| A hospitalized patient with AIDS became agitated | | | | hepatitis B vaccination can prevent transmission in |
| and tried to remove the intravenous (IV) catheters in | | | | most cases) 40% |
| his arm. During the struggle, an IV infusion line was | | | | Hepatitis C 3-10% |
| pulled. A nurse at the scene recovered the connector | | | | (If this urgent preliminary risk assessment considers |
| needle at the end of the IV line and was attempting | | | | there is a significant risk of HIV, post exposure |
| to reinsert it when the patient kicked her arm, | | | | prophylaxis (PEP) needs to be started as soon as |
| pushing the needle into her hand. The nurse who | | | | possible - ideally within 1 hour. This reduces risk of |
| sustained the needle stick injury tested negative for | | | | transmission by 80%. It may be appropriate to give |
| HIV that day, but she tested HIV positive several | | | | the first dose of PEP pending a fuller assessment |
| months later. This is not the only case. Everyday | | | | after the HIV status of the 'donor' is known. Where |
| healthcare workers are exposed to dangerous and | | | | the donor is unknown, epidemiological likelihood of |
| deadly blood-borne pathogens and are at risk of | | | | HIV in the source needs to be considered, although in |
| occupational acquisitions of blood-borne illnesses. | | | | most cases PEP will not be justified.) |
| Occupational exposure to blood-borne pathogens | | | | -Your next step is to advise the patient about the |
| among healthcare workers include percutaneous | | | | precautions to take until final testing confirms lack of |
| exposure i.e. exposure to needles and other sharp | | | | disease transmission. Counseling should be offered |
| objects, and mucocutaneous exposure i.e. contact | | | | during this worrying period. Finally, in the unfortunate |
| with intact or nonintact skin, the contact with | | | | event of disease transmission occurring, the patient |
| mucous membranes. In the healthcare settings, | | | | may call on you for evidence in support of their claim |
| percutaneous injuries are the most common form of | | | | that transmission was related to the exposure injury. |
| occupational exposures and most likely to result in | | | | Your documentation and the patient's negative |
| infection. Needle stick injuries account for upto 80 per | | | | baseline test results provide this evidence. |
| cent of accidental exposure to blood-borne | | | | Is Prevention possible? |
| pathogens. It is one of the greatest risks faced by | | | | According to the CDC, up to 86% of needlestick |
| the front line healthcare workers in the light of HIV/ | | | | injuries can be prevented by using safer needlestick |
| AIDS pandemic and Hepatitis B and C. Yet, these | | | | devices. Advances in engineering controls have made |
| exposures have often been considered as part of | | | | it possible to eliminate sharps from many uses-such |
| the job and neglected. | | | | as IV piggybacks-and to blunt or retract the needle |
| You may be among the thousands of health care | | | | so it's no longer a danger. Placing sharps containers |
| workers who annually receive a needlestick | | | | within reach and at eye level in every patient room |
| contaminated with HIV. According to a recent report, | | | | also reduces the risk of injury. You can be active on |
| more than one million needlestick injuries to health | | | | several levels in order to help prevent needlestick |
| care workers occur every year. Anecdotal | | | | injuries. Review needlestick injury data in your facility |
| information considers that this exposure figure is | | | | and ask the following questions: |
| under reported. The use of intravenous cannulae is | | | | - In what areas have needlestick injuries increased, |
| generally regarded as representing the highest risk of | | | | and where has there been a decrease? |
| transmission of blood-borne disease to health care | | | | - Have nurses and other health care workers been |
| workers. Hypodermic needles are commonly used in | | | | reporting injuries? |
| medical, veterinary and laboratory work and | | | | - What happens at your workplace in the event of a |
| needlestick injuries are a known risk for people who | | | | needlestick incident? |
| work in these areas. Carelessly or maliciously | | | | - Can you receive support, including immediate |
| discarded needles can present a risk to people who | | | | evaluation for postexposure prophylaxis? |
| clean or service such areas. Although an unusual | | | | - What is being done to reduce the injury rate? |
| event, hypodermic needles may also be found in | | | | General preventive measures: |
| areas frequented by the general public. Hypodermic | | | | - Wash hands before and after contact with each |
| needles are hollow needles designed to penetrate the | | | | patient, and before putting on and after removing |
