Hospitals allay needlestick fears with advance consent

Patients agree to postexposure test before surgery

The minutes or hours immediately after a needlestick can be the most devastating for an injured employee. To allay fears and begin any necessary postexposure prophylaxis (PEP) as quickly as possible, some hospitals have begun gaining patient consent for HIV testing prior to surgery.

Used hand in hand with new rapid HIV tests that can be conducted in-house, hospitals are able to tell employees the patient’s HIV status within as little as 30 minutes after the injury — in some cases before the patient has even emerged from anesthesia.

"It’s a nightmare for anybody who’s been exposed to sit around and wait and wonder," says Sharol Mackie, RN, BSN, CIC, infection control coordinator at Redding (CA) Medical Center. "And to take those medications [unnecessarily], those are pretty toxic medications."

Redding Medical Center includes the consent on the general consent form for surgery or for procedures that use conscious sedation, such as cardiac catheterization. The advance consent for blood testing is voluntary, and refusal to sign does not affect the surgery, Mackie says.

Laws regarding consent for HIV testing vary from state to state, so hospitals should consult their legal counsel, notes Linda Chiarello, RN, MS, an epidemiologist with the Hospital Infections Program at the Centers for Disease Control and Prevention in Atlanta.

When a health care worker suffers a needlestick injury, the first question may involve the risk profile of the patient. If the patient is known to be in a high-risk category for HIV and the blood exposure was significant, postexposure prophylaxis should begin immediately, says Chiarello.

"If someone has a significant exposure, it’s better to start PEP than to delay it because of the rapid test," she says.

The CDC has relied on animal studies that show prompt administration of PEP is important, but there’s no exact time recommendation.1 "We think it’s very important to start it as soon as possible," Chiarello says. "[The rapid HIV test] is very reliable, and you can stop PEP if it has been started."

However, with advanced consent and a rapid test, it is possible to avoid unnecessary PEP, which carries significant side effects.

At Enloe Medical Center in Chico, CA, Alivia Strawn, RN, BS, CIC, manager of epidemiology and safety, was particularly concerned about needlesticks that occurred during lengthy surgery.

"Do you really want your surgeons, or anybody involved in the case, who may be committed to a six- or seven-hour surgical procedure to be popping chemotherapeutic agents and still doing surgery?" she says. "Most people don’t handle those therapeutic agents well."

Enloe now asks physicians to talk to patients about the advance consent for blood tests in the event of occupational exposure. The question is included on surgical consent forms, with a separate signature for consent.

"You have to make sure that the teaching is being done with the patient at the time the consent is being signed and that the physician has had the conversation with patients," says Strawn.

Laws that allow for testing without consent often aren’t a substitute for advanced consent.

For example, the Ryan White Act, a federal law that requires disclosure of available medical information about a patient’s HIV status, does not involve testing and only covers emergency care technicians who treat patients before they reach the emergency department.

Other laws, such as one in California, require the notification of the patient and primary care physician in writing before testing blood samples, creating a delay of 72 hours, says Strawn.

Meanwhile, patients don’t balk at signing the advance consent, says Strawn. "The patients are understanding because they’re educated by the media that this is a time-sensitive matter," she says. "They don’t want to put people at risk."

Reference

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.