Download Needlestick and Blood Exposure Injuries

Policy No: 1/A/14:9123-01:00
Policy: Needlestick and Blood Exposure Injuries: Health Care Worker
NEEDLESTICK AND BLOOD EXPOSURE
INJURIES: HEALTH CARE WORKER
POLICY
©
DOCUMENT SUMMARY/KEY POINTS
•
This policy has been developed to prevent, detect, and initiate management of the blood
borne viruses human immunodeficiency virus (HIV,) hepatitis B virus (HBV) and
hepatitis C virus (HCV) following needle stick incidents or exposure to blood or
(potentially) blood contaminated secretions.
•
All these blood borne infections may become chronic and carry a significant risk of longterm morbidity and mortality.
•
This document provides details on the management of staff exposed (or potentially
exposed) to blood or blood contaminated secretions. This can include:
o
Skin puncture
o
Ingestion
o
Splashing of mucous membranes
o
Contact with broken skin
•
Identifies initial action to take after exposure (Immediate Care) and follow-up
management requirements.
•
Details the risk assessment process and the risk classification of exposures.
•
Provides links to a range of related NSW Health Directives
Related Information
•
Work Health Safety and Injury Management Policy:
http://chw.schn.health.nsw.gov.au/o/documents/policies/policies/2013-9040.pdf
Approved by:
Date Effective:
Team Leader:
SCHN Policy, Procedure and Guideline Committee
1st January 2015
WHS & IM Coordinator
Review Period: 3 years
Area/Dept:: WHS & IM - CHW
Date of Publishing: 22 December 2014 6:08 PM
Date of Printing: 22 December 2014
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This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/A/14:9123-01:00
Policy: Needlestick and Blood Exposure Injuries: Health Care Worker
CHANGE SUMMARY
•
CHW version of the same title has been rescinded & replaced by this SCHN version.
•
Due for mandatory review – no major changes made.
•
Removed links to obsolete NSW MoH Policy Directives.
READ ACKNOWLEDGEMENT
•
Managers are to acknowledge the document and refer staff to this document as
required.
Glossary
Abbreviation or Term
Definition
Anti – HBs
antibody to hepatitis B surface antigen
Anti - HBc
antibody to hepatitis B core antigen
Anti - HCV
antibody to Hepatitis C virus
Anti - HIV
antibody to Human immunodeficiency virus
HBIG
Hepatitis B immunoglobulin
HBsAg
Hepatitis B surface antigen
HBcAb
Hepatitis B core antibody
HBeAg
Hepatitis B e antigen
HBV
Hepatitis B virus
HBV DNA
Hepatitis B virus deoxyribonucleic acid
HCV
Hepatitis C virus
HIV
Human immunodeficiency virus
PCR
polymerase chain reaction
The time from exposure to seroconversion when the source
may be asymptomatic or experiencing seroconversion illness.
window period
Approved by:
Date Effective:
Team Leader:
SCHN Policy, Procedure and Guideline Committee
1st January 2015
WHS & IM Coordinator
Review Period: 3 years
Area/Dept:: WHS & IM - CHW
Date of Publishing: 22 December 2014 6:08 PM
Date of Printing: 22 December 2014
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This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/A/14:9123-01:00
Policy: Needlestick and Blood Exposure Injuries: Health Care Worker
TABLE OF CONTENTS
Glossary ..................................................................................................................................2
1
Introduction.................................................................................................................. 4
1.1
Hepatitis B .....................................................................................................................4
1.2
HIV (AIDS) .....................................................................................................................4
1.3
Hepatitis C .....................................................................................................................5
2
Staff member exposed – What to do? ....................................................................... 5
2.1
Immediate care (First Aid) ............................................................................................. 5
2.2
Report the Incident IMMEDIATELY ............................................................................... 5
For CHW Staff .....................................................................................................................5
For SCH Staff ......................................................................................................................6
3
Initial management taken by WH&S /AMO ................................................................ 6
4
Risk Assessment ......................................................................................................... 7
4.1
Assess the injury ........................................................................................................... 7
4.2
Assess the source ......................................................................................................... 8
4.2
Assess the staff ............................................................................................................. 9
5
Initial Treatment of the Staff member ........................................................................ 9
5.1
If source negative for HBV, HCV and HIV ..................................................................... 9
5.2
