Case 5: blood borne infections

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While replacing a central venous line on a 29 year-old intravenous drug user, the resident receives a sharps injury from the syringe used for the local anaesthetic. The injury, which bleeds freely, is on his left index finger. The resident notes that there was visible blood in the syringe.
Case Five Questions:
1. What are the immediate preventive measures the resident should take and to what organisms has the resident potentially been exposed?

Immediate steps: wash wound with soap and water (CDC, p4). Save contaminated syringe for lab testing. Inform occupational health and safety department of the hosptial as they are the “first stop for any employee with a blood or body fluids exposure” (Lautenbach, p 322).

According to the CDC blood and bodily fluids exposure the resident should:

  • Allow the wound to bleed freely
  • not promote bleeding by squeezing the wound. This may damage the tissues and increase uptake of any pathogen(s).

Lautenbach and blood and bodily fluids CDC guidelines state:

(Occupational health and safety will)

  • evaluate the nature/risk of the exposure
  • determine the clinical status of the source patient and resident via lab testing
  • assess the underlying health status of the health of the employee
  • determine the risk of the infectious disease transmission
  • determine the need of post exposure prophylaxis. (Lautenbach, p 322)
  • Administration of PEP treatment when appropriate to prevent infection
  • Counseling the exposed person to address anxiety,
  • ensure follow-up testing
  • modify behavior to prevent transmission to contacts

Occupational health providers will work closely with infectious diseases specialists to administer antiretroviral drugs as postexposure prophylaxis to the resident who may have been exposed to blood borne pathogens such as HBV, HCV and HIV. (Lautenbach, p 322)

2. What post-injury preventive measures should be undertaken and under whose direction? What long-term follow-up should the resident receive?

Under direction of Occupational health and safety the following post injury prevention measures will be undertaken:

  • evaluate the nature/risk of the exposure
  • determine the clinical status of the source patient and resident via lab testing
  • assess the underlying health status of the health of the employee
  • determine the risk of the infectious disease transmission
  • determine the need of post exposure prophylaxis. (Lautenbach, p 322)
  • Administration of PEP treatment when appropriate to prevent infection
  • do not delay PEP unless HIV testing available on site provides results in less than 2 hours
  • Counselling the exposed person to address anxiety,
  • ensure follow-up testing
  • modify behavior to prevent transmission to contacts (CDC, p4 )

According to page 8 of the CBC blood and bodily fluids exposure guideline long term follow up will include

  • Notifying the resident’s GP and arrange for follow up with them within 3 days
  • If lab works done immediately following exposure for HIV, HBV and HCV (HBsAg, Anti-HBs, Anti-HBc Total, Anti-HCV, HIV Ag/Ab (detects both anti-HIV and P24 antigen) is negative then test again at:
  • 3 weeks post exposure for HIV Ag/Ab, HCV RNA (if source HCV+ or high risk group)
  • 6 weeks post exposure: HIV Ag/Ab
  • 3 months post exposure: HIV Ag/Ab, Anti-HCV, HBsAg, Anti-HBs, Anti-HBc Total

Note: we need only test the patient for what the source patient tests positive for. (CDC, p8)

Implications for the resident’s continuing practice according to CBC BBE guildeline, p13:

“Exposed healthcare workers can continue to practice if:

  • Follow-up testing is completed
  • Counselling from occupational health, infection control or the Public Health Unit is provided with regard to the use of routine precautions
  • Based on their risk exposure there is virtually no risk to the public
  • They seek immediate assessment if symptoms or signs of infection develop.”

3. Discuss the difference between active and passive sharps injury prevention devices. Give examples of each. Give examples of work practice modifications that reduce the risk of exposure to blood-borne pathogens.

Active sharps injury prevention devices require the health care provider to “do something above and beyond the normal use of the product for protection from the sharps tip of the contaminated needle” (Baran, 2003 p.67). Examples are: needles which must be manually covered by the user after th injection is given and IV catheters whose needles retract when the user pushes a button or manually sheathed by the user.

Passive sharps injury prevention devices require no activation of the safety mechanism (Baran, 2003). Examples are: hypodermic needles that automatically retract into the syringe after the injection is given, needleless connection for IV lines, needleless connection for subcutaneous butterflies, IV needles whose bevels are automatically covered when the needle is removed from the catheter.

Examples of work practice modifications that reduce the risk of exposure to blood-borne pathogens are the use of needleless systems wherever safe, effective alternatives are available, provide needle device safety features, provide sharps containers for safe, readily accessible disposal of sharps, investigate all sharps related injuries, and provide post-exposure medical evaluations (NIOSH CDC, p.1).

4. After reading the article on human factors engineering in the link below, please give your own unique examples of how this approach could be used to prevent injuries and enhance task performance.

Understanding the principle of human factors is essential to healthcare because they are key to most adverse events that occur (WHO, p. 100 ). Human factors are the relationships of people to the system with which they intereact (WHO, p.100). Human factors, or erogenomics is three interrelated aspects, the relationships between humans at work, the task at hand and the place of work. These interrelated aspects are directly related to injury prevention and enhance task performance. Devices used must be designed “as though the task was to be accomplished not only by a calm, rested experienced clinician, but also for an inexperienced health-care worker who might be stressed, fatigued and rushing” (WHO, p.102)

For example, needless subcut butterfly systems may prevent a needlestick injury when staff are rushing to adminster medications during a crisis situation. These systems may also prevent needlestick injury during medication administration to a patient who is moving around due to restlessness or seizures.

