MANAGEMENT OF EXPOSURE TO HEALTH CARE ASSOCIATED INFECTIONS (HCAI) AND INOCULATION INCIDENTS (INCLUDING SAFE MANAGEMENT OF SHARPS)

Transcription

1 MANAGEMENT OF EXPOSURE TO HEALTH CARE ASSOCIATED INFECTIONS (HCAI) AND INOCULATION INCIDENTS (INCLUDING SAFE MANAGEMENT OF SHARPS) INFECTION PREVENTION AND CONTROL POLICY NO. 4 Applies to: Staff employed by Wirral Community NHS Trust Group for Approval Infection Prevention & Control Group Date of Approval 18 July 2012 Committee for Ratification Quality and Governance Committee Date Ratified 17 th September 2012 Review Date: 2015 Name of Lead Manager Head of Infection Prevention & Control UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION

2 CONTROL RECORD Title Management Of Exposure To Health Care Associated Infections (HCAI) And Inoculation Incidents (Including Safe Management of Sharps). Purpose Author Infection Prevention and Control (IPC) Equality Assessment Screening Yes No Document Librarian IPC Groups Consulted with:- Infection Prevention Control Group Method of distribution Staff Bulletin Intranet Archived Date: Location: S Drive IPC Access Via IPC VERSION CONTROL RECORD Version Number Author Status Changes / Comments 2 IPC Revised Removal of flow chart from policy due to revision Status New / Revised / Trust Change

3 CONTENTS Paragraph 1 Introduction 2 Scope 3 Statement of Intent 4 Definitions 5 Equality impact assessment 6 Duties 7 Blood Borne Viruses (BBVs) 8 Management/Treatment of Inoculation Injuries 9 Post Exposure Prophylaxis 10 Management and Treatment of other Health Care Associated Infections 11 Training 12 Process for monitoring effective implementation 13 Other relevant procedural documents 14 References (as evidence base) Appendices Appendix 1 Appendix 2 Appendix 3 Appendix 4 Safe Management of Sharps Guidance on assessing risk of blood borne infection Testing of source patient Process for monitoring compliance

4 1. INTRODUCTION Wirral Community NHS Trust (WCT) is firmly committed to reducing Healthcare Associated Infections (HCAI) and in doing so acknowledges its responsibility under Health and Safety Law to protect staff, service users and other persons who come into contact with our services against acquiring HCAI, as far as reasonably practical through the promotion of good clinical practice and the provision of suitable facilities. All WCT staff also have a responsibility under Health and Safety Law to adhere to local policy/procedure and report unsafe practices/working environments. Furthermore WCT will ensure that the risk of exposure to hazardous substances including pathogens is assessed and effective measure to protect workers and others from risks are implemented as far as reasonably practical. 2. SCOPE Inoculation incidents referred to within this policy include sharps injuries, bites and scratches (if the skin is broken) and splashes to exposed mucous membranes (e.g. eyes, mouth etc). For the purpose of this policy the term health care associated infection (HCAI) encompasses any infection by an infectious agent acquired by a health care worker in the course of their NHS duties such as: Blood borne viruses, for example: Hepatitis B (HBV); Hepatitis C (HCV); Human immunodeficiency virus (HIV). Other pathogens, for example (list not exhaustive): Varicella (Chickenpox); Measles; Mumps; Rubella; Tuberculosis; MRSA - please refer to WCT MRSA Policy. 2.1 Other healthcare associated infections Occupational transmission of other HCAI s can be via airborne or droplet transmission e.g. following coughing/sneezing or from personal contact with an infected individual. 2.2 Transmission to staff from patients Infection control procedures are necessary not only to protect vulnerable patients but also to protect healthcare workers from infection; Page 2 of 23