If source HBsAg Positive OR anti-HBc Positive and anti-HBs Negative ....................... 9
5.3
If source anti-HCV Positive.......................................................................................... 11
5.4
If Source anti HIV Positive ........................................................................................... 11
5.5
Tetanus........................................................................................................................12
6
Complete Appropriate Documentation .................................................................... 12
At CHW ..............................................................................................................................12
At SCH: ..............................................................................................................................13
7
Follow-up Management............................................................................................. 13
7.1.1 Source Negative for HIV, HBV, and HCV ............................................................. 13
7.1.2 Source of Unknown Infectious Status or Unable to be tested .............................. 13
7.1.3 Source Likely to be in the Window Period for HIV, HBV or HCV ......................... 13
7.1.4 Source Positive or Likely to be Positive for HBV .................................................. 13
7.1.5 Source Positive or Likely to be Positive for HCV. ................................................. 13
7.1.6 Source Positive for HIV ........................................................................................ 14
8
General Advice for Staff Exposed to HIV, HCV or HBV Positive Blood................ 14
9
NSW Health Policy Directives .................................................................................. 15
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Policy No: 1/A/14:9123-01:00
Policy: Needlestick and Blood Exposure Injuries: Health Care Worker
1
Introduction
Certain infectious agents may be transmitted from person to person following accidental
percutaneous or mucosal exposure to blood or blood-contaminated secretions. Of particular
concern at this hospital is the possible transmission of the viruses Hepatitis B, Hepatitis C
and Human Immunodeficiency Virus (HIV) which causes Acquired Immunodeficiency
Syndrome (AIDS). All these infections may be chronic and carry a significant risk of longterm morbidity and death. Adherence to infection control practices, particularly safe sharps
use and appropriate use of personal protective equipment (PPE) remains the first line of
protection against occupational exposure to HIV, HBV, or HCV.
•
This policy has been developed to prevent or reduce morbidity following needle stick
incidents or exposure to blood or potentially blood contaminated secretions.
•
The risk is infection with a blood-borne virus, hepatitis B virus (HBV), hepatitis C virus
(HCV) or Human Immunodeficiency virus (HIV).
•
The situation should be assessed and any prophylaxis, if indicated, given as soon as
possible.
•
Confidentiality should always be maintained.
•
These injuries are usually very minor in themselves but engender a very high degree of
anxiety and therefore need careful, sensitive and thoughtful evaluation and
management.
1.1
Hepatitis B
Hepatitis B is an acute or chronic infection caused by the hepatitis B virus. Around 30% of
infected patients develop acute symptoms with jaundice, signs and symptoms of liver
involvement and raised liver enzymes. Diagnosis is by demonstrating HBsAg in the staff
member’s blood, which is usually cleared in 3 - 6 months. Failure to clear HBsAg after 6
months is associated with the chronic carrier state, which can lead to lasting liver damage.
Hepatitis B virus is mainly transmitted in developed countries from blood transfusions (now
rare in Australia), the use of shared syringes and exposure to infected blood (eg. from needle
stick incidents). In the general community, transmission may occur via sexual intercourse or
by the sharing of such items as razors, needles, or toothbrushes.
1.2
HIV (AIDS)
Infection with this virus may produce no symptoms or an initial glandular - fever like condition
(lasting 3 – 14 days). After resolution of this initial “seroconversion illness”, infected people
usually remain well for months to years but are still infectious. Untreated HIV infection results
in AIDS in up to 50% of all infected individuals within 10 years and may present with
pneumonia, chronic diarrhoea, dementia, malignancies, encephalitis, etc.
HIV is transmitted by blood transfusions or contaminated blood products, IV drug use
involving contaminated needles and syringes, by intimate sexual contact and can be
transmitted vertically from mother to child.
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Policy No: 1/A/14:9123-01:00
Policy: Needlestick and Blood Exposure Injuries: Health Care Worker
1.3
Hepatitis C
Infections with Hepatitis C virus produce a clinical illness, indistinguishable from that
produced by other hepatitis viruses and includes jaundice, other features of liver involvement
and elevated liver enzymes levels. However, only 5 - 10% of infections are associated with
acute symptoms, and 65 - 80% of patients remain infected with the virus, developing chronic
hepatitis, with some progressing to liver failure and/or liver cancer.