| body and either introduce or remove liquids. Thus, as | | | | gloves. |
| well as causing a puncture wound, needlestick injuries | | | | - Change gloves between patients. |
| can introduce into the body harmful materials or | | | | - Cover existing wounds, skin lesions and all breaks in |
| micro organisms from the skin, from contaminants on | | | | exposed skin with waterproof dressings, wear gloves |
| the outside of the needle and from the needle bore | | | | if hands are extensively affected. |
| (and syringe if attached).The risk of suffering further | | | | - Wear gloves where contact with blood can be |
| injury or an infection from a needlestick injury | | | | anticipated. |
| depends to what use the needle was put prior to | | | | - Avoid sharps usage where possible, and where |
| the injury: clean and sterile needles present a low risk; | | | | sharps usage is essential, exercise particular care in |
| if needles have been used to transfer chemicals or | | | | handling and disposal. |
| microorganisms then the risk will depend upon the | | | | - Avoid wearing open footwear in situations where |
| properties of the chemical or characteristics of the | | | | blood may be spilt, or where sharp instruments or |
| microorganism; if needles are contaminated with | | | | needles are handled. |
| human blood or other body fluids then they may be | | | | - Clear up spillage of blood promptly and disinfect |
| a source of blood borne viruses (BBV); needles | | | | surfaces. |
| contaminated with animal body fluids can be a source | | | | - Pre-employment occupational health assessment |
| of zoonoses and needles contaminated with soil may | | | | should identify those with damaged skin e.g. fissured |
| be a source of tetanus. Needlestick injuries can also | | | | hand eczema, who may be at higher risk of |
| cause mental trauma as the injured person may have | | | | occupationally acquired infection, and ensure that |
| to cope with the fear that they have been infected. | | | | advice is given about minimizing any occupational |
| The use of safety devices, such as guarded needles, | | | | health risk to which they may be exposed. |
| resheathable needles, bluntable vacuum systems, and | | | | - Wear gloves when cleaning equipment prior to |
| blunt suture needles, could reduce the risk of injury. | | | | sterilization or disinfection, when handling chemical |
| The effectiveness of each varies considerably; | | | | disinfectant and when cleaning up spillages. |
| however, the use of blunted suture needles showed | | | | - Follow safe procedures for disposal of |
| a significant reduction in the number of glove | | | | contaminated waste. |
| punctures compared with cutting needles. Staples and | | | | Specific measures: |
| glue are also safer methods of wound closure | | | | - This will obviously depend on the procedure being |
| because there is no exposure to suture needles and | | | | undertaken, but may include: |
| should be encouraged when appropriate. Relatively | | | | - Use of new, single-use disposable injection |
| new intravenous systems are available such as | | | | equipment for all injections is highly recommended. |
| safety cannulae and needleless IV systems, and | | | | Sterilisable injection should only be considered if single |
| these can significantly reduce the risk of needlestick | | | | use equipment is not available and if the sterility can |
| injuries. | | | | be documented with Time, Steam and Temperature |
| What are the Fact Sheet on Needle Stick Injury? | | | | indicators. |
| -Health care workers (HCWs) suffer between | | | | - Discard contaminated sharps immediately and |
| 600,000 and one million injuries from conventional | | | | without recapping in puncture and liquid proof |
| needles and sharps annually. These exposures can | | | | containers that are closed, sealed and destroyed |
| lead to hepatitis B, hepatitis C and Human | | | | before completely full. |
| Immunodeficiency Virus (HIV), the virus that causes | | | | - Document the quality of the sterilization for all |
| AIDS. | | | | medical equipment used for percutaneous procedures. |
| -At least 1,000 HCWs are estimated to contract | | | | - Wash hands with soap and water before and after |
| serious infections annually from needlestick and | | | | procedures; use of protective barriers such as |
| sharps injuries. | | | | gloves, gowns aprons, masks, goggles for direct |
| -Registered nurses working at the bedside sustain an | | | | contact with blood and other body fluids. |
| overwhelming majority of these exposures. | | | | - Disinfect instruments and other contaminated |
| -Needlestick injuries are preventable. Over 80% of | | | | equipment. |
| needlestick injuries could be prevented with the use | | | | - Handle properly soiled linen. (Soiled linen should be |
| of safer needle devices. | | | | handled as little as possible. Gloves and leak proof |
| -In 1992, the Food and Drug Administration issued an | | | | bags should be used if necessary. Cleaning should |
