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Needle Stick Exposure Protocol

last modified on: Mon, 04/01/2024 - 09:21

Note: last updated before 2020

See updated contemporary link: Evaluation Following Exposure to Human Blood/Body Fluids | University of Iowa Hospitals & Clinics (uihc.org)

General Considerations

  1. Definitions:
    1. Blood-borne Pathogens: Pathogenic microorganisms that can be present in human blood and can cause disease in humans. 
    2. Other Potentially Infectious Materials (OPIM): Body fluids with the potential for transmission of HBV, HCV or HIV. These include semen, synovial fluid, pleural fluid, pericardial fluid, vaginal secretions, CSF, amniotic fluid, saliva, any body fluid contaminated visibly with blood, or unfixed tissues.
    3. Contaminated sharps: An item or object that can penetrate the skin with the reasonably anticipated presence of potentially infectious material, including but not limited to: needles, scalpels, broken glass, broken capillary tubes and exposed dental wires.
    4. Exposure: A percutaneous injury with a contaminated sharp, or contact with mucous membranes or non-intact skin (chapped, abraded, or inflamed) with blood, tissue or OPIM. This also includes human bites that break the skin.
  2. Epidemiology:
    1. OSHA estimates 5.6 million workers are at risk for occupational exposure to blood-borne pathogens
    2. NIOSH estimates 600,000 to 800,000 percutaneous needle stick injuries occur annually in hospitals in the United States.
    3. Worldwide in 2000 it was estimated that percutaneous injuries led to 16,000 cases of hepatitis C, 66,000 cases of hepatitis B and 1000 cases of HIV
  3. Risk
    1. HIV:
      1. Approximately 0.3% risk of seroconversion after needle stick injury. This risk varies with type of needle (hollow vs solid), type of injury (superficial vs intravenous etc), contamination (visible blood present on needle) and viral load of patient.
      2. Approximately 0.09% risk of seroconversion after exposure of mucous membrane or open skin.
      3. Taken from: Henderson DK et al, Risk for occupational transmission of human immunodeficiency virus type 1 (HIV-1) associated with clinical exposures.  Ann intern Med. 1990;133(10):740
    2. Hepatitis C Virus:
      1. Approximately 1.8% from percutaneous injury
      2. Weber, Rutala et al. Management of a Healthcare worker exposed to hepatitis. UpToDate.com, copyright 2012
    3. HBV:
      1. HBV is the most virulent, and can be transmitted not only through percutaneous and mucosal exposure but also via human bites
      2. 62% of exposed workers eventually show seroconversion and 22 to 31% show clinical Hepatitis B infection
      3. B.G. Werner and G.F. Grady, Accidental hepatitis-B-surface-antigen-positive inoculations: use of e antigen to estimate infectivity. Ann Intern Med 97 (1982), pp. 367--369
  4. Risk by Occupation:
    1. Increased risk at academic vs non-academic institutions
    2. Risk by Occupation (broken down by percent of reported exposures)
      1. Nurses: 34%
      2. Residents/Fellows: 18%
      3. Attending physicians: 14%
      4. Surgery attendants: 6%
      5. Phlebotomists: 5%
    3. Long work hours and sleep deprivation increase the risk of exposure
      1. Fisman DN, Harris AD, Rubin M, et al. Fatigue increases the risk of injury from sharp devices in medical trainees: results from a case-crossover study. Infect Control Hosp Epidemiol 2007; 28:10.

Protocol

  1. Prevention
    1. Standard precautions:
      1. Hepatitis B Vaccine Series: provided free for UIHC employees, may be refused by waiver.
      2. Protective personal barriers (safety goggles, gloves, gowns), hand hygiene
      3. Needles should not be: bent, sheared or recapped by hand.
      4. Proper use of sharp boxes
    2. Surgical precautions:
      1. Neutral Zone: eliminate hand-to-hand passing of sharps, instead place them on a common area
      2. Instrumentation while suturing: Use instruments to pick up needle while suturing
      3. Use instruments to remove scalpel blades
      4. Proper restraints/precautions when working on patients predicted to move during procedure
    3. First Aid
      1. Clean wounds thoroughly with soap and water for 10 minutes
      2. Flush mucous membranes with clean water for 10 minutes
      3. Flush eyes with clean water or sterile eye irrigant for 15 minutes. If no eye wash is on site, report to the ETC as soon as possible for eye irrigation.
      4. Record patient name/date of birth/MRN/location
      5. Follow the post exposure protocol specific to your institution