Hepatitis C is principally a blood borne infection transmitted through blood or blood products,
and intravenous drug use.
Hepatitis C has epidemiological characteristics similar to those of hepatitis B. Health care
workers may be infected by contact with blood, particularly where standard (universal)
precautions were not followed. Although Hepatitis C is substantially less infectious than
Hepatitis B, it is occasionally transmitted by close personal contact, particularly sexual
contact.
2
Staff member exposed – What to do?
2.1
Immediate care (First Aid)
After exposure and if appropriate the ‘recipient” should:
•
Encourage bleeding if the exposure involves a cut or puncture, then wash with soap
and water;
•
•
Wash with soap and water where the exposure does not involve a cut or puncture;
•
If blood or other body substances get into the mouth, spit them out and rinse mouth with
water several times;
•
If clothing is contaminated remove clothing and shower if necessary.
If eyes are contaminated, rinse them while they are open, gently but thoroughly with
water or normal saline;
2.2
Report the Incident IMMEDIATELY
For CHW Staff
•
Monday to Friday Office Hours:
o
•
report to WHS & IM Department (CHW)
If unavailable or Out-of-Hours/Weekend/Public Holidays, perform the following;
o
Apply First Aid
o
Collect a Blood and Body Fluid Exposure Pack from the Emergency Department,
Operating Suite, or the after-hours NUM
o
Follow the step by step checklist contained therein,
o
Take the pack to:

the Westmead Adults Hospital Emergency unit .


OR Your General Practitioner
OR Wentworthville Medical Centre 22 Station St Wentworthville NSW.
(8am – 10 pm).
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Policy No: 1/A/14:9123-01:00
Policy: Needlestick and Blood Exposure Injuries: Health Care Worker
For SCH Staff
•
•
Apply First Aid
Monday to Friday Office Hours:
o
•
After Hours, Public Holidays or Weekends contact:
o
•
•
•
•
Contact CHESS - p42782.
Prince of Wales (POW) Needle Stick Injury Assessor on POW switch Ext 9.
Follow instructions.
Report incident to supervisor.
Do not enter in IIMS unless incident involved an act of aggression.
A confidential NSW Health Reporting form is used on the intranet or CHESS.
3
Initial management taken by WH&S /AMO
The process to follow is:
1. Initial management
o
Check or implement immediate care of the exposed site if required.
2. Complete a risk assessment (refer to section 4 for more information):
o
Assessment of the injury, staff and source
o
Ensure Hepatitis B immune status of injured staff member is known and adequately
documented.
o
Perform appropriate blood tests with written/verbal consent:

Obtain consent for baseline testing of the staff member for HBV, HCV and HIV

Obtain consent for baseline testing of the source child for HBV, HCV and HIV
3. Perform appropriate initial management (refer to section 5 for more information):
o
Arrange for appropriate initial vaccination and prophylactic treatment for the staff
member.
o
Arrange follow up for the source and staff member.
If it appears likely that HIV prophylaxis is warranted, then the (CHW) WHS & IM
Department or (SCH) CHESS/Needlestick Injury Assessor should immediately;
o
At CHW: contact the Infectious Disease (ID) Registrar at Westmead Hospital
(Phone: 9845-5555) for an urgent referral for (CHW staff)
o
At SCH: the Staff member is to be seen immediately by the Prince Of Wales
Emergency Dept.
Note:
Anti-retroviral prophylaxis, because of possible exposure to HIV, should be
commenced as soon as possible after exposure, preferable within 1-2 hours but
even up to 36 hours post exposure it is still considered worthwhile.
4. Complete appropriate documentation. (refer to section 6 for more information)
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Policy No: 1/A/14:9123-01:00
Policy: Needlestick and Blood Exposure Injuries: Health Care Worker
4
Risk Assessment
Risk assessment includes assessment of the significance of the injury and the status of the
source if known. This information is to be carefully documented appropriately. Assessment of
risk is given in Table 1 ‘Classification of exposures’.