5 HCWs are usually healthy and are generally less susceptible to infection than the patients they care for. However they may acquire skin infections such as herpes simplex, respiratory/skin infections such as chickenpox, mycobacterium tuberculosis (TB) and enteric (gut) infections; Good infection control practice to minimise risk and prevent patients and HCWs acquiring infections must therefore be used routinely during all patient care, not just when it is known that the patient has an infection; It is also important to note that healthcare workers infected with blood borne viruses may transmit infection to the patient. The main route of such transmission is associated with exposure prone procedure in which injury to the health care worker could result in blood entering the patients open tissues. 3. STATEMENT OF INTENT This policy sets out the arrangements for the prevention (including safe management of sharps) and management of exposure to healthcare associated infections and inoculation incidents within the Trust. The key responsibilities are outlined with the reporting arrangements. In compliance with the Department of Health Guidance WCT will: Make immunisation available to staff appropriate to the requirements of their occupation; Set out procedures that must be followed to ensure that staff receive the most appropriate treatment without delay following exposure to a HCAI/inoculation incident. 4. DEFINITIONS A&E Accident and Emergency Department BBV Blood Borne Viruses referred to in this policy include Hepatitis B, Hepatitis C and Human Immunodeficiency Virus Donor EPP HBIG HBsAb HBsAg HBV HCV HCW HCAI HIV Inoculation Person who is the origin of blood or body fluid. The preferred term is source. Exposure Prone Procedure Hepatitis B immunoglobulin Hepatitis B surface antibody Hepatitis B surface antigen Hepatitis B Virus Hepatitis C virus Health Care Worker Health Care Associated Infection Human Immunodeficiency Virus Consists of exposure to blood or other body fluids involving: Page 3 of 23

6 incident Broken skin such as abrasions, fresh cuts, eczema Percutaneous exposure - when contaminated material penetrates the skin e.g. needle stick injury, bites Mucocutaneous exposure- exposure of blood or other body fluids to the lining of eyes, nose or mouth MMR Measles, Mumps and Rubella OH/OHD Occupational Health / Occupational Health Department PEP Recipient RIDDOR Sharps Source Post Exposure Prophylaxis against HIV which is given following exposure in cases considered high risk for possible HIV exposure Person who was exposed to the body fluid The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations Are objects with sharp edges such as suture needles, hollow needles, scalpels, blades lancets, surgical instruments, broken ampoules, bone, teeth or equipment used in dentistry e.g. burr which carry the risk of transmission of BBV s Person who is the origin of blood or body fluid. Also known as donor. 5. EQUALITY IMPACT ASSESSMENT As part of its development, this policy and its impact on equality have been reviewed using the Policy Equality Impact Assessment Screening tool. The purpose of the assessment is to minimise and if possible remove any disproportionate impact on employees on the grounds of race, sex, disability, age, sexual orientation or religious belief. No detriment was identified. 6. DUTIES 6.1 Chief Executive The Chief Executive has overall responsibility for Infection Prevention and Control within the Trust and to ensure that as far as is reasonably practicable, the health, safety & welfare of the employees and others who come into contact with our services 6.2 Director of Quality and Governance/Director of Infection Prevention and Control It is the responsibility of the Director of Quality and Governance/Director of Infection Prevention and Control to oversee the development and implementation of infection prevention and control policies, and to ensure that the Trust has safe effective management systems in place in relation to HCAI and inoculation incidents. Page 4 of 23

7 6.3 Trust Board The Trust Board is responsible for ensuring that it corporately meets its legal duties in relation to Infection Prevention and Control. This responsibility is delegated to the Quality and Governance Committee via the Infection Control Group. 6.4 Quality and Governance Committee The primary function of the Quality and Governance Committee is to provide assurance to the Board of overall compliance with all statutory and regulatory obligations and will ensure the effective management of incidents, complaints, and subsequent dissemination of lessons learnt. The Quality and Governance Committee is responsible for ratifying Infection Prevention and Control policies. 6.5 Infection Prevention & Control Group The Infection Prevention & Control Group is responsible for approving Trust Infection Prevention and Control policies; Monitoring of inoculation/exposure to HCAI incidents; Review significant exposure incidents and disseminate shared learning. 6.7 Occupational Health Department The OHD have the responsibility: To advise/immunise WCT personnel who are referred to OHD by their Manager in accordance with work place health/occupational Health protocol; To provide risk management advice including where necessary advice on work restrictions/redeployment; Advise the healthcare worker (HCW) regarding the risk of the exposure and the indications for prophylaxis; Manage the follow up, monitoring, testing and vaccination for HCWs who have sustained a high risk exposure whether or not Post Exposure Prophylaxis (PEP) was commenced; Offer support and arrange counselling if required to all HCWs who have sustained an occupational exposure to blood/body fluids; Report all incidents of occupationally acquired infection reportable under RIDDOR to WCT Quality and Governance Department. 6.6 Accident and Emergency (A&E) Department The A&E department is responsible for the initial assessment and management of HCAI incidents blood / body fluids exposure incidents and will: Assess the immediate treatment / prophylaxis requirements which will be determined by the risk of transmission of HBV, HCV and HIV posed by the donor and / or the circumstances in which the exposure occurred; Page 5 of 23

