After an exposure: first steps

Even with the best devices and habits, exposures will sometimes happen. When one does, the first hour matters. Simple first aid, an immediate report and a prompt assessment give the exposed worker the best chance of protection, especially if post-exposure prophylaxis for HIV or hepatitis B immune globulin is needed, because both work best when started quickly. This lesson covers what to do in those first minutes and hours. Lesson 10 covers the testing and follow-up that come after.

Each hospital's own exposure procedure sets out the local details, such as which clinic to call and who covers nights. Every worker should know where their workplace's procedure is posted and the number to call, day and night.

What counts as an exposure

An exposure that needs assessment is any of these, involving blood or one of the body fluids listed in Lesson 1:

• A needlestick, cut or other injury from a used sharp, even a small one and even through a glove.
• A splash into the eyes, nose or mouth.
• Contact with skin that is broken, chapped, scratched or affected by dermatitis.
• A human bite that breaks the skin.

Blood on intact skin is not an exposure, though it should be washed off promptly. A scratch from a sharp that was never used on a patient is not a bloodborne exposure. When in doubt, treat it as an exposure and let Employee Health and Safety decide.

First aid, right away

• Needlestick, cut or bite: wash the area right away with soap and running water. Let it bleed freely for a moment, but do not squeeze, scrub or try to suck the wound. Do not use bleach or other harsh chemicals on the skin; there is no evidence they help, and they damage the skin. Cover it with a waterproof dressing.
• Splash to the eyes: flush with clean water, saline or an eyewash for several minutes, holding the eyelids open. Remove contact lenses if you can do so easily, and do not put them back in.
• Splash to the mouth: spit it out and rinse your mouth with water several times. Do not swallow.
• Splash to the nose: blow gently and rinse with water.
• Splash onto broken skin: wash with soap and water.

If the injury itself needs care, such as a deep cut that needs stitches, that care comes first. But for most exposures, first aid takes a minute or two, and the next step should follow immediately.

Report at once

The worker stops what they are doing, makes the patient safe and tells their supervisor or charge nurse straight away. The charge nurse finds someone to take over the worker's patients. This is the most important moment in the whole process, and the one where things most often go wrong. Workers delay because they are busy, because the injury seems small, because they feel embarrassed, or because they do not want to leave the unit short. Lesson 1 noted that about half of sharps injuries are never reported at all.

Delay matters because the treatments that may be needed work best early. HIV post-exposure prophylaxis is most effective when started within a couple of hours and is generally not started more than 72 hours after the exposure. Hepatitis B immune globulin for a non-immune worker is best given within 24 hours. Neither can be decided on until the exposure has been assessed.

At Northbridge, the route depends on the time of day. During weekday business hours, the worker calls Employee Health and Safety, whose nurse assesses them in the clinic within the hour. Evenings, nights, weekends and holidays, the worker goes straight to the emergency department, which follows the same protocol and hands the case to Employee Health and Safety the next working day. Northbridge Home Health staff call the on-call line and go to the nearest emergency department. The hospital also displays the number of the national clinician consultation line for post-exposure prophylaxis, which clinicians can call for expert advice at any hour.

The assessment

The nurse or physician who assesses the exposure asks a series of questions to judge how serious it was:

• What happened, exactly? A needlestick from a hollow-bore needle that was in a vein is very different from a splash of blood onto chapped skin.
• What device or fluid was involved, and was there visible blood?
• How deep was the injury, and was a glove worn?
• When did it happen? This sets the clock for any treatment.
• Who is the source patient, and what is known about them?
• What is the worker's own hepatitis B vaccination and antibody status?
• Does the worker have any health conditions, medications or pregnancy that affect treatment choices?

Baseline blood tests are taken from the worker, usually for hepatitis B, hepatitis C and HIV, so that any later change can be shown to have happened after the exposure. If HIV post-exposure prophylaxis is recommended, the first dose is often given at this visit, before all test results are back, because waiting would reduce its effect. It can be stopped later if the source turns out to be negative.

The source patient

Knowing whether the source patient has one of the viruses makes a large difference. If the source tests negative, most follow-up can stop. If the source is positive or the results are unclear, the follow-up is more intensive.