| alert to all health care facilities to utilize needleless IV | | | | occur outside patient areas, using detergent and hot |
| systems wherever possible. This alert is merely a | | | | water) |
| recommendation, not a mandate. Therefore, health | | | | Can we reduce the risk? |
| care facilities are under no legal obligation to comply. | | | | Risks to the healthcare workers of the future are |
| -The first safe needle designs were patented in the | | | | rising because of increasing rates of viral infection in |
| 1970s and the FDA has approved over 250 devices | | | | patients. This is particularly relevant to medical and |
| for marketing as safety devices. | | | | nursing students undertaking electives abroad in areas |
| -More than 20 other infections can be transmitted | | | | where procedures for infection control are |
| through needlesticks, including: tuberculosis, syphilis, | | | | sometimes poor; standards of supervision vary; and |
| malaria and herpes. | | | | students often take part in invasive procedures that |
| What is your role when someone presents to your | | | | may place them at increased risk of bloodborne |
| practice after a needlestick injury or any other | | | | infections. Also unfortunately many students and |
| hazardous exposure to blood or other body | | | | even senior staff are indifferent to these injuries and |
| substance? | | | | often don't report them. Often injuries are not |
| -Your initial efforts need to be directed at reducing | | | | reported because the exposure is not deemed |
| the risk of the exposed patient contracting an | | | | "significant." Students are also often embarrassed by |
| infectious illness. Immediate first aid is required if the | | | | these injuries and may be afraid to implicate another |
| event is recent: | | | | healthcare worker, particularly a faculty member who |
| -Contaminated needlestick, sharps injury, bite or | | | | is responsible for their evaluation. Failure to report an |
| scratch - encourage bleeding, wash with soap and | | | | injury, however, can delay essential medical |
| running water. | | | | evaluation and treatment and leave doubt as to |
| -Blood or body fluid in eyes or mouth - irrigate with | | | | where the infection was transmitted. |
| copious quantities of cold water | | | | In summary, needlestick injuries among HCWs in |
| -Blood or body fluid on broken skin - encourage | | | | training are common and often not reported to an |
| bleeding if possible, and wash with soap under running | | | | employee health service. |
| water (but without scrubbing) | | | | These findings underscore the need for ongoing |
| -Report incident and discuss with local public health | | | | attention to strategies to reduce such injuries in a |
| consultant immediately. | | | | systematic way and to improve reporting systems |
| -The next step is to collect blood from the patient | | | | so that appropriate medical care can be delivered. |
| for baseline testing after counseling and obtaining | | | | With considerable lifetime risks for health care |
| informed consent. | | | | workers contracting serious bloodborne diseases and |
| -A thorough assessment of the exposure is then | | | | the greatest risk in a long career occurring at the |
| required to determine the risk of disease | | | | start, there is a greater need for sharps safety and |
| transmission. Reassure the patient that only a small | | | | training in medical schools and affiliated hospitals. The |
| proportion of blood exposures result in infection. It is | | | | introduction of devices designed to reduce needle |
| impossible to precisely determine this risk, but factors | | | | exposure during suturing and phlebotomy would help |
| that have been identified as being associated with | | | | protect students, particularly in units where safety |
| HIV transmission include: | | | | methods are not well enforced. Clearly, there is much |
| -terminal AIDS illness in the source person, | | | | room for improvement in protecting the healthcare |
| -deep injury, visible blood on device, procedure | | | | workers from needle stick injury, which can be |
| involving needle placed directly into a vein or artery. | | | | accomplished through a comprehensive programme |
| The following estimates of disease transmission rates | | | | that addresses institutional, behavioral, and |
| from percutaneous injuries have been made for | | | | device-related factors that contribute to the |
| occupational exposures and these may be used as a | | | | occurrence of these injuries. Apart from this, greater |
| guide in explaining the risk to the patient. | | | | collaborative efforts by all stakeholders are needed |
| HIV 0.2-0.5% | | | | to prevent such injuries and the tragic consequences |
| Hepatitis B - HBeAg absent 2% | | | | that can result. |
| - HBeAg present (prompt administration of HBIG and | | | | |