8 Advise and counsel the HCW regarding the risk of the exposure and the indications for prophylaxis; Facilitate the collection of a blood sample from the recipient to be stored (or tested for Hepatitis B immunity status, if this is unknown). The results of any tests should be copied to the OHD; Counsel / issue PEP (starter pack) in the event of a HIV high risk exposure incident Give HBIg in the event of a HBV high risk exposure incident; Following the incident fax a copy of the risk assessment form to Occupational Health for further follow up 6.9 The Infection Prevention and Control Service (IPCS) The IPCS will provide advice regarding the risk of transmission of HCAI; Will monitor exposure incident reports and liaise with OHD; Are responsible for assuring the Trust board regarding activity in infection prevention and control within the Trust. Written reports are submitted 4 times per financial year; Will ensure that training, information and policies are available to staff in the risk of transmission of blood borne viruses and other HCAI and in the use of standard precautions Quality and Governance Service Will report all incidents of occupationally acquired infection reportable under RIDDOR Divisional Managers Will ensure that appropriate actions are taken for issues reported/escalated directly via the Infection Prevention and Control Group or Divisional Governance meetings/service Leads 6.12 Service Leads/Managers Will ensure risk assessments have been undertaken and the findings made known to employees; Encourage and enable staff to attend the OHD for vaccination in accordance with local risk assessment; Identify those staff who will perform exposure prone procedures within their area and refer them to the OHD for appropriate investigations/immunisation/advice/ update prior to being allowed to undertake these procedures: Ensure staff are aware of the procedure to follow in case of exposure to infectious diseases; Will seek advice from OHD/IPC Service once informed of staff contact/potential contact with a HCAI; Ensure incidents are completed via Datix in all cases when notified of inoculation injury and review action taken/assess further action required; Page 6 of 23

9 Ensure all occupational exposure incidents are referred to the OH Department as soon as possible; Ensure that Source (Donor patient) risk assessment is carried out and forward to A & E; Escalate identified trends, incidents or concerns to Divisional Governance Meeting Employees All Staff must comply with Trust policies. Failure to comply with or act in accordance with a Trust policy may result in disciplinary action; To attend mandatory training; To practice standard precautions; To attend as arranged for immunisation and advice relating to their work activity and contact their manager to advise/report any concerns regarding workplace immunisations any side effects they may have experienced which they feel are/may be related to immunisations they have received; If they are likely to be at increased risk of developing infection e.g. immunocompromised, for advice in relation to their work; To comply with risk management advice given by the OHD; To report potential/actual exposure to HCAI in line with their professional body recommendations; Report any incident/exposure to the appropriate manager; Report to manager/a&e department following an exposure incident; Attend OHD following a management referral. 7. BLOOD BORNE VIRUSES (BBVs) Transmission occurs when the infected bodily fluid of an individual makes contact with the bodily fluid/mucous membrane of another person. Bodily fluids with the potential to transmit BBVs include: Blood; Synovial fluid; Cerebrospinal Fluid; Semen; Vaginal secretions; Amniotic fluid; Pericardial fluid; Pleural fluid. (Urine, faeces, vomit and saliva do NOT represent a significant risk unless blood stained). 7.1 Significant occupational transmission of BBVs to health care workers can occur following: Page 7 of 23

