While having a comprehensive exposure control plan, investing in safety sharps, and training surgeons and staff in their use are the most important strategies for sharps injury prevention, they can't guarantee that a sharps injury won't occur in your facility. If one does occur, it's vital to have an effective plan in place for treating the injury, determining if the employee has been exposed to bloodborne pathogens, and taking the necessary follow-up steps.
To understand the critical steps for managing a sharps injury, we called on Boris Lushniak, MD, MPH, Medical Officer with the Division of Surveillance, Hazard Evaluations, and Field Studies at the Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH). Dr. Lushniak conducts the annual bloodborne pathogen training at NIOSH and was a member of a team that developed the "Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis", which can also be found at www.cdc.gov. Here are the six steps he recommends for handling a sharps injury which may result in an occupational exposure to bloodborne pathogens.
1. Treat the wound and seek medical care.
Immediately wash the affected area with soap and water; if mucous membranes have been exposed, flush them with water as well. Cleaning a wound with antiseptic is good basic first aid, but there is no evidence to prove that washing the site with antiseptics reduces the risk of bloodborne pathogen transmission. Dr. Lushniak warns against squeezing the wound to draw out blood, washing the site with harsh chemicals such as bleach, or injecting antiseptics or disinfectants into the wound. Seek medical care for further treatment, and, if indicated, blood testing, counseling, and postexposure prophylaxis (PEP).
2. File an occupational exposure report.
The Needlestick Safety Act, signed into law in November 2000, requires facilities to have a system in place to document sharps injuries. Dr. Lushniak recommends that every health-care facility where health-care personnel might experience exposures to bloodborne pathogens have a written policy for the management of exposures, establish exposure-reporting systems, and have personnel who can manage an exposure readily. An occupational exposure report needs to be completed as soon as possible after the injury; this report records the details of the incident. This form should include:
- the date and time of exposure;
- details about the procedure being performed, including where and how the exposure occurred;
- what type and brand of device caused the injury (this information will help you to evaluate the safety of the devices your facility is currently using);
- how the exposed person was handling the device when the exposure occurred;
- the type and amount of fluid or material contained in or on the device (if any);
- the severity of the exposure, including the depth of the injury and whether fluid was injected;
- the condition of skin or mucous membranes that may have been exposed (i.e. whether the skin was chapped or broken);
- details about the patient (or potential source), including whether he or she has HBV, HCV, or HIV; if the source is HIV-infected, record what stage of the disease is he or she in;
- the source's history of antiretroviral therapy, viral load, and antiretroviral resistance information, if known;
- as much information as you know about the exposed person, such as if he or she had been vaccinated for hepatitis B or had been previously been infected with hepatitis B, or whether the person has hepatitis C or AIDS (more on this later).
Once the report is complete, you can evaluate the exposure to determine the chances of transmission of HBV, HCV, and HIV based on the type of body substance involved and the route and severity of the exposure. Blood or fluid containing blood are a higher risk for transmission of bloodborne pathogens than other potentially infectious fluid, such as semen, vaginal secretions, and cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids or tissue, although they all can be infectious. Different kinds of sharps require different responses. Exposure to a blood-filled hollow needle or a visibly bloody device would pose a higher risk of infection than exposure to a needle that was most likely used for giving an injection.
3. Evaluate the exposure source.
If the source's infection status is unknown, the source should be informed of the incident and the source's blood should be tested for HBV, HCV, and HIV infection. In most states, physicians can not perform these tests unless the patient has given signed consent. Obtain informed consent to perform the blood tests and perform the tests as soon as possible.
For HIV testing, an FDA-approved rapid HIV-antibody test kit should be considered for use in this situation. Other HIV tests, such as enzyme-linked immunoabsorbent assay (ELISA), Western Blot and immunofluorescent antibody tests, can take at least 24?48 hours. Here's what you should know about these HIV tests:
- The Rapid HIV-antibody test is the fastest HIV test available, yielding results in 10 to 30 minutes. It is considered to be just as accurate as the ELISA test, but it is more expensive. Like the ELISA test, it is just a preliminary screening for HIV; a positive result must be confirmed with a more specific test. The Rapid test that is currently available requires only a blood sample and centrifuge equipment.
- ELISA (enzyme-linked immunoabsorbent assay) is commonly used as the initial screening test because it is relatively easy and inexpensive to perform. It has been know to give false positives, so a second, more specific test such as an HIV Western Blot is required to confirm all positive results.
- Western Blot: The Western Blot is a confirmatory test, and it is only performed if the Rapid test or the ELISA test is positive. The Western Blot can be positive, negative, or indeterminate. In the rare cases in which an indeterminate result occurs, the person will need to be retested, usually about one month later. False positive results are extremely rare with the Western Blot.
