent transmission after contact is to wash the site thoroughly with soap and water

  • Take your time to perform this well

  • Flush the nose and mouth if they were exposed

  • Copious irrigation of the eyes if there was ocular exposure

Reporting

This is the last thing you want to be doing, but....

  • It is critical to report the incident. Each institution has its own protocol that health care professionals are required to follow. The first step usually deals with informing the charge nurse or unit manager if you are in a healthcare facility. Follow your local institutional protocols to document and report the exposure.

  • Every healthcare facility has protocols for occupational exposure. Remember-this is not a unique event and these exposures happen. If there is uncertainty on how to proceed, see if the institution has infection control personnel, occupational health agents, or other administrators or staff who would be familiar with the process.

  • This happens. Follow the institutional process and remember this is not uncommon. By not reporting or following protocol you risk transmission of blood borne infectious agents without timely diagnosis and treatment.

Management + Blood Draws

1. Collect the Source Patient's Blood -- Disclose the Incident

  • If unable to acquire (patient no longer present, refuses, or unknown source), post-exposure prophylaxis will need to be considered carefully

  • Council the source patient on the standard practice to test for blood born infectious agents given the exposure

  • Determine the source patient's baseline disease characteristics and any treatment history

2. Your Blood Work

  • Determine your baseline disease characteristics

  • Hepatitis B status

    1. Vaccinated with or without response

    2. Un-vaccinated without infection

    3. Evidence of current infectivity

    4. Hepatitis B immune globulin (HBIG) may be utilized post exposure particularly for those who are not vaccinated

  • Hepatitis C status

  • HIV status

3. Follow Up Blood Work - Short and Long Term Monitoring

  • Hepatitis B: repeat test at 6 months post exposure

  • Hepatitis C: repeat testing at 2, 4, 8 weeks post exposure

  • HIV : repeat testing at 6 weeks, 3 months, 6 months, 1 year post exposure

Post Exposure Prophylaxis

Hepatitis B

  • Hepatitis B Immune Globulin Alongside Vaccination Series

  • Roughly 75% effective and preventing infection

  • Administer ASAP - effectiveness after 7 days is unclear

Hepatitis C

  • No available post exposure prophylaxis

  • Follow your blood work to monitor disease status

Human Immunodeficiency Virus (HIV):

  • Three Drug Cocktail: Truvada QD (Tenofovir 300mg + Emtricitabine 200mg) + Raltegravir 400mg BID is the preferred regimen

  • Dual Nucleoside Reverse Transcriptase Inhibitor +

    • Integrase Inhibitor

    • Protease Inhibitor

    • Non Nucleoside Reverse Transcriptase Inhibitor

  • Multiple Regimens Exist: Can target specific resistance patterns. Expert consultation can be made with local experts or by calling the National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline) at 888-448-4911.

  • Initiate ASAP - effectiveness unknown after 72 hours

  • 28 Day Regimen

  • Close physician/laboratory follow up to monitor toxicity

Prevention

Always take the the time to apply proper personal protective equipment (PPE)

  • It will save you time and save you stress

Gowns, Gloves, Goggles

  • Common mistake to forget eye protection

  • Double glove in higher risk circumstances

Safe practices: Never reuse needle / Never re-cap needle

  • Safe needle disposal


Expert Commentary

Thank you to Dr. Wedel on an excellent review and summation of what is a frequent and yet frustrating topic for EM physicians.  The evaluation and management of potential blood or body fluid exposures is an area riddled with logistical nuances that frequently change and can be state and institution-specific.  As such, it can be very helpful to mentally break the topic down as has been done so nicely here, into considerations of risk, reporting, testing, and management (including PEP). There are a few important points and nuances that deserve further discussion:

Safety 

Safety is of utmost priority - safety for yourself, your colleagues, and your patients and their family members.  These events are vastly underreported for a variety of reasons, but often this is the first step in tracking these events, mitigating downstream morbidity, addressing issues upfront, and preventing transmission.  A safety culture is built on a daily basis by each and every one of us. 

Nature of Exposure

This post focuses on occupational exposures to healthcare workers, which are relevant to us, but are by far not the only possible or definite exposure we will see.  The more detailed and thorough history we can elicit in these situations may make the difference between initiation or not of post-exposure prophylaxis, as an example.  It is incumbent upon us in emergency medicine to remain up to date on state and local laws and regulations as well as institutional policies and procedures, which help guide us to correctly managing these situations.  As an example, the evaluation and management plan of an exposed healthcare worker may differ compared to that of a patient’s family member, pregnant female, or law enforcement officer or other government official. The more details we can gather regarding the nature of exposure and possible risk of blood-borne pathogen transmission will help us in these nuanced situations. 

