Blood exposure : Minimize the risk in clinical setting Dr. Ahmed Fawzy BD Medical
Health care Acquired infections : a growing issue Nearly 6 million annually Increasing 1.7% per year Widespread antibiotics use Drug-resistance 2
How does blood exposure occur? 3
Why is it Important to Treat NSIs seriously? Some Interesting facts.. The healthcare workforce, 35 million people worldwide, suffer from two million needlestick injuries (NSI) per year resulting in infections with Hepatitis B and C and HIV. The projected two million NSI are probably a low estimate because of the lack of surveillance systems and underreporting of injuries. Research has shown 40-75% of underreporting of NSI. The Global Occupational Heath Network, Newsletter Preventing NSI & Occupational Exposure to Bloodborne 4 Pathogens. Winter 2005
What Can you Contract From a Needlestick and blood exposure? Viral Infections Bacterial Infections Fungal Infections Hepatitis B Brucella Abortus Blastomyces Dermatitidis Hepatitis C Corynebacterium Diphteriae Cryptococcus Neoformans Hepatitis G Neisseria Gonhorreae Sporotrichum Schenkii Human Immunodeficiency Virus Leptospira Icterohaemorrhagiae Simian Immunodeficiency Virus Mycobacterium Marinum Protozoal Infections Herpes Simiae Mycoplasma Caviae Plasmodium Falciparum Herpes Simplex Orientia Tsutsugamushi Toxoplasma Gondii Herpes Zoster Rickettsia Rickettsii Ebola/Marburg Staphylococcus Aureus Tumors Dengue Streptococcus Pyogenes Humon Colonic Adenocarcinoma Creutzfeldt-Jakob Disease Treponnema Pallidum Sarcoma Mycobacterium Tuberculosis Today there are 30 known pathogens.tomorrow??? Jagger J, De Carli G, Perry J, Puro V, Ippolito G. Chapter 31. Occupational exposure to bloodborne pathogens: epidemiology and prevention. 5 In: Wenzel RP; Prevention and Control of Nosocomial Infections. 4th ed. Baltimorek Md: Lippincott, Williams & Wilkins; 2003.
Mucocutaneous Exposure Even though the naked eye may not be able to see it. 4The Global Occupational Heath Network, Newsletter Preventing NSI & Occupational Exposure to Blood-borne Pathogens 2007 5 Strauss K.W. Onia R. And Van Zundert A.A.H., 2008 Peripheral intravenous catheter use in Europe: towards the use of safety devices, Acta Anaestesiol Scand 2008.1-7 6 Bond WW, Favero MS, Petersen NJ, et al. Survival of hepatitis B virus after drying and storage for one week. Lancet 1981;1(8219);550-1 6
Mucocutaneous Exposure 4The Global Occupational Heath Network, Newsletter Preventing NSI & Occupational Exposure to Blood-borne Pathogens 2007 5 Strauss K.W. Onia R. And Van Zundert A.A.H., 2008 Peripheral intravenous catheter use in Europe: towards the use of safety devices, Acta Anaestesiol Scand 2008.1-7 7 6 Bond WW, Favero MS, Petersen NJ, et al. Survival of hepatitis B virus after drying and storage for one week. Lancet 1981;1(8219);550-1
Expect the unexpected 8
Time to think? Each month, 46% of healthcare workers sustain at least one blood exposure during I.V. catheter insertion and 42% during I.V. catheter removal 9 1 Jagger J, et al. Blood exposure risk during peripheral I.V. catheter insertion and removal. Nursing2011, Volume 41, Number 12, December 2011
The Cost 10
Most Cited Sources of Needle stick Injuries 1. Improper sharps disposal Overfilled sharps containers 2. Uncooperative patients 3. Improper lighting 4. Not familiar with device 5. Improper handling 1. Improper passing of sharps to other personnel 2. Improper suture technique
CDC Exposure Risk Percutaneous injury transmission rates with blood or blood products: HBV 2-40% HCV 3-10% HIV 0.2-0.5%
Universal Precautions Treat all human blood and certain body fluids as if they are infectious Must be observed in all situations where there is a potential for contact with blood or other potentially infectious materials
How to Minimize the risk Risk management: An integrated risk management policy is a must Risk assessment: 1 identify the risks 2 Manage and minimise eliminate unnecessary injections Training & Education Standard precautions Safer technology (ENGINEERING CONTROL) Immunisation & vaccination Source: NHS Employers 2005
RISK ASSESSMENT Assessing the risks Risk assessment should be made of all situations where HCW might be exposed to blood or other potentially infectious material. The aim is to: Identify what technologies could be used to limit exposures Allow consideration of possible alternatives Eliminate the unnecessary use of sharps by implementing changes in practice and providing, where practicable sharp free devices or safer needle technologies which retract or shield needles after use Source: NSH Employers 2005
Reporting sharps injuries A core component of risk management: Underreporting is a serious threat to management of such injuries Some studies suggest underreporting as high as 85% Prompt reporting is critical following local policy This ensures quick management and reduces risk of BBV transmission The incident is documented in case of future litigation Helps with accurate surveillance to inform =development of effective risk reduction strategies Source: NSH Employers 2005
