Whole 30 nsv meaning
Needlestick Injury Management
Background: An estimated 1 million needlestick injuries (NSI) occur in Europe every year. The EU guideline 2010/32 on the avoidance of NSV lays down minimum requirements for prevention and requires the implementation of local, national and pan-European reporting systems. The directive must be implemented by all EU member states by May 11, 2013 at the latest. The aim of the present study was to evaluate and optimize the reporting and care concept after NSI at a clinic providing indispensable emergency care.
METHODS: The authors conducted a prospective observational study on reporting procedures and incidence of NSI, infectivity of index patients, post-exposure measures and serological examinations of affected employees during an 18-month observation period.
Results: A total of 519 NSI were reported to the in-service doctor on 547 working days. A serological test for hepatitis B (HBV), hepatitis C (HCV) and HIV was carried out in 86.5% of the index patients; two initial diagnoses (active hepatitis B and hepatitis C infection) were made in index patients. Every fifth index patient (92 of 449 patients) had at least one blood-borne infection. HIV post-exposure prophylaxis was initiated in 41 employees. Hepatitis C virus was transmitted, which was successfully treated. No further transmission of infections was recorded.
Conclusion: The most complete and complete recording of NSI is a prerequisite for identifying risky activities and ensuring optimal support for the employees concerned. Controlling the healing process according to NSI requires a high level of interdisciplinary competence on the part of the in-service doctor.
The European Agency for Safety and Health at Work estimates that there are an estimated 1 million needlestick injuries (NSI) in Europe each year (1). For those affected, NSI represent a serious risk to the blood-borne infections hepatitis B (HBV), hepatitis C (HCV) and HIV (2–4). Follow-up examinations after NSI are important both for the medical workers concerned and for the patients being cared for, in order to prevent any nosocomial infections or to detect the transmission of infections as early as possible.
The EU Directive 2010/32 / EU published in June 2010 contains regulations for the prevention of injuries from sharp / pointed instruments in the hospital and health sector and lays down minimum requirements for prevention. It must be implemented by all EU member states by May 11, 2013 at the national and local level (5). The new EU directive requires changes to existing laws and regulations in the member states. In Germany, for example, the Biological Agents Ordinance and the Technical Rule for Biological Agents (TRBA 250) (6) have to be revised. For example, the EU directive requires the implementation of local, national and pan-European reporting systems in order to improve the epidemiological recording and evaluation of NSI. Against the background of a considerable number of unreported NSIs (underreporting rates of 20–90% have been described in the literature ), important preventive approaches are expected from an improved reporting system.
The aim of the present study was to evaluate and determine the frequency of NSI reported to the transit doctor (D doctor) in order to obtain an infection-epidemiological overview of the disease burden caused by NSI (7).
In Germany, transit doctors are doctors approved by the employers' liability insurance associations and accident insurance funds for the treatment of work and commuting accidents, who control the healing process with a special obligation as a representative of the accident insurance company. The reporting process of the university hospital was evaluated against the background of the new EU directive in the observation period with regard to the duration of the reporting process and the initiation of post-exposure measures.
The University Hospital Frankfurt am Main is a hospital for indispensable emergency care with 1,187 beds, 4,223 employees and 3,775 human and dental students. In October 2010, the medical follow-up care for employees after NSV at the university hospital was reorganized. From this point on, close interdisciplinary cooperation and a joint evaluation of previous NSIs took place between the D-doctor and the company medical service (Figure 1). The focus on infectiology of the medical clinic was consulted with regard to HIV post-exposure prophylaxis (PEP) and the Institute for Medical Virology with regard to the evaluation of the virological laboratory parameters.