At risk situations (Determine nature of exposure)
Those incidents whereby blood or blood contaminated secretions involve:
•
•
•
Skin puncture
Splashing of mucous membranes
Contact with broken skin
4.1
Assess the injury
Factors which should be considered are:
•
The nature of the injury (esp depth of penetration, whether it drew blood)
•
•
•
The nature of the item that caused the injury (e.g. gauge of the needle);
The nature of the body substance involved;
The volume of blood and body substances to which the staff member was exposed.
In the case of percutaneous blood exposures, other significant percutaneous exposures, and
significant mucous membrane or skin exposures the staff member should be assessed
further as detailed in Table 1.
In the case of other exposures then no further testing or examination is required, apart from
the possibility of further counselling. This should be determined according to individual
circumstances.
Table 1: Classification of Exposures
Exposure
Percutaneous
exposures to blood
Other significant
percutaneous
exposures
Significant mucous
membrane exposures
Significant skin
exposures
Other exposures
Risk
Highest Risk
BOTH exposure to a large volume of blood (eg deep injury with a large
diameter hollow needle previously in the source patient’s vein or artery, and
especially involving injection of patient’s blood) AND exposure to blood
containing high titre of HIV, HCV, HBV (eg in the case of HIV, blood from a
source with acute seroconversion illness or a terminally ill AIDS patient).
Increased Risk
EITHER exposure to a large volume of blood OR exposure to blood with a high
titre of HIV, HCV, HBV (eg percutaneous injury with a soiled solid needle).
No Increased Risk
NEITHER exposure to a large volume of blood NOR exposure to blood with a
high titre of HIV, HCV, HBV.
Percutaneous exposures involving fluids containing visible blood, or other
potentially infectious fluids (includes semen, vaginal secretions, cerebrospinal,
synovial, pleural, peritoneal, pericardial and amniotic fluids) or tissue.
Exposures (usually splashes) to eye or mouth involving blood, fluid containing
visible blood or other potentially infectious body fluids.
Exposures of non-intact skin or extensive or prolonged skin contact involving
blood, blood-stained fluid or other potentially infectious body fluids.
Percutaneous, mucous membrane or cutaneous exposures to (non-blood
stained) urine or saliva.
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Policy No: 1/A/14:9123-01:00
Policy: Needlestick and Blood Exposure Injuries: Health Care Worker
4.2
Assess the source
Identify and assess source, and consider whether immediate referral to Westmead Staff
Health/Westmead Emergency (CHW) or CHESS/Prince of Wales Hospital (SCH) is
indicated. If source is a patient, the attending Medical Officer/Medical Team must be notified.
With significant exposures every effort should be made to ascertain the HIV, HBV and HCV
status of the source. The source details need to be documented with the medical record
number, name, date of birth and diagnosis. Testing of the source must follow accepted
guidelines with pre- and post- test counselling and informed consent must be obtained.
•
Source tests:
o
HBsAg,
o
anti-HBc (HBcAb),
o
anti-HBs (HBsAb),
o
anti-HCV
o
anti-HIV
Every effort should be made to ascertain the HIV, HBV, and HCV status of the source,
particularly in the case of percutaneous, significant percutaneous, significant mucous
membrane, or significant skin exposures. If the status of the source individual is unknown at
the time of the accident, then baseline testing should be undertaken to determine the
source's infectious status for HIV, HBV, and HCV.
Testing of the source child must follow accepted guidelines. Pre and post-test counselling
must be given and informed consent obtained before testing can proceed.
•
At CHW; Refer to the “Consent for Blood Testing” form:
http://chw.schn.health.nsw.gov.au/o/forms/ohs/staff_health/testing_a_child_following_blood_exposure.pdf
•
At SCH, refer to CHESS or the Needle Stick Assessor at Prince of Wales.
It is appropriate for the admitting team, when available, to approach the patient and/or
parent/guardian to gain written consent for testing of the source for issues of consent
associated with HIV antibody testing. Blood should be collected from the source if the patient
and/or his/her parents or carers give consent. (Age of consent for HIV testing is 14 years).
With infants less than 6 months of age, maternal blood should be tested, in preference to the
infant. However, if maternal blood is unavailable, 2mL of clotted blood from the infant should
be adequate. If any maternal results are positive, infant testing is indicated. The source
patient can be tested for HIV without consent in certain limited circumstances if authorised by
the Chief Health Officer, NSW Health Department.
