Needle stick Injury

from “Management of occupational exposure to blood and body fluids — Infection prevention and control – QLD Health” – https://www.health.qld.gov.au/__data/assets/pdf_file/0016/151162/qh-gdl-321-8.pdf

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Immediate Care of the Exposed Person

First Aid

Eye Exposures:

• Irrigate eyes thoroughly with clean water or normal saline for at least 30 seconds while keeping the eyes open.
• If contact lenses are in place, remove them before irrigating.

Mucous Membrane Exposures (e.g., Mouth):

• Spit out any blood or body fluids immediately.
• Rinse the mouth thoroughly with water.

Intact Skin Exposures:

• Wash the affected area with soap and water to remove any blood or body fluids.

Skin Wounds/Non-Intact Skin Exposures:

• Do not squeeze the wound to express blood.
• Wash the area with soap and water to remove any contaminants.
• Ensure appropriate clinical care is provided for the wound.

Clothing Contamination:

• Remove contaminated clothing.
• Shower if necessary to decontaminate.

Absence of Water:

• If water is unavailable, use a non-water cleanser or antiseptic for washing intact skin or skin cuts/punctures.
• While topical antiseptics like chlorhexidine have not proven to lower transmission risks, their application is not contraindicated.

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Relief from Duty

• The exposed person must inform a supervisor or manager immediately after exposure to facilitate prompt assessment and follow-up.
• The exposed person should be relieved from duty as soon as possible to undergo an immediate risk assessment.

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Risk Assessment

The following must be assessed and documented promptly by a trained professional following occupational exposure:

Details of the Exposure:

• Date and time of exposure.
• Type of exposure, including site and specific blood or body fluid involved.
• First aid measures applied.
• Nature and extent of any injury.
• Characteristics of the item causing injury (e.g., needle gauge).

Details of the Body Fluids:

• Volume and type of blood/body substances the healthcare worker was exposed to.

Source Person Information:

• BBV (blood-borne virus) status.
• Relevant demographic factors that may increase infection risk with a BBV.

Details of the Exposed Person:

• BBV status and vaccination history.
• Current pregnancy status, risk, and lactation considerations.
• Relevant medical history.

Risk Assessment Considerations:

• Assess the type and amount of infectious material.
• Consider the degree of exposure, using any relevant risk guidance (e.g., Table 2 in the protocol).
• Referral to specialist practitioners should occur as necessary.
• For human bites, evaluate the possibility of BBV exposure for both the bitten individual and the person inflicting the bite.

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Exposure Classification

(1) Definite exposure to blood or body fluids associated with a risk of transmission of BBV

Injury Type and Examples:

• Injection of a large volume of blood/body fluid (>1mL)
• Parenteral exposure to laboratory specimens containing a high titre of virus
• Any skin-penetrating injury, e.g.:
  • With a needle contaminated with blood or body fluid
  • Which causes bleeding and is produced by an instrument that is visibly contaminated with blood or body fluid
  • Mucous membrane or conjunctival contact with blood or body fluid
  • Human bite or scratch with exposure to blood or other body fluids infectious for BBV
  • Non-intact skin directly exposed to blood or body fluid
• In laboratory settings, any direct inoculation with HIV tissue or material, or material likely to contain HIV, HBV, or HCV not included above

Recommended Actions:

• Immediately identify the source individual (if known) and undertake baseline testing
• Undertake baseline screening of the exposed person
• Provide follow-up as per section 4.5 Post-exposure management of the exposed person
• Seek advice from the relevant specialist practitioners as required

(2) Possible exposure to blood or body fluids associated with a risk of transmission of BBV

Injury Type and Examples:

• Intradermal (‘superficial’) injury with a needle considered not to be contaminated with blood or body fluid
• A superficial wound not associated with visible bleeding produced by an instrument used on a patient but not considered to be contaminated with blood or body fluid
• Non-intact skin directly exposed to a body fluid not associated with a risk of transmission of BBV with no trace of blood (e.g., urine, faeces, nasal secretions, saliva, sputum, sweat, tears, or vomitus)
• Human bite with no blood exposure (e.g., saliva with no visible blood, bite without broken skin)

