Sharps Container

Image: "Sharps Container" photographed by William Rafti of the William Rafti Institute is licensed under CC BY-SA 3.0. Link to the source.

Needlestick Injuries

Introduction | Aetiology and Risk Factors | Clinical Presentation | Diagnosis and Immediate Actions | Management and Treatment | Legal and Ethical Considerations | Prevention | When to Refer | References

Introduction

Needlestick injuries occur when a needle or other sharp object accidentally penetrates the skin. These injuries pose a significant risk of transmission of bloodborne pathogens, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Needlestick injuries are a common occupational hazard in healthcare settings but can also occur in other environments. Immediate and appropriate management is crucial to reduce the risk of infection and provide support to the affected individual.

Aetiology and Risk Factors

Needlestick injuries can result from a variety of situations, particularly in healthcare settings:

  • Inappropriate Handling of Needles: Recapping needles, improper disposal, or handling needles without using safety devices can increase the risk of injury.
  • Accidental Injuries: Needlestick injuries can occur during medical procedures, such as drawing blood, administering injections, or suturing, especially when working quickly or under stress.
  • Improper Disposal: Injuries can occur when needles are disposed of inappropriately or when someone accidentally comes into contact with improperly discarded needles, such as in public areas.
  • Reusing Needles: Reusing needles, particularly in low-resource settings, significantly increases the risk of needlestick injuries and transmission of bloodborne pathogens.
  • Handling Sharp Instruments: Injuries can also occur with other sharp instruments such as scalpels, lancets, or glass ampoules.
  • Fatigue and Inexperience: Healthcare workers who are fatigued, inexperienced, or insufficiently trained are at higher risk of sustaining needlestick injuries.
  • Overcrowded Workspaces: Cluttered or overcrowded work areas can contribute to accidental injuries.

Clinical Presentation

The clinical presentation of a needlestick injury is typically straightforward:

  • Immediate Pain: A sharp pain or pricking sensation at the site of injury.
  • Visible Wound: There may be a small puncture wound, sometimes with slight bleeding.
  • Anxiety and Distress: Psychological impact due to concern about potential infection with bloodborne pathogens.
  • Local Reactions: In some cases, mild redness or swelling may occur at the puncture site.

Diagnosis and Immediate Actions

The diagnosis of a needlestick injury is based on the reported incident. Immediate actions are crucial to minimise the risk of infection:

1. Immediate First Aid

  • Wound Care: Allow the wound to bleed gently; do not squeeze or scrub the injury site.
  • Cleansing: Wash the area thoroughly with soap and running water. Do not use harsh antiseptics or bleach.
  • Covering the Wound: Apply a waterproof plaster or dressing to protect the area.

2. Reporting and Documentation

  • Report the Incident: Inform a supervisor or occupational health department immediately.
  • Documentation: Record details of the incident, including date, time, circumstances, and any information about the source patient or material.

3. Risk Assessment

  • Assess the Exposure: Evaluate the type of device, the amount of blood involved, and the depth of the injury.
  • Source Evaluation: Determine the infection status of the source patient if known, including HIV, HBV, and HCV status.

Management and Treatment

The management of needlestick injuries involves assessing the risk of infection, administering prophylactic treatments if necessary, and providing follow-up care:

1. Post-Exposure Prophylaxis (PEP)

  • HIV PEP: If the source patient is HIV-positive or if there is a high risk of HIV transmission, start HIV post-exposure prophylaxis as soon as possible, ideally within 1 hour and no later than 72 hours after exposure. PEP typically involves a 28-day course of antiretroviral therapy (ART).
  • HBV Prophylaxis:
    • Vaccination: If the exposed individual is unvaccinated or non-immune, administer the hepatitis B vaccine series and consider hepatitis B immunoglobulin (HBIG) if the source is HBsAg-positive.
    • Booster Dose: If the individual's antibody levels are low, a booster dose may be recommended.
  • HCV Management: There is currently no prophylaxis for hepatitis C; however, early identification and treatment of acute HCV infection can improve outcomes. Regular monitoring of HCV RNA and liver function tests is recommended following exposure.
  • Tetanus Prophylaxis: Assess the need for tetanus vaccination based on immunisation history and wound characteristics.

2. Follow-Up and Monitoring

  • Baseline Testing: Perform baseline blood tests for HIV, HBV, and HCV in the exposed individual.
  • Follow-Up Testing: Schedule follow-up tests at 6 weeks, 3 months, and 6 months post-exposure to monitor for seroconversion.
  • Monitoring PEP Side Effects: If HIV PEP is initiated, monitor the individual for medication side effects and adherence to the regimen.
  • Counselling and Support: Provide psychological support and counselling to address anxiety and stress related to the injury and the potential risk of infection.
  • Occupational Health Involvement: Ensure ongoing communication with occupational health services for support and guidance.
  • Confidentiality: Maintain confidentiality regarding the source patient's infection status and the exposed individual's medical information.
  • Consent for Testing: Obtain informed consent from the source patient for testing of bloodborne pathogens, following local regulations and guidelines.
  • Reporting Requirements: Comply with local laws and regulations regarding the reporting of occupational exposures and infections.

Prevention

Preventive measures are crucial in reducing the risk of needlestick injuries in healthcare settings:

  • Use of Safety Devices: Utilise needles with safety features, such as retractable needles or needle guards, to minimise the risk of injury.
  • Proper Disposal: Dispose of needles immediately after use in designated sharps containers. Never recap needles after use.
  • Training and Education: Regularly train healthcare workers on the safe handling of needles and sharps, including the correct disposal methods.
  • Universal Precautions: Follow standard infection control practices, including wearing gloves and other protective equipment when handling needles or other sharp instruments.
  • Workplace Policies: Implement and enforce policies that promote safety and proper procedures for handling sharps.
  • Vaccination Programs: Ensure that all healthcare workers are up-to-date with their hepatitis B vaccination and have documented immunity.
  • Staffing Levels: Maintain adequate staffing to reduce fatigue and overwork, which can contribute to errors and injuries.

When to Refer

Referral to a specialist or occupational health may be necessary in the following situations:

  • High-Risk Exposure: If the needlestick injury involves a high-risk source, such as a known HIV-positive or hepatitis-infected patient, referral to an infectious disease specialist for further management may be necessary.
  • Complex Cases: If there are complications or unusual circumstances, such as exposure to multiple pathogens or drug-resistant strains.
  • Psychological Impact: If the injured person experiences significant anxiety or psychological distress following the injury, referral to counselling or psychological services may be appropriate.
  • Adverse Reactions to PEP: If the individual experiences severe side effects from prophylactic medications, specialist input may be required to adjust the regimen.
  • Seroconversion: If there is evidence of seroconversion to HIV, HBV, or HCV, immediate referral to a specialist for management is essential.

References

  1. British Association of Occupational Health (2024) Guidelines for the Management of Needlestick Injuries. Available at: https://www.bohrf.org.uk (Accessed: 26 August 2024).
  2. National Institute for Health and Care Excellence (2024) Needlestick Injuries: Diagnosis and Management. Available at: https://www.nice.org.uk/guidance/ng110 (Accessed: 26 August 2024).
  3. British National Formulary (2024) Post-Exposure Prophylaxis for Bloodborne Viruses. Available at: https://bnf.nice.org.uk/ (Accessed: 26 August 2024).
 

Check out our YouTube channel

 

Blueprint Page

Explore the comprehensive blueprint for Physician Associates, covering all essential topics and resources.

Book Your Session

Enhance your skills with personalised tutoring sessions tailored for Physician Associates.