•
The blood should be taken as soon as possible after the incident from both the staff
member and the source and sent for urgent testing.
•
A positive HIV antibody test, although it would be treated confidentially, would have to
be reported to the NSW Health Department in the usual way (identified by the first two
initials of the surname and date of birth only).
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Policy No: 1/A/14:9123-01:00
Policy: Needlestick and Blood Exposure Injuries: Health Care Worker
4.2
•
Assess the staff
Staff tests:
o
anti-HBs (HBsAg),
o
anti-HBc
o
anti-HCV
o
anti-HIV
Staff testing can be done through the hospital or through a doctor of the person’s choice. 5 10mL clotted blood from the staff member should be tested (with explanation and written or
verbal consent) for hepatitis B, hepatitis C and HIV. Pre-test counselling for HIV antibody
testing may need to encompass, with sufficient information, very detailed, extensive,
confidential, personal and legal issues that make it inappropriate to be undertaken by fellow
staff members involved in the implementation and management of this policy. If a staff
member declines to be tested at the time of the incident, this should be documented. If blood
has been taken for HBV and/or HCV testing, this will be stored under standard conditions
and can be tested at a later stage for HIV antibodies if the staff member later requests.
Counselling may be sought from Doctor of choice including GP; specialists and many
government agencies (refer to Health Care Facilities with Clinicians Experienced in
Prescribing Drugs for Treatment of HIV and HCV).
5
5.1
•
Initial Treatment of the Staff member
If source negative for HBV, HCV and HIV
Provide counselling and perform anti-HIV and anti-HCV. If the staff member was not
hepatitis B immune perform HBsAg, anti-HBc and anti-HBs.
Hepatitis B - Notes
Since one millilitre of serum can contain up to one thousand million particles of hepatitis B
virus, an accident involving even the smallest amount of serum may result in the
transmission of infection. The occupational risk of exposure to blood or body fluids that are
known to contain, or might contain, the hepatitis B virus requires prophylaxis. An effective
vaccine for hepatitis B is available, as well as specific hepatitis B immunoglobulin. If the
source is HBsAg positive, then HBeAg and HBV DNA testing will be performed to estimate
the risk of transmission. The risk of transmission of HBV from a needlestick injury ranges
from 1-6% for e-antigen negative blood to 22-40% for e-antigen and/or HBV DNA positive
blood.
5.2
•
•
If source HBsAg Positive OR anti-HBc Positive and anti-HBs
Negative
If the source was found to be HBsAg positive or anti-HBc positive and anti–HBs
negative, the staff member should be offered prophylaxis and vaccination if nonimmune or if their immunity status cannot be rapidly determined. See Table 2.
Follow-up testing of the recipient for HBsAg and anti – HBs after completion of
vaccinations should be offered.
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Policy No: 1/A/14:9123-01:00
Policy: Needlestick and Blood Exposure Injuries: Health Care Worker
Test staff member for anti-HBs/obtain documented evidence of immunity to hepatitis B.
•
•
If anti HBs >10 lU/mL, no treatment is required.
If anti HBs< 10 lU/mL: screen for HBsAg: if HBsAg negative administer 400IU HBIG
and/or HB vaccine as appropriate. Refer to Table 2.
(For HBIG Phone Red Cross Blood Bank – City: 9229-4444 or Parramatta: 9840-5815)
AND
•
If anti HBs< 10 lU/mL and BsAg negative: and never vaccinated offer 3 doses at 0, 1
and 6 months. If negative and previously vaccinated (non-responders) offer a double
dose of vaccine, a rapid course of three doses at monthly intervals, or intradermal
vaccination (off-label use of vaccine – requires individual informed consent)
Table 2: Recommendations for Hepatitis B Prophylaxis following Percutaneous or Permucosal Exposure
N.B. Take blood for testing BEFORE administering HBIG and/or HB vaccine.
Exposed Person
Previously fully immunised and
immunity confirmed (‘known
responder’) or immunity from
past resolved infection
Previously fully immunised and
response unknown
Partially immunised
Previously immunised but nonresponder
Unimmunised
Source is HBsAg positive, unknown,
untested or epidemiologically high risk
Test exposed person for anti-HBs
Result available within 24 hours:
- if ≥ 10 lU/mL no treatment
- if < 10 lU/mL and HBsAg negative hepatitis
B vaccine booster dose.
