Needlestick Injury from a Patient with Unknown Blood-Borne Status
At 2030 on a 24-bed hospital ward, a newly graduated RN has just given an intramuscular injection to a 38-year-old man admitted with confusion and fever. While recapping the needle, she sustains a deep needlestick injury to the pad of her left index finger; the device is visibly blood-stained. The patient’s HIV, hepatitis B and hepatitis C status are unknown; he was transferred from another facility and is too confused to give a history. The ward has no HIV post-exposure prophylaxis starter pack. The district hospital, two hours away, holds PEP and can test the source patient. Facility policy requires immediate reporting to the nurse in charge and infection prevention and control, and PEP should begin within 72 hours, ideally within hours. The RN is crying and asks whether she should just wash the wound and finish her shift.
1. What immediate first aid and risk assessment should be done?
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Immediate first aid: wash the wound thoroughly with soap and running water, allow it to bleed gently, and do not scrub, suck or apply bleach or alcohol. Dry and cover with a waterproof dressing. Then assess risk: deep injury, visible blood on the device, hollow-bore needle, source patient with unknown status and a high-prevalence setting; the risk is not zero. Check the nurse’s hepatitis B vaccination status and antibody titre, tetanus status, and any previous PEP. Record the time, device, depth, site, source patient details and the circumstances. The nurse should not simply finish the shift; she should report immediately to the nurse in charge and IPC. Baseline blood tests for HIV, hepatitis B and C should be arranged according to policy, with consent and confidentiality. The source patient should be approached for testing with appropriate consent and counselling, because knowing the source status guides PEP. The emotional impact should be acknowledged; she should not be blamed for recapping, but the incident should be reviewed as a systems issue.
2. What should the nurse in charge do about PEP and source testing, given the two-hour transfer?
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The nurse in charge should treat this as time-critical. Report to IPC and the medical officer, and arrange transfer to the district hospital where PEP and source testing are available. The district hospital should be contacted before departure so that PEP is ready on arrival. Source testing requires consent; if the patient lacks capacity because of confusion, follow facility policy and legal advice for testing in the patient’s best interests and for staff safety. If the source is HIV-positive or unknown and the risk assessment warrants it, start a 28-day PEP regimen according to national guidelines, ideally within hours and no later than 72 hours. Check hepatitis B: if the nurse is unvaccinated or a non-responder, hepatitis B immunoglobulin and vaccine may be indicated. Tetanus prophylaxis should be given if needed. Baseline HIV, HBV and HCV serology should be taken before PEP, but do not delay PEP for results. Document consent, counselling and the drugs dispensed. The nurse should be offered psychological support and not be left alone.
3. What follow-up, documentation and infection prevention actions are required?
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Follow-up: HIV testing at 6 weeks, 3 months and 6 months according to policy; hepatitis B and C monitoring; review of PEP adherence, side effects and renal function if tenofovir-based. The nurse should be advised to use condoms and avoid blood donation until cleared. Complete an incident report and a root-cause review of recapping and sharps disposal; check whether safety-engineered devices and sharps containers are available. Provide education to the new graduate without humiliation. Document the exposure in the staff health record and the incident system, maintain confidentiality, and ensure the nurse knows who to contact for results and support. The ward should audit needlestick incidents and review staffing and supervision of new graduates. The nurse should be given time to attend appointments and be reassured that most exposures do not result in transmission, while understanding the need for follow-up.