Post-Exposure Prophylaxis

This is nicely outlined by Dr. Wedel - to highlight a few points:

  1. HBV - immunization is key.  Please ensure your own HBV immunization status is up to date and obtain history of HBV immunization in all patients who are able to provide this. 

  2. Tetanus - depending on the nature of the exposure, be mindful that tetanus immunization may be necessary.  

  3. HIV - post-exposure prophylaxis has been shown to be very effective in this situation, decreasing likelihood of HIV transmission by as much as 81%.  The effectiveness is best the sooner it gets started after the exposure and is recommended within 72 hours. While there are widely used and preferred regimens, the specific details of each situation may alter the choice of PEP regimen, including kidney function, source patient’s HIV status and resistance patterns, pregnancy, cost, dosing frequency, and side effect profile.  The decision to initiate PEP should be involve a detailed and informed conversation with the patient, as 50% of HCW’s have reported side effects to PEP and as many as 33% have prematurely stopping taking the medicines. 

Consent

Make sure to consider one’s local practice environment, policies, and procedures with respect to potential body fluid exposure testing and treatment. Certain states, such as Illinois, require consent, pre-test information, and other considerations when performing HIV testing in the ED setting.  However, as is the case in Illinois with the AIDS Confidentiality Act and in as many as 35 other states, informed consent and pre-test information may not be required when HIV testing is either medically indicated or in cases of blood or body fluid exposure with certain individuals, including health care workers, law enforcement officers, and paramedics. Be mindful that exception from informed consent does not compel the source patient to submit to testing if a blood specimen is not already available, as this usually requires a court order.  Further, exception from informed consent does not waive us of the responsibility to thoroughly discuss with these patients the rationale behind testing, reporting, and details of unconsented HIV testing.

Overall, blood and body fluid exposure in the health care setting is extremely common and relatively easy to manage, but often gets relegated to standard institutional protocols that may or may not be applied appropriately given the unique circumstances of each patient encounter.  Thank you again to Dr. Wedel for an excellent review, as a thoughtful approach to these situations can help guide us in having a detailed, informed conversation with our patients surrounding transmission risk, testing procedures, post exposure prophylaxis, and rationale behind follow-up timing and testing procedures.  


There are many resources out there to help us, including each institution’s corporate/occupational health, risk management, state and local laws and regulations, and the PEPline. 

Loftus.png

Timothy Loftus, MD, MBA

Assistant Professor

Department of Emergency Medicine

Northwestern University


How to Cite this Post

[Peer-Reviewed, Web Publication] Wedel L, Zaidi H. (2019, Oct 14). Needlestick Injuries. [NUEM Blog. Expert Commentary by Loftus T]. Retrieved from http://www.nuemblog.com/blog/needlestick.


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References

  1. "CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Prophylaxis Management." Centers for Disease Control and Prevention, U.S. Department of Health & Human Services, https://www.cdc.gov/mmwr/PDF/rr/rr6210.pdf.

  2. "Exposure to Blood: What Healthcare Personnel Need to Know." Centers for Disease Control and Prevention, U.S. Department of Health & Human Services, https://www.cdc.gov/HAI/pdfs/bbp/Exp_to_Blood.pdf.

  3. "HIV/AIDS PEP." Centers for Disease Control and Prevention, U.S. Department of Health & Human Services, https://www.cdc.gov/hiv/basics/pep.html.

  4. "HIV/AIDS Post Exposure Prophylaxis (PEP)." Centers for Disease Control and Prevention, U.S. Department of Health & Human Services, https://www.cdc.gov/hiv/risk/pep/index.html

  5. "Oral Health: Occupational Exposure to Blood." Centers for Disease Control and Prevention, U.S. Department of Health & Human Services, https://www.cdc.gov/oralhealth/infectioncontrol/questions/occupational-exposure.html.

  6. "The National Surveillance System for Healthcare Workers." Centers for Disease Control and Prevention, U.S. Department of Health & Human Services, https://www.cdc.gov/nhsn/PDFs/NaSH/NaSH-Report-6-2011.pdf

  7. "Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis." Centers for Disease Control and Prevention, U.S. Department of Health & Human Services, https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm.


Posted on October 14, 2019 and filed under Procedures.

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