Needlestick injury in a pregnant inpatient in an overcrowded hospital.
A 25-year-old primigravida at term, who had gestational hypertension, was referred to hospital for further care. On arrival at the hospital her blood pressure was 143/93 mmHg and she was admitted to the antenatal ward for work-up and labour induction. Her antenatal care was uneventful prior to developing hypertension. Her risk factors for this condition were primiparity and obesity (body mass index of 30 kg/[m.sup.2] at booking). The clinical work-up showed no evidence of proteinuria, target organ damage or intrauterine growth restriction. During the first two days of her hospital admission, all the available beds in the antenatal ward were occupied, as the number of patients was twice the number of beds. As a result, the patient had to wait in the corridor of the antenatal ward until an empty bed became available. In this article she is referred to as the injured patient.
Another patient, referred to as the source patient, was seated on a chair in the corridor of the antenatal ward and was receiving intravenous fluids through infusion set A (Fig. 1). To this was attached a second intravenous infusion set, set B, through a needle at site X on set A, to administer medication. The needle of set B became disconnected without being discovered by the source patient or the nurses. The source patient had been diagnosed HIV-positive 3 years previously and was on antiretroviral therapy (ART) for maternal health. The injured patient, having waited for approximately 48 hours without a bed, took to walking during the day and on her way to join other patients seated on chairs in the corridor of the antenatal ward, stepped on the disconnected needle of set B and sustained an NSI on her right big toe.
The patient reported the adverse event to the medical staff on duty and the following immediate measures were taken: blood was squeezed from the injured site; and the site was washed liberally with water and cleaned with an antiseptic solution. The patient was counselled and tested HIV-negative. She was immediately initiated on a 4-week course of prophylactic ART as per hospital policy. Screening for hepatitis in both patients was negative, and a full blood count and liver and renal function tests of the injured patient were normal. Following hospital discharge of other stable pregnant women, the source and the injured patients were provided with beds for their continued medical care. A day after the incident, the injured patient was started on misoprostol to induce labour, but had a caesarean delivery due to fetal compromise and delivered a normal healthy boy (weight 2 870 g) who was started on a 6-week course of nevirapine syrup, 15 mg daily, as recommended by the neonatologist.
[FIGURE 1 OMITTED]
The injured patient and her baby were discharged in a stable condition on the 3rd day after delivery. They completed the ART prophylaxis without any side-effects. Six weeks after the incident, they remained healthy, tested HIV-negative and were scheduled for further HIV testing at 3 and 6 months.
When the optimal patient care capacity of a healthcare system or provider is exceeded, patient safety is compromised,  as was seen in this case. At the time of the NSI, the number of patients in the ward was more than the available beds and the nurses who were on duty during the incident had to perform menial functions that prevented them from monitoring patients closely. The lighting was good where the injury occurred and the injured patient had no visual or physical impairment, but she may have been tired, given that she had no bed at the time of the injury.
The health facility where this incident occurred had a policy on NSI for HCWs, but owing to the rarity of NSI in patients, no policy was available for this scenario. The hospital management were aware that the number of patients in the antenatal ward usually exceeds the available beds, and had a long-term plan to construct additional wards to prevent overcrowding. Nonetheless, the adverse incident was reported to the hospital management and the interim actions taken included starting the process of converting sections of other less busy wards with extra beds to antenatal ward extensions, and deployment of additional staff to the antenatal ward.
To our knowledge, this is the first reported case where: (i) a pregnant inpatient had an NSI; and (ii) nevirapine was administered to a baby due to an NSI sustained by the mother. Nevirapine was used as it is recommended for prevention of mother-to-child transmission (PMTCT) of HIV in South Africa/71 Owing to the urgent need to avert further NSIs in patients, particularly in overcrowded health facilities, we outline preventive measures to be taken before the injured patient and her baby complete their follow-up visits (Table 1). These consist of components relating to: health facility administration, including developing a patient NSI policy; HCWs, including safe use of needle-containing devices; and patients and their visitors adhering to the patients' rights charter and hospital policies. These interventions are based on the authors' many years of clinical experiences in different countries. Nonetheless, different settings may require other interventions and the personnel responsible for implementing a particular task may vary.