In Minnesota, as in most states, testing a patient's blood for HIV, hepatitis B and hepatitis C after a worker exposure follows state law on consent and confidentiality. The patient's physician or the emergency physician, not the exposed worker, explains why the test is being asked for and obtains consent. Minnesota law sets out a detailed process for testing source patients after exposures to emergency medical services personnel and other out-of-hospital responders, including the use of blood already drawn when consent cannot be obtained, and hospitals follow their own policies, consistent with state law, for their employees. If the patient refuses, the refusal is respected, and the worker is managed as if the source status were unknown.

The source patient's results are given to the exposed worker's clinician, who tells the worker what they need to know for their own care. The worker must keep the source patient's information confidential. And under no circumstances should the exposed worker approach the patient to ask about their health, or look up the patient's chart for that reason.

When the source is unknown, such as a needle found in linen or a container, the assessment is based on the circumstances: where the needle was found, how likely it is to have been used on a patient with one of the viruses, and how long ago. The needle itself is not tested for viruses, because testing a discarded needle is unreliable and can be dangerous to the person handling it.

The emotional side

An exposure is frightening, even for experienced staff who know the numbers. Workers describe a wave of fear in the first minutes, followed by worry about their partners and children, embarrassment at having been hurt, and sometimes anger at a colleague who left a sharp behind. All of these are normal. The people who handle the assessment are trained to answer questions plainly, to explain what the actual risk is for this exposure, which is usually very low, and to make sure the worker knows what happens next and whom to call. Northbridge also offers its employee assistance program to every exposed worker, and the Employee Health and Safety nurse calls each one the day after the assessment to check how they are doing.

Colleagues can help too. The most useful thing a coworker can do is take over the exposed worker's patients without fuss, so they can leave at once, and avoid gossip about what happened. Questions about the source patient's status must never be discussed on the unit.

The timing in practice

Joanne tracks the time from exposure to assessment for every case, because it is the measure that most directly affects whether treatment can work.

# Hours from exposure to assessment for last year's blood exposures
cases = [
    ("needlestick", "day", 0.6), ("needlestick", "day", 0.9), ("needlestick", "night", 1.4),
    ("needlestick", "night", 6.5), ("needlestick", "day", 0.5), ("needlestick", "night", 2.8),
    ("needlestick", "day", 1.1), ("needlestick", "evening", 1.8), ("needlestick", "night", 26.0),
    ("splash", "day", 0.8), ("splash", "evening", 3.5), ("splash", "night", 1.2),
    ("cut", "day", 0.7), ("cut", "evening", 1.6), ("bite", "night", 12.0),
]

def band(h):
    if h <= 2:
        return "within 2 h"
    if h <= 24:
        return "2 to 24 h"
    if h <= 72:
        return "24 to 72 h"
    return "over 72 h"

order = ["within 2 h", "2 to 24 h", "24 to 72 h", "over 72 h"]
for shift in ("day", "evening", "night"):
    hs = [h for kind, s, h in cases if s == shift]
    counts = {b: 0 for b in order}
    for h in hs:
        counts[band(h)] += 1
    row = "  ".join(f"{b}: {counts[b]}" for b in order)
    print(f"{shift:8} n={len(hs):2}  {row}")

day      n= 6  within 2 h: 6  2 to 24 h: 0  24 to 72 h: 0  over 72 h: 0
evening  n= 3  within 2 h: 2  2 to 24 h: 1  24 to 72 h: 0  over 72 h: 0
night    n= 6  within 2 h: 2  2 to 24 h: 3  24 to 72 h: 1  over 72 h: 0

Every day-shift case was assessed within 2 hours, and so were most evening cases. Nights were the problem: of the six night cases, only two were seen within 2 hours, and one, a needlestick, was not reported until the next day. When Joanne asked night staff why, the answers were that they did not want to leave the unit short, and that some did not know they could go to the emergency department at night. The committee asked managers to make it clear that a charge nurse will always cover a worker who needs to be assessed, and posted the night route on every unit.