Audit of emergency department assessment and management of patients presenting with community-acquired needle stick injuries
Antonio Celenza A G , Lloyd J. D’Orsogna B , Shervin H. Tosif C D , Samantha M. Bateman C D , Debra O’Brien E , Martyn A. French B and O. Patricia Martinez FA University of Western Australia, QEII Medical Centre, Hospital Avenue, Nedlands, WA 6009, Australia.
B Department of Clinical Immunology and Immunogenetics, Royal Perth Hospital, Wellington Street, Perth, WA 6009, Australia. Email: ldorsogna@hotmail.com; martyn.french@health.wa.gov.au
C University of Western Australia, Stirling Highway, Crawley, WA 6009, Australia. Email: shervs@gmail.com; Samantha.bateman@health.wa.gov.au
D Present address: Royal Perth Hospital, Wellington Street, Perth, WA 6000, Australia.
E Emergency Department, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia. Email: debra.obrien@health.wa.gov.au
F School of Pathology and Laboratory Medicine, University of Western Australia, c/o Royal Perth Hospital, Wellington Street, Perth, WA 6009, Australia. Email: patricia.martinez@health.wa.gov.au
G Corresponding author. Email: tony.celenza@uwa.edu.au
Australian Health Review 35(1) 57-62 https://doi.org/10.1071/AH09846
Submitted: 21 October 2009 Accepted: 18 May 2010 Published: 25 February 2011
Abstract
Objectives. To describe characteristics and management of people with community acquired needle stick injuries (CANSI) attending urban emergency departments; and suggest a guideline to improve assessment, management, and documentation.
Methods. A retrospective analysis of cases with CANSI attending emergency departments in two tertiary hospitals between 2001 and 2005 using medical record review with follow up phone and written survey.
Results. Thirty-nine cases met the criteria for CANSI. Persons younger than 30 years sustained 48.72% of all injuries. Source serology was available for only five cases (12.82%). Thirty-one of thirty-nine patients (79.49%) were classed as not immune to hepatitis B but only four of these (12.90%) received both hepatitis B vaccination and hepatitis B immunoglobulin. Six patients (15.38%) received HIV prophylaxis; of which two (33.33%) did not receive baseline HIV testing. Of ten patients referred to immunology clinic for follow up only two (20.00%) attended at 6 months.
Conclusion. We have identified groups that are at high risk of CANSI, including young males, security workers and cleaners. In the majority of cases protection against hepatitis B was inadequately provided, and a substantial proportion had inadequate baseline assessment and documentation. A guideline is suggested that may be used to improve these deficits.
What is known about this topic? Occupationally acquired needle stick injury guidelines are well established, but no guidelines currently exist for community acquired needle stick injuries (CANSI) which may require different risk stratification, assessment and management. Management of CANSI in Emergency Departments has not been well described.
What does this paper add? An audit of Emergency Department management of community acquired needle stick injuries demonstrates deficits in risk assessment, documentation and use of post-exposure immunisation and prophylaxis. A guideline is suggested that may be used to improve these deficits.
What are the implications for practitioners? Practitioners need to perform and document a risk assessment of the injury, perform baseline serology, and provide tetanus and hepatitis B immunisation. Use of HIV post-exposure prophylaxis is determined by local prevalence of disease, injury risk assessment, source serology if known, and time since injury.
References
[1] Lorentz J, Hill L, Samimi B. Occupational needlestick injuries in a metropolitan police force. Am J Prev Med 2000; 18 146–50.| Occupational needlestick injuries in a metropolitan police force.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3c7mt1Sksw%3D%3D&md5=2db5cb586057a93e5ea940763326d50eCAS | 10698245PubMed |
[2] Russell FM, Nash MC. A prospective study of children with community-acquired needlestick injuries in Melbourne. J Paediatr Child Health 2002; 38 322–3.
| A prospective study of children with community-acquired needlestick injuries in Melbourne.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD38zotlCktg%3D%3D&md5=4aa2f438637428c5c3d3d2a3496b8e08CAS | 12047709PubMed |
[3] Loxley WM, Phillips M, Carruthers SJ, Bevan JS. The Australian study of HIV and injecting drug use. Part I: prevalance for HIV, hepatitis B and hepatitis C among injecting drug users in four Australian cities. Drug Alcohol Rev 1997; 16 207–14.
| The Australian study of HIV and injecting drug use. Part I: prevalance for HIV, hepatitis B and hepatitis C among injecting drug users in four Australian cities.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2MrivV2luw%3D%3D&md5=66fd18a3e96b88801911aaeda9ef09a1CAS | 16203429PubMed |
[4] Shooting up: infections among injecting drug users in the United Kingdom 2008. London: Health Protection Agency, Health Protection Scotland, National Public Health Service for Wales, CDSC Northern Ireland, CRDHB; 2009.
