Sharps, Needlestick Injury and Body Fluid Exposure Management Policy and Procedure

Transcription

1 Sharps, Needlestick Injury and Bdy Fluid Expsure Management Plicy and Prcedure Inclusive f HIV Pst-Expsure Prphylaxis Please be advised that the Trust discurages the retentin f hard cpies f plicies and prcedures and can nly guarantee that the plicy n the Trust Intranet is the mst up t date versin Dcument Type: Plicy / Prcedure Versin: 5 Date f Issue: January 2018 Review Date: January 2021 Lead Directr: Pst Respnsible fr Update: Apprving Cmmittee: Apprved by them in the minutes f: Distributin t: Wrkfrce and Organisatinal Develpment Lead Nurse Occupatinal Health Executive Infectin Preventin and Cntrl 23 rd January 2018 All Trust staff via the Trust Intranet

2 Cntents: Heading Number Heading (Insert Title) Page Number Cntents / Risk rating 2 1 Intrductin / Purpse 4 2 General Dcument (Sharps Injury Management Plicy) 4 3 Definitins 19 4 Assciated Dcuments 20 5 Duties 20 6 Cnsultatin and Cmmunicatin with Stakehlders 7 Implementatin 23 8 Educatin and training 24 9 Mnitring and review References / Bibligraphy Appendices 1. Out Of Hurs Risk Assessment Questinnaire 2. Situatins when HIV pst expsure chemprphylaxis (PEP) shuld be cnsidered fllwing nn-sexual/ccupatinal expsure 3. HIV pst expsure chemprphylaxis infrmatin sheet 4. Patient infrmatin sheet Truvada and Raltegravir 5. Flwchart-Sharps injury treatment 6. Flwchart-immediate actins fllwing inculatin injury r accidental expsure t bld r bdy fluid Risk Rating Wh will be affected by Trust Emplyees / Patients / Cntractrs this prcedure? Is there an existing risk Yes assessment related t this prcedure? If N is ne required? Yes Yes December 2010 If Yes des it require updating? N Yes Date cmpleted A Cnsequence (1-5) B Likelihd f Occurrence (1-5) C Risk rating Page 2 f 40

3 Raw Risk Rating (N cntrl measures in place) Final Risk Rating (Cntrl measures in place) (A x B = C) Name: Keith Williamsn Date: Page 3 f 40

4 1 Intrductin / Purpse This plicy and assciated prcedure sets ut the standards fr minimising the risk f transmissin f bld brne viral infectins (i.e. hepatitis B, C and HIV) fllwing staff accidental bdy fluid expsure. The plicy is applicable t all sites frm which Cheshire Occupatinal Health service perates. Purpse: T ensure that all emplyees are aware f their respnsibilities fllwing expsure t bdy fluids, and that n ne suffers ill-health due t cntracting bld brne virus via ccupatinal injury with cntaminated sharp r bdy fluid T prvide a clear framewrk fr the management f bdy fluid expsure including pst expsure chemprphylaxis (PEP) T prvide infrmatin regarding the preventin f expsure t bdy fluids, and the prtectin f emplyees It is the plicy f the Trust that n ne will be discriminated against n grunds f age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religin r belief, sex r sexual rientatin. The Trust will prvide interpretatin services r dcumentatin in ther mediums as requested and necessary t ensure natural justice and equality f access. 2 General Dcument Principles 2.1 Sharps Injury Management Plicy Ptential rutes f expsure: Percutaneus Expsure: The skin f the recipient is cut r penetrated via needle r ther sharp bject e.g. scalpel, blade, trchar, bne fragment r tth, which is cntaminated by bld r ther bdy fluids. Muccutaneus Expsure: Bld r ther bdy fluid cntaminates the eyes, the inside f the nse r muth, r an area f nn-intact skin f the recipient. Expsures t lw risk bdy fluids e.g. urine, vmit, faeces, sputum and saliva (except when assciated with dentistry) are nt nrmally cnsidered a risk unless visibly bld stained. Expsure f unbrken skin r mucus membranes t bld r bdy fluids has nt been assciated with bld brne virus transmissin. Injuries with unused needles r sharps shuld be cleaned, a waterprf dressing applied and an incident frm cmpleted; in this circumstance there is n reasn t infrm Occupatinal Health r reprt t ED ut-f-hurs. It is recgnised that healthcare wrkers may be expsed t surces f infectin utside their emplyment. This prcedure will be fllwed in such circumstances t minimise the nward transmissin f infectin t thers. Bdy fluids, which may transfer infectin: Bld Page 4 f 40

