needle stick and sharp injuries..protocols
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this is a series of lectures on microbiology, useful for undergraduate and post graduate medical and paramedical students
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needle stick and sharp injuries..protocols
- 1. NEEDLE STICKS AND SHARPS INJURIES FACTS , LEGAL CONCERNS, AND CARE Dr. Ashish Jawarkar Dr. Ashish V. Jawarkar 1
- 2. THE PROBLEM ā¢ ~385,000 sharps injuries annually among hospitalbased healthcare personnel (>1,000 injuries/day) ā¢ Many more in other healthcare settings (e.g., emergency services, home care, nursing homes) ā¢ Increased risk for blood borne virus transmission ā¢ Costly to personnel and healthcare system 2
- 4. Exposures which place health personnel at risk of blood borne infection ā ā¢ A percutaneous injury e.g. Needle stick injury (NSI) or cut with a sharp instrument ā¢ Contact with the mucous membrane of eye or mouth ā¢ Contact with non-intact skin (abraded skin or with dermatitis) ā¢ Contact with intact skin when the duration of contact is prolonged with blood or other potential infected body fluids 4 4
- 5. WHO IS AT RISK ? ā¢ Nursing Staff ā¢ Emergency Care Providers ā¢ Labor & delivery room personnel ā¢ Surgeons and operation theater staff ā¢ Lab Technicians ā¢ Dentists ā¢ Health cleaning/ mortuary staff / Waste Handlers 5
- 6. WHO GETS INJURED? Occupational Groups of Healthcare Personnel Exposed to Blood/Body Fluids, NaSH June 1995ā December 2003 (n=23,197) Housekeeping/ Maintenance 3% Student 4% Technician 15% Clerical / Admin 1% Dental 1% Other 5% Nurse 43% Physician 28% 6
- 7. HOW DO INJURIES OCCUR WITH HOLLOW-BORE NEEDLES? Circumstances Associated with Hollow-Bore Needle Injuries NaSH June 1995 āDecember 2003 (n=10,239) Access IV Line 5% Transfer/Process Specimens 5% Handle/Pass Equipment 6% Recap Needle 6% Collision W/Worker or Sharp 10% Other 5% During Sharps Disposal 13% Improper Disposal 9% During Clean Up 9% Disposal Related: 35% In Transit to Disposal 4% Manipulate Needle in Patient 28% 7
- 8. WORK PRACTICES WHICH INCREASE THE RISK OF NEEDLE STICK INJURY ā¢ Recapping needles (Most important) ā¢ Performing activities involving needles and sharps in a hurry ā¢ Handling and passing needles or sharp after use ā¢ Failing to dispose of used needles properly in punctureresistant sharps containers ā¢ Poor healthcare waste management practices ā¢ Ignoring Universal Work Precautions 8 8
- 12. WHAT KINDS OF DEVICES USUALLY CAUSE SHARPS INJURIES? ā¢ Hypodermic needles ā¢ Blood collection needles ā¢ Suture needles ā¢ Needles used in IV delivery systems ā¢ Scalpels 12
- 13. WHAT INFECTIONS CAN BE CAUSED BY SHARP INJURIES? Sharps injuries can expose workers to a number of blood borne pathogens that can cause serious or fatal infections. The pathogens that pose the most serious health risks are ā¢ Hepatitis B virus (HBV) ā¢ Hepatitis C virus (HCV) ā¢ Human immunodeficiency virus (HIV) 13
- 14. RISKS OF SEROCONVERSION DUE TO SHARPS INJURY FROM A KNOWN POSITIVE SOURCE Virus HBV HCV HIV Risk (Range) 6-30%* ~ 2% 0.3% (*Risk for HBV applies if not HB vaccinated) 14
- 15. WHAT IS THE RISK FOR HIV ALONE? ā¢ Percutaneous 0.3% ā¢ Mucous membrane 0.1% ā¢ Non-intact skin <0.1% 15
- 16. HOW DO SHARPS INJURIES HAPPEN? ā¢ Who gets injured? ā¢ Where do they happen? ā¢ When do injuries occur? ā¢ What devices are involved? ā¢ How can they be prevented? 16
- 17. WORK PRACTICES WHICH INCREASE THE RISK OF NEEDLE STICK INJURY ā¢ Recapping needles (Most important) ā¢ Performing activities involving needles and sharps in a hurry ā¢ Handling and passing needles or sharp after use ā¢ Failing to dispose of used needles properly in punctureresistant sharps containers ā¢ Poor healthcare waste management practices ā¢ Ignoring Universal Work Precautions 17 17
- 18. RISK FACTORS FOR HIV SEROCONVERSION IN HCWS Risk Factor Adjusted Odds Ratio* Deep Injury 15.0 Visible Blood on Device 6.2 Terminal Illness in Source Patient 5.6 Needle in Source Vein/Artery 4.3 *All Risk Factors were significant (P < 0.01) From: NEJM 1997;337:1485-90. 18
- 19. PROTECTING YOURSELF ā¦ ā¢ Report all needle stick and sharps-related injuries promptly to ensure that you receive appropriate follow-up care. ā¢ Tell your employer about any sharps hazards you observe. ā¢ Participate in training related to infection prevention. ā¢ Get a Hepatitis B vaccination. 19
- 20. A. CATEGORIES OF EXPOSURE Category Definition and Example Mild exposure Mucous membrane/non-intact skin with small volumes e.g. a superficial wound with a low caliber needle, contact with eyes or mucous membrane, subcutaneous injections with a low caliber needle. Moderate exposure Mucous membrane/non-intact skin with large volumes or percutaneous superficial exposure with solid needle e.g. a cut or needle stick injury penetrating gloves. Severe exposure percutaneous exposure with large volumes e.g. an accident with a high caliber needle visibly contaminated with blood, a deep wound, an accident with material that has been previously been used intravenously or intra-arterially 20