[5] National guidelines for post-exposure prophylaxis after non-occupational exposure to HIV. Australian Government Department of Health and Ageing; 2007. Available at http://www.ashm.org.au/images/publications/guidelines/2007nationalnpepguidelines2.pdf [verified April 2010]
[6] Carruthers SJ. The ins and outs of injecting in Western Australia. J Subst Abuse 2003; 8 18–33.
[7] O’Leary FM, Green TC. Community acquired needlestick injuries in non-health care workers presenting to an urban emergency department. Emerg Med 2003; 15 434–40.
| Community acquired needlestick injuries in non-health care workers presenting to an urban emergency department.Crossref | GoogleScholarGoogle Scholar |
[8] Libois A, Fumero E, Castro P, Nomdedeu M, Cruceta A, Gatell JM, Garcia F. Transmission of hepatitis C virus by discarded-needle injury. Clin Infect Dis 2005; 41 129–30.
| Transmission of hepatitis C virus by discarded-needle injury.Crossref | GoogleScholarGoogle Scholar | 15937781PubMed |
[9] Haber PS, Young MM, Dorrington L, Jones A, Kaldor J, De Kanzow S, Rawlinson WD. Transmission of hepatitis C virus by needle-stick injury in community settings. J Gastroenterol Hepatol 2007; 22 1882–5.
| Transmission of hepatitis C virus by needle-stick injury in community settings.Crossref | GoogleScholarGoogle Scholar | 17914964PubMed |
[10] Gómez Campderá J, Rodríguez Fernández R, Navarro Gómez M, González Sánchez MI. Accidental contact with syringes used by intravenous drug users (IDU): a decade of study. An Esp Pediatr 1998; 49 375–80.
| 9859551PubMed |
[11] Zamora AB, Rivera MO, García-Algar O, Caylà Buqueras J, Vall Combelles O, García-Sáiz A. Detection of infectious human immunodeficiency type 1 virus in discarded syringes of intravenous drug users. Pediatr Infect Dis J 1998; 17 655–7.
| Detection of infectious human immunodeficiency type 1 virus in discarded syringes of intravenous drug users.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK1czkvFGhtQ%3D%3D&md5=cf4d8f9327ce5d9cdcfea0fbda4fc1f2CAS | 9686738PubMed |
[12] Makwana N, Riordan FAI. Prospective study of community needlestick injuries. Arch Dis Child 2005; 90 523–4.
| Prospective study of community needlestick injuries.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2M3hs1Smuw%3D%3D&md5=173becdbb43792ad4d35668f216bf5a5CAS | 15851438PubMed |
[13] van Wijk PThL, Pelk-Jongen M, de Boer E, Voss A, Wijkmans C, Schneeberger PM. Differences between hospital- and community-acquired blood exposure incidents revealed by a regional expert counseling center. Infection 2006; 34 17–21.
| Differences between hospital- and community-acquired blood exposure incidents revealed by a regional expert counseling center.Crossref | GoogleScholarGoogle Scholar | 16501897PubMed |
[14] McCausland JB, Linden JA, Degutis LC, Ramanujam P, Sullivan LM, D’Onofrio G. Nonoccupational postexposure HIV prevention: emergency physicians’ current practices, attitudes and beliefs. Ann Emerg Med 2003; 42 651–6.
| Nonoccupational postexposure HIV prevention: emergency physicians’ current practices, attitudes and beliefs.Crossref | GoogleScholarGoogle Scholar | 14581917PubMed |
[15] Center for Disease Control and Prevention Updated US public health service guidelines for the management of occupational exposures to HBV, HCV, HIV and recommendations for postexposure prophylaxis. MMWR Morb Mortal Wkly Rep 2001; 50 1–42.
| 11215787PubMed |
[16] Center for Disease Control and Prevention Antiretroviral postexposure prophylaxis after sexual, injection-drug or other non-occupational exposure to HIV in the United States. MMWR Morb Mortal Wkly Rep 2005; 54 1–20.