10 A penetrating injury from a sharp object or instrument that is contaminated with the blood or body fluids of an individual; Exposure of mucous membrane (eyes, mouth etc) to blood or body fluids; A human bite that breaks the skin. 7.2 Non significant Exposure to BBVs is defined as: Contamination of intact skin; Exposure to urine, faeces, vomit or saliva that is not blood stained; Injury from a sterile or non contaminated instrument or sharp object. 7.3 Risk Factors There is no evidence that HBV, HCV or HIV can be transmitted under conditions of usual social contact unless significant exposure to blood or bodily fluids occurs. The risk of a transmission of a BBV from a significant source is as follows: HBV In an un-immunised HCW, the risk of transmission of HBV from a known infectious source (via a percutaneous route e.g. following sharps injury) is approximately 1in 3 (HPA, 2008); HCV In a non immune HCW, the risk of percutaneous transmission of HCV from a known positive source is approximately 1 in 30 (HPA 2008). This risk is significantly reduced in relation to mucous membrane exposure; HIV The risk of percutaneous transmission of HIV to a HCW from a known positive source as approximately 1 in 300 (HPA 2008). This risk reduces to 1 in 1000 in relation to mucous membrane exposure. 7.4 Prevention The adoption of standard precautions when handling blood/body fluids, tissues and sharp instruments, is the most effective means of reducing occupational exposure/transmission. Exposure to Blood Borne Viruses has been risk assessed by the Trust and an immunisation programme is available to all employees. This is available via the Occupational Health Department (OHD). Employees who decline to be immunised or fail to sero convert. Employees who decline immunisation will be counselled about the implications of not being immunised. As a result the tasks, which they perform, could be restricted. They will also be asked to sign a disclaimer. Staff who fail to sero convert following an initial course of Hepatitis B vaccine and therefore do not have a satisfactory level of immunity will be monitored and counselled by Occupational Health in line with guidance from Department of Health (Green Book 2006). Staff may also be required to attend for further periodic blood tests as required by Occupational Health Department. Page 8 of 23

11 Exposure Prone Procedures (EPPs): Exposure Prone Procedures are those where there is a risk that the injury to the worker may result in exposure of the patients open tissues to the blood of the worker. These procedures include those where the workers gloved hands may be in contact with sharp instruments, needle tips or sharp tissues (spicules of bone or teeth) inside a patient s open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times (Department of Health 2007). Those health care workers who undertake procedures which pose a risk of infecting patients are required to demonstrate whether they are an infection risk or not prior to undertaking such procedures by means of a blood sample result which has been tested in a UK laboratory. The Primary Care Division is the main division within WCT where exposure prone procedures may, but not necessarily always, occur as part of patient care e.g. Community Dental Service and General Practitioners. Further information regarding EPP s can be accessed on the Department of Health website 8. MANAGEMENT/TREATMENT OF INOCULATION INCIDENTS The process for the management of an inoculation incident (Appendix 2), including prophylaxis (definition of prophylaxis: is the prevention of disease or control of its possible spread). It is imperative that there should be as little delay as possible from the time of exposure to the assessment of transmission of risk and the commencement of appropriate treatment; Following an inoculation incident and completion of immediate first aid HCWs must attend A&E Department to access/administration of prophylaxis and vaccination if indicated/available. Immediate first aid (following any exposure, whether or not the source is known to pose a risk of infection) should be undertaken as follows: Penetrating wound / non intact skin; Gently encourage free bleeding from puncture wounds (do not suck); Wash site of exposure liberally with soap and running water without scrubbing; Cover with impermeable dressing; Dispose of any item involved safely i.e. sharps container; Exposed mucous membrane; Page 9 of 23

12 Irrigate eyes copiously with water before and after removing contact lenses; Wash mouth and nose out liberally using tap water, do not swallow water; Ensure all incidents are reported via Datix in line with Trust incident reporting policy. 8.1 Risk Assessment: Source Patient A designated doctor/practitioner should assess if the reported exposure was significant based on type, route, nature and extent of exposure. A significant exposure is one from which a blood borne virus may be transmitted to an employee it may be: A penetrating injury from a sharp object or instrument that is contaminated with the blood or body fluids; Exposure of mucous membrane (eyes, mouth etc) to blood or body fluids; Exposure of non-intact skin (cuts, abrasions, dermatitis etc) to blood or body fluids from an individual; A human bite (where the skin is broken) 8.2 Risk Assessment: Injured HCW (recipient) The recipient s Hepatitis B immunity status should be established in all cases of significant exposure; A sample of the recipient s blood will be taken for storage (and antibodies to Hepatitis B if immunity status is unknown) following significant exposure; If the source patient s consent for testing is withheld/delayed the decision as to whether or not to recommend Post Exposure Prophylaxis (PEP) will be made based on the risk assessment taking account of the type, nature and extent of exposure and the assumed risk of the donor; 9. POST EXPOSURE PROPHYLAXIS 9.1 HIV In view of the need for very prompt treatment and the serious consequences of HIV sero-conversion, significant occupational exposure to known or possible sources of HIV constitutes a medical emergency. There is currently no immunisation/immunoglobulin available for HIV however there is evidence that the administration of antiretroviral medication can significantly reduce the risk of developing HIV following an exposure incident. Arrowe Park Hospital A&E Department is the only site in Wirral that can assess and initiate PEP; Page 10 of 23

