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How to deal with a needle-stick injury

By Margaret Stone and Tim Harrison

 

PICTURE this:

You are working in a small hospital aseptic manufacturing unit. One of the pharmacy technicians, who has been making cytotoxic injections in a negative pressure isolator, calls over the intercom: he has accidentally stuck a needle into his finger. He is in the small room on his own.

colin cuthbert/SPL

Considerations

What are the risks?

There is a risk of pain, ulceration, tissue death and permanent damage to the pharmacy technician if he has injected himself with a cytotoxic agent. The risk of infection is small in this case.

If the technician has automatically put the needle into a product after the needle stick, there is also a risk of infection to the user of that product. Because there is now a hole in the glove of the isolator, its contents are no longer sterile (a negative pressure isolator will suck air in through the hole) there is an infection risk to all the patients who have products made in the isolator.

What are the priorities?

The immediate priority is the technician. Once injury has been dealt with, patient safety must be considered. The normal running of the unit might be interrupted but other staff should be able to continue with their duties once they are reassured about their injured colleague.

The safety of the isolator and other equipment used by the technician must then be reviewed. For example, when was the isolator last tested for suitability? Had the technician been using a piece of equipment, such as a needle resheathing device, that failed? The training of the technician and other staff should also be considered. If they have not received adequate training in the use of the equipment, this must be rectified before the equipment is used again.

Where do responsibilities lie?

Employers must ensure a safe working environment for employees. They must ensure that necessary equipment is provided, fit for purpose and regularly maintained, that standard operating procedures are in place, where applicable, and that these are reviewed as necessary. They must also ensure that staff are adequately trained to be competent in the daily tasks they are expected to undertake.

Employees have a responsibility to co-operate with their employer and adhere to any relevant SOPs, ensuring that they do not act in a way that puts themselves or their colleagues at risk.

What actions are needed?

 

If the injury requires first aid, a first aider should be called. Because the incident has taken place in an aseptic manufacturing unit, the first aider may need to put on a gown before entering the room — the safety of the technician must be balanced against the safety of users of other products manufactured in the unit.

The first aider should identify the agent injected. If the technician has injected a cytotoxic agent into his finger, the first aider should seek advice from control of substances hazardous to health (COSHH) documents or hospital guidance about the best action to take to reduce any damage. Some cytotoxic drugs can cause damage if they escape from the intended site of delivery to the surrounding tissue (extravasation) and hospitals administering these agents will usually have an extravasation document setting out what to do in such cases [See Clinical comment below]. This is usually written for use with patients but could be applied here. There is no risk of blood-borne virus (BBV) transmission in this case but the Panel outlines how to reduce risks in other needle-stick cases.

Prevent infection with blood-borne viruses

Workers can acquire a blood-borne virus (BBV) infection if they are exposed to infected blood or body fluids via mucous membranes (eg, eyes, insides of mouth and nose), through broken skin or where the skin is punctured or scratched by a needle or other sharp device that has been used in a medical procedure. The main viruses concerned are hepatitis B (HBV), hepatitis C (HCV) and HIV. A vaccine against HBV is available, but no such protection is available against the other BBVs.
Because the carriage rates of BBVs in the general UK population is low, the risk of infection from needle stick injuries remains low. However, UK standards for the prevention of needle-stick injuries consider all blood and body fluids to contain infectious agents, regardless of their source, and those injured are treated as at risk.

Immediate action Those contaminated with blood or other body fluids, should take the following immediate action:

•    Splashes should be washed off the skin with soap and running water
•    f the skin is broken, the wound should be encouraged to bleed (but not by sucking) and the area rinsed thoroughly under running water
•    Splashes in eyes should be washed using tap water or an eye wash bottle. Splashes in the nose or mouth should be washed with plenty of tap water — do not swallow the water

The source of contamination should be recorded where possible (ie, the source individual and his or her infection status) and the incident reported to a supervisor, line manager or health and safety adviser and the occupational health department or medical adviser if there is one. Prompt medical advice is important. If a workplace does not have a medical adviser, the nearest accident and emergency department should be contacted for advice.

Post-exposure prophylaxis The circumstances of the incident need to be assessed and consideration given to any medical treatment required. Treatment might be appropriate following infection with a BBV, but to be effective, it may need to be started quickly. Following exposure to HBV passive immunisation (ie, administration of hepatitis B immunoglobulin) or active immunisation (with hepatitis B vaccine, usually an accelerated course) are considered. Following exposure to HCV the person should be monitored for evidence of infection over six months, and antiviral therapy considered if acquisition has occurred. Post-exposure prophylaxis for HIV involves a regimen of three anti-HIV drugs.

* Adapted from information on the HSE website

 

A referral to occupational health and safety could be considered, especially if the technician is distressed or has injected some of the cytotoxic agent. To ensure the safety of other staff, the condition of equipment used, including the isolator, must be inspected. If a problem with a piece of equipment is suspected, it must not be reused until it has been fully investigated and arrangements made for its repair or replacement. However, if a piece of equipment is needed for vital services (eg, it is the only isolator in the hospital suitable for making cytotoxic products in), a risk assessment should be done to consider the risk to the patients, staff and the hospital in continuing to use it rather than taking it out of service temporarily. Every effort must be made to find an alternative suitable piece of equipment if one is suspected of being faulty.

