Staff Occupational Exposures
Unfortunately despite everyone's best efforts occupational exposure to blood and other potentially infectious fluids remains a problem in health care. This has been the case for as long as health care has existed.
While our forbears were troubled by occupational exposure to plague or tuberculosis our greatest concern at the present time are three blood borne viruses: Hepatitis B (HBV), Hepatitis C (HCV) and HIV.
A comprehensive orientation to the issue of occupational exposure to HBC, HCV and HIV is provided as part of general hospital orientation to all interns. All medical staff are encouraged to make themselves familiar with this hospital policies in this area on PROMPT or by contacting the helpful infection control staff.
Staff members exposed to blood or other potentially infectious substances through needle-stick, splash injury on injured skin or mucosal exposure will be sent to ED triage for counselling, drawing of blood specimens and referral to infection control. Consenting of sources for testing and ordering tests from the source is generally the responsibility of the treating doctor which generally means someone from outside ED. When the treating doctor is the recipient they should get a colleague from their unit to take over the process for them. The ED staff treating that doctor can help in arranging this.
All staff occupational exposures are managed by a straighforward protocol. There are envelopes at triage containing a datasheet that needs to be completed and sent to infection control by internal mail so that they can effect followup and pre-printed blod test request slips for recipient and source. As the source blood is being obtained elsewhere in many cases the source blood slip should be sent to the relevant clinical area.
All healthcare workers should be vaccinated against HBV. After an exposure document vaccination status and check the titre of antibody. Non-immune people exposed to HBV can be treated with immunoglobuin if required.
HCV is very infectious and is very common amongst IV drug users (even people who only occasionally used IV drugs in the past) and alcoholics (usually because of previous IVDU experimentation) as well as immigrants from parts of Africa and South East Asia and hameophilliacs aged over 40 years old. There is some experimental work going on with use of early interferon soon after seroconversion to increase clearance rates for HCV. Staff exposed to confirmed HCV positive blood need early referral to infection control and an early discussion directly with the Austin Infectious Diseases Service (Dr Lindsay Grayson provides clinical governance for our infection control service) may be warranted.
HIV remains uncommon in central Victoria however it is not unknown. A risk assessment should be made of the source. The decision to provide post-exposure prophylaxis with antiretrovirals is fairly straightforward in cases where the source is HIV positive however in cases where the source is HIV negative but may be in the window period between infection and sero-conversion the decision is more complex. After a risk assessment the case can be discussed with the Austin ID team. While consenting and obtaining tests from the source is usually not the responsibility of the ED (when the source is on the ward) this issue will recquire some liason between ED medical staff and the treating doctor so that a risk assessment can be made.
On occasions we will see members of the public who have been exposed to blood or a body fluid in a way that concerns them. This may include members of the emergency services. These cases are not managed by the infection control service and the occupational exposure envleopes are not used. There is a single starter pack of HIV antiretrovirals available in the drug room as an extension of the Alfred Hospital Non-Occupationa Post-Exposure Prophylaxis (NPEP) program. Use of this should be in consultation with the Alfred Hospital ID team and the relevant forms supplied with the drugs must be filled out and sent to the A;fred so that the drugs can be replaced. These patients are not to be treated with the supply of occupational Post-exposure prophylaxis drugs provided for hospital staff.