13 Exposed HCWs should immediately attend Arrowe Park Hospital A&E Department (within 1-2 hours) for assessment and treatment with PEP if indicated; It is not acceptable for staff to be asked to wait until the end of the working day/shift to attend A&E; Starter packs of anti retrovirals are dispensed (if indicated) in A&E and staff will be referred to Genito-urinary Medicine (GUM) for review; If PEP is continued this will be dispensed via GUM. Follow up and support will be provided by the OHD in conjunction with GUM if required. 9.2 Hepatitis B The Recipient s Hepatitis B status should be established and vaccination / immunoglobulin will be offered as indicated; Hepatitis B immunoglobulin offers short term protection against the virus and should be considered in non-immune HCW s exposed to a known / suspected high risk source; Follow up care/treatment will be co-ordinated via the OHD. HCWs who are identified as a chronic carrier of Hepatitis B may only return to exposure prone procedures if they meet the criteria outlined by the Department of Health (DH, 2007) including risk assessment and regular monitoring via the OHD. 9.3 Hepatitis C There is currently no prophylactic treatment (i.e. immunisation / immunoglobulin) for Hepatitis C. Exposed HCWs will be counselled by A&E and advised to attend OHD for follow up monitoring (blood testing) at the required times. Managers will refer HCW to the OHD and it is essential that staff attend the OHD for post exposure monitoring to ensure that they benefit from therapeutic intervention, and ongoing support if required. HCWs that are identified as carrying the virus i.e. who are hepatitis C virus RNA positive must not undertake exposure prone procedures. Hepatitis C infected health care workers who have responded successfully to treatment with antiviral therapy will be allowed to resume exposure prone procedures if they meet the criteria outlined by the Department of Health (DH, 2007) which includes risk assessment and regular monitoring via the OHD. 10. MANAGEMENT AND TREATMENT OF OTHER HEALTH CARE ASSOCIATED INFECTIONS 10.1 General Principles Potential exposure to healthcare associated infections should be reported by managers to the OHD as soon as possible after exposure occurs; Page 11 of 23

14 If exposure occurs outside of Occupational Health opening hours and managers are therefore unable to liaise/refer to OHD advice should be sought from the A&E Department; Redeployment/medical exclusion may be required depending on the circumstances; HCWs should be encouraged to attend the OHD for their immunisation status to be assessed and updated where indicated, to prevent the likelihood of becoming ill following future exposure to HCAI; PEP is not available for all health care associated infections. Where PEP/treatment is available it is listed below: 10.2 Varicella (Chickenpox) Varicella is an acute highly infectious disease transmitted by droplet spread or personal contact. Varicella is preventable in 75% cases by immunisation Management of HCWs following Varicella exposure: Vaccinated HCWs or those with a definite history of chickenpox are considered immune and there is no need for them to be restricted from work; They should however contact their manager or nominated deputy (if neither manager or deputy available then the HCW should contact OH) for advice before having patient contact if they feel unwell or develop a fever or rash within 3 weeks following exposure; Management of unvaccinated HCWs or those without a definite history of chickenpox and having significant exposure to Varicella includes: - Referring the HCW to the OHD for assessment/immunisation; - Excluding the individual from contact with high risk patients e.g. pregnant women, immuno-suppressed patients/colleagues etc from 8-21 days after exposure (Immunisation against Infectious Diseases 2006): - Reporting to their line manager/nominated deputy (if neither manager or deputy available then the HCW should contact OHD) should they feel unwell or develop a fever/rash Post Exposure Prophylaxis: Varicella As well as providing preventative protection against the virus, Varicella vaccination can also be used to reduce the likelihood of infection developing post exposure if the vaccine is administered within 3 days of exposure. Regardless of the time since exposure, non immune HCWs should be offered vaccination to reduce their risk from future contamination and prevent exposing patients to varicella in the future. A second dose of vaccine is required 4-8 weeks later. Page 12 of 23