A prospective observational study was carried out. This was based on the D-doctor report and the occupational medical follow-up examinations on the incidence of NSI, the infectivity of the index patients, the hepatitis B vaccination status of the employees and the initiation of post-exposure measures. The D-doctor procedure was assessed with regard to the duration of the individual treatment steps. The observation period extended over 18 months (mid-October 2010 to mid-April 2012). The accident logs were assessed by two study authors with regard to the severity of the injury:
- Category 1: deep cut with a scalpel or hollow needle
- Category 2: superficial injuries - puncture injuries with sewing needles or dental hooks et cetera (no hollow cannulas)
- Category 3: Mucosal contamination or contact with non-intact skin
If there was no consensus, a third investigator was consulted.
Employees who received an HIV-PEP presented to the company medical service after 14 days and after completing the HIV-PEP (day 28). During the presentation, the subjective well-being was recorded using a standardized questionnaire. The data protection officer of the University Hospital Frankfurt and the ethics committee of the medical department of the Johann Wolfgang Goethe University received a positive vote for the study (reference no. 106/12).
Needlestick injuries (NSV) are stab, cut or scratch injuries with sharp or pointed medical instruments (such as cannulas, lancets, scalpels), which may be contaminated by the patient's blood or other body fluids, as well as blood contacts with non-intact skin and mucous membrane contacts (eyes , Mouth, nose).
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A total of 519 NSI were reported to the D-doctor within 547 working days. This corresponds to 29.2 NSI per 100 beds per year and just under one NSI per working day. The distribution of NSI according to occupational groups, specialist disciplines and injury severity is shown in graphics 2–4.
Serological tests for HBV, HCV and HIV were performed in the index patient in 86.5% (449/519) of the NSI. In the remaining 13.5% (70/519) of the NSI, the index patient was either not known (for example, NSI with cannula from an unknown index patient in the context of disposal, for example in an overfilled drop box or during tidying up and cleaning work) or a blood test was requested waived (e.g. for outpatients). Only one index patient refused the blood test. A total of 20.5% (92/449) of the index patients examined had at least one blood-borne infection. 11.4% (51/449) of the index patients were HIV-positive, 9.8% (44/449) had a positive HCV-PCR (PCR, polymerase chain reaction) and 3.6% (16/449) had an active HBV- Infection. 4.2% of this collective (19/449) had a co-infection, HCV / HIV co-infections dominated here (15/19).
Trypanosoma rhodesiense infection and viremic cytomegalovirus, Epstein-Barr and parvovirus infections were diagnosed as rare infections in the index patients.
During the study period, HCV transmission to a medical colleague occurred, with the diagnosis being made using PCR on the 15th day after NSV (8, 9). Due to the low spontaneous healing rate of acute hepatitis C and the good response to antiviral therapy in the early phase of the infection, the indication for the initiation of antiviral therapy was made (10). The HCV therapy was successful; after the end of the treatment, no more HCV RNA could be detected. No further transmission of infections was found in the follow-up period (as of October 28, 2012).
HIV post-exposure prophylaxis
HIV post-exposure prophylaxis (PEP) was prescribed for 41 employees. The viral load of the index patients with positive HIV-RNA-PCR detection was between 20 and 7,360,000 copies / mL in a total of 19 patients; in 16 HIV-positive index patients, the viral load at the time of NSI was ≤ 20 copies / mL. Due to the severity of the injury, six employees who contracted NSI in an unknown index patient received an HIV-PEP. A total of 75.6% (31/41) of HIV-PEP took place according to the recommendations of the German AIDS Society with the daily dose tenofovir 300 mg / emtricitabine 200 mg and lopinavir 800 mg / ritonavir 200 mg (11).
Due to proven HIV resistance in the index patient or drug intolerance to the above-mentioned combination of active ingredients, a correspondingly adapted antiviral therapy regimen was administered to ten employees. A total of 58.5% (24/41) of the employees stated that they had not tolerated the PEP (quote: “That was a catastrophe” or “The whole time I felt as if I had been run over by the bus”); 31.7% (13/41) rate the tolerability of the PEP as “moderate”; only four employees stated that they had tolerated the PEP well (Figure 5).
