You are supervising a registrar who suffers a needle stick injury during the insertion of a central line in a patient with a history of intravenous drug use.
Outline your approach to this problem.
Answer and interpretation
- Stop the procedure
- Ensure patient is safe
- Takeover / delegate patient management as required
- Wash the registrar’s wound immediately with soap and water
- Express any blood from the wound
- Initiate injury-reporting system used in the workplace
- Patient may need to be consented and then tested for HIV, hepatitis B, Hepatitis C
- Refer registrar to designated treatment facility: Emergency Department / Infectious Disease Physician / Immunology as per hospital protocol
- With consent, registrar to be tested immediately and confidentially for HIV, hepatitis B and C
- Document the exposure in detail for your own record and for the employer
- If the patient is HIV positive, post exposure prophylaxis needs to be started within two hours of the exposure.
- For possible Hepatitis C exposure, no treatment is recommended but advice must be obtained from Infectious Disease Specialist
- If the source patient tests positive for HIV, hepatitis B, hepatitis C, get post-exposure prophylaxis in accordance with CDC guidelines and as per recommendations from Infectious Disease Specialist or other expert.
- Registrar to have follow up with post exposure testing
- Advise re: taking precautions (including safe sex) to prevent exposing others until follow up testing is complete.
- If exposed to blood borne pathogen, he/she should not donate blood for six months until cleared
- While definitive testing is essential, counsel the registrar that the risk factors for infection are: deep injury, visible blood on devices, and needle placement in a vein or artery, lower risk with solid suture needle.
Related to procedure:
- Review of registrar’s technique, equipment used, unit policy for procedural training, assessment of competency, etc.
- Pass rate: 74%
- Highest mark: 7.6
- Candidates who failed did not give enough detail, e.g. “take bloods” without specifying for which investigations.
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.