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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


The person who has used the sharp is responsible for its immediate safe disposal following use, preferably at the point of use.


Needles should not be recapped, bent or broken by hand, removed from disposable syringes or otherwise manipulated by hand.


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.


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.


High-risk procedures All invasive procedures Blood taking Suturing Giving injections Inappropriate disposal of sharps.


High-risk procedures

Recapping needles (Most important) Transferring a body fluid between

containers. Poor healthcare waste management

practices


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


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.


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.


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


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.


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


Low-titer exposures are asymptomatic patients with high CD4 counts

These are HIV status code 1.

CDC guidelines


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


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


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

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