15 HCWs with localised Herpes Zoster (Shingles), on a part of the body that can be covered with a suitable dressing/clothing can be allowed to continue working unless they are in contact with high risk patients in which case a full risk assessment should be undertaken Measles Measles is an acute viral illness that is spread by airborne or droplet transmission. It is preventable by vaccination in over 90% of cases. As part of pre-employment screening all staff are required to have documented evidence of having received two doses of MMR or a positive antibody tests for measles and rubella. MMR immunisation is available to staff in line with national guidance Management of HCWs following Measles exposure: HCWs who are able to demonstrate satisfactory evidence of measles immunity by either having received 2 doses of Measles, Mumps and Rubella (MMR) vaccination or a positive antibody test can continue working without restriction; Management of unvaccinated HCWs or those without a positive antibody test includes: - Referring the HCW to the OHD for assessment/immunisation; - Reporting to line manager/nominated deputy (if neither manager or deputy available then the HCW should contact OH) should they feel unwell or develop a fever/rash Post Exposure Prophylaxis: Measles As well as providing preventative protection against the virus, MMR vaccination may reduce the likelihood of infection developing post exposure if the vaccine is administered within 72 days of exposure. Regardless of the time since exposure, non immune HCWs should be offered vaccination to reduce their risk from future infection and prevent exposing patients to Measles, Mumps and Rubella in the future. A second dose of vaccine is required 4 weeks later. Non immune staff exposed to Measles, should contact the line manager/nominated deputy (if neither manager or deputy available then the HCW should contact OH) either the same/following day. In the event of the OHD being closed for 2 or 3 days e.g. weekends or bank holiday weekends, the employee should contact line manager/nominated deputy for referral to OHD on the next normal working day. Measles immunoglobulin is available for post exposure prophylaxis in individuals for who vaccination is contraindicated. Further advice will be sought from the Health Protection Agency/Consultant Microbiologist if required. 11. TRAINING Page 13 of 23

16 Infection prevention and control training (including inoculation incident procedure) is a mandatory requirement for both clinical and non clinical staff as detailed in the Trusts core mandatory training Matrices. All core mandatory training is recorded centrally by the Quality and Governance service. Quarterly monitoring reports are prepared for the Learning and Development Group to monitor attendance rates. Full details of the processes in place for managing and monitoring attendance are set out in the Policy for Learning and Development GP PROCESS FOR MONITORING EFFECTIVE IMPLEMENTATION Reporting arrangements: All exposures to HCAI and inoculation incidents will be reported via the Trust s incident reporting process; Summaries of numbers and trends of inoculation incidents are reported to the Infection Prevention and Control Group and are included in the IPCS Board reports submitted four times per financial year; Monitoring Arrangements: Monitoring of inoculation/exposure to HCAI incidents/near misses will be undertaken by the IPCS to include: Review of the number of reported incidents Identification of causation factors Identification of preventative measures and action taken Adherence to Trust policy. Reports of the number and type of inoculation injuries/ near misses will be submitted four times per year to the IPCG. Support: Follow up care / support following exposure to HCAI / inoculation incidents will be provided via the OHD; Additional support will be offered via the Trust s Counselling Service; 13. OTHER RELEVANT PROCEDURAL DOCUMENTS This policy should be read in conjunction with relevant Organisational documents. Page 14 of 23

