Needlestick injury

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Blood sampling with a safety cannula, which can be secured against needle stick injuries after use
Metal stand for pushing back the cannula

A needle stick injury (NSV, NSTV) refers to any stab, cut or scratch injury , primarily by medical staff, with sharp or pointed objects ( cannulas , scalpels or similar objects) that have been contaminated with patient's blood or body fluids, regardless of whether the Bleeding or not. They are among the most frequent occupational accidents for employees in the health care system and represent a serious risk to those affected. In the case of needlestick injuries, a wide variety of infectious pathogens can be transmitted. In practice, the human immunodeficiency virus (HIV) and hepatitis virus B (HBV) and the hepatitis virus C (HCV).

Legal basis

At the end of July 2013, a new version of the Biological Agents Ordinance came into force. Above all, employees in the health service should be better protected against the risk of infection from stab wounds and cuts. The reason for the new version was the necessary implementation of the EU needle stick directive from 2010 in national law. According to § 10 BioStoffV , used pointed and sharp work equipment, including injection needles or scalpels, must be safely disposed of. In detail:

  • Establish and use safe procedures for handling and disposing of sharp medical instruments and contaminated waste.
  • Introduction of appropriate disposal procedures as well as clearly marked and technically safe containers for the disposal of sharp / pointed medical instruments and injection devices.
  • Avoidance or restriction of the unnecessary use of sharp / pointed instruments.
  • Provision and use of medical instruments with integrated security and protection mechanisms.
  • It is forbidden to replace the protective cap on the used injection needle ( recapping ).

Recapping has been prohibited in Austria since May 2013 according to NastV § 4 Paragraph 2, No. 2.

Dentistry

The Technical Rules for Biological Agents (TRBA 250), which are published by the Committee for Biological Agents (ABAS) in the Joint Ministerial Gazette, explicitly describe one-handed recapping for local anesthesia in dentistry as a safe tool in the sense of the TRBA 250. One -handed recapping is therefore permitted in dental practices in Germany. This means that after the injection, the injection needle can be reinserted into the protective cover with one hand, provided the other hand is not in the vicinity of the protective cover. For example, a protective cap holder can be used to ensure a safe distance when recapping. Injection cannulas are screwed onto the cylinder ampoule syringe so that they cannot simply be disposed of, but have to be unscrewed from the carpule set. Injection cannulas must also not be bent or kinked, unless this manipulation is used to activate an integrated protective device.

frequency

Reliable figures on epidemiology are not available, which is mainly due to the high number of unreported cases and is made more difficult by the responsibility of various insurance carriers. For Germany, the number of injuries is estimated at around 500,000 per year, for the USA at 800,000. Another study suggests a higher rate of one injury per year per employee. Worldwide, the rate of stings with infected material is estimated at over 3.5 million per year; this causes about 66,000 infections with HBV, 16,000 with HCV and 1,000 with HIV.

The injury rate within the various disciplines varies considerably. The disciplines with the highest rate are surgery , ear, nose and throat medicine , dentistry (mainly when administering local anesthesia ), internal medicine and dermatology ; the fewest needlestick injuries occur in radiology and paediatrics . Doctors have the highest risk of injury among the medical professional groups, taking into account working hours of up to a five-fold factor. A study among American surgeons found that almost all of the respondents had stabbed themselves at least once during their training.

The unreported number of unreported needlestick injuries is high; it is estimated at over 50%, for Germany in the range of 90%. The reasons given include lack of time, the assumption of a low risk of infection and self-sufficiency, as well as trivialization for fear of stigmatization or professional consequences.

Transmission probabilities

Activities on the patient

The risk of such work-related infection from blood-borne pathogens depends on how many infectious patients there are in the respective facility, which pathogens the patients are infected with, and how frequent the blood contacts may be due to the working conditions. Of course, the risk of infection also depends on the type of injury - but the greatest caution is required here, because even the smallest injuries, often classified as minor injuries, can lead to a serious infection or even an occupational disease.

The risk of infection following a needlestick injury is made up of two factors: On the one hand, the source patient must be infectious ( prevalence ), and on the other hand, an infection depends on the probability of transmission or virulence . It should be noted that the prevalence of the relevant pathogens in health care facilities (hospitals, etc.) is significantly higher than in the general population.

Transmission ( infection ) occurs after a needlestick injury

  • with HBV in 300 out of 1000 cases (30% probability of transmission),
  • with HCV in 30 out of 1000 cases (3% probability of transmission),
  • with HIV in 3 out of 1,000 cases (0.3% probability of transmission).