Recommended Actions:

• Undertake baseline screening of the exposed person, at a minimum
• Assess risk using further information about the source person and the exposed person
• Source testing and further follow-up may be indicated based on risk assessment
• Assess for risk of tetanus exposure (refer to the Australian Immunisation Handbook)
• Incident reporting documentation and the possibility of counselling (e.g., by employee assistance services) may still be required
• Provide follow-up as per section 4.5 Post-exposure management of the exposed person

(3) Not a Body Fluid Exposure

Injury Type and Examples:

• Intact skin visibly exposed to blood or body fluid
• Needlestick with a non-contaminated needle or sharp (sterile/not used on a patient)
• Skin not breached

Recommended Actions:

• No further follow-up, although documentation through incident reporting and the possibility of further counselling may still be required
• Clean needlestick injuries should be documented to allow facilities to identify all causes of needlestick injuries to facilitate appropriate risk management

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Assessment of the HIV, HBV, and HCV Status of the Source

Importance of Source Status Assessment

• Assessing the HIV, HBV, and HCV status of the source individual is critical in determining the risk to the exposed person for all cases of definite exposure.
• If the source’s status is unknown at the time of exposure, undertake baseline testing to determine their infectious status.
  • Regional and Rural Areas: Consultation with the laboratory is recommended to ensure timely availability of results.

Baseline Testing for the Source Patient:

• HIV Testing: HIV antigen/antibody (HIV Ag/Ab) testing
• HBV Testing: HBV surface antigen (HBsAg) testing
• HCV Testing: HCV antibody (anti-HCV)
  • If the source patient is known to be HIV positive or a positive HIV result is found during screening, HIV viral load testing should be performed.
  • If the source patient is known to be HCV positive or a positive anti-HCV result is detected, confirm the current HCV infection with PCR or HCV antigen testing.

Consent, Communication, and Confidentiality:

• Obtain informed consent for testing, conduct necessary tests, and communicate the results to the source.
• Follow guidelines for informed consent and conveying BBV test results, available through the ASHM Testing Portal.
• Maintain strict confidentiality concerning the source individual, the exposure incident, and the identity of the exposed person.
• If the source is found to be HIV, HBV, or HCV positive and is not under the care of a medical specialist, they should be referred to an appropriate specialist.

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Handling Unknown Sources

Assessment Considerations:

• If the source of exposure is unknown or cannot be tested, assess the likelihood of HBV, HCV, or HIV transmission using available information about:
  • The setting and context of the exposure.
  • The type of exposure, which may influence the estimated risk level.
  • The prevalence of HBV, HCV, or HIV in the population group relevant to the possible source patient, if known.

Post-Exposure Prophylaxis (PEP) Considerations:

• The decision to use PEP should be made on a case-by-case basis and in consultation with an expert when the source is unknown.
• Example Scenario for Consideration of HIV PEP:
  • Instances involving deep trauma or injection of blood from an unknown source may warrant HIV PEP consideration.

Follow-Up Testing for the Exposed Person:

• When the source is unknown or unable to be tested, the exposed individual should undergo follow-up testing for HBV, HCV, and HIV.

Additional Recommendations:

• Refer to the “Post-exposure prophylaxis after non-occupational and occupational exposure to HIV: Australian national guidelines (third edition)” for comprehensive guidance on PEP use.
• Testing of needles or sharp instruments implicated in an exposure is not recommended, regardless of whether the source is known or unknown.

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Baseline Testing of the Exposed Person

Baseline Testing Requirements:

• HIV Testing: HIV antigen/antibody (HIV Ag/Ab)
• HBV Testing: HBV surface antibody (anti-HBs)*
• HCV Testing: Anti-HCV

Informed Consent and Confidentiality:

• Discuss tests, obtain informed consent, and convey the test results to the exposed person.
• Guidance on obtaining informed consent and conveying test results can be referred to through the ASHM Testing Portal.
• Maintain strict confidentiality regarding both the exposed person and the circumstances of the exposure or injury.

