24-hour PEP plan needed to treat injured employees
July 1, 2000 4 minutes read
24-hour PEP plan needed to treat injured employees
Beepers, hotlines help HCWs get qualified opinion
If a health care worker has a blood exposure from a high-risk patient, every minute counts. In the middle of the night, who is ready to help the employee make a swift but educated decision about starting postexposure prophylaxis (PEP)?
Employee health professionals should set up a protocol that provides for a qualified physician to evaluate employees quickly after each significant needlestick, says Daymon Evans, MD, MPH, director of employee health services at Community Hospitals of Indianapolis.
"We’re talking a golden hour here," says Evans, who spoke on PEP at the recent American Occupational Health Conference in Philadelphia. "We used to talk about the golden hour for trauma, heart attack, and strokes, things that can be done to save lives in that time frame. This falls right in there, too."
Animal studies indicate that antiviral drugs are most effective before the HIV virus has had time to replicate significantly.1 Experts recommend starting PEP as soon as possible after exposure.
That requires clear procedures and education of health care workers and the people who will treat them. "You have to have contingency plans to know how your system is going to work if you have exposures when employee health services is not available," says Evans. "Everyone needs to know this is a life-or-death emergency, not to brush it off."
A needlestick hotline may be the fastest way to get a response to an exposure. At Warren G. Magnuson Clinical Center of the National Institutes of Health in Bethesda, MD, a single phone call reaches an on-call occupational medicine physician within five minutes.
The person who answers the beeper is knowledgeable about postexposure management, notes David K. Henderson, MD, deputy director for clinical care. "In all but one instance in the past two years, we’ve [been able to start appropriate PEP] within two hours," he says. "Our average is a little less than an hour."
At The Valley Hospital in Ridgewood, NJ, a clinical nursing supervisor carries the "needle beeper" 24 hours a day, seven days a week. If a health care worker has any bloodborne pathogen exposure, he or she is directed to wash the area immediately, then call the beeper.
"We have a wallet card that we give to everybody" with those instructions, explains Peg Meyersburg, RN, COHN-S/CM, director of employee health services. In addition to the individual card, instructions are posted in all departments.
That nursing supervisor completes an evaluation form that is based on guidelines from the Centers for Disease Control and Prevention in Atlanta.1 The employee then takes the form with him or her to the emergency department for evaluation and treatment. The ER physician looks for significant information supplied by the form. (See a sample copy of the evaluation form, inserted in this issue.)
"If a shaded area of the form is checked yes,’ the ER physician must call the infectious disease physician," says Meyersburg.
This system ensures that the employee gets swift attention from someone who is knowledgeable about bloodborne pathogen risks, she says. "We needed to have absolutely immediate assessment of the source patient and the injury to enable the infectious disease physician to make an appropriate decision about PEP," she says.
If the infectious disease physician recommends PEP and if the employee agrees to the regimen, the pharmacy delivers starter doses to the emergency department. Employee Health Services then follows up with postexposure counseling.
Since the needle beeper was implemented two years ago, just two employees began PEP after a needlestick. No one has seroconverted to HIV-positive status after a needlestick exposure.
"There were two pieces to this: Get them the medication ASAP, and give them the sense that someone wasn’t just writing a prescription, an ER physician following a set of guidelines," says Meyersburg. "There is an infectious disease physician who is actually evaluating the risk."
Employees need to understand the urgency
To ensure a quick and proper response to blood exposures, ongoing education is critical — both for employees and for the people who will treat them.
"I’m really trying to get this [issue] into the core curriculum of emergency medicine," says Evans. "It’s one of those skills emergency physicians need to know."
Henderson stresses that the evaluating physicians need to understand the particular issues involved in occupational exposures.
Of course, the evaluation for possible prophylaxis actually starts with the employee. "The occupational medicine doc can’t do anything about whether or not the employee reports the exposure or how promptly he or she seeks help," says Henderson. "That is a real important part of the protocol."
Employees may downplay the risk associated with an exposure. Even though the rate of seroconversion after a percutaneous exposure to HIV-infected blood is only about 0.3%, that rare case can have deadly consequences.
"Unfortunately, some very trivial exposures have been shown to transmit virus," Henderson says. "The likelihood is probably way smaller, but just like lightning strikes some places, things happen. [We say,] Just report it and let the experts in occupational medicine help you.’"
Giving PEP after an exposure may seem the safe course of action. But the drugs have significant side effects, making the decision more complex. "We neither want to undertreat or overtreat," cautions Henderson.
References
1. Public Health Service guidelines for the management of health-care worker exposures to HIV and recommendations for postexposure prophylaxis. MMWR 1998; 47(RR-7):1-28.
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