Needles that retraction into the syringe as soon as the injection is given may for example prevent injury to staff running a code who are rushing any may not take the time or have the time to immediately dispose of the used syringe.

Yet another example is “a nurse who is taking a medication order over the telephone and is interrupted by a colleague asking a question; the nurse may mishear or fail to check the medication or dosage as a result of the distraction.” (WHO, P102)

The use of a checklist is another way to prevent adverse events and enhance performance. Surgical supply counts before a surgery is started and after it is completed to account for each piece of equipment such as forcepts and gauze is another working example.

5. Describe the “bundles” or Class A (Strong evidence) recommendations to prevent central line associated infections.

The following terms are used in the desciption: Institute for Healthcare Improvement (IHI) and central line-associated bloodstream infection (CLABSI).

Bundle: “a small set of evidence-based interventions for a defined patient population and care” (APIC, p.6)

The IHI CLABSI “identified a group of interventions supported by the highest level of research, which when used together would ideally produce better outcomes than if one or more had been used separately. The practices described in the IHI CLABSI bundle include:

• Hand hygiene

• Maximal sterile barrier precautions upon insertion

• Chlorhexidine skin antisepsis

• Optimal site selection (avoidance of femoral vein in adults)

• Daily review of central line necessity and prompt removal of unnecessary lines

These five evidence-based interventions remain the cornerstone of CLABSI prevention, especially at the time of catheter insertion.”(APIC, p. 7)

“As previously described, the initial set of bundled CLABSI prevention practices has been widely adopted and often used in combination with an insertion checklist. However, the terms “bundle” and “checklist” are not interchangeable. A checklist can be used to supplement a bundle and is most effective when used as part of a broader, more comprehensive approach to patient safety. 1,2 The checklist usually includes additional practices, some of which may not be based on level I evidence and may, in certain instances, be optional. Checklist content may also be developed to include specific regulatory or accreditation requirements. The checklist can also describe specific products that must be used (or be available) during the procedure. The checklist format allows the broad bundled strategies to be carefully aligned with detailed institutional policies, procedures, and specific resources. Of note, in 2013, the Agency for Healthcare Research and Quality named bundles that include checklists to prevent central line-associated bloodstream infection (CLABSI) one of the top 10 “strongly encouraged patient safety practices.” (APIC, p.32)

Expanding on skin antiseptics:

(Appropriate skin prep)

– Chlorhexidine gluconate (CHG) for patients > 60 days old

– Povidone iodine, alcohol, CHG, or other specified for children < 60 days old

• Skin prep agent completely dry before insertion (APIC, 35)

Expanding on maximizing sterile barrier precautions upon insertion:

• All 5 maximal sterile barriers used:

– Sterile gloves

– Sterile gown

– Cap – Mask worn

– Large sterile drape (a large sterile drape covers the patient’s entire body) (APIC, p.35)

Expanding on optimal site selection:

“Insertion of central lines, guided by the patient’s anatomy or “landmarks,” has been replaced by ultrasound guided placement. In two meta-analyses, the use of real-time two-dimensional ultrasound for the placement of central venous catheters substantially decreased mechanical complications and reduced the number of attempts at required cannulation and failed attempts at cannulation compared with the standard landmark placement. Evidence favors the use of two-dimensional ultrasound guidance over Doppler ultrasound guidance. Site selection should be guided by patient comfort, ability to secure the catheter, and maintenance of asepsis, as well as patient-specific factors (e.g., pre-existing catheters, anatomic deformity, and bleeding diathesis), relative risk of mechanical complications (e.g., bleeding and pneumothorax), the availability of bedside ultrasound, the experience of the person inserting the catheter, and the risk for infection.8,11,12″(APIC, p.37)

Expanding on daily asessment and central line catheter care

“In general, post-insertion care focuses on:

• Hand hygiene prior to all infusion-related procedures

• Aseptic technique with all catheter access procedures

• Proper changing of administration sets

• Changing needleless connectors according to manufacturer guidelines

• Attention to disinfection of needleless connectors prior to access

• Regular site care and dressing changes

The IHI central line insertion bundle does include central venous access device (CVAD) removal when it is no longer needed. This needs to be part of post-insertion care as well. Because the very existence of the CVAD is a risk factor for catheter-associated bloodstream infection, daily review of catheter necessity, and prompt removal when it is no longer needed, are critical because the risk of bloodstream infection is increased as catheter duration is extended. Catheter removal when it is no longer needed, are equally applicable in all healthcare settings.” (APIC, p.43)

References:

1. Lautenbach, E., Woeltje, K., and Malani, P. (2010) Practical HealthcareEpidemiology, 3rd ed.

2. BCCDC Blood and bodily fluids exposure management. (2016). Accessed 25/2/17 from: http://www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20Manual/Chapter%201%20-%20CDC/CPS_CDManual_BBFExpManage.pdf

3. Baran, Louise. (2003) Active and Passive Safety devices. Accessed Feb28, 2017 from http://5diamondpatientsafety.org/Files/SharpsSafety/SS-15.aspx

4. NIOSH CDC (2012) How to prevent needlestick and sharps injuries. Accessed Feb 28, 2017 from https://www.cdc.gov/niosh/docs/2012-123/pdfs/2012-123.pdf

5. WHO. What is Human Fators and why is it important to patient safety.  Accessed Mar1, 2017 from http://www.who.int/patientsafety/education/curriculum/who_mc_topic-2.pdf

6. APIC. (2015). Guide to preventing central line-associated bloodstream infections. Accessed March 2, 2017 from http://apic.org/Resource_/TinyMceFileManager/2015/APIC_CLABSI_WEB.pdf

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