17 REFERENCES Department of Health (2010) The Health and Social Care Act 2008 Code of practice on the prevention and control of infections and related guidance. Department of Health (2008). HIV post-exposure prophylaxis: Guidance from the UK Chief Medical Officers Expert Advisory Group on AIDS. Department of Health (2007). Hepatitis B infected healthcare workers and antiviral therapy. Department of Health (2006). The Immunisation against infectious disease Green Green Book. uments/digitalasset/dh_ pdf Department of Health (2005). HIV Infected Health Care Workers: Guidance on Management and Patient Notification. Department of Health (2002). Health Service Circular 2002/010. Hepatitis C Infected Health Care Workers. Health Protection Agency, Eye of the Needle. Surveillance of Significant Occupational Exposure to Blood Borne Viruses in Healthcare workers. Health Protection Agency (2010). National Measles Guidelines; Local and Regional Services. Page 15 of 23

18 APPENDIX 1 Safe Management of Sharps Avoid the use of sharps wherever possible; Establish means for the safe handling of disposal of sharps devices before the beginning of a procedure Used sharps must never be left for other staff to dispose of. This is the users responsibility; Keep handling to a minimum. Never pass sharps from hand to hand; Discard immediately after use directly into a sharps container; Never re-sheath a used needle by hand. Never remove scalpel blades by hand, use forceps, scalpel blade removing unit or blade remover on a sharps container; Never bend or break needles prior to disposal; Syringe/cartridges and needles should be disposed of intact; Discard cannulae and intravenous lines immediately after use never cut into pieces; Always get help when using sharps with a confused or agitated patient; Needle safety devices must be used where there are clear indications that they will provide safer systems of working for healthcare personnel. Sharps Containers: Sharps containers must comply with UN3291 and BS7320 standards; Ensure sharps containers are fully assembled and labelled according to the manufacturer s instructions; Ensure containers and lids which require assembly prior to use are fully attached at all points before use; Do not fill the sharps container above the manufacturers marked line (approximately 2/3rds); Containers must be free from protruding sharps; The container must be free from external contamination of blood; Staff must not attempt to retrieve items discarded in the containers or empty the contents of a sharps container; Use an appropriately sized sharps containers dependant on the amount of waste produced that will last for approximately 1 month; Attention must be paid to the provision of appropriate numbers of sharps containers in use and spare containers must be easily available to reduce potential overfilling; Ensure a spare container is available during home visits; Ensure the temporary closure mechanism is in place when not in use and containers are kept in a locked room; Ensure in use sharps containers are never stored on the floor and are always out of the reach of children. Consider the use of trolley or wall brackets in a clinic/treatment room. Sharps boxes that are transported in the health care workers car must always have the temporary closure mechanism in place and be secured within the boot area of the car in a way that will prevent spillage; Page 16 of 23

19 Lock sharps containers before disposal in accordance with the manufacturer s instructions; Label the sharps containers before disposal according to the manufacturer s instructions; After sealing and labelling, sharps containers ready for disposal must be stored safely in a designated waste storage area away from public access; Never place a used sharps container in a clinical waste bag for disposal; Place damaged sharps container into a larger sized sharps container and label. Sharps Practice Within a Patients Home: Always take a suitable sharps container into the home when sharps are to be used; If sharps container is to be left at a patients home for ongoing treatment the visiting HCW must ensure that the safe management of sharps containers is followed and that the container is safely stored out of access of children if present; Sharps containers collected by the home collection service must not be placed in a hazardous waste bag or bin. Containers must not be left for collection where they could be accessed by the general public; Sharps must not be placed in non approved sharps containers; Sharps must not be placed in the domestic refuse system; Patients cannot return full sharps containers to a Trust clinic/service for disposal; Pen Injectable Devices: These devices are intended for self administration of injectable medications. Healthcare workers are at risk of needlestick injury when using these devices and wherever possible use of these devices for the administration of medication should be avoided. If using pen devices staff must not re-sheathe the needle with the small inner plastic cover supplied, the pen needle removing device on sharps containers must be used; Lancing Devices: Disposable single use devices with fully retractable needles are the only device to be used within the Trust and must be disposed of into a sharps container. Venepuncture Gloves must be worn when performing venepuncture as they protect the skin from blood splashes. Gloves cannot prevent a sharps injury but may reduce the risk of acquiring a blood borne infection due to the wiping effect which can reduce the volume of blood to which the workers hand is exposed and in turn the volume inoculated in the event of a sharps injury. Page 17 of 23