5 Saliva, assciated with dentistry. Cerebral-spinal fluid. Pericardial fluid. Peritneal fluid. Pleural fluid. Synvial fluid. Unfixed human tissue and rgans. Exudate r tissue fluid frm burns/wunds. Vaginal fluid. Semen. Amnitic fluid. Human breast milk. Any ther bdy fluid if visibly bld stained Prtectin f Staff: Expsure t bld brne viruses has been risk assessed by the Trust and an immunisatin prgramme is available t all qualifying Trust emplyees. Immunisatin is available t all staff via the Occupatinal Health Department. During the recruitment f healthcare wrkers, all clinically based emplyees are required t cmplete a health declaratin frm, which includes a jb risk assessment sectin. The recruiting manager cmpletes this; the jb risk assessment identifies emplyees wh are ptentially expsed t bld brne viruses and they will be ffered immunisatin. Thse healthcare wrkers wh undertake prcedures which pse a risk f infecting patients will be required t prve they are nt an infectin risk prir t undertaking such prcedures by means f a bld sample result which has been tested in a UK labratry (It maybe necessary fr a bld sample t be btained and tested prir t perfrming expsure prne prcedures). Thse emplyees wh are an infectin risk will nt be allwed t carry ut expsure prne prcedures, until cnsidered and extensive advice has been btained surrunding the particular situatin and the necessary steps taken t minimise the risk f transmissin. Refer t viral hepatitis and Aids/HIV emplyment plicies if psitive fr bld brne viruses. Immediate pst expsure actin t be taken by the health care wrker: Any healthcare wrker wh has had an expsure t a needle stick/sharp r bdy fluid expsure shuld: Wash the site with sap and water, n scrubbing. (Antiseptics and skin wash shuld nt be used) Irrigate expsed eyes, muth r brken skin with saline/ water (eyes shuld be cleaned pre and pst remval f cntact lenses) attend ED if assistance required). Gently encurage free bleeding f puncture wunds, milk the wund d nt suck the wund. Reprt the injury t the persn in charge and cmplete an incident frm. Establish surce and risk assess (Manager) Essential aspects f pst expsure risk assessment: Dnr Patient: Page 5 f 40

6 It is essential that full and thrugh risk assessment f the dnr patient be undertaken by the mst senir medical/nursing persn available (Risk Assessment f the dnr patient shuld nt be undertaken by the recipient/injured health care wrker) The decisin n whether any pst-expsure prphylaxis is administered depends n risk assessment f the surce f the injury and must include as a minimum: Dnr s age Dnr s sex Diagnsis Race Sexual rientatin Sexual prmiscuity Intravenus drug abuse bth past and present Cuntry f rigin r return frm areas with high prevalence f HIV infectin in the cmmunity e.g. Sub-Saharan urban Africa. Medical histry f liver disease, jaundice and hepatitis Recipient health care wrker: Of equal imprtance as the risk assessment f the dnr patient fr active/ptential f bld brne virus infectin is the cmpletin and thrugh risk assessment f the recipient healthcare wrker. Risk assessment f the recipient healthcare wrker will be perfrmed by the Occupatinal Health Department and in the event f the injury ccurring utside f ffice hurs then by the Emergency Department. Healthcare wrkers must nt cmplete their wn risk assessment and equally shuld nt ask a clleague t d it; treatments ther than first aid must nt be administrated at departmental level. Failure t cmply with this stipulatin culd have ptentially life threatening cnsequences and may result in disciplinary sanctins. Essentially the risk assessment must include: Nature f injury i.e. bite, scratch, puncture wund, splash injury Deepness f injury Visible bld n injury device Injury frm needle r device frm surce patient s artery/vein Timescale since injury First aid measures emplyed Hepatitis B immunity status f the recipient healthcare wrker Health status f recipient healthcare wrker, i.e. hepatic disease, pregnancy etc. 2.3 Mandatry bld sampling (at time f injury): In all circumstances where expsure has been assessed t have ccurred then the fllwing bld samples must be btained: Dnr patient: Cnsensual blds shuld be btained fr: Hepatitis B surface antigen Hepatitis C antibdy HIV 1&2 antibdies and P24 antigen Page 6 f 40

7 Dnr patients shuld be infrmed that the test des nt frm part f their clinical ntes and they will receive feedback if they are discvered t have carrier status. Dnr patients shuld be infrmed that the test is similar t testing that is undertaken when dnating bld and des nt require declaratin n life insurance plicy applicatins. Dnr patients must be infrmed that the results f their tests will be made knwn t the Occupatinal Health department and t the recipient if any tests return psitive. Recipient healthcare wrker: Cnsensual bld shuld be btained fr strage nly If the Hepatitis B antibdy status is unclear then this must be requested at this juncture 2.4. Preventin f expsure t bld and bdy fluids: Prir t cmmencement f hands n patient care all health care wrkers must: Wash hands befre and after patient cntact and befre putting n and after remving glves; glves must be changed between patient cntacts. Use glves where there is likelihd f expsure t bdy fluids (including venepuncture) Surgens shuld duble glve except fr exceptinal circumstances. Use waterprf plasters and glves t cver all breaks in skin especially where cntact with bdy fluids is anticipated. Use gggles, visrs, masks and gwns and aprns t avid splash injuries in t eyes, muth, bdy and clthing where prvided and instructed. Seek advice frm the Occupatinal Health department fr skin cnditins such as dermatitis/eczema. Spillages f bdy fluids shuld be dealt with by fllwing the apprpriate infectin cntrl plicy; apprpriate use f persnal prtective equipment and use f spillage kit where available. Wear apprpriate ftwear in lcatins where bld spillages may ccur r sharp instruments r needles are being handled. T help reduce the risk f sharps injuries and bdy fluid expsure healthcare staff must: Take particular care when handling sharps n hand-t-hand transfers r prcedures directed twards the hand. Be vigilant and acknwledge fatigue, which may affect cncentratin. Take the sharps bin t the pint f use befre starting the prcedure. Use glves t prevent percutaneus expsure t bld. Never becme distracted frm the task in hand. Never re-sheathe, bend r break needles befre dispsal. It is the sharps users respnsibility t dispse f the sharp in a recgnised cntainer. Carefully remve needle and apply bturatr when transprting arterial bld fr analysis. Intravascular guide wires and chest drain trcars must be dispsed f in the apprpriate sized sharps bins. Avid unnecessary use f sharps e.g. cllectin f urine samples frm catheter bags using needles. Use needle free devices where it is reasnably practicable t d s Use safer sharps where it is reasnably practicable t d s prviding the device des nt: Cmprmise patient care And is reasnably practicable t d s 2.5 Safe use f cntainers fr sharps dispsal: Page 7 f 40