Identifying alternatives Independent studies show that a combination of training, safer working practices and the use of devices incorporating sharps protection mechanisms can prevent more than 80% of needlestick and sharps injuries. Provision of portable sharps containers for all staff at all times is crucial to allow used sharps to be disposed of at the point of use Source: NSH Employers 2005
Training Induction and ongoing training should cover sharps safety for all staff and particularly: The risks associated with blood and body fluid exposure Correct use and disposal of sharps The use of medical devices incorporating sharps protection mechanisms Refresher training is important Source: NSH Employers 2005
Standard precautions Sharps must not be passed directly from hand to hand and handling should be kept to minimum Needles must not be bent or broken prior to use or disposal Needles and syringes must not be disassembled by hand prior to disposal Prevention of HCAI in Primary and Community Care (2003)
Standard precautions Needles should not be recapped. Used sharps must be discarded into a sharps containers at the point of use. These must not be filled above the mark indicating that they are full. Containers in public areas must not be placed on the floor and should be located in a safe position Prevention of HCAI in Primary and Community Care (2003)
Standard precautions: Hands & gloves Hands must be decontaminated immediately before each and every episode of direct patient contact/care and after any activity or contact that potentially results in hands becoming contaminated. Use an alcohol based hand rub on hands not visibly soiled Gloves must be worn for invasive procedures, contact with sterile sites, and non-intact skin, mucous membranes, and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions and excretions; and when handling sharp or contaminated instruments. Source: EPIC 2001
Standard precautions: Hands & gloves Gloves should be worn as single use items. Put gloves on immediately before an episode of patient contact or treatment and remove them as soon as the activity is completed. Full body, fluid repellent gowns should be worn where there is a risk of extensive splashing of blood, body fluids, secretions and excretions, with the exception of sweat, onto the skin of health care practitioners. Face masks and eye protection should be worn where there is a risk of blood, body fluids, secretions and excretions splashing into the face and eyes. Source: EPIC 2001
Engineering controls Safer needle devices Needle safety devices must be used where there are clear indications that they will provide safer systems of working for health care personnel. USA : ACT 2000 EU: Safety Directive 2011 (it is law!!) Recent estimates suggest that safety devices exist in 11 different product groups. Safety devices on the whole minimise risks in association with venepuncture, IV therapy, injections and "downstream" injuries following disposal (housekeeping and portering staff) Prevention of HCAI in Primary and Community Care (2003)
Catheter injuries per 100,000 I.V. Catheter Injury Rates conventional versus safety 8 7 6 5 4 3 2 1 0 7.5 6.6 1.2 0.7 3 hosps 92-93 1 hosp 93-99 Conventional Catheters Safety Catheters From: Jagger J. Bentley M. J Intraven Nurs 1997;20(6):S33-S39 25 From: Mendelson M, Chen L, et. Al. (abstract) 4th Decennial Int l Conference on Nosocomial & Healthcare Associated Infections, Atlanta, 3/5/2000 devices
Engineering controls sharps devices with an integrated engineered sharps injury prevention feature should accomplish the following: Be an integral part of the device, Be simple and obvious in operation, Be reliable and automatic, Provide a rigid cover that allows the hands to remain behind the needle, Ensure that the safety feature is in effect before disassembly and remains in effect after disposal, Ensure the user technique is similar to that of conventional devices, Minimize the risk of infection to patients and should not create infection control issues beyond those of conventional devices, Be cost effective. 26 CDC Workbook for designing, implementing and evaluating a sharps injury prevention programme (2004): http://www.cdc.gov/sharpssafety/
Safe Enviroment Questions for consideration:` At ward or department level whose responsibility is this? Are roles assigned and are checks made? How would a situation be managed if there was a failure to apply these simple measures? Is a monthly, quarterly or annual audit enough? Source: EPIC 2001 Prevention of HCAI in Primary and Community Care (2003)
After an injury or exposure Local policy. Key points: First aid Place under running water Flush splashes to nose, mouth with water Irrigate eyes with clean water or saline Report to occupational health Know your Hepatitis B vaccination status. Prompt reporting is important in all cases to determine whether post exposure prophylaxis is required (this needs to be started as soon as possible)
CDC Workbook for designing, implementing and evaluating a sharps injury prevention programme (2004): http://www.cdc.gov/sharpssafety/ Root Cause Analysis (RCA) The key to RCA is asking the question "why?" as many times as it takes to get down to the root cause of an event: What happened? How did it happen? Why did it happen? What can be done to prevent it happening in the future?