Test exposed person URGENTLY for antiHBs Contact lab to ensure that result will be
available within 24 hours3.
- if adequate (≥10 lU/mL) no treatment.
- if inadequate (< 10 lU/mL) HBIG4 and HB
vaccine booster dose.
Check immunity after 3 months.
Result not available within 24 hours:
HBIG within 24 hours4 + HB vaccine booster
dose later if indicated by anti-HBs <10 lU/mL.
Check immunity after 3 months.
Test exposed person URGENTLY for antiHBs Contact lab to ensure that result will be
available within 24 hours.
- if adequate (≥ 10 lU/mL) no treatment
- if inadequate (<10 lU/mL) HBIG + HB
vaccine dose.
Result not available within 24 hours: HBIG4 +
continue HB vaccine doses.
Check immunity 3 months after completion of
immunisation course.
HBIG within 24 hours3. Repeat dose at 4
weeks and then again at 6 months
HBIG within 24 hours3 + commence HB
immunisation (HBIG and first HB vaccine at
separate sites - one in L deltoid, one in R
deltoid). Check immunity 3 months after
completion of course.
Source is HBsAg negative1
No treatment
No urgent action. Test for antiHBs within 7 days. If result shows
antibody level (<10 U/mL) offer
vaccine booster and check
immunity after 3 months. (An
antibody level <10 IU/mL is non
protective).
Continue hepatitis B immunisation
course. Check immunity 3 months
after completion of course
No treatment.
Commence hepatitis B
immunisation. Check immunity 3
months after completion of course.
Note: HBIG (hepatitis B immunoglobulin) 400 IU, by deep IM injection Adult dose available from Red Cross Blood Bank-Phone:
City-: 9229 4444 or Parramatta-: 9840 5815. HBIG is most effective at preventing HBV infection if administered immediately
after exposure. Effectiveness falls rapidly with delay in commencement & is of doubtful value after 3 days. Effective for
approximately 3 months, so retest for antibodies 3 months post HBIG administration and 3 months post course completion.
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Policy No: 1/A/14:9123-01:00
Policy: Needlestick and Blood Exposure Injuries: Health Care Worker
5.3
If source anti-HCV Positive
Staff members may be exposed to blood from patients with hepatitis C. Blood from staff and
source should be tested for hepatitis C antibody. If the source is known to be anti-HCV
positive then a HCV PCR test should be ordered to estimate transmission risk. Check with
the microbiologist on duty for collection details. At this stage there is no effective prophylaxis
against HCV infection, but antivirals effective against Hepatitis C are in development so
discussion with a practicing hepatologist is advised. Immunoglobulin is not effective as it
does not contain HCV antibodies. Staff follow up will be initiated by the WHS Coordinator.
Referral to a specialist hepatologist is advisable.
•
If the source is positive for anti–HCV there is around 65% to 80% chance that they are
infectious. If the source’s blood tests are positive for anti–HCV, a polymerase chain
reaction (PCR) test should be performed if possible.
•
PCR test positivity is currently the best marker of the potential to transmit HCV infection.
As PCR positivity can be intermittent, a PCR negative result in a HCV antibody positive
source does not preclude infectivity. However it may be reassuring to the staff member
to know that the risk of transmission of HCV is lower if the source blood is HCV PCR
negative.
•
If the source was found to be anti–HCV positive, the staff member should be followed
up specifically for liver function tests, anti–HCV testing, and Hepatitis C PCR at 6 weeks
and again at 6 months or as ordered by the treating hepatologist, to determine if they
have become infected. If any abnormality is detected in this testing, the staff member
should be referred to a Hepatologist for further management.
5.4
If Source anti HIV Positive
IMMEDIATE referral to Westmead Hospital (CHW) and CHESS or Prince of Wales Hospital
(SCH) for counselling and possible anti-retroviral prophylaxis if source is either HIV positive
or at high risk for HIV for possible prophylactic treatment.
The risk of staff contracting HIV infection from needlestick injuries or contact with blood or
other body fluids from patients with HIV infection appears to be small. Nevertheless,
occasional cases have occurred, so staff who have been accidentally exposed should seek
advice immediately after the incident.