8 Trust staff must: Only use sharps cntainers apprved by the Infectin Preventin & Cntrl team and thse that cmply with British Standard (7320) Never frce anything in t a sharps cntainer Never attempt t retrieve anything frm a sharps cntainer. Never place sharps cntainers in a public place r n the flr. Label sharps bin n assembly and clsure. Ensure temprary clsure f sharps bins during any transprtatin Secure and replace sharps bins when they are 3/4 full r appraching that level, never verfill. Thrughly dispse f giving sets in sharps bins apprved fr that purpse. Respnsibility fr the preparatin use and strage f used cntainers rests with the manager in accrdance with natinal plicy Use needle free devices r safer sharps device where prvided and reasnably practicable t d s. Respnsibility fr the cllectin f used sharps bins fr incineratin rests with the Supprt Services Manager. 2.6 Prcedure fr sharps injury and bdy fluid management, including pst-expsure chemprphylaxis Prtectin against hepatitis B, management and risk assessment: The actin needed t be taken in the immediate pst expsure perid t prtect the recipient health care wrker against Hepatitis B is dependent n the vaccinatin status f the health care wrker and the Hepatitis B surface antigen level f the dnr (bth if knwn). This will be managed by the Occupatinal Health Department and ut f hurs it will be dealt with by the Emergency Department using the designated expsure risk assessment and prcedure frm (appendix D) All staff dealing directly with patients and/r bdy fluids r likely t cme in t cntact with bld/bdy fluids in the executin f their rutine duties shuld be immunised against hepatitis B virus. Each member f staff wh has been immunised has a respnsibility t knw their Hepatitis B antibdy status after cmpletin f the curse. The titre level falls ver a perid f years and staff members shuld have a ne ff bster at 5 years. Respnse t Hepatitis B vaccinatin: Knwledge f the recipient healthcare wrker s respnse t Hepatitis B vaccine is required t perfrm a satisfactry assessment f risk. Respnse t vaccinatin will be: a. Respnders less than 10 units/ml : nn-respnders are particularly susceptible t Hepatitis B infectin s shuld be extra vigilant t avid inculatin injuries. Will have titre levels less than 10 units/ml. b. Respnder greater than 10 units/ml: titre levels greater than 10 units/ml and less than 100 units/ml are recgnised as having a degree f prtectin, but will be at high risk frm Hepatitis B e antigen psitive patients. c. Satisfactry respnder: will have titre levels greater than 100 units/ml and will be cnsidered immune t Hepatitis B virus and fllwing a bster dse after 5 years are cnsidered immune fr life. Page 8 f 40

9 Hepatitis B pst expsure prphylaxis: HBV status f persn expsed. Less than 2 dses f Hep B vaccine pre-expsure. Mre than 2 dses f Hep B vaccine pre-expsure. Hepatitis B antibdies unknwn. Knwn respnder t Hep B vaccine. Antibdies unknwn. Knwn nnrespnder t Hep B vaccine. Surce Hep B antigen psitive. Accelerated curse f Hep B vaccine& Hepatitis B Immunglbulin x1. (HBIG) 1 dse f Hep B vaccine fllwed by 2 nd dse 1 mnth later. Give bster dse f Hep B vaccine if recipient has nt had 5-year bster. HBIGx1** and bster dse Hep B vaccine. Surce Hep B antigen negative. Start a curse f Hep B vaccine. Cmplete the curse f Hep B vaccine. Cnsider bster dse f Hep B vaccine if recipient has nt had 5-year bster. N HBIG required. Cnsider bster f Hep B vaccine. Surce Unknwn. Accelerated curse f Hep B vaccine. * Administer 1 dse Hep B vaccine as a bster within 48 hurs. Cnsider bster dse f Hep B vaccine if recipient has nt had 5- year bster. HBIGx1** required if high risk Cnsider bster Of Hep B vaccine. *Accelerated curse f Hepatitis B vaccine is given at 0, 1 and 2 mnths with a bster dse at 12 mnths fr anyne remaining at risk frm Hepatitis B virus. **If hepatitis B immunglbulin is required this can be btained frm Public Health England labratry fllwing discussin with the n-call micrbilgist. Hepatitis B immunglbulin shuld be given as sn as pssible preferably within 12-hurs, ideally with 48-hurs hwever n later than 1 week. Dse fr adults ver 10-years f age is 500 units Prtectin against hepatitis C, management and risk assessment: Currently there is n vaccine r recgnised pst expsure prphylaxis against Hepatitis C virus therefre universal precautinary measures need t be adpted as detailed in the plicy sectin f this dcument. If the surce patient is fund r knwn t be Hepatitis C psitive then the healthcare wrker must attend Occupatinal Health fr fllw-up. Treatment in the early stages f Hepatitis C infectin has been shwn t be effective therefre bth the surce patient and the recipient healthcare wrker shuld be referred t an apprpriate specialist if Hepatitis C psitive. A psitive Hepatitis C RNA (ribnucleic acid plymerase chain reactin) test in an individual with Hepatitis C antibdies indicates that they have active disease and are capable f infecting thers expsed t their bdy fluids. A negative Hepatitis C RNA test in an individual with Hepatitis C antibdies indicated that they are unlikely t have active disease and therefre unlikely t infect thers expsed t their bdy fluids. Page 9 f 40

