The Staff Member with a Needle Stick Injury

Created on Sat, 09/05/2015 - 02:40
Last updated on Tue, 12/05/2017 - 17:17

Previous Chapter:

The clumsy staff member has appeared in Question 25 from the first paper of 2007, Question 5 from the first paper of 2015 and Question 18 from the second paper of 2017. These questions have all been essentially identical: in each, a registrar is putting in a central line, they stab themselves, and you are asked to manage the situation. In the most recent questions the patient was also identified as an intravenous drug user, to add a layer of social cynicism. 

As far as reading about this for the exam, LITFL have an excellent short and sweet article on the approach to staff needlestick injuriesDavid 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".

An answer to this question, as a summary of the abovementioned references:

  • Abort procedure / delegate / ensure patient is safe
  • Express blood, wash wound
  • Report incident
  • Risk assessment (big needle, large volume)
  • Test patient and staff member serology with written consent
  • Discuss with ID, arrange follow-up (6 weeks and 6 months)
  • Safe sex for 6 months

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
  • Take over the procedure and finish it yourself
  • 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 Hep 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