A Needlestick in the Emergency Department at 2 A.M.
At 2 a.m., a 24-year-old ED nurse sustains a hollow-bore needlestick to the left index finger while recapping a needle after drawing blood from a patient with unknown HIV status who is confused and combative. The wound bled briefly. The source patient's chart shows he is a person who injects drugs and has no documented HIV test. The nurse is visibly shaken, has never had a needlestick before, and asks whether she will "get AIDS." The hospital's exposure protocol requires source testing and post-exposure prophylaxis evaluation, but the on-call physician is in the operating room and the lab is closed until 6 a.m.
1. List your immediate actions in priority order and explain the rationale for each.
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1. First aid. Wash the site with soap and water; do not scrub or use caustic agents. Bleeding was brief and should not be encouraged further. Rationale: reduces inoculum without tissue damage.
2. Risk assessment. Hollow-bore needle, visible blood, deep injury, and a source with likely high-risk history place this in a higher-risk category. Document the device, gauge, depth, and blood exposure.
3. Source evaluation. Obtain consent for HIV, hepatitis B, and hepatitis C testing per local law; many jurisdictions allow testing without consent in exposure settings or permit expedited testing. Do not wait for the 6 a.m. lab opening; use a rapid HIV test if available in the ED or call the lab in. If the source refuses, follow the jurisdiction's process for source testing.
4. Worker's immune status. Check hepatitis B vaccination and surface antibody titer, and baseline HIV and HCV status.
5. Prophylaxis decision. HIV post-exposure prophylaxis should start as soon as possible, ideally within hours and no later than 72 hours. Do not delay for the source result if the risk is significant; a three-drug regimen is standard and can be adjusted or stopped if the source is negative. Hepatitis B immune globulin and vaccine if she is a non-responder.
2. Describe how you would support this nurse emotionally and what follow-up and reporting steps are required.
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Emotional support. Acknowledge her fear directly and without minimizing it; use plain language that HIV transmission after a needlestick is uncommon and that prophylaxis reduces risk substantially. Stay with her through the initial steps, arrange coverage for her patients, and offer a private space. Screen for acute stress and offer the employee assistance program. Arrange a follow-up contact within 48–72 hours, because the first night is often the hardest.
Follow-up. Baseline labs, HIV testing at 6 weeks, 12 weeks, and 6 months per protocol; HCV testing at baseline and later intervals; monitor for seroconversion symptoms and for prophylaxis side effects, with adherence support. Refer for hepatitis B management if needed.
Reporting and prevention. Complete the incident report and OSHA sharps injury log entry (device type, department, description). Notify infection prevention and the safety committee. Review the recapping practice: recapping is prohibited by the bloodborne pathogens standard unless no alternative exists. Recommend safety-engineered devices, sharps containers at point of use, and a just-culture review rather than blame. Confirm the exposure control plan and hepatitis B vaccination status of all ED staff.