10 Hepatitis C Psitive Dnr Patient: If the dnr patient is Hepatitis C psitive, then the dnr s bld will be need t be checked fr Hep C RNA. The recipient healthcare wrker will be tested at 6 and 12 weeks in cases where the dnr is Hep C RNA psitive and if there is evidence f acquisitin they will be referred t a Cnsultant Hepatlgist fr advice and cunselling. Surce Unknwn: In the event that the surce/dnr patient cannt be tested fr whatever reasn then management f the recipient shuld be based n a risk assessment. Clinical infrmatin abut the incident and/r surce will be reviewed. If due t the incident it is cnsidered that the recipient is at high risk f becming infected with Hep C virus then the healthcare wrker may be managed as if the surce was knwn t be Hep C RNA psitive (this wuld nrmally nly be if the surce was knwn t be r highly suspected t be an intravenus drug user) Summary: (Investigatins and fllw-up f recipient healthcare wrkers when dnr patient is knwn t be Hepatitis C infected) Obtain serum/edta fr HCV-RNA (viral lad) at 6 and 12 weeks Obtain serum/ EDTA fr genme detectin at 6 and 12 weeks Obtain serum fr antibdies-hcv at 12 and 24 weeks. Hepatitis C virus status f surce unknwn: Perfrm a risk assessment f incident and clinical details. If surce cnsidered high risk then treat incident as if an infected surce as abve. If surce cnsidered lw/unknwn risk then btain base line serum/edta sample fr strage and serum fr anti-hcv at 24 weeks. Gentyping f the surce and the recipient will help establish if transmissin f Hep C virus frm patient t healthcare wrker has ccurred Human immundeficiency Virus (HIV), Management and Risk Assessment: There is n risk f HIV transmissin when intact skin is in cntact with HIV infected bld, regardless f viral lad. Currently there is n vaccinatin against HIV but pst-expsure prphylaxis is available. Department f Health studies have shwn there is a lw chance f HIV transmissin fllwing percutaneus r mucutaneus injury frm a knwn HIV infected surce. Hwever, sme factrs are assciated with increased risk f HIV transmissin: Deep injury Page 10 f 40

11 Bld n the device frm which the injury ccurred Injury frm a needle r device that had been in the surce patient s artery r vein. Terminal HIV infectin in the surce patient Fresh bld n the device, HIV is affected by UV light and drying The initial risk assessment shuld be based n the ptential fr viral transmissin, i.e. the type f bdy fluid invlved, the rute and severity f expsure. Fr example sme ccupatinal expsures after careful assessment may nt be cnsidered t be significant and d nt pse any risk f HIV transmissin. In such circumstances pst-expsure prphylaxis shuld nt be given. HIV Expsure Circumstances: High risks f HIV crss-infectin Pst-expsure prphylaxis wuld be recmmended fr percutaneus expsures invlving all f the fllwing: (reference appendix 2) Deep injury. Visible bld n injury device Injury with needle r device that has been in a dnr patient s artery/vein Terminal HIV related illness in dnr patient High viral lad; a recent infectin with HIV that has resulted in sercnversin r ne with late stage HIV infectin r with a measured HIV viral lad f greater than 50,000 cpies/ml. Or dnr patient suspected t be infected i.e. Psitive HIV antibdy test. On antiretrviral drugs but refuses test. Surce patient is unable t give histry/cnsent (uncnscius, mentally impaired) but histry frm medical ntes/family etc. strngly suggests HIV infectin. Current r remte histry f immune deficiency which is acquired plus ne f the fllwing risk factrs: 1. Hmsexual/bisexual male wh partakes/partk in unprtected anal intercurse. 2. Intravenus drug user, bth recent and remte. 3. Haemphiliac receiving factr viii/cryprecipitate prir t 1986 r frm verseas 4. Sex wrker male/female. 5. Recent arrival frm r hspitalisatin in urban sub-saharan Africa. 6. Unprtected sex with persns at high risk f HIV. Bth males and females. Actins required: Refer the recipient healthcare wrker t the Occupatinal Health Department between 8.30am and 4.30pm, Mnday t Friday. Outside these hurs managers shuld ensure that the recipient healthcare wrker reprts t nearest Emergency Department prmptly s HIV pst expsure chemprphylaxis can be cmmenced withut delay (if recmmended fllwing risk assessment). Managers shuld ensure that the recipient health care wrker reprts the incident t Occupatinal Health the next wrking day fr fllw-up. Mderate risk f HIV crss Infectin: Page 11 f 40

