TITLE : STANDARD OPERATING PROCEDURE FOR

NEEDLE STICK INJURY

SOP NO: SOP/XXXX/YYYY PAGES: 2
DEPARTMENT : MICROBIOLOGY EFFECTIVE DATE : 20.07.2018

1. PURPOSE : Purpose of this SOP is to instuitionalize the effective system in to prevent the risk of
occupatuional exposure to HIV , Hepatitis viruses amongst health care workers of all cadre working at
XYZ HOSPITAL, MUMBAI.

2. SCOPE : The incidence of hospital acquired Hepatitis B virus infection ( 9-30%), Hepatitis C virus
infection (1- 10 %) far exceeds that of HIV infection (0.3%). This SOP will provide practical guidelines
for all healthcare workers.

3. RESPONSIBILITY:
3.1. It is the duty of the Bio Medical Waste Management ( BMW ) Team to train and guide all doctors,
residents, nursing staffs, other paramedical and non paramedical staffs of the hospital.
3.2. Time to time and instruct to follow this SOP.
3.3. For getting immunized against Hepatitis B so as to prevent oneself from needle stick, sharp cut
injuries and accidental exposures of skin and mucous membranes.

4. POTENTIALLY INFECTIOUS BODY FLUIDS: The potentially infectious body fluids include blood, semen,
vaginal secretions, amniotic, cerebrospinal, synovial, pleural, peritoneal and other fluids
contaminated with visible blood.

5. HEALTH CARE WORKER WITH FREQUENT BLOOD EXPOSURE: All employees working in clinical
departments, pathology department, facility cleaning staffs, waste handling staffs.

6. FOLLOWING PRACTICES TO BE DONE TO REDUCE RISK OF NEEDLE STICK INJURY ( NSI):

6.1. Avoid use of needles, preferably use vacutainers.
6.2. Take proper precautions during transfer of fluids between containers.
6.3. After using needle the needle should be cut by the needle cutter and syringe to be disposed properly.
AVOID RE-CAPPING of syringes.
6.4. All health personnels should be vaccinated with Hepatitis B and periodic antibody titre should be
done as per the recommendations.

7. PROCEDURE AFTER NEEDLE STICK INJURY:

7.1. Any NSI should be immediately brought into notice of the Infection Control Nurse (ICN).
7.2. All NSI case should fill the “NEEDLE STICK NJURY FORMAT FORM” and submitted to ICN for record.

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Page 1 of 2
TITLE : STANDARD OPERATING PROCEDURE FOR
NEEDLE STICK INJURY
SOP NO: SOP/XXXX/YYYY PAGES: 2
DEPARTMENT : MICROBIOLOGY EFFECTIVE DATE : 20.07.2018

8. MANAGEMENT OF NEEDLE STICK INJURY:

8.1. DO NOT panic or put finger in mouth or squeeze the wound to bleed it.
8.2. Immediately wash the wound and surrounding skin with soap and water and rinse.
8.3. DO NOT scrub or use bleach, chlorine, spirits or any antiseptics.

9. MANAGEMENT OF BLOOD, BODY FLUIDS SPLASH OVER BROKEN SKIN, EYE, MUCUS MEMBRANE:
9.1. If broken skin or eye is splashed, wash immediately with plenty of water and DO NOT use soap,
detergents, antiseptics and antibiotics.
9.2. If wearing contact lens in eye and eye is splashed then leave the lens in place and rinse eye with water
only. Later remove lens and clean with usual process.
9.3. If mouth is splashed, spit immediately rinse mouth thoroughly with water or saline and spit
repeatedly. and DO NOT use soap, detergents, antiseptics and antibiotics.
9.4. Consult the designated physician immediately.

10. EVALUATION FOR POST EXPOSURE PROPHYLAXIS (PEP):

Evaluation to be done by designated PEP In-charge and PEP medicine to be administered as per the
protocol within 2 hours and certainly within 72 hours.

11. ASSESSMENT OF EXPOSURE, RISK OF TRANSMISSION AND PEP DRUG ADMINISTRATION:

Assessment of exposure, risk of transmission and PEP drug administration is done as per the protocol
of the concerned department.

12. ASSESSING THE HIV AND HEPATITIS STATUS OF THE SOURCE AND PERSON EXPOSED:
12.1 In case of exposure with discarded needles/ sharps, contaminated for over 48 hours, the risk of HIV is
negligible, but risk for Hepatitis remains significant.
12.2 A baseline rapid testing of HIV, Hepatitis B & C is done of source and exposed person.
12.3 Proper counselling should be done and INFORMED CONSENT to be taken before testing of both
source and exposed persons.
12.4 Initiation of PEP where indicated should not be delayed while waiting for the results of HIV testing of
the source of exposure.
12.5 Exposed individuals who are known or discovered to be HIV or Hepatitis B or C positive should not
receive PEP. Refer to ART ( Anti Retroviral Therapy) centre for further management as per guidelines.

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Name
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Date
Page 2 of 2
 Effective date: 20/07/18

NEEDLE STICK INJURY FORMAT

(To be filled up and sent with sample of patient and victim to ART centre)

A. Name of patient________________ Age_______ Sex________

IP no___________ Dt. of admission____________

Admitting doctor______________________ Diagnosis___________

HBV,HCV,HIV status ___________Reported on ____________vaccination status_____--

(if status is unknown send blood for serology)

B. NEEDLE STICK INJURY

Name of victim ___________________Date of occurrence _______Time_____

Type of Injury____ superficial/deep bore

You had the injury while

______________________________________________________________________________
______________________________________________________________________________

Your immunization status(HBV)_________________________________

C. Initial actions taken_

Washed under running water-yes/no
Informed Doctor on Duty-yes/no
Informed your HOD-yes/no
Sent blood for serology both of yours and patient-yes/no

D. Reports
Serology report of patient is ___________________
Serology report of victim is ____________________

E. Comments of In-charge ART Centre

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

F. Follow up care____

G. Signature of victim ___________Signature of In-Charge ART Centre___________