- 21. POST EXPOSURE PROPHYLAXIS (PEP) It refers to the comprehensive management to minimize the risk of infection following potential exposure to blood borne pathogens (HIV, HBV, HCV ).It includes ā ļ¶First Aid ļ¶Risk Assessment ļ¶Counseling ļ¶PEP drugs (4Weeks) depending upon risk assessment ļ¶Relevant Lab Investigation on informed consent of the source and exposed person ļ¶Follow up and support 21
- 22. MANAGEMENT OF EXPOSED PERSON 1st step: Management of exposed site - First Aid ļ¶ Skin: Do not squeeze the wound to bleed it, do not put the pricked finger in mouth. Wash with soap &water, donāt scrub, no antiseptics or skin washes (bleach, chlorine, alcohol, betadine). ļ¶ Eye: wash with water/ normal saline/ donāt remove contact lens immediately if wearing, no soap or disinfectant. ļ¶ Mouth: spit fluid immediately, repeatedly rinse the mouth with water and spit / no soap/ disinfectant. 22
- 23. 2ND STEP: ESTABLISH ELIGIBILITY FOR PEP Evaluation must be made rapidly so as to start treatment as soon as possible-ideally within 2hours but certainly within 72 hours of exposure. However all exposed cases donāt require prophylactic treatment. Factors determining the requirement of PEPļ¶ Nature/Severity of exposure and risk of transmission ļ¶ HIV status of the source of exposure ļ¶ HIV status of the exposed individual 23
- 24. 3 rd step : administer PEP Status of index case HBV Follow up Positive HAART (zido+lami) within 1-2 days, continue for 28 days Check HIV antibody levls at 6 weeks, 3 months and 6 months Negative HIV PEP Counselling only Do [psotove Counselling Not required HBIG prophylaxis Negative HCV Counselling Not required Positive No prophylaxis available Check anti HCV at 3 and 6 month Treatment if disease occurs
- 25. QUICK FACT: HBV VACCINATION IS RECOMMENDED FOR ALL HEALTHCARE WORKERS (UNLESS THEY ARE IMMUNE BECAUSE OF PREVIOUS EXPOSURE). HBV VACCINE HAS PROVEN TO BE HIGHLY EFFECTIVE IN PREVENTING INFECTION IN WORKERS EXPOSED TO HBV. HOWEVER, NO VACCINE EXISTS TO PREVENT HCV OR HIV INFECTION. 25
- 26. SUPREME COURT DIRECTIVE TO ENSURE PEP DRUGS IN ALL GOVERNMENT HOSPITALS IN INDIA 1. Universal Work Precautions (UWP) and PEP guidelines should be followed by HCPs to prevent occupational transmission of HIV, Hepatitis B and hepatitis C. 2. This will develop confidence in HCPs while working with patients some of whom might be infected with HIV/HBV/HCV. 3. PEP drugs should be available in all Govt Hospitals to enable protection of HCPs dealing with potentially infected patients to make sure that no patients suffering from HIV be denied treatment/surgery/ procedures etc 4. Availability of UWP and PEP can minimize the stigma and discrimination against PLHIVs in Health Care facilities. 5. Above regulations to be practiced in Private hospitals and Establishments 26
- 27. RESPONSIBILITY OF HEAD OF THE INSTITUTION ā¢ To ensure that the hospital has a written protocol to handle exposure and the same is displayed at prominent locations within the hospital for information of staff. ā¢ Sensitization of Doctors, Nurses, Paramedics & waste handlers ā¢ To ensure that Universal precautions are followed. ā¢ Availability of Personal protective equipment. ā¢ Dissemination of procedure to be followed in case of accidental exposure to Blood and Body fluids ā¢ Availability of Rapid HIV test kits. ā¢ Availability of other preventive measures including vaccinations. 27
- 28. AVAILABILITY OF PEP AT HEALTHCARE FACILITY It is recommended that PEP drugs be kept available round-theclock in any of the three locations - Emergency room, Labor room and ICU. Drug Stock at the Healthcare facility PEP kit comprises of 2 drug regimen: Zidovudine(AZT) 300mg + Lamivudine (3TC) 150 mg as a fixed dose combination 28
- 29. WHAT ARE STRATEGIES TO ELIMINATE SHARPS INJURIES? ā¢ Eliminate or reduce the use of needles and other sharps ā¢ Use devices with safety features to isolate sharps ā¢ Use safer practices to minimize risk for remaining hazards 29
- 30. DO NOT FORGET HEPATITIS B VACCINATION AND UNIVERSAL PRECAUTIONS ā¦ā¦.. 30
- 31. THANK YOU
Editor's Notes
- CDC estimates that approximately 385,000 injuries with contaminated needles and other sharps devices occur annually among hospital-based healthcare personnel. Thatās over 1,000 injuries a day! Many more occur in other healthcare settings, such as emergency services, home care, and nursing homes. Injuries with contaminated needles and other sharp devices are an important concern because they pose the risk of transmission of blood borne viruses, and they are costly to personnel and to the healthcare system.
