Use packet to treat occupational exposure
Although current guidelines recommend that health care workers be treated within hours, not days, after an occupational exposure (OE) to infectious disease including human immunodeficiency virus (HIV), hepatitis B (HBV), and hepatitis C (HCV), this treatment doesn’t always happen, notes Anna Smith, RN, MSN, director of emergency services at University of Louisville (KY) Hospital. "The process is often confusing," she says. "Also, nurses often don’t know how soon the medications need to be given."
This is partly due to the episodic nature of those incidents, says J. Celeste Kallenborn, RN, BSN, senior nurse coordinator in the department of emergency medicine at the University of Louisville School of Medicine. "For instance, we may have four OEs in one month, and then not see another one for two months," says Kallenborn. "Materials not used on a regular basis tend to be forgotten."
There is a tendency to push an incident of OE aside since it wasn’t considered an emergency, she notes. "When the Centers for Disease Control and Prevention [CDC] came out with new recommendations that these patients should be given postexposure prophylaxis within hours, we developed a packet of clear-cut guidelines to address this issue and avoid delays," says Kallenborn.1
A multidisciplinary team set a goal of a two-hour turnaround time for ED treatment of OE patients. "Two hours is the recommended time factor for the most effective benefit of the medications," says Smith. "You can still treat and medicate after two hours, but the efficacy decreases with increased time."
Based on CDC guidelines
The ED’s OE packet of forms is based on the CDC guidelines of occupational exposure. "By putting all the forms together in a packet, it eliminates searching for forms, as well as prompting them to use all of the appropriate forms," says Kallenborn.
The ED packet for occupational exposure includes the following items:
• protocol checklist (see Occupational Exposure Checklist, pp. 73-74);
• health care worker information sheet regarding postexposure care;
• consent for HIV testing;
• consent for postexposure prophylaxis therapy;
• laboratory slips and labels for rapid HIV testing;
• MMWR recommendation tables for physician reference;
• education information sheets explaining side effects, interactions, and instructions;
• discharge instruction sheet.
Here are key components to include when creating an OE packet:
• Use a flowchart to standardize care.
A flowchart takes the guesswork out of what needs to happen, Smith notes. (See ED flowchart for OE, above.) The algorithm is attached to the outside of the packets, which are kept at the triage station.
"It tells you what type of exposure you may possibly be dealing with, so you can address the patient’s concerns right there at triage. It also tells you whom you are to notify, such as lab and the attending," she explains.
For example, an employee may have a scratch on his or her arm, which is a lower risk exposure, while another employee may have stuck him or herself on the dialysis unit, which is a much higher risk exposure, Smith says. The algorithm directs the nurse to follow certain steps, depending on which exposure category the patient falls under, she explains.
• Refrigerate test kit at triage.
The algorithm directs nurses to call the lab right from triage and refrigerate the test kit as needed so that by the time the physician assesses the patient, the kit is ready to be used.
"If you don’t let the lab know the patient is there until they are back in the treatment room, it delays care," says Smith. At that point, it would take another 45 minutes for the kit to reach optimal temperature. "That’s more time you are eating up in the two-hour time limit, which is our goal for treatment of these patients."
Protocol saves time
• Address the timeframes for treatments.
The protocol jump-starts the process and saves time, says Smith. "There is a timeline to have an effective outcome from interventions, and there is not a lot of time to work with," she stresses.
Before the CDC guidelines were published, there was not a push to get prophylaxis determination made within two hours, notes Kallenborn. "These patients tended to sit in the ED for hours because it was not perceived as emergent care.’"
In the first six months after the OE packet was developed, 11 health care workers were treated with an OE. A review showed that average turnaround time from triage to discharge from the ED was 2 hours and 2 minutes, Kallenborn reports.
The OE protocol has reduced delays in treatment, notes Smith. "Since we had no protocol to begin with, we had various treatment regimens and associated time factors involved in care, some as high as four hours."
If prophylaxis medications are started within a few hours of exposure, it is thought that their seroconversion rate is lower, Kallenborn says. "This has not been proven in human studies, due to the ethical dilemma of withholding medications. But at any rate, it is suggested to start medications right away, rather that waiting until the following day at employee health."
Meeting the two-hour deadlineM
• Include a checklist.
A detailed checklist is used to guide you through the steps of the process, says Kallenborn. This ensures that nurses meet the goal of the two-hour "door to decision/treatment" time, she explains. The process begins in the triage area, including the following:
— rapid registration;
— notification of the laboratory to prepare for the rapid HIV testing;
— notification of the physician to include immediate evaluation;
— evaluation of the need for initiation of pregnancy testing for women of child-bearing age.
• Include a lab slip and packet.
This simplifies the steps that involve the lab, says Kallenborn. "It requires a miscellaneous lab charge slip, and this is potentially something that may not be readily available, so we include it in the packet," she explains. "Also, this ensures that both the hepatitis and HIV tests are ordered correctly."
• Inservice nurses.
A 20-minute inservice on the OE packet was given to ED nurses during other mandatory educational sessions, says Kallenborn. After one year, a mandatory update is also given with a 15-minute inservice.
The university also created a self-study binder for new employees to review during orientation. The binder explains the packet in detail, Kallenborn says.
1. Centers for Disease Control and Prevention. Public health service guidelines for the management of health care workers’ exposures to HIV and recommendations for postexposure prophylaxis. MMWR 1998; 47:1-34.