Prevention and Management of Sharps Injuries Flashcards
3 Blood borne viruses
- hep B
- hep C
- HIV
what are the potential risks of sharps injuries?
contracting a BBV (hep b, hep C or HIV)
bacterial infections
stress and mental impact of sustaining (especially if managed poorly)
4 methods of exposure to sharps injury
Needles or sharp objects (e.g. probes, scalpels etc.) that are contaminated with blood/bodily fluids that pierce/break the skin
- Pre, during and post procedure and post disposal (if disposed of poorly)
Splashing of blood/bodily fluids onto skin that is broken (e.g. abraded, chapped, open sores, dermatitis)
Contamination of eyes, nose or mouth with blood/bodily fluids
A human bite that breaks the skin
6 common sharp injuries
During IDB, needle goes into thumb
Adjusting posts, CoCr dentures etc. out with the mouth
Burs or ultrasonic tips left in situ in handpieces which are placed at elbow height (legs/arms as passing by)
Slipping luxators
Anaesthetic spraying from palate
Unsheathed needles left on messy trays Needles left on messy trays
- Responsibility of dentist to dispose of sharps equipment not nurse
IDB
inferior alveolar nerve block
why is it hard to establish number of occupational exposures in Scotland?
incidents under reported to the system
Only secondary care (hospital)
Only see GP, GDP if got to local NHS health board
what BBV is of the highest prevalence of significant occupational exposures
hep C
81%
- (HIV 10%; HBV 6%; mixed 3%)
Especially among IV drug users in Scotland
who gets sharps injuries?
Doctors 40%
Nurses and healthcare assistance 43%
Dentist/nurse 6%
Midwife 3%
Professions allied to medicine 8%
Other and NK 4%
most common timing of needlestick injuries
during the procedure (63%)
but can occur either side
how can a cleaner obtain a sharps injury?
when moving waste bags can get needle stick - ended in wrong waste not sharp bin
what should staff know in the case of a needlestick injury?
What action to take – you have a legal responsibility to report all sharps injuries
- Law
Who has responsibility to ensure proper assessment
- Not yourself – never assess own injury
Where to go for treatment of the injury and follow-up
How to report the incident so that systems can be revised to reduce future injuries
acronym for what to do following a sharps injury
be sharps AWARE
Apply pressure and allow to bleed Wash don’t scrub Assess type of injury Risk of source blood? Establish contact
be sharps AWARE stands for
Apply pressure and allow to bleed Wash don’t scrub Assess type of injury Risk of source blood? Establish contact
Apply pressure and allow to bleed
Gently squeeze injury site to induce bleeding
Wash don’t scrub
Wash affected area with soap and warm running water – DO NOT scrub
Treat mucosal surfaces by rinsing with warm water or saline e.g. eyes
2 areas to Assess in the type of injury
high risk material?
significant injury?
Risk of source blood - how to assess
establish whether know the source of the blood
- whether their BBV status is known, or IV drug user
assess prevalence of BBV in general population
Establish contact
Report injury promptly to a senior member of staff
Call occupational health
Record injury (accident book and official reporting)
Employees who have had injuries must be followed up for prophylaxis, counselling and prevention
examples of high risk materials
blood and bodily fluids with visible blood
Saliva*
- with no visible blood, only risk is HBV
- need visible blood for HIV and HCV risk
examples of significant injuries
percutaneous,
human bite* with skin broken
- biter is at more risk of infection than bitten is pierce the skin and blood in the mouth
exposure of broken skin or mucous membrane to blood or body fluids
what would the risk be of a superficial graze, exposure of intact skin
non-significant injury
should still report
examples of high risk injuries
deep penetrating injury by a device visibly contaminated with blood
Injury with a device that had previously been placed directly in the source patient’s artery or vein
what would be greater risk - injury by hollow bore or solid instrument?
Hollow bore device - greater volume of blood compared to solid which will only have blood on the surface
how to assess the risk of source blood if status unknown?
is the patient in a high risk group?
