By Dr. Rubina Lone
A hospitalized patient with AIDS became agitated and tried to remove the intravenous (IV) catheters in his arm. During the struggle, an IV infusion line was pulled. A nurse at the scene recovered the connector needle at the end of the IV line and was attempting to reinsert it when the patient kicked her arm, pushing the needle into her hand. The nurse who sustained the needle stick injury tested negative for HIV that day, but she tested HIV positive several months later. This is not the only case. Everyday healthcare workers are exposed to dangerous and deadly blood-borne pathogens and are at risk of occupational acquisitions of blood-borne illnesses. Occupational exposure to blood-borne pathogens among healthcare workers include percutaneous exposure i.e. exposure to needles and other sharp objects, and mucocutaneous exposure i.e. contact with intact or nonintact skin, the contact with mucous membranes. In the healthcare settings, percutaneous injuries are the most common form of occupational exposures and most likely to result in infection. Needle stick injuries account for upto 80 per cent of accidental exposure to blood-borne pathogens. It is one of the greatest risks faced by the front line healthcare workers in the light of HIV/ AIDS pandemic and Hepatitis B and C. Yet, these exposures have often been considered as part of the job and neglected.
You may be among the thousands of health care workers who annually receive a needlestick contaminated with HIV. According to a recent report, more than one million needlestick injuries to health care workers occur every year. Anecdotal information considers that this exposure figure is under reported. The use of intravenous cannulae is generally regarded as representing the highest risk of transmission of blood-borne disease to health care workers. Hypodermic needles are commonly used in medical, veterinary and laboratory work and needlestick injuries are a known risk for people who work in these areas. Carelessly or maliciously discarded needles can present a risk to people who clean or service such areas. Although an unusual event, hypodermic needles may also be found in areas frequented by the general public. Hypodermic needles are hollow needles designed to penetrate the body and either introduce or remove liquids. Thus, as well as causing a puncture wound, needlestick injuries can introduce into the body harmful materials or micro organisms from the skin, from contaminants on the outside of the needle and from the needle bore (and syringe if attached).The risk of suffering further injury or an infection from a needlestick injury depends to what use the needle was put prior to the injury: clean and sterile needles present a low risk; if needles have been used to transfer chemicals or microorganisms then the risk will depend upon the properties of the chemical or characteristics of the microorganism; if needles are contaminated with human blood or other body fluids then they may be a source of blood borne viruses (BBV); needles contaminated with animal body fluids can be a source of zoonoses and needles contaminated with soil may be a source of tetanus. Needlestick injuries can also cause mental trauma as the injured person may have to cope with the fear that they have been infected.
The use of safety devices, such as guarded needles, resheathable needles, bluntable vacuum systems, and blunt suture needles, could reduce the risk of injury. The effectiveness of each varies considerably; however, the use of blunted suture needles showed a significant reduction in the number of glove punctures compared with cutting needles. Staples and glue are also safer methods of wound closure because there is no exposure to suture needles and should be encouraged when appropriate. Relatively new intravenous systems are available such as safety cannulae and needleless IV systems, and these can significantly reduce the risk of needlestick injuries.
What are the Fact Sheet on Needle Stick Injury?
- Health care workers (HCWs) suffer between 600,000 and one million injuries from conventional needles and sharps annually. These exposures can lead to hepatitis B, hepatitis C and Human Immunodeficiency Virus (HIV), the virus that causes AIDS
- At least 1,000 HCWs are estimated to contract serious infections annually from needlestick and sharps injuries.
- Registered nurses working at the bedside sustain an overwhelming majority of these exposures.
- Needlestick injuries are preventable. Over 80% of needlestick injuries could be prevented with the use of safer needle devices.
- In 1992, the Food and Drug Administration issued an alert to all health care facilities to utilize needleless IV systems wherever possible. This alert is merely a recommendation, not a mandate. Therefore, health care facilities are under no legal obligation to comply.
- The first safe needle designs were patented in the 1970s and the FDA has approved over 250 devices for marketing as safety devices.
- More than 20 other infections can be transmitted through needlesticks, including: tuberculosis, syphilis, malaria and herpes.
What is your role when someone presents to your practice after a needlestick injury or any other hazardous exposure to blood or other body substance?
- Your initial efforts need to be directed at reducing the risk of the exposed patient contracting an infectious illness. Immediate first aid is required if the event is recent:
- Contaminated needlestick, sharps injury, bite or scratch – encourage bleeding, wash with soap and running water.
- Blood or body fluid in eyes or mouth – irrigate with copious quantities of cold water
- Blood or body fluid on broken skin – encourage bleeding if possible, and wash with soap under running water (but without scrubbing)
- Report incident and discuss with local public health consultant immediately.
- The next step is to collect blood from the patient for baseline testing after counseling and obtaining informed consent.
- A thorough assessment of the exposure is then required to determine the risk of disease transmission. Reassure the patient that only a small proportion of blood exposures result in infection. It is impossible to precisely determine this risk, but factors that have been identified as being associated with HIV transmission include:
- terminal AIDS illness in the source person,
- deep injury, visible blood on device, procedure involving needle placed directly into a vein or artery.