If the staff member has been exposed to blood or blood contaminated secretions from a
patient with HIV or possible HIV infection;
•
At CHW: the WHS & IM Department will contact Westmead Emergency or for
immediate referral. Ph : 9845 5555
•
At SCH: CHESS will refer the staff member to Prince of Wales Hospital for review.
If the source was considered low risk for HIV infection but later found to be antibody positive,
the exposed Staff Member should be sent to Westmead Emergency for (CHW) or
CHESS/Prince of Wales Emergency for (SCH) at the earliest opportunity for appropriate
management.
If the source was found to be anti–HIV positive, consider degree of risk as determined
previously (Table 1) and offer HIV prophylaxis as indicated. Refer to Table 3 - CDC
Recommendations for (Occupational) HIV Post exposure Prophylaxis (PEP)
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This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/A/14:9123-01:00
Policy: Needlestick and Blood Exposure Injuries: Health Care Worker
Table 3: HIV Prophylaxis
•
Two drug regimen use either tenofovir-emtricitabine (Truvada) OR zidovudinelamivudine (Combivir).
Drug
Tenofovir-emtricitabine
(Truvada)
Zidovudine-lamivudine
(Combivir)
•
Dose
300-200mg
daily
300-150mg twice
daily
Dose and presentation
1 tab daily
Max dose 300-200mg
1 tab twice daily.
Main toxicity
Nephrotoxicity
Three drug regimen use either tenofovir-emtricitabine (Truvada) OR zidovudinelamivudine (Combivir) PLUS one of the following combinations of protease inhibitors.
Drug
Lopinavir-ritonivir
(Kaletra)
Dose
>40kg 400-100mg
twice daily.
Dose and presentation
Should be taken with food.
100-25mg tablets
Main toxicity
Diarrhoea, hepatitis,
pancreatitis,
headache
200-50mg tablets
Atazanavir-ritonivir
300-100 mg once daily
Darunavir-ritonivir
800-100 mg once daily
Max 400-100mg twice daily.
Discuss with virologist or ID
physician
Discuss with virologist or ID
physician
Jaundice, renal
stones hepatitis
Hepatitis
Note: If the staff member is HBsAg positive discuss anti-retroviral therapy with the
virologist or ID physician.
5.5
Tetanus
Tetanus prophylaxis should be considered and instituted if the injury circumstances warrant it
(e.g. injuries sustained during the handling of garbage bags, or injuries from discarded
needles in a soiled environment such as a garden bed or outside grounds of the hospital).
6
Complete Appropriate Documentation
At CHW
•
Document the incident on Safety at Kids (IIMS).
•
The "Record of Staff Exposed to Blood/or Potentially Blood Contaminated Secretions"
form is to be completed by the attending Medical Officer or WHS & IM staff health nurse
for the source and person exposed to blood/ body fluid.
•
The blood exposure packages containing the forms are available from the:
o
the WHS & IM Department (Level 1)
o
Operating Suite (Level 3)
o
Emergency Department (in Blood Exposure Packages)
o
The Afterhours NUM (Level 4)
Note: All forms on completion must be sent to the WHS & IM Department
Date of Publishing: 22 December 2014 6:08 PM
Date of Printing: 22 December 2014
K:\CHW P&P\ePolicy\Dec 14\Needlestick and Blood Exposure Injuries - Health Care Worker.docx
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This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/A/14:9123-01:00
Policy: Needlestick and Blood Exposure Injuries: Health Care Worker
At SCH:
•
Contact CHESS p 42782 Mon- Fri office hours and follow instructions or Page the
Prince of Wales (POW) needle stick Assessor via Switch Ext 9 if after hours.
•
Report the incident to your supervisor
•
Complete a confidential NSW Health Reporting form
•
Report to the POW Emergency Department and the Needle Stick Assessor will be
paged for management and reporting.
7
Follow-up Management
All staff should be offered follow-up testing if required.
7.1.1
•
Provide counselling and perform anti-HIV and anti-HCV. If the staff member was not
hepatitis B immune perform HBsAg, anti-HBc and anti-HBs.
7.1.2
•
Source Negative for HIV, HBV, and HCV
Source of Unknown Infectious Status or Unable to be tested
Management will depend on the outcome of the risk assessment.