A total of six employees were unable to work for between one and four weeks during the PEP. The most common side effects mentioned were gastrointestinal symptoms (nausea, vomiting, diarrhea) and dermatological complaints (drug eruptions, generalized pruritus). Two employees developed scleric terus with elevated liver values and one employee developed hematemesis. A total of 58.5% (24/41) of those treated had consistently taken the PEP for 28 days, 41.5% (17/41) discontinued the therapy due to side effects.
The time interval between NSI and the start of PEP was on average 75 minutes, the earliest PEP start was 10 minutes after NSI, two employees did not appear at the D-doctor until the day after the NSI, so that the start of therapy was delayed.
Hepatitis B vaccination status
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Timing of the D-doctor procedure
For a total of 94.4% (490/519) of the employees concerned, the time lapse of D-medical care could be analyzed. After NSI, those affected presented themselves at the registration desk of the Central Emergency Department (ZNA) after 145.3 ± 278.2 minutes (median 39 minutes). The following average waiting time at the D-doctor was 52.4 ± 57.2 minutes (median: 34 minutes, minimum waiting time: 5 minutes, maximum 560 minutes).
The duration of the waiting time at the D-doctor changed significantly during the observation period. While the mean waiting time (mean) at the beginning of the observation period was 60.7 ± 59.5 minutes, it was 31.9 ± 19.3 minutes at the end of the observation period (p <>
Even with index patients who were known to be infectious, the NSV sufferers did not present a quicker introduction to medical care; No statistically significant relationship was found between the infectiousness of the index patient and the time of presentation (infectious index patient versus unknown infection status: 152.4 ± 308.9 minutes versus 143.8 ± 271.9 minutes, p = 0.799).
Almost every fifth index patient at the Frankfurt University Hospital had a blood-borne infection. This initially unexpectedly high number of infections (seroprevalence of HIV, HCV, HBV in the German “normal population”: 0.05–0.7% [12, 13]), however, corresponds with information in the international literature. Data from Switzerland show that 12.3% of the index patients examined were HCV-positive, 6.5% HIV-positive and 2.2% HBV-positive (14). At a university hospital in the United States, 26% of trauma patients and 24% of non-trauma patients were HIV-positive (15). Similar data could already be documented in an American emergency room in 1992: Here 24% of the examined patients had at least one blood-borne infection (16).
In a study by our own working group, increased infection rates in patients at the Frankfurt University Hospital compared to the “normal population” were documented in the past (17). The infection rates detected at the time (HIV 4.1%, HCV 5.8%) were, however, significantly below the infection numbers that have now been established. Similar data were found in an HCV seroprevalence study in the central emergency department of the Frankfurt University Hospital, which showed an HCV prevalence of 3.5% (18).
Interestingly, in their seroprevalence study (17) from 2005–2007, the authors of the present study were able to demonstrate a slightly higher HBV prevalence (5.3%) than in the index patients now examined (3.6%). If necessary, the increasing hepatitis B vaccination of the population comes into play here.
NSI in known infectious patients or high-risk patients are certainly reported more frequently (19), but NSI in known infectious index patients are often not reported either (20). An American multicenter study of surgeons showed that 99% of surgeons had suffered at least one NSI during their training. 53% of these NSIs occurred in a high-risk patient; a total of 16% of the blood contacts were not reported (19). Although there are no reliable figures on reporting behavior, it can be assumed that NSIs are reported more consistently in known infectious patients. For example, our own data from 2006/2007 showed that more than half of the employees do not report their NSI (21). Compared to the “underreporting” in infectious index patients (16%), this is roughly three times as high a rate, which is subsequently reflected in the infection rates of the index patients.
Index patients may also benefit from their blood tests (22). Two initial diagnoses of hepatitis virus infections were made during the study period. Both patients were able to receive appropriate therapy for their hepatitis virus infection.