- Data from NaSH show that nurses sustain the highest percentage of percutaneous injuries. However other patient-care providers (such as physicians and specialized technicians), laboratory staff and support personnel (such as housekeeping and maintenance staff) are also at risk. [ NOTE to presenter: Depending on audience, the collective data can be used to elicit discussion on issues that contribute to this distribution: devices, training, staffing, disposal problems, etc. Ask audience members how they think injuries to housekeeping and maintenance staff occur. If the targeted group is primarily laboratory staff, you may want to include other bloodborne pathogens important to lab workers (See Workbook, OverviewāRisks and Prevention of Sharps Injuries in Healthcare Personnel, Table 1).]
- You may also know that there are many possible mechanisms for injuries. In NaSH hospitals, 26% of hollow-bore needle injuries occur while the needle is being inserted, manipulated or withdrawn from the patient, and the patient moves or jars the device. Some needle injuries occur when accessing intravenous lines, such as giving an IV flush. With needle-free IV systems now available, these injuries should not be occurring. The same applies to recapping injuries. Why do you think people recap needles when it is so dangerous? [NOTE to presenter: Encourage discussion of this subject if time permits] You can see that many injuries in NaSH hospitals occur after use on the patient, such as during clean up, in transit to disposal, and during disposal. An additional 9% of injuries are due to improper disposal or result from leaving a sharp device on a table, stuck in a mattress, on the floor, or some other location. Another 10% of injuries occur when healthcare personnel collide with each other during a procedure. [NOTE to presenter: Encourage discussion of the different injury mechanisms, including some not mentioned here.]
- The three bloodborne viruses of primary concern for transmission from sharps injuries are hepatitis B (HBV) and C (HCV) viruses, and human immunodeficiency virus (or HIV), the virus that is associated with AIDS. The average risk of transmission after an occupational percutaneous exposure varies by the type of bloodborne virus. As you can see, one is at a higher risk for being infected with HBV following a sharps injury than for HCV or HIV. Fortunately, for hepatitis B virus, a vaccine and immune globulin are available that can protect healthcare personnel from becoming infected. This is why this vaccine is heavily promoted for healthcare personnel. The average risk for HCV transmission after a percutaneous exposure to HCV-infected blood is approximately 1 in 50 exposures. The average risk for HIV infection after a percutaneous exposure to HIV-infected blood is about 1 in 300 exposures.
- For all bloodborne viruses, the percutaneous route of exposure (for example, a needlestick injury) carries the greatest risk for transmission of infection. The average risk for HIV transmission after a mucous membrane exposure (for example, blood splashed in the eye) is estimated to be 0.09%, or about 1 in 1,000. Although episodes of HIV transmission after skin exposures have been documented, the average risk for transmission has not been precisely quantified but is estimated to be less than the risk for mucous membrane exposures.
- To prevent sharps injuries, we first need to understand how they occur. Who gets injured? Where do they happen? What devices are involved? When and how do injuries occur? And, how can they be prevented? [Note to Presenter: The following slides may be augmented or replaced using local data. Use the questions above as a guide.]
- The prevention of sharps injuries is a priority at __________ [your facility name]. In the hierarchy of priorities to prevent sharps injuries, the first priority is to eliminate and reduce the use of needles and other sharps wherever possible. For example, use alternate routes for medication delivery and vaccination when available and safe for patient care. The next priority is to isolate the hazards and thereby protect otherwise exposed sharps, through the use of engineering controls. The emphasis on engineering controls has led to the development of many types of devices with engineered sharps injury prevention features. When these strategies are not available or do not provide total protection, the focus shifts to work-practice controls and the use of personal protective equipment. In the operating room, for example, instruments, rather than fingers, can be used to grasp needles, retract tissues, and load and unload scalpels; verbal announcements should be given when passing sharps; and hand-to-hand passage of sharps instruments can be avoided by using a basin or neutral zone.