|
| A) | scalpel blades. | ||
| B) | disposable syringes. | ||
| C) | winged steel needles. | ||
| D) | intravenous catheter stylets. |
The most common devices associated with injury are disposable syringes (31%), suture needles (24%), scalpel blades (8%), winged steel needles (5%), intravenous catheter stylets (3%), and phlebotomy needles (3%) [1,9]. Specific tasks that cause the highest percentage of injuries include intramuscular or subcutaneous injection (29.2%), suturing (27.5%), cutting (7.7%), and venous blood sampling (5.3%) [10]. Approximately 30% of injuries happen to workers who are not the primary user of the device [14].
| A) | HIV. | ||
| B) | HBV. | ||
| C) | HCV. | ||
| D) | tuberculosis. |
The most alarming potential exposures are to HBV, hepatitis C virus (HCV), and HIV, with several other pathogens (e.g., herpes viruses, malaria, Mycobacterium tuberculosis) identified as concerning, but less often transmitted during patient care [1,4,21]. Because of under-reporting, it is difficult to assess the true prevalence of transmitted infections from percutaneous exposures in the workplace, but the risk of becoming infected subsequent to exposure is well documented. According to the CDC, the risk of transmission from an infected patient to a healthcare worker following a needlestick or sharps injury is 6% to 30% for HBV (in unvaccinated workers), 2% to 4% for HCV, and 0.3% for HIV [4,21]. These figures are solely for known percutaneous exposure to infected blood. The likelihood of transmission though percutaneous exposure to other bodily fluids is lower, because blood contains the greatest amount of infectious virus particle titers of all bodily fluids. In contrast, exposure to blood splash on mucous membranes or skin presents a lower risk of infection (less than 0.1% for HIV); no documented cases of HIV infection from a few drops of blood on intact skin have been reported [4]. Deep injuries, injuries from a needle that was in the source patient's artery or vein, or injuries from devices visibly contaminated with blood are most likely to result in seroconversion [15]. High source-patient viral load increases the risk.
| A) | express or suck the wound. | ||
| B) | apply caustic agents (e.g., bleach) to the wound. | ||
| C) | inject antiseptics or disinfectants into the wound. | ||
| D) | gently wash the exposed area with soap and water without scrubbing. |
The first step after a needlestick or sharps injury is to gently wash the exposed area with soap and water without scrubbing; skin washes and topical antiseptics (e.g., 2% to 4% chlorhexidine) have not been found to reduce rates of disease transmission but can be used [11,12,15,25]. Allowing the wound to bleed freely is recommended, but expressing or sucking the wound is contraindicated, as are caustic agents (e.g., bleach) or the injection of antiseptics or disinfectants into the wound. Drying the area and using a sterile dressing or bandage to cover the wound is the final step. Deep scalpel or other sharps injuries should receive treatment as needed.
| A) | Date and time of exposure | ||
| B) | Details about the exposure source | ||
| C) | Details about counseling, post-exposure management, and follow-up | ||
| D) | All of the above |
Employers must follow all workplace, state, and federal requirements for documenting and reporting workplace sharps injuries and exposures to blood, bodily fluids, or tissue [4]. This includes adherence to the OSHA requirements. Exposure information should be included in the report and recorded in the exposed worker's confidential medical record [4]. The medical record and report should be made available to a healthcare provider who can provide counseling and perform all medical evaluations, procedures, and treatments (including PEP, when indicated) in accordance with the recommendations of the U.S. Public Health Service. The report and medical record should contain [4]:
Date and time of exposure
Details of the procedure being performed, including where and how the exposure occurred, whether the exposure involved a sharp device, the type of device, whether there was visible blood on the device, and how and when during its handling the exposure occurred
Details of the exposure, including the type and amount of fluid or material and the severity of the exposure. For a percutaneous injury, details would include the depth of the wound, the gauge of the needle, and whether fluid was injected.
Details about the exposure source, including whether the patient was infected with HIV, HCV, and/or HBV and his or her hepatitis B e antigen (HBeAg) and, if the source was infected with HIV, the stage of disease, history of antiretroviral therapy, and viral load, if known. If this information is not known from the medical record, then the source patient should be asked to obtain serologic testing for HBV, HCV, and HIV.
Details about the exposed person (e.g., HBV vaccination and vaccine-response status)
Details about counseling, post-exposure management, and follow-up
| A) | seven days. | ||
| B) | four weeks. | ||
| C) | eight weeks. | ||
| D) | four months. |
The preferred regimen for PEP following exposure to HIV is a basic regimen that should be appropriate for most HIV exposures: emtricitabine and tenofovir dispensed together as Truvada, a fixed-dose combination tablet, 1 mg once daily, plus raltegravir, 400 mg twice daily [17]. This preparation is available as a starter packet that should be stocked at every healthcare facility where exposure to HIV is possible. PEP regimens should be started as soon as possible after occupational exposure to HIV, and they should be continued for a four-week duration. As noted, the regimen has been selected for its tolerability and safety profile. There are several alternative regimens that may be selected due to individual patient concerns. For example, tenofovir is associated with renal toxicity, and an alternative nucleoside/nucleotide reverse-transcriptase inhibitor pair, such as zidovudine plus lamivudine (available as Combivir) would be selected for patients with renal disease [17]. The antiviral dolutegravir is contraindicated in pregnant women or women who could become pregnant because of the risk of neural tube defects. It is recommended that all women of childbearing potential should have a pregnancy test performed before beginning a PEP regimen and should use an effective birth control method until the PEP regimen is completed [13].