Risk from working on corpses and biopsy material

After death, human remains pose a risk of transmission for various pathogens. In a study it was shown that HI viruses in the whole blood of cadavers that were stored without refrigeration for 36 hours after death could no longer be detected by the polymerase chain reaction . HCV and HBV can also be transmitted. Data on how long these viruses survive in corpses are not available. The transmission of meningococci is also possible for a short time post mortem. Tubercle bacteria are particularly resistant and stay in the dead body for years. In general, there is a risk of transmission for every bacterial pathogen in sepsis . After adequate formaldehyde fixation, human tissue is not considered to be infectious with regard to viruses and bacteria.

Prion diseases such as Creutzfeldt-Jakob disease are an exception . As pure protein structures, prions are very resistant and withstand normal formaldehyde treatment. Prions can be transmitted through aerosols. As a result, particular caution should be exercised if such a condition is suspected. Affected surfaces should be cleaned with caustic soda. Preparations that need to be fixed only become harmless after pre-treatment with formate and subsequent formaldehyde fixation.

Actions after injury

As an immediate attempt is made to increase the blood flow with a low blood flow for one to two minutes or excite, then the site of injury, in particular the puncture channel extensively with suitable means is (disinfectants based on alcohol) at least ten minutes disinfected . After the immediate presentation at an emergency room or a D-doctor both the patient and the person concerned should bled immediately and by immuno serology are tested for HIV, hepatitis B and C. This is intended to check the vaccination status of the “recipient” and the infectiousness of the “donor”.

If an infection has been found in the patient, further measures are required. If the donor is HIV positive, post-exposure drug prophylaxis is carried out within a few hours . In the case of a hepatitis B infection, if the recipient is not vaccinated, hepatitis B immunoglobulin is administered simultaneously and a vaccination is carried out. If the vaccination titer is low, the vaccination is sufficient; if the titer is sufficient, it is not necessary, the injured person is considered to be protected. There is no vaccination against hepatitis C. Immediate post-exposure prophylaxis is not recommended in the event of inoculation of material positive for hepatitis C. In the following weeks, however, the development of antibodies is checked several times and, if necessary, therapy with interferon and ribavirin is initiated. The accident is reported to the trade association by a doctor.

The professional association for health services and welfare services (BGW) has developed a standard diagnostic procedure, the so-called regular check-up program, for the simple and reliable clarification of an infection after stab wounds and cuts in the health service. In Switzerland, recommendations of the Federal Office of Public Health for exposure to blood or other biological fluids (EBF) have been in effect since 2007 .

prophylaxis

The following measures are used for prophylaxis (prevention of injuries with sharp contaminated objects):

  • organizational measures
  • Security products
Safety indwelling venous cannula
Pre-filled syringe with safety mechanism.

In addition to organizational measures (such as regular training in the correct, safe handling of pointed and / or sharp instruments), the use of safe instruments is becoming increasingly important. Antithrombotics (e.g. Fraxiparin, Clexane, Arixtra) but also vaccines (e.g. Gardasil) with suitable safety syringes (with needle protection: for example, a protective shield for the cannula that can be activated with one hand or a protective cover that can be extended by a spring mechanism and self-locking after a single use) are increasingly being used - engages in disposal position). Since the amendment to TRBA 250 in May 2006, the use of these products has been prescribed for many areas (prison hospitals, emergency rooms, etc.) and activities (treatment of patients who pose a risk to others, treatment of infected patients).

When using needle-free injection devices , needle stick injuries are fundamentally excluded.

pregnancy

According to Section 11 of the Maternity Protection Act , an employer may not allow a pregnant woman to carry out any activities or expose her to working conditions in which she is exposed to hazardous substances , biological agents, physical impacts, physical stress or mechanical impacts to the extent that this is for her or her child represents an irresponsible hazard . According to case law, the requirements for this employment ban are very strict. According to the case law, it is therefore not sufficient that the risk of infection is almost completely excluded by means of suitable protective measures. According to the case law, the risk of injury and infection must be excluded with all activities that are carried out by pregnant women. This means that any activity in connection with injection sets, whether taking blood or cleaning or sterilizing the instruments once the pregnancy has become known, is prohibited.

High risk patients

For activities on special isolation wards in the context of the treatment and care of patients who are infected with a highly contagious, life-threatening pathogen - such as the Ebola virus - a person with special specialist knowledge is required: He supports the employer in risk assessment, checking the effectiveness of protective measures and of instruction. In this protection level 4 , the Biological Agents Ordinance of 2013 introduced a permit procedure for activities with highly pathogenic biological substances instead of the previous notification procedure.