Serum Storage:

• Serum samples should be stored for at least 12 months to allow for parallel testing if required in the future.

Special Note on HBV Testing:

• If the exposed person shows evidence of current or previous immunity to HBV (anti-HBs ≥10 IU/L documented following a complete HBV vaccination course or from past cleared infection in an immunocompetent individual), baseline testing of anti-HBs is not required.
• Do not delay baseline testing if historical results are not immediately available.

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Post-Exposure Management of the Exposed Person

General Post-Exposure Management Steps:

• Management depends on the results of the risk assessment and baseline testing.
• Develop and document a post-exposure management plan based on all available information, discuss it with the exposed person, and obtain informed consent for any interventions.
• Refer to relevant tables and resources, such as “Quick reference summary of actions” and “Exposed person laboratory assessment,” for detailed decision-making guidance.

Key Recommendations for All BBV Exposures:

• Inform the exposed person about the importance, timing, and method of follow-up.
• Patient care responsibilities of an exposed healthcare worker should not be modified based solely on BBV exposure, unless they are confirmed positive for HIV, HBV, or HCV.
• If the exposed individual tests positive for HIV, HBV, or HCV, they should be referred to a specialist for appropriate care.
• Advise the exposed individual on reducing secondary transmission risks, including:
  • No donation of blood, organs, tissues, breast milk, or sperm until the final test results are obtained.
  • Safer sex practices (e.g., barrier contraception) and avoiding pregnancy until final testing.
  • Seeking expert advice on pregnancy and breastfeeding, if applicable.
• Educate the exposed person on symptoms of relevant BBVs and encourage prompt medical attention if symptoms develop:
  • HIV seroconversion symptoms: Fever, sore throat, night sweats, lymphadenopathy, muscle aches, rash.
  • HBV symptoms: Jaundice, malaise, abdominal pain, dark urine, clay-colored stool.
  • HCV symptoms: Fever, fatigue, nausea, vomiting, abdominal pain, dark urine, pale stool, joint pain, jaundice.
• Follow local procedures for incident reporting and occupational exposure surveillance, which may involve using systems like RiskMan and meeting Workplace Health and Safety notification requirements.

Special Considerations for HIV Post-Exposure Management:

1. HIV Post-Exposure Prophylaxis (PEP):
   • Decision-making around HIV PEP should follow the “Post-Exposure Prophylaxis after Non-Occupational and Occupational exposure to HIV: Australian National Guidelines (Third edition).”
   • PEP should ideally start within 24 hours (and no later than 72 hours) after exposure.
   • Starter packs for PEP (3-day supply) are available in many emergency departments, and follow-up with a specialist within 72 hours is required to complete a 28-day course.
2. Laboratory Assessment:
   • Conduct baseline, 4-6 weeks, and 12-week testing for HIV Ag/Ab.
   • Additional tests (e.g., renal function and pregnancy tests) may be indicated depending on PEP and clinical assessment.
   • If HIV seroconversion occurs, manage according to Queensland Health guidelines for healthcare workers living with a BBV.
3. Transmission Risk Estimation (from Table 4):
   • Intact skin exposure: Negligible risk.
   • Human bite: Negligible risk.
   • Community needle stick (discarded needle): Negligible risk.
   • Mucous membrane/non-intact skin exposure: 1:1000 risk.
   • Occupational needle stick injury: 1:440 risk.

Special Considerations for HBV Post-Exposure Management:

1. Immunity Status Assessment:
   • If the exposed person is immune (anti-HBs ≥10 IU/L documented), no HBV post-exposure management is needed.
2. HBV Post-Exposure Prophylaxis (PEP):
   • Indicated if the exposed person is not immune and the source is HBV positive, unknown, or unable to be tested rapidly.
   • Follow the Australian Immunisation Handbook recommendations for vaccine and immunoglobulin administration within 72 hours for percutaneous, ocular, or mucosal exposures.

