Needle-stick injury at 7 p.m.: first aid, PEP timing and waste segregation
A 20-year-old nursing student on her first posting in a district hospital is giving an intramuscular injection of ceftriaxone to a patient admitted with pneumonia. As she pushes the plunger the patient jerks, and while she is trying to recap the needle one-handed, the needle passes through her left glove and punctures the pad of her thumb. It bleeds a little. The source patient's HIV and hepatitis B status are not recorded in the file, and he is drowsy and cannot be asked tonight. It is 7 p.m. The ward does not keep a post-exposure prophylaxis (PEP) starter pack. The antiretroviral therapy centre is 40 km away and its board says 9 a.m. to 4 p.m. The student washes the wound at the sink, wraps it in a bandage and says she will "see about it tomorrow". The sharps container is in the dirty utility room at the far end of the ward, and the used needle is still lying in her tray.
1. Critically evaluate what the student did and set out the correct first aid and reporting actions, including when PEP must start and why.
Read the worked answer
What she got right: washing at the sink.
What she got wrong: (a) she recapped a needle, which is the commonest cause of such injuries; (b) she wrapped the wound tightly and delayed; (c) she planned to wait until morning; (d) she left the needle in a tray where it can injure the next person.
Correct sequence, now:
- Let the wound bleed freely under running water, wash with soap and water, and do not squeeze, rub, or apply spirit, bleach or antiseptic. Do not bandage tightly.
- Report immediately to the sister-in-charge and the infection control officer and complete the incident form tonight - an unreported injury cannot be followed up.
- Establish the source patient's HIV and HBsAg status with consent; if he cannot consent, a relative may be approached, and if that fails he is managed as unknown risk.
- Start HIV PEP as soon as possible - ideally within 2 hours and always within 72 hours. A 28-day course is standard, with baseline HIV testing after counselling. Do not wait for 9 a.m.: telephone the ART centre's 24-hour line or the district hospital and arrange the starter pack tonight. Every hour of delay reduces the benefit; an overnight wait is not acceptable practice.
- Hepatitis B: if she is unvaccinated or a non-responder, hepatitis B immunoglobulin plus vaccine within 24 hours.
- Put the needle straight into the puncture-proof sharps container at the point of use.
2. What follow-up tests and support should she receive over the next six months, and why is each one needed?
Read the worked answer
Baseline (day 0): HIV test after counselling, HBsAg and anti-HBs/anti-HBc, and hepatitis C if the source is positive; pregnancy test before starting PEP. The baseline tells you whether she was already infected before the injury, so a later positive result can be interpreted.
HIV testing at 6 weeks, 3 months and 6 months after exposure. The window period means an early negative test does not prove she is uninfected, so the six-month test is what closes the episode. Explain this explicitly, because many students stop testing after six weeks and assume they are safe.
PEP adherence: 28 days, no missed doses; discuss side effects (nausea, headache, renal effects with tenofovir) and arrange review so she does not abandon the course on day three. Provide condoms and advise on blood donation and breastfeeding during follow-up, as per national guidance.
Hepatitis B: complete the vaccine schedule, and check anti-HBs response afterwards.
Support: confidentiality - tell only those who need to know; the incident is a system failure as much as an individual one. Occupational health should review why no starter pack was available and why the sharps container was at the far end of the ward. Record every step with dates in her own health record.
3. State where each of the following must be disposed of, and why: the used needle, her contaminated glove, blood-stained cotton wool, and a partly used ceftriaxone vial.
Read the worked answer
Under the Bio-Medical Waste Management Rules (2016) colour coding:
Used needle - white translucent, puncture-proof, leak-proof sharps container, filled only to the three-quarter mark, capped and labelled. Sharps must never go into a yellow or red bag, because plastic bags are torn open by handlers and the needle becomes a weapon against the next worker. It must be dropped in at the point of generation, not carried to the far end of the ward.
Contaminated glove - red bag (contaminated recyclable plastic). Red bags go for autoclaving or shredding and recycling; gloves are plastic and recyclable after disinfection, so mixing them with general waste loses the material and pollutes.
Blood-stained cotton wool - yellow bag (soiled waste). It is blood-soaked, non-recyclable and potentially infectious, so it is incinerated or deep-buried according to the rules.
Partly used ceftriaxone vial - yellow bag (discarded medicines). Antibiotic residues must not enter general waste or drains.
The principle behind all four: segregate at the point of generation, because once waste is mixed it must all be treated as the most hazardous category. The needle in her tray is precisely the moment when segregation either works or fails.