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Needlestick injury in a pregnant inpatient in an overcrowded hospital.

Despite the availability of medical safety programmes, [1] more than 10% of patients suffer harm during hospital care. [2] The occurrence of needlestick injury (NSI) in an inpatient in particular raises serious safety concern. There are reports of NSIs sustained by healthcare workers (HCWs), [3-5] but there is no publication, to our knowledge, on such injuries occurring among inpatients. We discuss an NSI in a pregnant inpatient and outline appropriate measures to prevent such incidents.

Case report

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.

Discussion

When the optimal patient care capacity of a healthcare system or provider is exceeded, patient safety is compromised, [6] 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.

Conclusion

NSI in inpatients has not been reported previously. The lesson is that it can occur, although it is preventable using the suggested measures.

References

[1.] World Health Organization. WHO Patient Safety--Programme Areas. http://www. who.int/patientsafety/about/programmes/en/ (accessed 6 March 2014).

[2.] World Health Organization. 10 Facts on Patient Safety. http://www.who.int/ features/factfiles/patient_safety/patient_safety_facts/en/index.html (accessed 6 March 2014).

[3.] Gounden YP, Moodley J. Exposure to human immunodeficiency virus among healthcare workers in South Africa. Int J Gynaecol Obstet 2000;69(3):265-270. [http://dx.doi.org/10.1016/S0020-7292(00)00207-1]

[4.] US Public Health Service Working Group. Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HIV and

Recommendations for Postexposure Prophylaxis. http://stacks.cdc.gov/view/ cdc/20711 (accessed 6 March 2014).

[5.] Hoffmann C, Buchholz L, Schnitzler P. Reduction of needlestick injuries in healthcare personnel at a university hospital using safety devices. J Occup Med Toxicol 2013;8:1-5. [http://dx.doi.org/10.1186/1745-6673-8-20]

[6.] Jha AK, Prasopa-Plaizier N, Larizgoitia I, Bates DW. Patient safety research: An overview of the global evidence. Qual Saf Health Care 2010;19(1):42-47. [http:// dx.doi.org/10.1136/qshc.2008.029165]

[7.] South African National Department of Health. The South African Antiretroviral Treatment Guidelines 2013. http://web.up.ac.za/sitefiles/file/45/1335/877/ PMTCT%20guidelines_March%202013_DoH.pdf (accessed 6 March 2014).

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 (ngenenc@gmail.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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Article Details
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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
Geographic Code:6SOUT
Date:Jun 1, 2014
Words:1809
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