Social medical importance

According to a survey by the University of Wuppertal, a reported needlestick injury costs an average of 487 euros. This amount only includes the necessary laboratory tests and the resulting loss of work. Any treatment costs in the event of an infection are not included in this sum. The accident insurance covers the majority . The hospital itself incurs costs of 148 euros (primarily due to the loss of work). This fact makes the targeted prevention as well as any additional investment in safe instruments and sufficient disposal containers also economically plausible.

swell

literature

Individual evidence

  1. ↑ DIRECTIVE 2010/32 / EU of the Council (PDF) of 10 May 2010 on the implementation of the framework agreement concluded by HOSPEEM and EPSU to prevent injuries from sharp / pointed instruments in the hospital and health sector
  2. ↑ Biological Agents Ordinance
  3. ↑ Needle Prick Ordinance
  4. ↑ TRBA250 , point 4.2.4 number 7, (as of May 22, 2014)
  5. ↑ Needlestick injury according to TRBA 250 ( memento of the original from July 15, 2014 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / nadelstichverletzung.de
  6. ↑ F. Hofmann, N. Kralj, M. Beie: [Needle stick injuries in health care - frequency, causes and preventive strategies]. In: Health Service (Federal Association of Doctors of the Public Health Service (Germany)). Volume 64, Number 5, May 2002, pp. 259-266, ISSN  0941-3790 . doi: 10.1055 / s-2002-28353 . PMID 12007067
  7. ↑ Exposure prevention information network data reports. University of Virginia: International Health Care Worker Safety Center. EPINet (1999).
  8. ↑ F. Hofmann, N. Kralj, M. Beie: [Needle stick injuries in health care - frequency, causes and preventive strategies]. In: Health Service (Federal Association of Doctors of the Public Health Service (Germany)). Volume 64, Number 5, May 2002, pp. 259-266, ISSN  0941-3790 . doi: 10.1055 / s-2002-28353 . PMID 12007067 . (Full text)
  9. ↑ A. Prüss-Ustün, E. Rapiti, Y. Hutin: Estimation of the global burden of disease attributable to contaminated sharps injuries among health-care workers. In: Am J Ind Med. 48, 2005, pp. 482-490. PMID 16299710
  10. ↑ S. Wicker, J. Jung, R. Allwinn, R. Gottschalk, HF Rabenau: Prevalence and prevention of needlestick injuries among health care workers in a German university hospital. In: Int Arch Occup Environ Health. 81, 2008, pp. 347-354. PMID 17619897 .
  11. ↑ JC Luthi, F. Dubois-Arber, A. Iten, A. Maziero, C. Colombo, J. Jost: The occurrence of percutaneous injuries to health care workers: a cross sectional survey in seven Swiss hospitals. In: Schweiz Med Wochenschrift. 128, 1998, pp. 536-543. PMID 9592895
  12. ↑ MA Makary include: Needlestick injuries among surgeons in training. In: N Engl J Med. 356 (26), Jun 28, 2007, pp. 2693-2699. PMID 17596603
  13. ↑ a b K. Mülder: needle stick injuries. 2005.
  14. ↑ U. Sarrazin et al.: Prophylaxis against HBV, HCV and HIV after occupational exposure. 2005.
  15. ↑ a b S. Koch, W. Schulz-Schaeffer, A. Kramer: Hygienic requirements for biopsy and autopsy diagnostics. In: Pathologist. 24 (2), Mar 2003, pp. 91-97. Epub 2003 Feb 19. PMID 12673496
  16. ^ Marianne Abele-Horn: Antimicrobial Therapy. Decision support for the treatment and prophylaxis of infectious diseases. With the collaboration of Werner Heinz, Hartwig Klinker, Johann Schurz and August Stich, 2nd, revised and expanded edition. Peter Wiehl, Marburg 2009, ISBN 978-3-927219-14-4 , p. 325.
  17. ↑ Employer's Liability Insurance Association for Health Services and Welfare Regular examination program after stab wounds and cuts ( memento of the original from March 15, 2014 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.bgw-online.de
  18. ↑ Procedure after exposure to blood or other biological fluids (EBF) by health care personnel - updated recommendations 2007. Federal Office of Public Health, Bulletin 31/2007 (PDF; 237 kB)
  19. ↑ Technical rules for biological agents: TRBA 250 . Joint Ministerial Gazette No. 35 v. July 27, 2007, p. 720.

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