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HBV Laboratory Assessment

Baseline and Follow-Up Testing:

• Baseline Testing: Test for HBV surface antibody (anti-HBs) at the initial evaluation.
• 12 Weeks and 6 Months Testing: Test for HBV surface antigen (HBsAg).
• Post-Vaccination Immunity Assessment:
  • For exposed persons who received the HBV vaccine post-exposure, assess for post-vaccination immunity. Anti-HBs should be re-tested:
    • 1 month after the final dose of the HBV vaccine or
    • 6 months after receiving hepatitis B immunoglobulin (HBIG), whichever is later.

Special Considerations for Healthcare Workers:

• Healthcare workers with a completed primary HBV vaccination series but who remain seronegative for anti-HBs (<10 IU/L) should have their HBV vaccination managed according to “The Australian Immunisation Handbook” recommendations. This may include:
  • Investigating for HBV carriage.
  • Administering further vaccine doses.
  • Advising about the need for hepatitis B immunoglobulin following future parenteral exposures.

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HCV-Specific Post-Exposure Management

General Management:

• There is no PEP available for HCV exposure.
• Inform the exposed person about available highly effective HCV treatment options in the event of infection, with a goal of viral eradication (cure).

Laboratory Assessment for HCV:

• Baseline Testing: Test for anti-HCV.
• 6-12 Weeks Testing: Test for HCV PCR (recommended between 6 and 12 weeks). An early result may reassure the exposed person, especially for high-risk exposures.
  • Repeat Testing: If HCV PCR testing is done earlier than 12 weeks, it must be repeated at 12 weeks alongside anti-HCV testing.
• 12 Weeks Testing: Retest for anti-HCV.

Summary of Laboratory Assessment Recommendations for the Exposed Person

• Follow-up testing should be conducted for BBVs to which the exposed individual has been exposed.
• No follow-up testing is needed for BBVs for which the source patient tested negative at baseline.
• For exposure from an unknown or untestable source, follow-up testing for HCV and HIV is required. Complete HBV follow-up only if the exposed person is not immune.

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Management of Exposure Incidents for Patients

General Requirements:

• The same protocols applied to occupational exposures should be followed when a patient is the exposed individual.

Immediate Actions:

1. Immediate Care:
   • Follow the processes described in the “Immediate care of the exposed person” section.
2. Disclosure of Exposure:
   • Disclose the incident involving exposure to blood or body fluids to the patient and/or their guardian as soon as possible.
   • In Queensland Health facilities, staff should adhere to local open disclosure procedures.

Communication and Documentation:

1. Notifying the Treating Medical Team:
   • Inform the patient’s treating medical team about the exposure as soon as possible.
2. Risk Assessment:
   • Conduct a risk assessment, considering the nature of the incident and applying occupational exposure criteria where applicable.
3. Medical Record Documentation:
   • Document the incident in the patient’s confidential medical record.
4. Incident Reporting:
   • Report the incident through the relevant patient incident management system.
   • For Queensland Health facilities, follow procedures outlined in the “Best Practice Guide to Clinical Incident Management.”

Confidentiality:

• Maintain confidentiality for both the exposed patient and the source patient or healthcare worker involved.

Treatment and Follow-Up:

• Treat the exposed patient according to protocols outlined in the relevant sections of the guideline, ensuring follow-up care is provided.
• Coordination of Follow-Up Testing:
  • Staff at the facility should coordinate follow-up testing, unless the patient prefers referral back to their general practitioner.
• Exposure to Healthcare Worker with BBV:
  • If the source of exposure is a healthcare worker with a BBV, refer to the “Australian National Guidelines for the Management of Healthcare Workers Living with Blood-Borne Viruses” and guidelines for healthcare workers performing exposure-prone procedures at risk of exposure to BBVs.
• Prophylaxis:
  • If prophylaxis is indicated, follow the processes described in the relevant sections of the guideline for post-exposure management.