University of Iowa Protocol

  1.  Report exposure immediately and bring patient identifying information:
    1. * Employees/Staff/Residents:
      1. If the exposure occurs between 7:30 AM and 4:30 PM, Monday - Friday, go to the University Employee Health Clinic (UEHC at Level 1 Boyd Tower, 356-3631)
      2. At and other time, go to the Emergency Treatment Center (ETC). Call UEHC on the next working day to schedule an appointment
        1. The ER will draw blood from the employee, and start the process for obtaining blood from the source patient for testing.
          1. If blood testing of the source patient can be started by another method (eg. blood sample already exists, such as intraop labs), employee could consider having their baseline blood drawn at UEHC the next working day while there to complete documentation and obtain test results of source patient, but then a follow up UEHC visit will be needed to receive employees own test results.
    2. Medical students: To Student Health Services between 8:00 AM and 5:00 PM, Monday – Friday, OR to the Emergency Treatment Center (ETC) at any other time.
      1. Visiting medical students: should follow the Employee/Staff/resident protocol
  2. Complete the provided forms of documentation:
    1. B-1a2 “Needle Stick/Hepatitis Exposure Report”, completed by the personnel in the University Employee Health Clinic/Student Health Services clinic to document the route of exposure and the circumstances under which the incident occurred.  This will be filed in the subject’s medical record.
    2. UEHC green form stating product brand and model of the device if one is implicated.  This will be provided at UEHC or Student Health Services
    3. If applicable, State of IA Employers Work Injury Report, Employers First Report of Injury (Worker’s Comp Form)
    4. File a Patient Safety Network (PSN)/UIHC Incident Report
  3. Initial evaluation (UEHC, Student Health Services, or ETC)
    1. Identify the source and obtain baseline tests
      1. Required tests: Hepatitis B Surface Antigen, Hepatitis C Antibody, HIV Antibody
      2. Forms
        1. A-1a Laboratory order for post-exposure evaluation of source patient.
        2. G-2d16 Consent to HIV-related testing. If the patient cannot be consented (eg. in the OR) and a blood sample is available, sign the box under "Significant Exposure"
          1. Consent should be obtained by another health care professional (not the exposed worker) if patient can give consent and a new blood sample is needed
      3. Specimen: PST (light green top tube)
    2. Obtain baseline tests on exposed healthcare professional
      1. Required tests: Hepatitis B Surface Antibody, Hepatitis C Antibody, HIV Antibody
      2. Forms: G-2d18 Consent for release of HIV-related information for payment of services of medical record review (Mark "Do not" authorize UIHC to release information about HIV testing to insurer (BC/BS for housestaff)
    3. Determine the exposure type and HIV infection status/viral load of the source
  4. Post Exposure Prophylaxis should be started within 1-2 hours if you are at high risk, but may be efficacious if started any time within 72 hours.

Initial Treatment of Exposed Healthcare Professional

  1. Hepatitis B Virus
    1. Health care professionals that have been vaccinated and have a history of an adequate antibody response require no further treatment of exposure to HBV
    2. If they are not vaccinated, or is unsure of his/her antibody response, UIHC protocol should be followed:
      1. UIHC Policy and Procedure Manual, Infection Prevention and Control: IC-05.001, Table
  2. Hepatitis C Virus
    1. Prophylaxis: None recommende
  3. HIV
    1. Determine Post Exposure Prophylaxis recommendation:
      1. UIHC Policy and Procedure Manual, Infection Prevention and Control: IC-05.001, Table 1
    2. For consultation contact Infectious Disease
      1. M-F, 8:00 AM – 5:00 PM Team II (pager 131-3232)
      2. Other times, contact Team I (pager 131-3230)
      3. Or PEPLINE (888)448-4911 between 6 AM and 9 PM Pacific Standard Time or http://nccc.ucsf.edu/about_nccc/pepline/
      4. If PEP is indicated:
        1. Explain risks and potential benefits of PEP
        2. Obtain baseline lab work before starting PEP treatment
        3. Give subject PEP packet made by pharmacy – daily dosing ETC and UEHC – as soon after the exposure as possible (preferably 1-2 hours, but up to 72 hours)
        4. Provide subject with enough PEP packets until they can be evaluated by a staff member at UEHC (up to 4 days)

Resources

University of Iowa Policies (Internal Link)

Evaluation Following Exposure to Human Blood/Body Fluids | University of Iowa Hospitals & Clinics (uihc.org)

Hepatitis C FAQs for Healthcare Professionals

http://www.cdc.gov/hepatitis/HCV/HCVfaq.htm

Hepatitis B Information for Healthcare Professionals

http://www.cdc.gov/hepatitis/HBV/

CDC: HIV Post Exposure Guidelines

HIV/AIDS Treatment Guidelines | Clinicalinfo.HIV.gov