Standard Operational Procedure For Sharps Injury/Mucocutaneous Exposure
Hospital Pulau Pinang
Introduction
Blood borne pathogens are microorganisms in the blood or other body fluids that may cause
illness and disease. Microorganisms such as Hepatitis B virus (HBV), Hepatitis C virus (HCV)
and Human Immunodeficiency Virus (HIV) are transmitted through contact with
contaminated blood and body fluids. Accidental needle sticks can cause a health care
worker (HCW) to come into contact with blood borne pathogens.
The Objective
The purpose of this document is to unify information provided within the Hospital Pulau
Pinang and to allow easy access for all users. It is a framework for management of sharps
injury that aims to protect staff from blood borne viruses.
The Location:
All wards and clinics should be provided with this document.
Responsibility
All sisters/ clinical supervisors of all clinical sites and all HCW should be aware of this
document.
IN THE EVENT OF A SHARPS INJURY/ MUCO-CUTANEOUS EXPOSURE
BIL Description
1
First Aid
 Encourage the wound to bleed if sharps
exposure
 Do not suck or rub the wound
 Wash the area thoroughly with soap and warm
running water
 If splash to the eye: rinse with sterile water
 If splash into the mouth: spit out and rinse with
water
 Cover the injury with a waterproof dressing
 Note the source patients name involved in the
incident to assist the risk assessment to the
HCW.
Responsibility
Health Care worker that is
involved in the incidence.
2
Report the incidence and forms to be filled

Report the incidence to the sister of the ward/
sister on call immediately

Fill up incidence report form (HPP/QUA/BR-08- HCW, Sister on Call/ Sister of
the ward
pindaan 1 Form IR 1) and send to QA unit

Contact Infection Control Unit to ask for further
guidance (Tel: 5738/ 5739) during office hour and
Sister Hafizah : 019-4957927 after office hour

HCW, Sister on Call/ Sister of
the ward, Infection Control
Nurse (ICN)
Collect Forms :
EPINet form, OHU/SIS-2a, OHU/SIS-2b , OHU/SIS-1 ,
PRE-PAT 301 X 2 and HPP Sharp Injury Form
( HPP/PAT/MM/QP/013-APPENDIX 1) from respective
ward/Infection Control Unit/ID clinic
3
HCW, Sister on Call/Sister of
the ward

Fill up OHU/SIS-2a, OHU/SIS-2b

Fill up OHU/SIS-1 and EPINet

All forms need to be returned to Infection Control
Unit ( OHU/SIS-1 and EPINet, OHU/SIS -2a and 2b
will need to be completed by 6th month of follow
up on the HCW involved then to be sent to Infection
Control Unit upon completion.)
HCW, Sister on Call/ Sister of
the ward, Infection Control
Nurse (ICN)
Physician /MO who assessed
the HCW and HCW
HCW involved and Sister IC
HCW involved, ICN, ID MO, ID
physician, ID Clinic Staff.
Blood Sampling

The HCW who had been exposed would be
required to have his/her blood screened for
HIV, HBV and HCV. (Informed Consent to be
taken prior to blood sampling)
HCW, ID MO, ED MO, ID
Physician

The source patient’s blood need to be screened
as well. Informed consent need to be taken by
the respective ward MO before blood test to be
done.
The ward MO where the
incidence occur

Take 5 ml blood from source patient and HCW
each in plain tube (red top)
o Source patient: Anti HIV, HBsAg, Anti HCV
o HCW: Anti HIV, Hep Bs Ag, Anti HCV, Hep
Bs Ab
4

If HCW or source refused to be screened for HIVNO HIV test to be taken.

Send both samples (HCW and source patient blood
in pair ) and use PER-PAT 301 forms and Sharp
Injury Form HPP ( HPP/PAT/MM/QP/013APPENDIX 1) to facilitate lab turnaround time.

Complete all data in the request form.

During Office Hour: To call serology at EXT 5987
after the blood had been sent to the lab to inform
about the incidence so that the test can be done
immediately.

After Office Hour: To call EXT 5152/5153 after the
blood had been sent to the lab from ED to inform
about the incidence so that rapid test on HIV and
HBV can be tested immediately.