12 HIV pst-expsure prphylaxis may be recmmended after expsures invlving the fllwing: Other ptentially infected bdy fluids i.e. amnitic fluid, vaginal secretins, semen, human breast milk, CSF, pleural/peritneal/synvial and any ther bdy fluid visibly bld stained, unfixed human tissues and rgans, saliva assciated with dentistry and exudate r ther tissue fluid frm burns r skin lesins. Mucus membranes splashes (t eyes and muth) with HIV infected bld r bld strngly suspected t be HIV psitive, i.e. dnr patient frm any listed in pints 1-6 abve. Strngly suspected: Includes dnr patients with clinical symptms indicative f HIV infectin and thse recently arrived frm sub-saharan Africa wh have nt yet been tested. It des nt include ne lifestyle factr such as Intravenus drug user r injuries frm unknwn surces. Actins required: Refer the recipient healthcare wrker t Occupatinal Health department between 8.30am and 4.30pm, Mnday t Friday. Outside f these hurs managers shuld ensure that the recipient healthcare wrker reprts t the Emergency Department prmptly s that HIV-pst expsure chemprphylaxis can be cmmenced prmptly if risk assessment necessitates. Managers shuld ensure that the healthcare wrker reprts the incident t the Occupatinal Health department the next wrking day fr fllw-up. Lw risk f HIV crss-infectin: Circumstances where HIV prphylaxis shuld nt be given: Intact skin expsed t HIV infected bld regardless f HIV viral lad. Dnr patient is prven t be HIV-negative. Actins required: N further actins required ther than cmpletin f accident frm and reprting f the incident t Occupatinal Health department, t ensure n risk has ccurred Illnesses that may be indicative f HIV/AIDS in dnr patients: Candidiasis: esphageal, tracheal, brnchi r lungs. Cccidiidmycsis: extrapulmnary. Cryptcccsis: extrapulmnary. Cryptspridisis: with diarrhea fr excess f 1 mnth. Cytmegalvirus: retinitis, disease (nt hepatic splenetic r ndal). Herpes simplex: ulcers greater than 1-mnth duratin r brnchitis, pneumnitis, seaphagitis. Histplasmsis: disseminated/extrapulmnary. Isspriasis: with diarrhea fr excess f 1 mnth. Kapsi s sarcma. Lymphma: immunblastic, primary in the brain. Mycbacterium avium cmplex: extrapulmnary Mycbacterium TB: pulmnary r extrapulmnary with psitive Mantux. Pneumcystis carinii, pneumnia. Pneumnia: excess f 2 episdes in 12 mnths. Prgressive multifcal leucencephalpathy. Page 12 f 40

13 Salmnella: septicaemia recurrent. Txplasmsis: brain. Sme f these illnesses may result frm ther causes f immundeficiency. Example: immunsuppressive therapy, bne marrw transplantatin, cyttxic therapy, and leukaemia. If the answer is yes t any f the abve then immediate specialist help is required. Cntact Occupatinal Health department (during wrking hurs) r A&E utside f ffice hurs the n-call Micrbilgist can als be cntacted via switchbard Risk frm discarded hypdermic needles/unidentified Dnr: The risk frm bld brne virus reduces with drying. The risk frm bld brne virus reduces with time. The risk f bld brne virus reduces with expsure t UV light. Health Prtectin England des nt recmmend rutine testing f needles r sharps fr presence f bld brne virus in this type f injury. Therefre in the case f the surce patient being unknwn because devise was discarded then lcatin f the sharp/device shuld be taken int accunt when cnsidering the risk. I.e. Infectius Diseases Unit, needle exchange clinic, tilet r psychiatric r medical ward with knwn Intravenus drug user. Actins required: Hepatitis B vaccinatin is ffered if nt previusly immunised r if last immunisatin was in excess f 1-year. Bld shuld be taken frm the recipient healthcare wrker fr strage. Nrmally Hep B immunglbulin is nt required r given. The risk frm such incidents is cnsidered lw. The recipient healthcare wrker must reprts incident t Occupatinal Health wh will arrange any fllw-up including Hepatitis C antibdy screen in 24 weeks frm expsure. 2.8 Dnr bld nt available fr testing: If dnr is knwn but bld is nt btainable, the decisins as t whether any pst-expsure prphylaxis depends n thrugh risk assessment f the surce f the injury. Including: Dnr s age Sex Diagnsis Race Sexual rientatin Sex industry wrker Intravenus drug user bth present/past Cuntry f rigin r return frm area with high prevalence f HIV infectin in the cmmunity, e.g. sub-saharan urban Africa. Past histry f liver disease, jaundice, hepatitis Actins fllwing inculatin/splash expsure: After sustaining an injury, the individual cncerned shuld perfrm immediate first aid Actins invlving the dnr patient: Page 13 f 40