Interestingly, in the present study, NSIs were not reported any faster in known infectious patients than in index patients with an unknown or negative infection status. On average, the employees did not present themselves to the D-doctor until 2.5 hours after their NSI. However, HIV-PEP only makes sense within a limited but not exactly definable time window after exposure. Experimental studies show an attachment of the HI virus to the host cell within two hours of exposure (11). As a general rule, HIV-PEP should be carried out as soon as possible (11, 23–25).
Interestingly, the tolerance of antiretroviral medication in the context of PEP in HIV-negative employees differs from the tolerance in the context of HIV treatment (26). Less than 10% of the employees in their own study group stated that they had tolerated the PEP well. Similar data were published in 2000 by an Italian working group. More than 70% of medical workers taking HIV-PEP complained of side effects; whereas only 11.1% of HIV-positive patients reported side effects with the same drug combination (27).
Female employees in their own study collective tolerated the PEP more poorly than their male colleagues, although the difference was not statistically significant (Figure 5). A French study came to a similar conclusion (26). However, a good tolerance is the prerequisite that the PEP is consistently taken over the recommended 28 days. Older model calculations show that HIV-PEP reduces the risk of HIV transmission by 81% (95% CI: 48–94%) (28). Case reports of HIV infections after occupational blood contact despite consistent use of PEP have been described (28, 29). However, a systematic analysis containing original data from large study groups has not yet been published.
Although the authors can make statements about a large number of NSI, the present study also has limitations.In their analysis, the authors refer exclusively to NSI that were reported to the D-doctor; They cannot provide any information on non-reported NSI and can only estimate the extent of the "underreporting" or adopt it from previous studies (3, 14, 17). In addition, the reporting behavior of the employees could have led to an overestimation of the number of infections in the index patients.
In spite of some limitations, a number of practice-relevant measures emerge from the available data, whereby the immediate treatment of NSI must be given high priority. The following processes have been optimized:
- Definition of clear responsibility for individual work steps
- Creation of an SOP (Standard Operating Procedure)
- interdisciplinary cooperation
- intensive communication with the interfaces
- regular meeting of all those involved
- Communication in the clinic's internal media (intranet, mail, clinic newspaper).
This enabled a significant reduction in the waiting time until treatment (from 60.7 ± 59.5 before the start of the observation period to 31.9 ± 19.3 minutes at the end of the observation period [p <>
However, the data collected also shows that employees need to be informed and trained even more intensively. In particular, the need to report NSI immediately in order to start HIV-PEP as soon as possible if an HIV-PEP is indicated, must be communicated intensively.
Statistically, the risk of transmission of infection is not great; however, the consequences of virus transmission are severe. For this reason, all hospitals should have a sufficient and easily accessible reporting and treatment regime that is available 24 hours a day, 365 days a year. The implementation of the EU Directive 2010/32 / EU will lead to improved occupational safety for medical workers.
The authors would like to thank Ms. Heike Kämmerer for her ongoing support in looking after the employees concerned.
Conflict of interest
Prof. Rabenau has received lecture fees from Mölnlycke Health Care.
PD Dr. Wicker was reimbursed for travel and accommodation expenses and received lecture fees from B. Braun, BD, BV-Med, pfm.
The other authors declare that they have no conflict of interest.
Taken in: August 17, 2012, revised version accepted on October 30, 2012
Address for the authors
PD Dr. med. Sabine Wicker
Hospital of the Johann Wolfgang Goethe University in Frankfurt
60590 Frankfurt am Main
Himmelreich H, Rabenau HF, Rindermann M, Stephan C, Bickel M, Marzi I, Wicker S: The management of needlestick injuries. Dtsch Arztebl Int 2013; 110 (5): 61-7. DOI: 10.3238 / arztebl.2013.0061
@ The German version of this article is available online:
Dtsch Arztebl 2007; 104 (45): A 3102-7. FULL TEXT
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