- e.g. intravenous drug user
what can lower the risk of transmission if the patient is HIV+?
patient on cART
- Combined anti-retroviral therapy
Undetectable viral load means no risk
- U = U
- Undetectable viral load means untransmissible HIV
- Most in Scotland as they are on treatment
what are the 2 factors which contribute to the risk of blood transmission
sero conversion rates
prevalence in general population
what BBV has the highest risk sero-conversion rate
highest risk is HBV
- particularly E antigens individuals
how to assess the BBV risk if do not know the source of the needle
Do not know the source of needle (e.g. out of bag)
- Think of prevalence in general population
- Multiply by risk of sero-conversion
Risk is low
Estimated risk of HCV transmission by NSI:
1/100 x 1/30 = 1/3000 (general population)
how to assess the hep C risk if know the source is an IV drug user
Risk of transmission high
2/5 x 1/30 = 1/75
PWID risk, HCV status NK
when is post exposure prophylaxis treatment given
If HIV transmission risk is less than 1 in 10,000 PEP is not recommended
but should only be prescribed if there are additional factors that may increase the likelihood of transmission.
who should interview the source patient/consent for bloods/their status?
Not your responsibility to ask source for consent for BBV assessment
- Need another member of the team
Hard operationally for dentist as smaller team
- May have to get them to go with you to A&E to get bloods taken when you are treated
if patient source comes back with negative BBV results this indicates
reassurance to HCW
if the patient source status is known then whats the next step?
test for BBVs or conform previous results with consent
is the patient source status is unknown or they refuse consent
risk assess on circumstance and likelihood for BBV (type of injury and limited information known on patient from records)
how to assess BBV status of recipient
History of HBV vaccination (partially or fully vaccinated) and response (known responder or non-responder)
- Hepatitis B is most infectious
- Dental professionals should all have Hep B vaccine
- Non-responder or contra-indications to getting vaccine, need to know as different management
History of previous tests for BBVs
Take baseline bloods for storage - Taken and stored - End of follow up indicated BBV - Test this to see if positive Than can see sero-conversion caused BBV and not prior acquired
reason for taking baseline bloods from recipient
- Taken and stored
- End of follow up indicated BBV
- Test this to see if positive
Than can see sero-conversion caused BBV and not prior acquired
post exposure prophylaxis HBV
Immunoglobulin and/or vaccine
how does Hepatitis B immune globulin act as a post-exposure prophylaxis agent for HBV?
- Hepatitis B immune globulin (HBIG) provides an estimated 70% - 75% protection from HBV infection
- If HBIG indicated administer at the same time or within 24hrs of the first dose of vaccine (but not after 7 days have elapsed since exposure)
- Immediate protection to prevent seroconversion from happening
how does the vaccine act as a post-exposure prophylaxis agent for HBV?
Vaccine will boost immunity
Takes a few days to respond
when is post exposure prophylaxis for HBV not required?
Not required for those who have successful response to vaccine
post exposure prophylaxis requirement is dependent on…..
vaccination status of recipient prior to exposure (vaccination status and responsiveness)
the type of exposure
the HBV status of the source
who should assess the sharps injury
occupational health team member
complicated
should not be carried out by recipient
post exposure prophylaxis for HIV
Combined anti-retroviral therapy
- start within 24h of exposure (if indicated)
Common side effects include headaches, fever, and nausea
- Many healthcare workers exposed to an HIV-positive source discontinue all or part of their PEP regimen prematurely because of drug toxicity (unpleasant)
Not routinely recommended if source has confirmed and sustained undetectable viral load or unless risk is less than 1 in 10,000
minimum follow up
for at least 6-12 weeks after the exposure event
if PEP was taken, follow up should be at least 12 weeks from when PEP was stopped
A negative test at 12 weeks provides a very high level of confidence of freedom from infection
follow up is PEP taken
follow up should be at least 12 weeks from when PEP was stopped
negative follow up indicates
very high level of confidence of freedom from infection for recipient
whats the best form of prevention of occupational exposure and BBV transmission by sharps
best to try and avoid them altogether
examples of initiatives to try and avoid occupational exposures and sharps injuries
Vaccination
Raising awareness
Safety engineered devices
Risk assessment
Elimination of unnecessary needles
PPE
Recording and reporting
No recapping
PEP
Sharps containers
Work practices
Hand hygiene
when did laws get put into action to target protecting HCW from occupational sharps exposures
Health and Safety (Sharp Instruments in Healthcare) Regulations 2013
transported from EU Council Directive 2010/32/EU the “Sharps Directive”
who does the laws about sharps regulations apply to
Employers and employees
Contractors working for HC employer
Students/trainees on placement with HC employers
Community or hospital pharmacies
what does the hierarchy of control focus on?
the most effective measure of removing the hazard first, rather than relying on training, behavioural or changes to work practices and the use of protective equipment.