- Immunofluorescent antibody test can be used instead of the WB to confirm Rapid or ELISA results. Because it is faster than a WB, it is becoming increasingly popular.
If the source person is HIV negative and has no clinical evidence of AIDS or symptoms of HIV infection, no further testing of the exposed person for HIV infection is indicated.
If the exposure source is unknown or will not agree to testing, consider the situation as well as the type of exposure to evaluate the overall risk. A significant factor to consider is the prevalence of HBV, HCV, or HIV in the community population. For example, an exposure that occurs in a geographic area where injection drug use is prevalent or involves a needle discarded in a drug-treatment facility would be considered to have a higher risk for transmission than an exposure that occurs in a nursing home.
Testing of needles or other sharps implicated in an exposure, regardless of whether the source is known or unknown, is not recommended, and it is also illegal in some states. The reliability of the findings is unknown, and testing the device might be hazardous to person conducting the test. The device should be placed in a proper container and disposed of according to state laws.
If the source is positive for HIV, collect all available information about this person's stage of infection, CD4 T-cell count, results of viral load testing, and current and previous antiretroviral therapy to help choose an appropriate Post Exposure Prophylaxis (PEP) regimen for the exposed person. If this information is not immediately available, begin the PEP without it. You can make changes in the PEP regimen after PEP has been started, as more information about the exposed person or the source becomes available.
4. Get baseline blood tests (if indicated).
If the source patient is not infected with a bloodborne pathogen, baseline testing or further follow-up of the exposed person is not necessary. If the worker has been exposed to the blood or body fluids of a source patient with HIV, HCV, or HBV, blood samples should be obtained from the exposed worker and appropriate baseline blood tests should be carried out. In addition, in sources whose infection status remains unknown or for unknown sources, the decision regarding blood tests for the exposed worker should be based on medical diagnoses, clinical symptoms, and history of risk behaviors of the source and the likelihood of bloodborne pathogen infection among patients in the exposure setting.
5. Treat for exposure posing a risk of infection transmission.
Exposure to HBV: All healthcare workers should receive a minimum of three vaccinations for HBV. If a person has had the three vaccinations and a positive follow up check for antibodies, he or she will have full immunity to the virus. Health care professionals who have contact with patients or blood and are at ongoing risk for percutaneous injuries should be tested for antibodies one to two months after completion of the three-dose vaccination series. A person can also have full immunity if he or she has previously contracted HBV.
If the worker has immunity, no treatment is necessary. If the exposed worker has only partial immunity (this would occur if the worker was not able to complete all three vaccinations, or if the vaccinations were not effective in developing antibodies) or has no immunity and is exposed to a source with hepatitis B, he or she should be given 0.06 ml/kg intramuscular hepatitis B immunoglobulin (HBIG) within 48 hours of the injury, and, if possible, within 24 hours. You do not need to keep the HBIG at your facility as long as you can get it within 24 hours after the exposure.
Exposure to HCV: There is no effective drug prophylaxis for HCV. However if the infection is diagnosed early, there are some experimental treatment possibilities. If exposed to a source with hepatitis C, the exposed person should be followed closely for 12 months and a serological examination for HCV should be done after three, six, and nine to 12 months. In case of a positive HCV test, the exposed person should be referred for medical management to a specialist knowledgeable in this area.
Exposure to HIV: The chance of an HIV infection can be reduced considerably if the affected worker starts taking antiretroviral drugs (PEP) within hours after the incident. However, PEP is potentially toxic and can have extensive side effects. After a review of the circumstances of the incident and blood test results (if available), a managing physician (this can be someone designated by the facility or the worker's personal physician) should determine whether or not to prescribe PEP and which regimen to prescribe. If in doubt, it is best to contact an AIDS expert and/or the National Clinicians' Postexposure Prophylaxis Hotline [PEPline] at 1-888-448-4911. If the doctor advises the PEP regimen, he should inform the worker of all the advantages and potential side effects of PEP, the necessary follow up testing for HIV infection after one, three, and six months, and how to avoid potentially transmitting the virus to sexual partners. PEP treatments should start as soon as possible, ideally within hours, after the incident. PEP should be discontinued if the final HIV test results of the source patient prove negative. PEP regimens should be administered for four weeks, if tolerated.
6. Follow-up testing and counseling.
The aftermath of a sharps injury can be prolonged and require testing for exposed persons at six weeks, three months, six months, and up to a year later. The emotional effect of an exposure also can be substantial and counseling should be provided. Information on counseling services can be accessed through the National AIDS Hotline at (800) 342-2437.
With the advance of safer techniques and devices, there may come a time when sharps injury protocols are rarely used. But the need for having a clear plan in place will never go away.