14 A risk assessment f the dnr patient must be carried ut as sn as pssible after the injury has ccurred. This shuld ideally be carried ut by the clinician respnsible fr the patent, but may als be perfrmed by a respnsible ther e.g. Ward Sister/Manager. If the surce is HIV psitive/strngly suspected then the recipient healthcare wrker MUST be risk assessed regarding cmmencing antiretrviral treatment immediately. Starter packs available via the Emergency Department/Occupatinal Health. The individual cmpleting the risk assessment shuld btain cnsent fr bld frm the dnr patient. A sample f the dnr patient s bld shuld be btained in an EDTA cltted tube and sent t Micrbilgy t test fr Hepatitis B surface antigen, Hepatitis C antibdies, and HIV 1&2 antibdies and P24 antigen. The sample must be btained with infrmed cnsent (frm the dnr r in the case f a minr then frm their legal guardian) and this must be dcumented in the patient s ntes. Bld samples frm uncnscius patients must nt be taken (Human Tissue Act 2004). In this circumstance decisins regarding PEP must be made n risk assessment nly. The dnr must be apprached with extreme tact and sensitivity, permissin must be sught and the circumstances explained. The test perfrmed will be fr the benefit f the recipient and the results will nt be referred back t the dnr patient s ntes unless requested by the dnr patient. It shuld be explained that the tests perfrmed are the same as fr bld dnrs and therefre d nt have t be declared t insurance cmpanies. The fact f testing fr HIV shuld nt be suppressed r ver emphasised. If any results return psitive then the Cnsultant in charge f the patient s care must take charge f the management f the feedback f results and any subsequent fllw-up. Actins invlving the recipient healthcare wrker: If the dnr patient is HIV psitive with high viral lad and the assessment f risk is high then the recipient healthcare wrker must receive antiretrviral therapy immediately withut delay. Starter packs are available via Emergency Department (ED) Leightn Hspital/Macclesfield Hspital r Pharmacy MCHFT/ECT. The recipient healthcare wrker invlved in the incident shuld prvide a sample f bld in a 10ml-cltted EDTA tube t be sent t micrbilgy fr strage. The healthcare wrker must be infrmed that this baseline bld sample will be stred fr 2 years. The Hepatitis vaccinatin histry f the recipient healthcare wrker shuld be ascertained and if apprpriate the sample shuld be tested fr Hepatitis B antibdies prir t strage. Bld samples can be sent frm either Occupatinal Health r ED. If the recipient Healthcare wrker has been successfully vaccinated against Hepatitis B n further treatment is required immediately. In circumstances where the recipient healthcare wrker has n/ incmplete histry f vaccinatin against Hepatitis B then a single dse f vaccine shuld be given within 48-hurs. If the surce is Hepatitis B surface antigen psitive/strngly suspected then Hepatitis B immunglbulin (HBIG) shuld be started preferably within 12-hurs, ideally within 48-hurs hwever n later than 1-week frm injury. HBIG is available frm Public Health England Labratry, Nrth West Regin. Page 14 f 40

15 Injuries frm unknwn dnrs are usually classed as lw risk. Actin fllwing expsure shuld invlve all steps except bviusly cllectin f dnr blds. All recipient healthcare wrker expsures must reprt via telephne t the Occupatinal Health department as sn as pssible, either immediately r if the injury ccurred ut-f-hurs then the next wrking day. Bld sampling required: The Virlgy request frm that accmpanies the dnr patient s bld must include the fllwing infrmatin: Clearly state that the bld sample is frm a Inculatin Injury dnr patient Clearly states the dnr patient s name, hspital number, and ward and department. Clearly states the recipient s healthcare wrkers Occupatinal Health number and Date f birth. Clearly states the date, time and nature f incident. Tests required are Hep B surface antigen, Hep C antibdy & HIV antibdies. Results t be returned t Occupatinal health department. The Virlgy request frm that accmpanies the recipient healthcare wrker s bld must include the fllwing infrmatin: Clearly state the bld sample is frm an Inculatin injury RECIPIENT healthcare wrker Clearly states that sample is fr STORAGE ONLY. Clearly states the name, ward and hspital number f dnr. Clearly states the date, time and nature f accident. Clearly states STAFF in place f hspital number. Results t be returned t Occupatinal Health Department. If the dnr patient has nt been tested and the risk is deemed significant then the recipient healthcare wrker shuld be tested as fllws: Time Scale Hepatitis B Hepatitis C Hepatitis C (Surce knwn (Surce unknwn r psitive r high risk) lw risk) At time f injury 6mls Cltted Sample Fr Strage HIV 6-Weeks Surface antigen PCR (viral lad) 12-weeks 24-weeks Surface antigen Surface antigen & surface antibdies* PCR and antibdy Antibdy Antibdy Antigen/antibdy cmbined test. * Hepatitis surface antibdy testing is nly required at 6-mnths if Hepatitis B vaccinatin was cmmenced at time f injury Accidents during surgery/expsure prne prcedures (EPP) What is an expsure prne prcedure? Page 15 f 40