Risk Factors that increase the likelihood of HIV transmission following a needlestick injury 1. Deep injury 2. High viral titre in the patient on whom the device had been used 3. Visible blood on the device 4. Device in artery/vein Source: CDC, MMWR 6/98
Critical questions for safer practice: Where is the needlestick policy kept and how is it publicised? What is the plan following an exposure and how are staff made aware of this? Are sharps injuries discussed at a regular team meeting? Are safer needle devices used and if so do you play a part in selection and evaluation of these devices Are there any informational materials eg leaflets on sharps injuries and are they readily accessible? Are these visible/pocket sized for example
Last remarks: Avoid the use of needles wherever possible Avoid recapping needles instead immediately place the uncapped needle into a sharps box Think ahead and plan the safe handling and disposal of sharps before using them is there a sharps container in the vicinity Never fill a sharps container more than three quarters full Don t open or empty sharps containers Store sharps containers in a secure place until ready for removal for incineration Make sure your immunisations are up to date Source: WHO 2005
Summary: While studies show that reductions of needlestick injuries are achievable, it is difficult to identify the efficacy of individual control measures in studies with numerous interventions. Reducing sharps injuries by the greatest amount possible will entail a combination of Elimination of procedures using sharps Education& training Safer devices Positive work conditions Standard precautions WHO (2005) Protecting Healthcare Workers, Preventing Needlestick Injuries Toolkit. Occupational and Environmental Health Unit
Sources of material and references Publications: Health Protection Agency (2005) Eye of the Needle: Surveillance of Significant Occupational Exposure to Bloodborne Viruses in Healthcare Workers. Centre for Infections; England, Wales and Northern Ireland Seven-year report Department of Health (2005) Saving Lives khcdja Pratt RJ, Pellowe C, Loveday HP, Robinson N, Smith GW, et al (2001) The EPIC Project : developing national evidence baesed guidelines for preventing healthcare associated infections. Phase 1 guideliens for preventing hospital-acquired infections J Hosp Infect 2001; 47: S3-S82 NHS Employers (2005) The management of health, safety and welfare issues for NHS staff, chapter 19: Needlestick Management NAO (2003) A safer place to work improving the management of health and safety risks of staff in NHS Trusts NIOSH (1998) How to Protect Yourself From Needlestick Injuries Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Instutute for Occupational Safety and Health Wilburn S, Eijkemans G (2004) Preventing needlestick injuries among HCWs: A WHO ICN collaboration. Int J Occup Environ Health vol 10 no 4 www.ijoeh.com Websites: EPIC Guidelines: http://www.epic.tvu.ac.uk/epicphase/1.html ICNA Audit Tools: Infection Control Nurses Association (2004) available from: www.icna.co.uk The European Forum for protection of Healthcare Professionals in a safer working environment http://www.needlestickforum.net NHS Purchasing and Supplies Agency product related information relating to sharps safety: www.pasa.nhs.uk/medicalconsumables/sharps/ WHO (2005) Protecting Healthcare Workers, Preventing Needlestick Injuries Toolkit. Occupational and Environmental Health Unit http://www.who.int/occupational_health CDC Workbook for designing, implementing and evaluating a sharps injury prevention programme (2004): http://www.cdc.gov/sharpssafety/