If a product may have been contaminated, it must be thrown away and a new batch made. If the isolator can continue to be used, the gloves on the isolator must be changed and the inside cleaned before any more products are made in it.

Next steps

Recording and reporting

It is a legal requirement for accidents at work to be recorded in an accident book or similar that complies with the Data Protection Act, so details of the accident, including the technician’s details, a description of what happened, actions taken and follow up should be noted. An incident form may also need to be completed, in line with the trust policy.

If the technician requires more than three days off work sick, the incident is reportable under The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR), and this must be done by the employer or the person responsible for the premises to the Health and Safety Executive Incident Contact Centre (ICC) by the quickest method. It is usual in a large organisation, such as a hospital, for there to be a specific health and safety manager who will receive the details of the incident from the accident book and report to the HSE.

Investigating

Accidents in any area of a pharmacy should be treated in a similar way to any other incident, so that there is a record of the incident and analysis can be done and trends identified. The accident should be evaluated to identify the cause and actions that can be taken to reduce the chances of a similar accident recurring. This evaluation can be undertaken by anyone and guidance can be sought from the appointed competent person (eg, the manager of the manufacturing unit). If the technician was harmed, details of his treatment, recovery and progress should be sought during this investigation.

Planning

The arrangements in the manufacturing unit to reduce the risk of needle-stick injuries to staff making up cytotoxic (or other) products should be reviewed. For example:

•    Are all the staff adequately trained in the correct aseptic technique, especially in using needles?
•    Are needle resheathing devices routinely used?
•    Are needle-free valves used as widely as practical and economic restraints allow?
•    Are there standard operating procedures in the use of these products? Are all the staff fully trained in their use? Do they follow them correctly?
•    Could products that need fewer manipulations to prepare them into the final, patient-ready product be used instead?
•    Do staff know what to do if they suffer a needle-stick injury?

Risk assessments should be completed to assess the risk to staff working in a manufacturing unit, including the risk of needle-stick injuries. It is unlikely that the risk of such injuries can be completely negated, but the risk should be managed until it is as small as possible. Risk assessments should be completed whenever something changes (eg, isolator type, staff skill mix, product range).

Sharing

Details of this incident should be shared within the organisation and, if required, with external bodies.

Clinical comment on extravasation

Cytotoxic drugs can be split into five categories (vesicant, irritant, exfoliant, “inflammatant” and neutral), says Andrew Stanley, pharmacist and chief executive of the National Extravasation Information Service. The consequences of extravasation can range from local discomfort to necrotic loss of tissue, with vesicants having the most serious consequences.

He added that although people have developed local policies on extravasation, there is no standard treatment and a new national policy is going out to consultation. “There are similarities [in policies], such as stop what you’re doing and identify the area, but beyond that there is controversy,” he said. Any demarcated area can be marked with a pen to aid observation. Aspiration should always be attempted (using the cannula or a small needle into the marked area), even if sometimes unsuccessful. The patient should be assessed and observed, the frequency depending on the agent.

Some local policies recommend elevating and immobilising the limb as part of initial first aid but there is no evidence that this improves the situation, Mr Stanley says. The proposed national policy recommends applying a cold compress in all circumstances rather than a hot one. It also covers symptom control (eg, applying topical hydrocortisone to the site or using an analgesic), use of specific antidotes and flush-out techniques. Where mixed agents are involved vesicant treatment would take priority.

“The vast majority of hospitals may have extravasation kits available,” he said.
However, focusing on a needle-stick scenario, Mr Stanley says that “the volume involved is likely to be extremely small, the risk low level and treatment probably not necessary — the trauma of treatment may be greater than
the risk.”

According to the National Extravasation Information Service website (www.extravasation.org.uk), around 5 per cent of patients who received a course of cytotoxic injections experienced extravasations. The website contains links to educational resources and is a way to report an extravasation incident via a green card reporting scheme.

The proposed national policy will be available for consultation shortly, at www.bopawebsite.org.



Resources

•    A Health and Safety Executive information sheet MISC615 “Safe handling of cytotoxic drugs” (2003) is available at www.hse.gov.uk.
•  A document from the Health and Safety Executive and the Medicines Control Agency “Handling cytotoxic drugs in isolators in NHS pharmacies”(2003) gives advice on factors to consider when selecting either negative or positive pressure isolators for the aseptic reconstitution of cytotoxic drugs.
•     National Patient Safety Agency patient safety alert on promoting safer use of injectable medicines (2007) is available at www.nrls.npsa.nhs.uk.
•    “The cytotoxics handbook” (4th edition) 2002 (Allwood M C, Wright P, Stanley A; Radcliffe Publishing Ltd) gives details of types of cytotoxics and can be used to make an extravasation policy.
•    A leaflet “Blood borne viruses in the workplace: guidance for employers and employees” is available from the HSE.
•  A good poster for first aid in case of a needle stick or other exposure to BBVs is available from the Health Protection Agency website (www.hpa.org.uk).
•    “Guidance for clinical health care workers: protection against infection with blood-borne viruses” is available at www.dh.gov.uk. This is a useful resource, particulary for managers wanting to ensure they comply with guidance.

Citation: The Pharmaceutical Journal URI: 11082541

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