| A) | No action is needed. | ||
| B) | two doses of HBIG separated by one month. | ||
| C) | one dose of HBIG and complete vaccination. | ||
| D) | no doses of HBIG, but complete vaccination. |
POSTEXPOSURE MANAGEMENT OF HEPATITIS B, BY VACCINATION AND RESPONSE STATUS
| Healthcare Personnel (HCP) Status | Postexposure Testing | Postexposure Prophylaxis | Postvaccination Serologic Testingb | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
|
Source Patient (HBsAg) | HCP Testing (Anti-HBs) | HBIGa | Vaccination | ||||||||
| Documented responderc after complete series (three or more doses) | No action needed | ||||||||||
| Documented nonresponderd after six doses | Positive/unknown | — | HBIG x2 separated by one month | — | No | ||||||
| Negative | No action needed | ||||||||||
| Response unknown after three doses | Positive/unknown | <10 mIU/mLe | HBIG x1 | Initiate revaccination | Yes | ||||||
| Negative | <10 mIU/mL | None | |||||||||
| Any result | ≥10 mIU/mL | No action needed | |||||||||
| Unvaccinated/incompletely vaccinated or vaccine refuser | Positive/unknown | — | HBIG x1 | Complete vaccination | Yes | ||||||
| Negative | — | None | Complete vaccination | Yes | |||||||
| |||||||||||
| A) | Cleanup | ||
| B) | Improper disposal or disposal related | ||
| C) | Manipulating a needle in the patient | ||
| D) | Handling or passing the device during or after use |
Since the implementation of Universal Precautions in healthcare settings (formalized during the HIV/AIDS epidemic in the mid-1980s), the incidence of blood and bodily fluid exposure to the skin and mucous membranes has decreased significantly [1,29,32]. Use of personal protective equipment and work-practice controls are the cornerstone of Universal Precautions. At its core, Universal Precautions are based on the principle that all blood and other bodily fluids should be treated as if they are infectious [1]. But no matter how effective protective equipment is at preventing surface contact, needles and other sharps easily penetrate most barrier precautions. Although safety-engineered devices and controls have lowered the occurrence of many types of injuries, percutaneous injuries and exposures continue to occur [1]. Understanding how and when percutaneous injuries occur is key to needlestick and sharps injury prevention. One analysis by the CDC found that needlestick injuries most commonly occurred at the following points in patient care [14]:
Manipulating a needle in the patient (27%)
Improper disposal or disposal related (22%)
Cleanup (11%)
Handling or passing the device during or after use (10%)
| A) | The top opening of the container should be visible to the user. | ||
| B) | Nurses should put their fingers into the sharps container when disposing used sharps. | ||
| C) | A sharps container for a standing workstation should be placed 52–56 inches from the floor. | ||
| D) | There should be unobstructed access to the container so that the worker can easily place the used device into the opening without having to make any awkward movements. |
Sharps containers are an integral part of percutaneous injury prevention [1]. Needles and sharps should always be disposed of immediately after use so the potential for accidents is minimized. Mandating the use of rigid, puncture-proof sharps containers was an important regulatory aspect of the original 1991 OSHA Bloodborne Pathogens Standard and remains so to this day [27]. An aspect of sharps container use that is often overlooked is the ideal location for placement. There should be unobstructed access to the container so the worker can easily place the used device into the opening without having to make any awkward movements [28]. The top opening of the container should be visible to the user. This is important, not only because workers need to know where the opening is, but because they need to be able to see the fill status of the container and if there are any potential hazards where they are reaching. Fingers should never enter the sharps container [1].
Most nurses are women, and a sharps container for a standing workstation placed between 52–56 inches from the floor will accommodate 95% of female nurses (Figure 1) [27,28]. For seated workstations, the preferred height is 38–42 inches. Taller healthcare practitioners will also be able to comfortably and safely use containers placed at these heights.
| A) | Double gloving | ||
| B) | Using hand-to-hand passage of sharp instruments | ||
| C) | Using pointed sharp-tipped scalpel blades instead of round-tipped blades | ||
| D) | Avoiding alternative cutting methods such as blunt electrocautery and laser devices |
Operating rooms are a setting in which a large percentage of injuries take place. In surgical settings, the CDC has identified work-control practices that can prevent or lessen the incidence of percutaneous injuries, including [1]:
Using instruments, rather than fingers, to grasp needles, retract tissue, and load/unload needles and scalpels
Giving verbal announcements when passing sharps
Avoiding hand-to-hand passage of sharp instruments by using a basin or neutral zone
Using alternative cutting methods such as blunt electrocautery and laser devices when appropriate
Substituting endoscopic surgery for open surgery when possible
Using round-tipped scalpel blades instead of pointed sharp-tipped blades
Double gloving
| A) | Risk-taking personality | ||
| B) | Decreased job demands | ||
| C) | Failure to anticipate the potential for exposure | ||
| D) | Belief that precautions are not warranted in some specific situations |
Willingness of healthcare workers to change behaviors that can lead to injury is influenced by a variety of factors. It has been shown that nurses are most willing to make changes to their set behaviors when they understand that they are at risk of injury and that the risk is substantial [1]. It is also important to know the change is worth the extra effort and the new techniques, devices, and practices will make a difference to personal safety. The CDC has identified factors that can inhibit the acceptance of safety practices, including [1,14]:
Perceived conflict of interest between providing optimal patient care and protecting oneself from exposure (e.g., failure to associate workplace safety with improved patient care)
Belief that precautions are not warranted in some specific situations (despite the lesson of Universal Precautions that every procedure and patient should be considered infectious)
Increased job demands that cause work to be hurried
Perceived poor safety climate in the workplace
Failure to anticipate the potential for exposure
Risk-taking personality