# Sharps & Splash Injuries

## Overview

Infection Prevention and Control (IPC) during procedures includes the safe management of ‘sharps’, encompasses high-level measures such as health facility design and management, protocol-based measures such as adherence to national and facility level guidelines, and individual actions by each health care provider and ancillary staff member. The health care provider is encouraged to familiarise themselves with their facility’s specific IPC protocols and reporting systems, which is outside the scope of this module.

This module describes how to manage sharps injuries and body fluid exposure/splash injuries.

## Procedure

1. Administer first aid:

   - For injuries: allow to bleed freely. Wash with soap and water.
   - For splashes in eyes, mouth and nose: rinse with water or saline for 15 minutes. Do not rub or disinfect the area.
   - For splashes on skin: wash with soap and water. Do not rub or disinfect the area.

2. If you are the victim, get someone to

   assist
   assist

   If your institution's designated person is unavailable, any healthcare worker may assist.

   .

3. Together with the assistant, assess the

   risk
   risk

   This is determined by the nature of the exposure and the infectiousness of the source patient. Adhere to institutional or EDL guidelines.

   of occupational exposure. Generally:

   - If the skin is intact and the source patient is HIV negative, no Post Exposure Prophylaxis (PEP) is indicated.
   - For a mucosal splash, non-intact skin or a percutaneous injury with a positive patient (or patient with unknown status), PEP is indicated.
   - If the patient tests HIV negative, but has clinical features of seroconversion illness, commence PEP until further tests are done.
   - If you become HIV infected, assess for ART initiation.

4. Take the first dose of

   PEP
   PEP

   Current guidelines for the Western Cape recommend tenofovir 300mg, lamivudine 300 mg and dolutegravir 50 mg PO stat. Refer to institutional guidelines as the drugs vary for pregnant women <6 weeks' gestation, eGFR<50ml/minute and whether the source patient is on ART and failing a drug regimen.

   tablets as soon as possible, preferably within minutes of exposure, up to 72h later. All other steps can be delayed if necessary.

5. An assistant should draw your

   blood
   blood

   Usually 2 EDTA tubes are used (check institutional protocols) and blood should be taken for Creatinine (if Tenofovir (TDF) is part of PEP), full blood count (if zidovudine (AZT) is part of PEP, HIV serology (rapid test plus ELISA), Hepatitis B surface antigen, Hepatitis C antibody and syphilis serology (RPR/TP antibody).

   for base-line measurements.

6. The assistant should draw blood from the

   source patient
   source patient

   Usually 2 EDTA tubes are used (check institutional protocols) and blood should be taken for HIV serology (rapid test plus ELISA), Hepatitis B surface antigen, Hepatitis C antibody and syphilis serology (RPR/TP) antibody.

   .

7. Register a folder as a patient, or draw your folder if already registered.

8. Obtain a

   prescription
   prescription

   As long as the first dose of PEP was taken, this can be delayed until the situation allows.

   for PEP for one month and commence treatment.

9. Follow up on your blood results and have your PEP prescription modified accordingly.

10. Follow up
    Follow up

    If there is a delay in obtaining HBsAb results of > 24 hours, initiate treatment as for vaccinated AND HBsAb < 10 units/ml.

    on your vaccination status and antibody response as well as the Hepatitis B surface antigen (HBsAg) result of the source patient. Get vaccinated or obtain hepatitis B immunoglobulin (HBIG) according to institutional guidelines.

11. Familiarise yourself with the

    follow-up procedure
    follow-up procedure

    This usually involves repeat bloods at 2 weeks depending on the PEP regimen, 6 weeks and 4 months.

    and further management.

## Reporting

1. Report the injury or exposure to your immediate superior.

2. Complete the

   incident documents
   incident documents

   These can also be completed at a later stage if you are engaged in a critical task.

   . These may vary between provinces, but usually include:

   - Adverse Incident Reporting and Risk Management Tool
   - The W.Cl.2 Employer’s Report of an Incident (complete details in the “Employee” section)
   - The W.Cl.4 First Medical Report (to be completed by a designated person, or the clinician who assisted you).

3. Put all the forms in your hospital folder.

4. Hand in
   Hand in

   Institutional protocols vary as to who receives your folder: your supervisor, the occupational health clinic, or the night matron.

   your folder and the completed documents.

## Troubleshooting

The source patient is HIV positive and failing 2nd line treatment.

Patients failing second line ART usually have no resistance to protease inhibitors so lopinavir/ritonavir should still be effective, but rather consult with a virologist or infectious disease physician for advice on which PEP to use.

The PEP drugs are causing side-effects such as nausea and diarrhoea.

Seek counselling and prescription for the side-effects. If unsuccessful, consult with the occupational health clinic/practitioner to consider a change in regimen. Do not stop using the PEP unless you have consulted a virologist or infectious disease physician.

## References

1. WHO Best Practices for Injections and Related Procedures Toolkit. World Health Organization: Geneva; 2010.

2. Department of Health South Africa. Post Exposure Prophylaxis, Occupational. In: Standard Treatment Guidelines: Essential Medicines List for South Africa. Available from: EML Clinical Guide Mobile Application.

3. Oosthuizen A. The PEP Box. A practical application for Northern Tygerberg Sub District, Cape Metropole. 2019.