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Healthcare workers (HCWs)

https://www.health.gov.au/sites/default/files/documents/2020/03/cdna-national-guidelines-healthcare-workers-living-with-blood-borne-viruses-perform-exposure-prone-procedures-at-risk-of-exposure-to-blood-borne-viruses-australian-national-guidelines-healthcare-workers-living-with-blood-b.pdf

https://www.health.gov.au/resources/collections/cdna-national-guidelines-for-healthcare-workers-on-managing-bloodborne-viruses

Reporting Requirements:

To Employer:

• Healthcare workers (HCWs) must report needlestick injuries to their employer or designated workplace health and safety representative.
  • Rationale: This ensures appropriate medical follow-up, facilitates risk assessment, and supports workplace safety measures.
    Reference: Queensland Health.

To Health Authorities:

• In some jurisdictions (e.g., New South Wales), certain BBV exposures may require notification to health authorities.
  • Example: If a worker requires post-exposure prophylaxis (PEP) for HIV or hepatitis B immunoglobulin, it must be reported to the relevant authority (e.g., SafeWork NSW).
    Reference: SafeWork NSW.

Disclosure Obligations:

To Patients:

• HCWs diagnosed with a BBV generally do not need to disclose their status to patients as long as:
  • They adhere to standard infection control practices.
  • If performing exposure-prone procedures (EPPs), they meet criteria specified in national guidelines, such as maintaining a low viral load and adhering to recommended treatment protocols.
    Reference: CDNA Guidelines.

To Employers:

• HCWs performing EPPs must know their BBV status and undergo testing at least every three years.
  • If diagnosed with a BBV, HCWs must cease performing EPPs until they meet criteria to safely resume, as per national guidelines.
    Reference: Health.gov.au.

To Partners:

• No specific laws mandate HCWs to disclose their BBV status to sexual partners.
  • However, individuals are legally required to take reasonable precautions to prevent transmission.
    Reference: SA Health.

Key Points:

Definition of Exposure-Prone Procedures (EPPs):

• EPPs are procedures where there is a risk of HCW injury resulting in exposure of the patient’s open tissues to the HCW’s blood.
  • This includes situations where the HCW’s hands may come into contact with:
    • Sharp instruments
    • Needle tips
    • Sharp tissues (e.g., spicules of bone) within a patient’s open body cavity, wound, or confined anatomical space where the hands/fingertips may not always be visible.
      Reference: CDNA Guidelines.

Confidentiality:

• HCWs’ BBV status is confidential. Disclosure to employers is only required if it affects their ability to perform specific duties, such as EPPs.

Infection Control Compliance:

• Adherence to standard infection control measures is essential to minimize BBV transmission risks in healthcare settings.

Legal Obligations:

• Individuals are required to take reasonable precautions to prevent BBV transmission, which may involve safe practices and, in some cases, disclosure to those at risk.

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Prevention of Needle Stick Injuries

https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/diseases-infection/infection-prevention/standard-precautions/sharps-safety/needle-stick-injuries

Hierarchy of Controls for Sharps Safety Program

• A risk management-based approach is used, incorporating a hierarchy of controls to systematically eliminate or reduce risks associated with sharps injuries.
• Controls are arranged from the highest level of protection and reliability to the lowest, with the goal of eliminating the hazard as the most effective approach.

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Control Measures

Level 1: Eliminate the Risk

• Use Alternative Routes of Administration
  • Where feasible, substitute injectable medications with non-needle-based methods, such as oral or transdermal routes.
• Alternative Skin Closure Methods
  • Replace sutures with alternative techniques, such as skin adhesives or staples, to minimize the use of sharp objects.

Level 2: Substitute, Isolate, and Engineer Controls

• Substitute the Sharp with a Safer Alternative
  • Use blunt tip drawing-up needles instead of sharp needles for preparation.
  • Employ needle-free intravenous (IV) access systems to reduce needle use.
• Isolate the Hazard from People
  • Avoid recapping needles. If necessary, a safe, single-handed recapping method may be used.
  • Do not pass sharps directly hand-to-hand; utilize trays or containers instead.
• Engineering Controls
  • Utilize sharps disposal containers conforming to Australian Standards AS4031 or AS/NZS 4261.
  • Employ sharps removal systems such as single-handed scalpel blade removers.
  • Provide medical devices with safety-engineered protection, including retractable syringes, to minimize needlestick injuries. Ideally, these devices should have passively activated safety features.