The following estimates of disease transmission rates from percutaneous injuries have been made for occupational exposures and these may be used as a guide in explaining the risk to the patient.
Hepatitis B – HBeAg absent 2%
- HBeAg present (prompt administration of HBIG and hepatitis B vaccination can prevent transmission in most cases) 40%
Hepatitis C 3-10%
(If this urgent preliminary risk assessment considers there is a significant risk of HIV, post exposure prophylaxis (PEP) needs to be started as soon as possible – ideally within 1 hour. This reduces risk of transmission by 80%. It may be appropriate to give the first dose of PEP pending a fuller assessment after the HIV status of the ‘donor’ is known. Where the donor is unknown, epidemiological likelihood of HIV in the source needs to be considered, although in most cases PEP will not be justified.)
-Your next step is to advise the patient about the precautions to take until final testing confirms lack of disease transmission. Counseling should be offered during this worrying period. Finally, in the unfortunate event of disease transmission occurring, the patient may call on you for evidence in support of their claim that transmission was related to the exposure injury. Your documentation and the patient’s negative baseline test results provide this evidence.
Is Prevention possible?
According to the CDC, up to 86% of needlestick injuries can be prevented by using safer needlestick devices. Advances in engineering controls have made it possible to eliminate sharps from many uses-such as IV piggybacks-and to blunt or retract the needle so it’s no longer a danger. Placing sharps containers within reach and at eye level in every patient room also reduces the risk of injury. You can be active on several levels in order to help prevent needlestick injuries. Review needlestick injury data in your facility and ask the following questions:
- In what areas have needlestick injuries increased, and where has there been a decrease?
- Have nurses and other health care workers been reporting injuries?
- What happens at your workplace in the event of a needlestick incident?
- Can you receive support, including immediate evaluation for postexposure prophylaxis?
- What is being done to reduce the injury rate?
General preventive measures:
- Wash hands before and after contact with each patient, and before putting on and after removing gloves.
- Change gloves between patients.
- Cover existing wounds, skin lesions and all breaks in exposed skin with waterproof dressings, wear gloves if hands are extensively affected.
- Wear gloves where contact with blood can be anticipated.
- Avoid sharps usage where possible, and where sharps usage is essential, exercise particular care in handling and disposal.
- Avoid wearing open footwear in situations where blood may be spilt, or where sharp instruments or needles are handled.
- Clear up spillage of blood promptly and disinfect surfaces.
- Pre-employment occupational health assessment should identify those with damaged skin e.g. fissured hand eczema, who may be at higher risk of occupationally acquired infection, and ensure that advice is given about minimizing any occupational health risk to which they may be exposed.
- Wear gloves when cleaning equipment prior to sterilization or disinfection, when handling chemical disinfectant and when cleaning up spillages.
- Follow safe procedures for disposal of contaminated waste.
- This will obviously depend on the procedure being undertaken, but may include:
- Use of new, single-use disposable injection equipment for all injections is highly recommended. Sterilisable injection should only be considered if single use equipment is not available and if the sterility can be documented with Time, Steam and Temperature indicators.
- Discard contaminated sharps immediately and without recapping in puncture and liquid proof containers that are closed, sealed and destroyed before completely full.
- Document the quality of the sterilization for all medical equipment used for percutaneous procedures.
- Wash hands with soap and water before and after procedures; use of protective barriers such as gloves, gowns aprons, masks, goggles for direct contact with blood and other body fluids.
- Disinfect instruments and other contaminated equipment.
- Handle properly soiled linen. (Soiled linen should be handled as little as possible. Gloves and leak proof bags should be used if necessary. Cleaning should occur outside patient areas, using detergent and hot water)
Can we reduce the risk?
Risks to the healthcare workers of the future are rising because of increasing rates of viral infection in patients. This is particularly relevant to medical and nursing students undertaking electives abroad in areas where procedures for infection control are sometimes poor; standards of supervision vary; and students often take part in invasive procedures that may place them at increased risk of bloodborne infections. Also unfortunately many students and even senior staff are indifferent to these injuries and often don’t report them. Often injuries are not reported because the exposure is not deemed “significant.” Students are also often embarrassed by these injuries and may be afraid to implicate another healthcare worker, particularly a faculty member who is responsible for their evaluation. Failure to report an injury, however, can delay essential medical evaluation and treatment and leave doubt as to where the infection was transmitted.
In summary, needlestick injuries among HCWs in training are common and often not reported to an employee health service.
These findings underscore the need for ongoing attention to strategies to reduce such injuries in a systematic way and to improve reporting systems so that appropriate medical care can be delivered. With considerable lifetime risks for health care workers contracting serious bloodborne diseases and the greatest risk in a long career occurring at the start, there is a greater need for sharps safety and training in medical schools and affiliated hospitals. The introduction of devices designed to reduce needle exposure during suturing and phlebotomy would help protect students, particularly in units where safety methods are not well enforced. Clearly, there is much room for improvement in protecting the healthcare workers from needle stick injury, which can be accomplished through a comprehensive programme that addresses institutional, behavioral, and device-related factors that contribute to the occurrence of these injuries. Apart from this, greater collaborative efforts by all stakeholders are needed to prevent such injuries and the tragic consequences that can result.