Needlestick injury from a hepatitis B e-antigen-positive dialysis patient
At 10:20 in a satellite haemodialysis unit in Zarqa, a staff nurse uncaps and recaps a 16-gauge fistula needle after disconnecting a patient and sustains a deep needlestick to the left index finger. The needle had been in the patient's arteriovenous fistula and the line had been flushed with heparinised saline. The source patient's chart shows hepatitis B surface antigen positive, hepatitis B e antigen positive, and HIV negative on testing three months ago; hepatitis C status is not recorded. The nurse completed a three-dose hepatitis B vaccination series six years ago but has never had an anti-HBs titre checked. She washed the wound with soap and water and reports to you at 10:40. The employee health clinic is closed until 08:00 the next day; the hospital's written exposure protocol is kept in the infection control office, which is locked. The dialysis schedule still has four patients to be disconnected.
1. Set out, in order, what must happen in the next 60 minutes and what post-exposure prophylaxis is indicated. Justify each decision.
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Do not let the closed clinic or the locked office delay treatment - escalate now.
- Wound care (already started): wash with soap and running water for at least 15 seconds; do not squeeze, milk or scrub the wound, do not apply bleach or caustic agents, allow it to bleed briefly, then cover with a waterproof dressing. Rationale: squeezing damages tissue and may increase viral inoculation.
- Report and record at 10:40: complete the sharps injury form, note time, device, bore, depth, source, glove use and hepatitis status, and give the nurse a copy. Time matters because HBIG effectiveness falls with delay.
- Source testing: hepatitis B surface antigen and e antigen are already known and indicate high infectivity. Send source blood for hepatitis C antibody/RNA and repeat HIV testing (the three-month-old result leaves a window if the patient has ongoing risk).
- Baseline tests for the nurse: anti-HBs, HBsAg, anti-HBc, ALT, and HIV and HCV baseline serology.
- Hepatitis B prophylaxis: three doses of vaccine six years ago with no anti-HBs titre means she must be managed as unprotected until proven immune. Give hepatitis B immunoglobulin 0.06 mL/kg IM, ideally within 12 hours and no later than 7 days, plus a hepatitis B vaccine booster dose, then complete an accelerated schedule and re-check anti-HBs 4–8 weeks later.
- HIV: a hollow-bore needlestick carries risk, but the source is documented HIV negative three months ago. Repeat source testing; if any risk factor or doubt exists, start HIV post-exposure prophylaxis within 2 hours (no later than 72 hours) for 28 days after discussion with the on-call physician.
- Hepatitis C: no prophylaxis exists; baseline, 4–6 week and 6-month testing with early treatment if seroconversion occurs.
- Escalate: page the infection prevention and control on-call and the medical director, and obtain HBIG from the emergency department pharmacy. The employee health clinic's opening hours are not a clinical reason to wait.
2. Identify the system failures that produced this injury and state what you will change on the unit within one week.
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Individual and system factors both matter; blaming the nurse alone will not prevent the next injury.
Failures visible in the scenario:
- Recapping a hollow-bore fistula needle - a known high-risk practice that persists when sharps containers are not within arm's reach at the chairside.
- No safety-engineered device or no-blade/retractable option in use for fistula needles.
- No 24-hour access to post-exposure prophylaxis, so the most time-critical step (HBIG) depends on an office that is closed.
- Protocol inaccessible and locked away - an exposure protocol must be available at every point of care, not in an office.
- No anti-HBs titre after vaccination - immunity was assumed, not documented.
- Understaffing or task pressure - four patients still to disconnect may have driven speed over safety.
Actions within the week:
- Move sharps containers to chairside, at eye level, no more than arm's reach, and replace when three-quarters full.
- Remove recapping from practice entirely; if a device must be carried, use a rigid tray, never the hand.
- Print a one-page exposure algorithm and post it at every dialysis station and in the dirty utility room; include the on-call numbers for infection control and pharmacy.
- Negotiate a 24-hour route for HBIG and HIV post-exposure prophylaxis through the emergency department.
- Audit anti-HBs titres for every dialysis nurse and offer catch-up vaccination; record results in the occupational health file.
- Run a 15-minute simulation at handover and audit sharps containers and recapping for four weeks, reporting results at the unit meeting.