Patient Safety: Percutaneous Sharp Injuries: Post-Exposure Procedures

From the AANEM Quality and Patient Safety Committee
 

Percutaneous sharp injuries, including needlestick injuries during EMG, pose a significant risk for healthcare workers (HCW). Many workers, however, are unfamiliar with proper post-exposure procedures, which can put them at a greater risk of seroconversion of blood-borne pathogens following an injury. After sharps injuries, the National Institute for Occupational Safety and Health (NIOSH) instructs HCW to immediately wash the area with soap and water, report the incident to their supervisor, and seek urgent medical care. Initial laboratory testing for the exposed HCW should include both HIV (fourth generation antibody-antigen test) and HCV (anti-HCV with reflex HCV RNA). Testing for HBV core antibody (HBcAb) is also necessary if the HCW is unvaccinated or undervaccinated for HBV. Testing for HBV (HBsAg), HCV, and HIV should also be performed on the source patient as soon as possible as it will guide further management. HCW should also expect to undergo follow-up testing at approximately six weeks and six months following the exposure.

If indicated, postexposure prophylaxis (PEP) for HIV should be initiated within 2-3 hours of exposure and consists of a 28-day three-drug antiretroviral regimen. No further management is necessary for HBV if the HCW is fully vaccinated. The CDC does not recommend HCV postexposure prophylaxis.

It is estimated that at least half of sharp injuries go unreported. Local or state reporting is mandatory in certain areas but HCW should also report incidents through their institution to aid in local quality and patient safety processes.

Scenario:

An experienced EDX physician is performing needle EMG of the pronator teres in a 33-year-old female patient without significant past medical history presenting with new right arm weakness. A resident walks into the exam room during the procedure to ask a question and the physician turns away from the patient to address the resident. The patient sneezes and pulls her arm away causing the physician to stick themselves in the hand with the EMG needle.
 

Question: Which of the following items leads to a “high risk” exposure when dealing with percutaneous sharp injuries?
 

A. Injury occurred with a sharp that was used on a non-blood vessel portion of the body (e.g. skin, subcutaneous tissue, tendon, muscle)
B. Injury occurred with an old, improperly discarded sharp
C. There is visible blood on sharp at time of injury
D. Injury occurred with a sharp that was not used on a patient prior to injury
 

Sources:

Diprose P, Deakin CD, Smedley J. Ignorance of post-exposure prophylaxis guidelines following HIV needlestick injury may increase the risk of seroconversion. Br J Anaesth2000;84:767-70.
 

Kuhar DT, Henderson DK, Struble KA, Heneine W, Thomas V, Cheever LW, Gomaa A, Panlilio AL; US Public Health Service Working Group. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271. Erratum in: Infect Control Hosp Epidemiol. 2013 Nov;34(11):1238. Dosage error in article text. PMID: 23917901.
 

Moorman AC, de Perio MA, Goldschmidt R, et al. Testing and Clinical Management of Health Care Personnel Potentially Exposed to Hepatitis C Virus — CDC Guidance, United States, 2020. MMWR Recomm Rep 2020;69(No. RR-6):1–8.
 

Mateen FJ, Grant IA, Sorenson EJ. Needlestick injuries among electromyographers. Muscle Nerve. 2008 Dec;38(6):1541-5. doi: 10.1002/mus.21118. PMID: 19016550.
 

Riddell A, Kennedy I, Tong CY. Management of sharps injuries in the healthcare setting. BMJ. 2015 Jul 29;351:h3733. doi: 10.1136/bmj.h3733. PMID: 26223519.

Answer: C) There is visible blood on sharp at time of injury

Author: Daniel Pierce, MD