16 Any prcedure where the peratr s hand is in a bdy cavity in the presence f a sharp instrument / needle r bne spicule r tth. Surgery Child birth Dentistry If expsure ccurs frm a Healthcare wrker undertaking an expsure prne prcedure t a patient (recipient), in this instance if the peratr s bld might have been inculated int the patient, the peratr is regarded as the dnr and will need t be cunselled apprpriately and their bld is tested fr bld brne agents. The patient will be reassured with the results f any tests and ffered apprpriate prphylaxis if indicated. It is Trust plicy t test all new emplyees partaking in expsure prne prcedures fr mandatry Hepatitis B antibdies and surface antigen, Hepatitis C antibdy, and since January 2007 HIV 1&2 antibdies, prir t starting emplyment, (Ref: Occupatinal Health Hepatitis Emplyment Plicy and HIV Emplyment Plicy). If fr any reasn the Healthcare wrkers bld brne virus status is unknwn then blds must be btained fr Hepatitis B surface antigen, Hep C antibdies and HIV antibdies withut delay, Infectin Preventin and Cntrl must be infrmed immediately. Refer t United Kingdm Expert Advisry Grup n AIDS. The cnsultant in-charge f patient s care must be infrmed immediately Infrmatin and advice n HIV pst expsure chemprphylaxis (HIV-PEP): If a significant expsure has ccurred and the dnr patient is knwn t be HIV psitive r risk assessment indicates high risk then HIV- PEP shuld be cmmenced (Appendix 2). Best practice indicates that that the first dse shuld be given within 1 hur (HIV-PEP can be given up t 72 hurs pst-expsure but the effectiveness is reduced by time). Specialist advice needs t be sught if the dnr patient is knwn t be HIV-psitive r is unwilling t give cnsent fr HIV testing. If the dnr patient s HIV status is uncertain r unknwn but the surce has been identified thrugh risk assessment, as having risk factrs fr HIV then expert cnsideratin needs t be given n whether t start PEP, pending further investigatin. Specialist advise can be sught frm Cnsultant Micrbilgist, lcal GUM/Sexual Health Centre. The recipient healthcare wrker must nt carry ut the risk assessment n the pssibility f the dnr patient being HIV psitive. Ideally the mst senir member f the medical team caring fr the dnr patient (that is available) cmpletes the risk assessment, r a cmpetent ther e.g. Senir Nurse, ward Manager/Sister, Nurse Practitiner r Mdern Matrn, in cnjunctin with a Cnsultant with specialist knwledge f HIV if required. If the risk assessment cncludes that the dnr patient is HIV psitive then HIV- PEP shuld cmmence immediately, ideally within 1 hur f the injury and the dnr patient tested (subject t infrmed cnsent) fr HIV. Based n the results f the dnr patient testing the recipient health care wrker. (Fllwing advice frm a specialist clinician) can make an infrmed decisin n whether t cntinue with HIV-PEP. If the HIV status f the dnr patient cannt be established, the recipient healthcare wrker shuld be given the pprtunity t decide whether t start and/r cntinue with HIV-PEP. Page 16 f 40

17 This decisin shuld be taken with advice frm a specialist in HIV t include all knwledge f the dnr patient, the risks f infectin and the nature and severity f the expsure. The recipient healthcare wrker must be advised n the ptential fr HIV-PEP t prduce unpleasant and ptentially serius side effects, and a cpy f the Trust infrmatin sheet fr healthcare wrkers cmmencing HIV-PEP shuld be given t the recipient healthcare wrker, infrmed cnsent shuld be established befre dispensing f medicatins. If n risk assessment the dnr patient is cnsidered t be highly unlikely t be HIV psitive, then HIV-PEP is nt nrmally recmmended r cmmenced. Hwever, there is still a requirement t test the dnr patient fr HIV and the recipient healthcare wrker can be ffered HIV-PEP in the event f a psitive result. This universal apprach t dnr patient testing reduces the need t make difficult judgements and helps t avid the pssibility f discriminatin. Ideally HIV-PEP shuld be cmmenced within 1 hur f ptential expsure t HIV. Hwever, the exact mechanisms f HIV infectin are nt currently fully understd, therefre if mre than 1 hur has elapsed after expsure this des nt autmatically exclude starting HIV-PEP. The Department f Health states that the effectiveness f HIV-PEP diminishes with time and it shuld be cmmenced within a 72-hur windw, but it is wrth cnsidering starting PEP up t 2 weeks fllwing expsure. Specialist advice must be sught in this circumstance. If the recipient healthcare wrker is female, cnsideratin shuld be give t the pssibility f pregnancy. Fr female healthcare wrkers wh cannt rule ut pregnancy advice frm a specialist in HIV shuld be sught prir t cmmencing PEP. Fr further advice cntact the Sexual Health department between 9am and 5pm Mnday t Friday r utside these hurs, the GUM/ID n-call at Ryal Liverpl Hspital. Starter packs fr HIV pst expsure prphylaxis are available via the Emergency Department r pharmacy r n-call pharmacist cntacted via switchbard. The prphylactic drugs act synergistically inhibiting the earliest stages f HIV infectin by interfering with the initial cycles f HIV. This cmbinatin f drugs is ne f the mst ptent ccktail f drugs available at present, but there are dcumented cases where the regimen has failed HIV pst Expsure prphylaxis regime: The recmmended starter pack regimen is: - TRUVADA* RALTEGRAVIR (1 tablet nce a day) fr 3-5 days (1 tablet twice a day) fr 3-5 days *An alternative t Truvada fr patients with renal failure is Cmbivir (zidvudine+lamivudine) at a dse f 1 tablet BD in adults; please discuss with lcal/reginal HIV team. This cmbinatin f drugs may have t be taken fr up t 4 weeks Befre cmmencing PEP, take blds fr: Full bld cunt Urea and electrlytes Liver functin test, amylase Glucse and lipids Page 17 f 40