20 Appendix 2. Guidance on Assessing Risk of Blood Borne Infection The person undertaking the assessment must not be the injured or exposed person. What is a significant injury? Significant Exposure = High Risk body fluid AND significant route What is a high risk body fluid? Blood CSF Pericardial fluid Peritoneal fluid Pleural fluid Synovial fluid Saliva associated with dentistry Amniotic fluid Breast milk Unfixed organs and tissue Visibly blood stained fluid Semen Vaginal secretions Tissue fluid from burns What is a significant route? Percutaneous e.g. sharps injuries from needles, instruments, bone fragments, Human bites where skin is broken Exposure of broken skin such as abrasions cuts, eczema Exposure of mucous membranes such as eyes, nostrils, mouth How do I assess whether the source of the contamination is High Risk? Are there any previous blood results for Hepatitis B, hepatitis C or HIV? The prevalence of HIV infection and other blood borne viruses is higher in certain groups: Originated from sub-saharan Africa Men who have sex with men Unprotected sexual activity with individuals from sub Saharan Africa Intravenous drug users Sex industry worker The source patient is known to have or is under investigation for an AIDS indicator illness. If the source is known or assessed to be high risk for HIV, then HCW should attend A&E within 1-2 hours for assessment and initiation of Post Exposure Prophylaxis (PEP) if indicated. Page 18 of 23

21 APPENDIX 3 TESTING OF SOURCE PATIENT The source patient s infectivity status should be established by blood testing as follows in all cases of significant exposure. TIME HEPATITIS B HEPATITS C HIV Immediate post incident Surface Antigen* PCR & Antibody Antigen/Antibody combined test *Source patient testing for Hepatitis B Surface Antigen only required if injured HCW is not immune to Hepatitis B. Under take risk assessment and forward the outcome of the risk assessment (i.e. indication of significant risk present) to the A&E Department as soon as it is completed; Informed consent must be obtained prior to venepuncture (this must not be conducted by the health care worker who sustained the injury); Services that do not have staff competent in venepuncture e.g. Community Dental Service and Therapy Services should contact the Community Nurse Managers. A home visit will be offered to housebound patients all other patients will be offered a clinic appointment. Services are expected to have discussed and agreed a community nursing referral with the patient prior to contacting the Community Nurse Manager. A community nursing referral form must be completed; If consent is withheld/delayed, the A&E Department should be notified; 10mls of clotted blood should be collected for immediate testing; The source patient must be informed that the remaining serum will be retained for 2 years in case testing is required at a later date; The laboratory form should clearly indicate that the blood has been taken following an inoculation incident. The name/date of birth of the injured health care worker should be included within the comments section along with the date of the incident. Request a copy to be sent to the Trusts Occupational Health Provider. Inform patients GP that inoculation incident has occurred that blood has been obtained from the patient for testing and that written notification will sent by secure or fax. Page 19 of 23

22 APPENDIX Process for Monitoring Compliance with the Procedure for Inoculation Incidents Minimum requirement to be monitored Process for monitoring (e.g. audit) Responsible individual / group/ committee Frequency of monitoring Evidence Responsible individual for development of action plan Responsible committee for monitoring of action plan and Implementation Process for monitoring duties across the organisation Will be reviewed as part of the policy review in response to change in national guidance or organisational structure Infection Prevention & Control Group (IPCG) Minimum of every 3 years and in response to change in national guidance or organisational structure Minutes & papers of IPCG Head of Infection Prevention & Control Quality & Governance Committee Process for monitoring reporting of inoculation incidents Datix Report Head of Infection Prevention & Control Minimum four times per year Minutes & papers of IPCG Divisional Managers/ Service Leads Quality & Governance Committee Process for monitoring management of inoculation incidents Datix Report Head of Infection Prevention & Control Minimum four times per year Minutes & papers of IPCG Divisional Managers/ Service Leads Quality & Governance Committee How the organisation trains staff in line with the training needs analysis Trust wide Mandatory Training Attendance Reports Learning & Development Group Minimum of twice per year Minutes/action plans of Learning & Development group Divisional Managers/ Service Leads Learning and Development Group and by exception to Education & Workforce Committee INOCULATION INCIDENTS (INCLUDING SAFE MANAGEMENT OF SHARPS) Page 20 of 23