Level 3: Administrative Controls and Personal Protective Equipment (PPE)

• Administrative Controls
  • Training and Education: Provide induction training and regular annual refreshers on sharps safety protocols, emphasizing device-specific usage and procedures.
  • Documented Procedures: Ensure that a comprehensive, locally documented sharps safety and management plan is part of the workplace safety program.
  • Training Programs: Educate staff on the correct use of devices, safe disposal procedures, and the risks associated with sharps.
  • Mandatory Vaccination: Ensure vaccinations for diseases transmitted via bloodborne pathogens (e.g., hepatitis B).
• Personal Protective Equipment (PPE)
  • Double Gloving: In operating theatres and high-risk environments, use double-gloving to provide an additional barrier against needlestick injuries.
  • Correctly Fitting PPE: Ensure all PPE, including gloves, is appropriately sized and worn correctly.
  • Footwear: Enforce the use of closed-in shoes to protect against dropped sharps.

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Recommended Practices for Safe Sharps Management

• Handling and Disposal of Sharps
  • Establish clear protocols for handling and safely disposing of sharps.
  • Ensure sharps are removed from procedures whenever possible and that suitable safety devices are utilized.
  • Regularly exchange or replace sharps containers to prevent overfilling.
• Training and Education
  • New employees should receive thorough induction training, and all staff should have regular refreshers, especially when new devices are introduced.
  • Keep records of all vaccination and training activities related to sharps management.
• Injury Protocols
  • Document and have agreed-upon procedures for assessing and providing first aid for sharps injuries and occupational exposures.

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Use of Safety-Engineered Medical Devices

• Incorporation of Safety Mechanisms
  • Utilize devices with built-in safety mechanisms to eliminate or reduce the risk of needlestick injuries. Preferably, these should be passively activated for ease of use.
  • Training and education on device usage must accompany the implementation of safety-engineered devices.

Needle-Free Intravenous Access Systems

• Risk Reduction
  • Standardize needle-free systems for intravascular access to reduce needlestick injuries. Uniformity in such systems helps minimize confusion and increases compliance with safety protocols.

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Product Selection for Safety-Engineered Devices

• Key Selection Criteria
  • The device must not compromise patient care and should perform reliably.
  • Safety mechanisms should be integral and not require separate accessories.
  • The device should be simple to use, with minimal change to existing healthcare professional techniques.
  • Activation of safety mechanisms must allow for continuous caregiver control, with passive activation being preferable.
  • Safety activation should have clear signals (audible, tactile, or visual) for user confirmation.
  • Mechanisms should not be reversible once activated.

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Sharps Disposal

• Container Standards
  • Use disposal containers compliant with AS4031 or AS/NZS4261 standards.
  • Sharps containers should be placed conveniently to encourage point-of-use disposal.
  • Containers should be wall-mounted or fixed on trolleys and placed at a height of 900mm to 1100mm per Australasian Health Facility Guidelines.
  • Containers should be replaced before becoming overfilled.

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Disposable Multiple-Dose Injecting Devices (Injector Pens)

• Safety Considerations
  • Healthcare workers should use a disposable, multiple-dose injector pen with a safety-engineered needle.
  • Ideally, hospital inpatients who are capable should self-administer under appropriate supervision.
  • Medication devices such as insulin pens, cartridges, or vials must only be used for a single patient to prevent cross-contamination.

Safety Device Failure and Product Complaint Management

• Complaint Documentation
  • Document any product complaints to identify statewide or local issues.
  • Investigate complaints locally to determine if they are due to product quality/failure or user error, with retraining provided if necessary.
  • Report trends to the manufacturer for further analysis and potential corrective action.