| 15647722PubMed |
[17] Rey D, Bendiane M-K, Moatti J-P, Wellings K, Danziger R, MacDowall W, The European Study Group On HIV Testing Policies and Practices In Europe Post-exposure prophylaxis after occupational and non-occupational exposures to HIV: an overview of policies implemented in 27 European countries. AIDS Care 2000; 12 695–701.
| Post-exposure prophylaxis after occupational and non-occupational exposures to HIV: an overview of policies implemented in 27 European countries.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3M7jsFKmuw%3D%3D&md5=a875ac0f37135a1f6daf5044231176eeCAS | 11177447PubMed |
[18] Merchant RC, Mayer KH, Browning CA. Development of guidelines on nonoccupational HIV postexposure prophylaxis for the state of Rhode Island. Public Health Rep 2004; 119 136–40.
| 15192899PubMed |
[19] HIV post-exposure prophylaxis: guidance from the UK Chief Medical Officer’s expert advisory group. UK Department of Health; 2008. Available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_088185 [verified January 2009].
[20] Havens PL, American Academy of Pediatrics Committee on Pediatric AIDS Postexposure prophylaxis in children and adolescents for nonoccupational exposure to human immunodeficiency virus. Pediatrics 2003; 111 1475–89.
| Postexposure prophylaxis in children and adolescents for nonoccupational exposure to human immunodeficiency virus.Crossref | GoogleScholarGoogle Scholar | 12777574PubMed |
[21] Diprose P, Deakin CD, Smedley J. Ignorance of post-exposure prophylaxis guidelines following HIV needlestick injury may increase risk of seroconversion. Br J Anaesth 2000; 84 767–70.
| 1:STN:280:DC%2BD3czlsVejuw%3D%3D&md5=deb2c06f6bb8aa1a5f7268e6dbc1d75fCAS | 10895754PubMed |
[22] Babl FE, Cooper ER, Damon B, Louie T, Kharasch S, Harris JA. HIV postexposure prophylaxis for children and adolescents. Am J Emerg Med 2000; 18 282–7.
| HIV postexposure prophylaxis for children and adolescents.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3c3ovFCqtQ%3D%3D&md5=bc62cc8a9ab8b659ee3614c364fe1784CAS | 10830685PubMed |
[23] Management of non-occupational post exposure prophylaxis to HIV (NONOPEP): sexual, injecting drug user or other exposures. Project Number 2000CVG4-022. European Commission; 2002. Available at http://www.inmi.it/news/LineeGuida/ReccommendationsNONOCC.PDF [verified 16 January 2009].
[24] Canadian Paediatric Society Needle stick injuries in the community. Paediatr Child Health 2008; 13 205–10.
| 19252702PubMed |
[25] The Australian Immunisation Handbook, 9th edn. National Health and Medical Research Council; 2008. Available at http://www.health.gov.au/internet/immunise/publishing.nsf/Content/2438118A16A8C30BCA2574E2000F9A54/$File/complete_handbook.pdf [verified 16 January 2009].
[26] Center for Disease Control and Prevention Serious adverse events attributed to nevirapine regimens for postexposure prophylaxis after HIV exposures-worldwide, 1997–2000. MMWR Morb Mortal Wkly Rep 2001; 49 1153–6.
| 11198946PubMed |
[27] Kahn JO, Martin JN, Rolan ME, Bamberger JD, Chesney M, Chambers D, Franses K, Coates TJ, Katz MH. Feasibility of postexposure prophylaxis (PEP) against human immunodeficiency virus infection after sexual or injection drug use exposure: the San Francisco PEP Study. J Infect Dis 2001; 183 707–14.
| Feasibility of postexposure prophylaxis (PEP) against human immunodeficiency virus infection after sexual or injection drug use exposure: the San Francisco PEP Study.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3M7ot1Gqug%3D%3D&md5=ba8aef58d30a949a1a8cc91d2c3b9bf5CAS | 11181146PubMed |
[28] Johnston JJE, O’Conor E. Needlestick injuries, management and education: a role for emergency medicine? Eur J Emerg Med 2005; 12 10–2.
| Needlestick injuries, management and education: a role for emergency medicine?Crossref | GoogleScholarGoogle Scholar | 15674078PubMed |