If source is known/diagnosed HCV positive: need to
send source patient and HCW blood for HCV RNA
PCR tests to Hospital Sungai Buloh ( as baseline) in 2
tubes EDTA bottle/purple/FBC tube each.

NEED PEAD INPUT FROM DR CHAN
The ward MO where the
incidence occur/ HCW
The ward MO where the
incidence occur, ID MO, ED
MO and lab staff.
The ward MO where the
incidence occur, lab staff.
The ward MO where the
incidence occur, ID MO
ED MO
The ward MO where the
incidence occur, ID MO
Laboratory Tests on HIV, HBV and HCV

The blood of HCW and the source patient need to
be screened immediately and the lab TAT is 4 hours
during office hour until 3 pm

After 3 pm – 8am the next day: Rapid test will be
done on both HCW and Source patient samples
(Hep B and HIV ONLY) The ELISA test of HIV , Hep
BsAg and Anti HCV will done the next working day
Lab staff
Lab staff

5
The results of the test will be informed to the ID
MO/ID Physician on call on the roster (Tel: 016
4124834, 7031, 7030), / ED MO after office hour,
hence the importance of completing the Sharp
Injury Form HPP properly including writing contact
number of the MO/specialist who assess the HCW.
Lab staff, ID MO and ID
Physician, ED MO on duty
who handle the HCW
Management
During office hour:
 Refer the HCW to ID MO C5 (5350/ 5419 / 016-412
4834) or contact 5711 (JT Zakiah)
Sister /MO of the unit where
the incidence occur
Sister, MO of the unit where
the incidence occur, HCW, ID
MO

Identify the Source patient:
Name, IC, RN, ward, diagnosis, risk assessment for
HIV, HBV, HCV.

HCW:
name, IC, unit, years in service
Sister /MO of the unit where
the incidence occur/HCW/ID
MO

Detail of incidence:
When did it occur, How did it occur , What was the
procedure/instruments involved
ID MO/ID Physician

Counseling to be done and assessment of risk
exposure

Provide post exposure prophylaxis therapy (PEP) for
HIV and Hep B (refer guidelines)
ID MO/ID Physician

Refer to PEP clinic on the next working Friday
morning.
Sister, HCW, ID MO, ID
Physician
ID MO/ID Physician
After office hour:

refer ED MO
Sister / MO of the unit,

Identify the Source patient:
Name, IC, RN, ward, diagnosis, risk assessment for
HIV, HBV, HCV.
ED MO

HCW:
name, IC, unit, years in service
ED MO

Detail of incidence:
When did it occur, How did it occur , What was the
procedure/instruments involved
ED MO

Only initial assessment will be done by ED MO

further counseling would be done the next
working day in ID clinic by ID MO/specialist

Discuss over phone with ID Physician (EXT
7030/70311) for PEP if doubtful.
ED MO / ID Physician

PEP drugs for HIV: Combivir one tablet 12houly
is available in A&E and C5.
Pharmacist/ ED MO/ ED MA/
C5 Sister/ C5 Staff Nurse

Refer the HCW to ID clinic the next working day
to be further assessed.
ED MO/ ID Clinic
Draft 5 - 14/3/2012
ID HPP
ED MO
ED MO/ ID Physician
Appendix
1. PER-PAT 301 blood investigation form (2 forms)
2. Sharp Injury Form Hospital Pulau Pinang (HPP/PAT/MM/Qp/013-APPENDIX 1)
3. Patient Safety Incident – Management & Reporting Form KKM (HPP/QUA/BR-08pindaan 1, FORM IR 1)
4. Sharp Injury Surveillance occupational Health Unit , Ministry of Health – OHU/SIS-1
5. Sharp Injury Surveillance occupational Health Unit , Ministry of Health – OHU/SIS -2a
6. Sharp Injury Surveillance occupational Health Unit , Ministry of Health – OHU/SIS-2b
7. Needlestick & Sharp Object Injury Report (EPINet)
8. Algorithm for Occupational Post Exposure Management (office hour)
9. Algorithm for Occupational Post Exposure Management (after office hour)
10. Guidelines for Management After Occupational Exposure of Potentially Infected
Material
11. Photo of blood test tubes