Assess if risk from sharps
- Yes - can you eliminate risk of sharp
- Most cases cannot change to blunt tip
Need to think of alternatives
- Engineering controls
- Safer sharps devices
- Disabling the sharp point (covering it)
If unable to use a safer sharps device (need justification) then look at processes, PPE and behavioural processes to minimise injuries
what is the underlying principle of EU directive to minimise occupational sharps exposure
prevention of exposure
- utilises hierarchy of controls
Historically, the focus on sharps injuries has been about changing behaviours of sharps users and effective follow up and support after an injury
the main requirements of the regulations for employers
need to assess the risk of sharps injuries under the COSHH regulations.
- Where risk are identified, the sharps in healthcare regulations require them to take specific risk control measures
Promote the safe use and disposal of medical sharps
Provide information and training for employees
Respond effectively if an injury occurs
Review procedures regularly
the main requirement of the regulations for employees
An employee who receives a sharps injury at work must notify their employer as soon as practicable (regulation 8)
- Clearly employers need to have adequate processes in place to allow for prompt notification particularly for out of hours and for those working in the community.
A number of underlying principles within the directive that relate to this duty
- Workers should take care, as so far as possible, of their own health and safety
- Never assume there is no risk of exposure following a sharps injury
- The need to promote a no blame culture to ensure that incident reporting procedures focus on systemic failures rather than individual mistakes
supported by
- Information and training on what to do in the event of a sharps injury (reporting incidences) (regulation 6(4))
how can an employee make a claim against an employer
by reporting the sharps injury exposure
- no report = no evidence that employer failure caused infection
reason in the future why sharps injuries should be reported by the employee now
to prevent future injuries
- learn lesson
are safety devices in wide use
yes in GDH
but many practices don’t use them
passive safety device
Activate themselves
Risk post procedure
active safety device
Require you to launch the mechanisms which enable the sharp
do safety devices cause a decrease in sharps injuries
General decrease in risk post procedures
US data suggest that effectiveness of safer devices ranges from 29%-89%
- Need to ensure disabled before disregarding
can still get injury e.g. if patient jumps
what are the most important elements in sharps injury prevention
staff training and strict adherence to policies on handling contaminated sharps
- safety devices do not automatically eradicate risk
- your responsibility to know how to use and activate them properly
exposure prone procedure
Those invasive procedures where there is a risk that injury to the worker may result in the exposure of the patient’s open tissues to the blood of the worker
EPPs
management of HBV infected HCW
HBV infected healthcare workers may perform EPPs if they:
- have a viral load <200 IU/ml (either from natural suppression or 12 months after cessation of antiviral therapy), and
- are subject to annual plasma viral load monitoring, and
- are under joint supervision of a consultant occupational physician and their treating physician,
used to be fear on old therapy that a breakthrough will cause viral load to spike – risk minimal on new treatment
cannot practice if infected or have high viral load
management of HCV infected HCW
Must be HCV RNA negative
- As a consequence of natural clearance, or
- At 6 months after cessation of antiviral therapy
Can only practice if clear infection
- 90%+ will clear infection if treated and after 6 months and can return practice
management of HIV infected HCW
Must either
- Be on effective combination antiretroviral therapy (cART), AND
- Have a plasma viral load <200 copies/ml
- Be an elite controller, and
- Be subject to plasma viral load monitoring every 3 months, (Blood taken by occupational health to assess viral load)
- Be under joint supervision of a consultant occupational physician and their treating physician, and
- Be registered with the UKAP-OHR
will the patients find out if their HCW has a positive BBV result
NO
- No notification exercises now for BBV positive healthcare workers
- No adverse repercussions to dentist if report sharps injury and acquire BBV
best policy in terms of occupational sharps injuries
prevention
- staff training important
what does successful prophylaxis require
careful planning in advance
EPP
exposure prone procedures
seroconversion
time period during which a specific antibody develops and becomes detectable in the blood. After seroconversion has occurred, the disease can be detected in blood tests for the antibody
