Question 5

Created on Mon, 10/12/2015 - 01:09
Last updated on Tue, 12/05/2017 - 17:17
Pass rate: 74%
Highest mark: 7.6

Other SAQs in this paper

Other SAQs on this topic

You are supervising a registrar who suffers a needle stick injury during the insertion of a central line in a patient with a history of intravenous drug use.

Outline your approach to this problem.

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College Answer

Immediate Response:

  • Stop the procedure
  • Ensure patient is safe
  • Takeover / delegate patient management as required

Further response:

  • Wash the registrar’s wound immediately with soap and water
  • Express any blood from the wound
  • Initiate injury-reporting system used in the workplace
  • Patient may need to be consented and then tested for HIV, hepatitis B, Hepatitis C
  • Refer registrar to designated treatment facility: Emergency Department / Infectious Disease Physician / 
Immunology as per hospital protocol
  • With consent, registrar to be tested immediately and confidentially for HIV, hepatitis B and C
  • Document the exposure in detail for your own record and for the employer
  • If the patient is HIV positive, post exposure prophylaxis needs to be started within two hours of the 
exposure.
  • For possible Hepatitis C exposure, no treatment is recommended but advice must be obtained 
from Infectious Disease Specialist
  • If the source patient tests positive for HIV, hepatitis B, hepatitis C, get post-exposure prophylaxis in 
accordance with CDC guidelines and as per recommendations from Infectious Disease Specialist or other 
expert.
  • Registrar to have follow up with post exposure testing
  • Advise re: taking precautions (including safe sex) to prevent exposing others until follow up testing is 
complete.
  • If exposed to blood borne pathogen, he/she should not donate blood for six months until cleared

Counselling:

  • While definitive testing is essential, counsel the registrar that the risk factors for infection are: deep injury, visible blood on devices, and needle placement in a vein or artery, lower risk with solid suture needle.

Related to procedure:

  • Review of registrar’s technique, equipment used, unit policy for procedural training, assessment of competency, etc.

Additional comments:
Candidates who failed did not give enough detail, e.g. “take bloods” without specifying for which investigations.

Discussion

This question is near-identical to Question 25 from the first paper of 2007. LITFL have an approach to staff needlestick injuries. David Tripp's notes for the fellowship exam are also a source of a nice point-form algorithm. A list of definitive sources for this information would include the 2017 NSW Health Policy Directive: HIV, Hepatitis B and Hepatitis C - Management of Health CareWorkers Potentially Exposed, as well as the Westmead Children's Hospital procedure "Needlestick and Blood Exposure Injuries: Health Care Worker". A NM

Immediate management:

  • Abort the procedure
  • Ensure the patient is safe:
    • Take over the procedure and finish it yourself; or
    • Delegate the task to a competent staff member
  • Ask the registrar to express blood from the wound
  • Wash the punctured area with soap and water
  • Report the incident

Risk assessment:

  • Is the patient known to have Hpe B, C, or HIV?

The following are associated with an increased risk of transmission:

  • Hollow needle
  • Large needle diameter
  • Needle was previously in an artery or vein
  • Absence of gloves 
  • Depth of wound 
  • Into artery or vein
  • Exposed to a large volume of blood
  • High blood titre of HIV, Hep B or C

Management

  • Document the Hep B immunisation status of the staff member
  • Perform antibody tests of both the staff member and the patient, with written consent
  • If the source is known to be Hep B C or HIV positive,
    • Solicit advice from infectious diseases authorities
    • Arrange appropriate vaccinations, antiretroviral prophylaxis and councelling
    • Arrange follow-up for the patient and staff member
  • Possible management strategies:
    • For Hep B, IV immunoglobulin may be appropriate
    • For Hep C, there is nothing.
    • For HIV, postexposure antiretroviral therapy is helpful (and needs to be commenced within 2 hours!)
  • Safe sex for 6 months
  • Follow-up testing: 6 weeks and 6 months 
  • Review unit guidelines and compliance
  • Some health districts include mandatory central notification of all health care worker exposure events
  • Offer emotional support to the staff member, and get help from infectious diseases authorities to aid post-exposure councelling

References