NSI in inpatients has not been reported previously. The lesson is that it can occur, although it is preventable using the suggested measures.
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N C Ngene, (1,2) MBBS, Dip Obst (SA), Dip HIV Man (SA), MMed (Fam Med), FCOG (SA), MMed (O&G); C O Onyia, (1) MBBS; J Moodley, (3) MB ChB, FCOG (SA), FRCOG, MD; M J Titus, (1,2) MB ChB, FCOG (SA), LLM, PGDip (Int Res Ethics)
(1) Department of Obstetrics and Gynaecology, Pietermaritzburg Metropolitan Hospitals Complex, KwaZulu-Natal, South Africa
(2) Department of Obstetrics and Gynaecology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
(3) Women's Health and HIV Research Group, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
Corresponding author: N C Ngene (email@example.com)
Table 1. Measures to prevent NSI in patients at different levels of the healthcare system Administration Develop a policy on NSI Provide appropriate staffing Organise continuing medical Provide clerks, porters and education on NSI for staff phlebotomists in the wards and medical trainees so that nurses/doctors can concentrate on their duties Ensure good record keeping Provide social workers, so that quality data are clinical psychologists, available for audit infectious disease physicians, occupational health personnel and appropriate medications to aid in managing any patient who sustains an NSI Organise quality improvement Promote the treatment and projects on patient safety prevention of HIV infection and NSI Ensure that patient safety is Promote vaccination addressed as part of HCW against hepatitis training Ensure that staff are aware Provide good leadership of what to do in the event and staff motivation of an NSI Improve structural facilities Promote teamwork among staff of the health institution in the health facility as the need arises Provide good lighting in Promote an awareness of the hospital environment patients' rights charter Ensure a regular supply of Regulate visiting hours in clean water to the health the health facility facility Provide appropriate equipment Provide appropriate for patient care laboratory facilities To address patient Establish appropriate overcrowding of a referral routes health facility: provide additional space where patients can be cared for; support referral of patients to alternative facilities; redeploy additional staff to work in the overcrowded unit; educate patients; support the establishment of a primary healthcare centre within or near the health facility for management of low-risk patients; if possible ensure that patients do not share one bed; inform district /municipal authority in charge of overcrowding should it persist despite appropriate measures having been taken, etc. HCWs Adhere to guidelines on NSIs Avoid inappropriate prescription of parenteral therapies Educate patients on what to Use needle-free devices where do if there is an NSI possible, e.g. needle-free syringes and intravenous infusion sets Show empathy, support and Ensure that all intravenous provide medical care to fluid administration sets any patient who sustains are properly fastened to an NSI prevent inadvertent disconnection Report NSIs Monitor patients with intravenous/intra-arterial lines Adhere to treatment Remove intravenous access as protocols and consult soon as there is no senior colleagues for indication for their use advice if necessary Manage patients at risk of Adhere to standard operating injury (such as children, procedures regarding the the mentally ill, the blind safe use/sterilisation of and unconscious patients, equipment and waste disposal etc.) appropriately Counsel patients before Avoid unnecessary admission any medical procedure of patients for inhospital care To address patient Engage in community health overcrowding of a health promotion so as to prevent facility: consider illnesses discharging stable patients; inform the supervisor; discuss with management, etc. Patients and their visitors Ask questions when in doubt Report concerns to HCWs (and to management if not satisfied) Adhere to medical advice Be aware of patient and visitor rights Adhere to health policies such as appropriate referral routes and facility visiting hours NSI = needlestick injury; HCW = healthcare worker.
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|Title Annotation:||CASE REPORT|
|Author:||Ngene, N.C.; Onyia, C.O.; Moodley, J.; Titus, M.J.|
|Publication:||Southern African Journal of HIV Medicine|
|Article Type:||Case study|
|Date:||Jun 1, 2014|
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