Case 5: blood borne infections (practice/redo)
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?
The resident has potentially been exposed to: Hep A,B,C, HIV (Lautenbach, p. 322).
Immediate preventative measures:
- Save the syringe to send to the lab for testing.
- The resident should continue to allow the wound to bleed freely
- not promote bleeding by squeezing the wound as it may damage the tissues and increase uptake of any pathogen(s) (BCCDC, 2016).
- Wash the area well with soap and water (BCCDC, 2016)
- Notify the hospital’s occupational medical service (Lautenbach, p.322) and file incident report.
4 Key measures:
1. Assessment of the risk of exposure
2. Laboratory testing on the exposed person and the source person
3. Administration of PEP treatment when appropriate to prevent the development of infection
4. Counseling the exposed person to address anxiety, ensure follow-up testing and modify behavior to prevent transmission to contacts (BCCDC, 2016).
The resident should undergo a risk assessment at the hospital ER or occupational health department which includes the following:
- HBV vaccine history or HBV immune status
- Personal risks for HCV and/or HIV
- Obtain verbal informed consent for testing for HBsAg, Anti-HBs, Anti-HBc Total, Anti- HCV and HIV.
- Also obtain consent for disclosure of their results to their Worksite occupational health department and WorkSafeBC
- Follow-up the resident’s family physician.
- Inform HIV testing will be done either Nominally – in which the test is conducted and reported using the client’s full name, address and contact information; or Non-nominally – in which the test is conducted using initials as per agency standards
- Positive HIV results will be reported to the Medical Health Officer using the nominal or non-nominal identifiers. Non-nominal HIV reporting is identified through checking a tick box on the laboratory requisition form.
- Test results for HBV and HCV, if positive, will be reported to the person’s testing physician and public health for follow-up.
2. What post-injury preventive measures should be undertaken and under whose direction? What long-term follow-up should the resident receive?
Post injury prevention for each top blood borne disease listed belowe under the hospital’s occupational medical service (Lautenbach, p.322)
- If the resident has not been immunized against HBV they should be given 0.06ml/kg of hepatitis B immune globulin IM. The first dose should be administered within 24hrs post-exposure.
- The first dose of HBV vaccine should be adminstered at the same time (Lautenbach, p. 323).
- An additional vaccine dose should be given 1 month later
- An additional vaccine dose should be given 6 months later
- a baseline level of HB antibody should be deterined pre-treatment, if the result is positive for HBV no further treatment is required.
- if the resident was previously vaccinated, a baseline anti-HB should be determined (Lautenbach, p. 323).
- tested to determine their level of aminotransferases (alanine and asparate) (Lautenbach, p. 324)
- determine HCV antibody level with sensitivity and antibody test at baseline within 15 weeks of exposure
- monitor for symptoms as acute hepatitis
- immune serum globulin should not be administered for occupational exposures
- monitor with HCV RNA polymerase chain reaction tests
- use immunomodulators to treat (Lautenbach, p. 324)
- follow antiretroviral regime for post-exposure prophylaxis
- Serology test at time of exposure
- follow up testing at 6 weeks, 3 months and 6 months post-exposure (Lautenbach, p.327)
- 1 year follow up testing post-exposure, varies on institution
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: Active devices require one- or two-handed activation by the healthcare professional after use (Stankovic, 2011). eg needle protection sheiths that need to be pushed over the needle post-use
Passive sharps injury prevention devices: do not require additional steps to initiate the safety mechanism since it activates automatically during device use (Stankovic, 2011). eg. insulin or subcut butterfly sheiths that automatically sheith the lance.
examples of practice modifications that reduce risk of exposure:
- using needless systems for subcut medication administration
- standard precautions so that health care workers hands have a barrier between them and open wounds/areas
- use of face shields to prevent spash/spray exposure.
- staff educational programs(CDC, 2008, p. 12)
- avoidance of recapping and safe needle disposal systems (CDC, 2008, p. 12)
- Using alternate routes for medication delivery and vaccination when available and safe for patient care(CDC, 2008, p. 13)
- specimen collection systems that consolidate and eliminate unnecessary punctures(CDC, 2008, p. 12)
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. (Human factors engineering article from WHO: http://www.who/int/patientsafety/education/curriculum/who_mc_topic-2.pdf )
Human factors help improve safety in areas such as
- safe prescribing practices
- team communication
- information handover in between healthcare team members (WHO, date unknown)
- “Human factors recognize that the workplace needs to be designed and organized to minimize the likelihood of errors occurring and the impact of errors when they do occur. While we cannot eliminate human fallibility, we can act to moderate and limit the risks.” (WHO, unknown)
- eg IV umps that require certain rate to function and beep to inform user if air is in the line
“The fact that we can misperceive situations despite the best of intentions is one of the main reasons that our decisions and actions can be flawed, resulting in making “silly” mistakes—regardless of experience level, intelligence, motivation or vigilance.” (WHO, unknown)
- eg routines like OR swab and instrument counts before and after surgery prevent a swab or instrument being left in the patient.
5. Describe the “bundles” or Class A (Strong evidence) recommendations to prevent central line associated infections. (Central line-associated bloodstream infections. http://www.apic.org/Resources/Topic-specific-infection-prevention/Central-line-associated-bloodstream-infections)
2. BCCDC. (2016). Blood and Body Fluid Exposure Management. 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. Stankovic, Ana. (2011). Porotection against needlestick injuries: active or passive safety. https://www.mlo-online.com/protection-against-needlestick-injuries-active-or-passive-safety.php
4. CDC. (2008). Workbook for designing, implementing and evaluating a sharps injury prevention program. https://www.cdc.gov/sharpssafety/pdf/sharpsworkbook_2008.pdf
5.WHO. Human factors engineering. http://www.who/int/patientsafety/education/curriculum/who_mc_topic-2.pdf