7.1.3
Source Likely to be in the Window Period for HIV, HBV or HCV
•
Source should be followed up for 3 months to determine if they develop antibodies.
•
Staff should be retested at:
o
6 weeks and 3 months for HIV post exposure
o
3 months and 6 months for HBV post exposure
o
6 weeks and 6 months for HCV post exposure.
7.1.4
•
Source Positive or Likely to be Positive for HBV
Prophylaxis and follow up management as per Table 2.
7.1.5
Source Positive or Likely to be Positive for HCV.
If the source is positive for anti-HCV there is around 3% risk of transmitting HCV from a deep
needlestick injury with a hollow needle. If source blood tests positive for anti-HCV, a
polymerase chain reaction (PCR) test should be performed if possible. PCR test positivity is
at present the best marker of the potential to transmit HCV infection. As PCR positivity can
be intermittent, a PCR negative result in a HCV antibody positive source does not preclude
infectivity, but it may be reassuring to the health care worker to know that the transmission of
HCV is very low if the source blood is HCV PCR negative (approximately 1.8% from a deep
needlestick injury with a hollow needle).
If the source was found to be anti-HCV positive, the staff member should be followed up
specifically for liver function tests, PCR, and anti-HCV testing as per treating physician,
alternatively, this can be arranged through a Doctor of choice. If an abnormality is detected in
Date of Publishing: 22 December 2014 6:08 PM
Date of Printing: 22 December 2014
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This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/A/14:9123-01:00
Policy: Needlestick and Blood Exposure Injuries: Health Care Worker
either test, the staff member should be referred to a Hepatologist for further management.
HCV PCR should be offered at 6 weeks post exposure and if negative at that time, the risk of
transmission is negligible but a HCV antibody test at 6 months post exposure should still be
undertaken to confirm that transmission has not occurred.
7.1.6
Source Positive for HIV
If the source was found to be anti-HIV positive, follow up management will be continued at
the Staff Health Clinic, (CHW) and CHESS (SCH).
8
General Advice for Staff Exposed to HIV, HCV or HBV
Positive Blood
If source positive or likely to be positive for HIV, HBV or HCV, during the 6 month period
following exposure the staff member should be advised:
•
Not to donate plasma, blood, body tissue, breast milk or sperm.
•
To protect sexual partners by adopting safe sexual practices (eg use of condoms).
•
To seek expert medical advice regarding pregnancy and/or breastfeeding.
•
To seek expert clinical advice regarding the need to modify work practices involving
exposure prone procedures. This will usually only be recommended in the case of
highest risk percutaneous exposures (as defined in Table 1).
•
To seek expert clinical advice and to modify work practices if involved in the
performance of exposure prone procedures if he/she develops clinical or serological
evidence of HBV.
Further Information
Resource for Staff:
o
Health Care Facilities with Clinicians Experienced in Treatment of HIV and
HCV:
http://chw.schn.health.nsw.gov.au/ou/ohs/resources/staff_health/resources_treatment_of_HIV_and_HCV.pdf
Date of Publishing: 22 December 2014 6:08 PM
Date of Printing: 22 December 2014
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This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/A/14:9123-01:00
Policy: Needlestick and Blood Exposure Injuries: Health Care Worker
9
NSW Health Policy Directives
Further Information and Bibliography
1. NSW Health Directive PD2005_311 “HIV, Hepatitis B and Hepatitis C – Management of
Health Care Workers Potentially Exposed”.
2. NSW Health Directive PD2005_162 “HIV, Hepatitis B and Hepatitis C - Health Care
Workers Infected”.
Copyright notice and disclaimer:
The use of this document outside Sydney Children's Hospitals Network (SCHN), or its reproduction in
whole or in part, is subject to acknowledgement that it is the property of SCHN. SCHN has done
everything practicable to make this document accurate, up-to-date and in accordance with accepted
legislation and standards at the date of publication. SCHN is not responsible for consequences arising
from the use of this document outside SCHN. A current version of this document is only available
electronically from the Hospitals. If this document is printed, it is only valid to the date of printing.
Date of Publishing: 22 December 2014 6:08 PM
Date of Printing: 22 December 2014
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This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.