18 EDTA bld sample t virlgy requesting HIV test and save clearly stating pre-pep, pst inculatin injury. Ensure that STAFF is written n the frm s any results are returned t Occupatinal Health t ensure cnfidentiality. The advantages f taking PEP: These drugs inhibit the grwth f HIV in the labratry. In studies thse wh tk Azidthymidine (Zidvudine/AZT) after an injury with HIV infected bld had a reduced risk f getting infected with cmpared with thse wh did nt take it. In sme animal mdels using very high dses f the virus, AZT given early did reduce virus multiplicatin and in 2 studies actually prevented infectin (relevance f animal experiments t human infectin is unknwn) Immediate cmbinatin therapy after significant expsure is nw recmmended in mst centres caring fr individuals with HIV in the UK, USA and Canada. The disadvantages f taking PEP: These drugs d have side effects. The cmbinatin f these drugs in the PEP packs have been specifically selected because they have relatively few side effects and are easy t take. Hwever, cmmn side effects (affecting 1-10 users in 100), when taking a cmbinatin f antiretrviral drugs may include: Diarrhea Lack f strength and energy Nausea and vmiting, abdminal pain, wind Changes in bdy fat distributin- lss f fat frm arms, legs and face and an increase in fat in the abdmen, breasts and back f the neck (buffal hump). Anaemia (lw red bld cell cunt) and neutrpenia/leukpenia (lw white bld cell cunt) may ccur within 4-6 weeks due t treatment with Cmbivir. Please refer t the current British Natinal Frmulary (BNF), the Summary f Prduct Characteristics (SPC) and Patient infrmatin leaflet (PIL) fr further infrmatin n adverse effects. The lng-term side effects f taking these drugs are nt knwn. These drugs can interact with ther drugs the patient may be taking (whilst taking HIV-PEP the individual shuld be advised t infrm the prescribing Dctr f all current medicatin that they are taking, and any medicatin that they have bught themselves. The effects f the drugs n the develping fetus are unknwn. These drugs are nt a guarantee that the persn will nt becme infected with HIV. If the individual is already infected with HIV then the individual shuld nt start PEP as it wuld be unnecessary and wuld have the ptential fr resistant virus t develp. Page 18 f 40

19 If the healthcare wrker decides t cmmence PEP then they must be advised t take adequate precautins t prevent pregnancy fr 3 mnths. Using cndms is imprtant, as it will prtect any sexual partner if the individual has becme infected with HIV thrugh this incident. Fr further infrmatin cntact the Sexual Health Service r n-call ID/GUM Cnsultant at Liverpl Ryal Infirmary, between 9am and 5pm Mnday t Friday. Any healthcare wrker cmmenced n HIV pst-expsure prphylaxis will be supprted by the ccupatinal health department via the Occupatinal Health Nurses and the Physician. The Occupatinal Health department will ensure that the necessary referral t a Specialist Physician in HIV medicine is cmpleted and c-rdinate specialist cunselling if necessary. Occupatinal Health staff will als be respnsible fr ensuring that fllw-up testing at 12 -weeks t exclude HIV cntaminatin f healthcare wrkers expsed t HIV psitive bld is cmpleted r 12- weeks after cmpletin f treatment if PEP was prescribed. The emtinal impact f taking HIV pst-expsure prphylaxis must nt be under-estimated, and the Occupatinal Health department is respnsible fr ensuring that all necessary supprt is in place Out-f-Hurs Management: The ut-f-hurs management f accidental inculatin incidents is the respnsibility f the Emergency Department. During these hurs they will assume the respnsibility fr risk assessment f the dnr, recipient and administratin f treatments including pst expsure prphylaxis if indicated as necessary by risk assessment. The Emergency Department, nursing and medical staff will cmplete the ut-f-hurs prfrma (Appendix) in full and will ensure that the Occupatinal Health Service received cpies f the cmpleted dcumentatin fr fllw-up and audit purpses. 3 Definitins Bld brne viruses refer t a virus, which is transmitted thrugh cntact with bdy fluids i.e., bld, and saliva. Recipient refers t the persn receiving the expsure t bdy fluids. Surce refers t patient/client/persn frm which the bdy fluid came. HbAB Hepatitis B antibdy HbIG Hepatitis B Immunglbulin HIV Human Immundeficiency Virus NSI Needlestick Injury BFC Bdy Fluid Cntact HIV-PEP HIV Pst Expsure Prphylaxis 3.1 Plicy A plicy is a statement f Trust intent fr a given issue and gives a clear psitin statement fr the Trust s custmers and emplyees n its values and beliefs (Parsley & Crrigan 1999). A plicy is a must d ; there shuld be n deviatin frm the actins as defined in the plicy. Any deviatin must be discussed and apprved by the Strategic Integrated Gvernance Cmmittee. 3.2 Guideline A guideline is an verview f prcesses either clinical r nn-clinical, t be undertaken in certain cnditins. A guideline gives practical guidance as t hw t deliver best practice Page 19 f 40

20 but allws fr prfessinal initiative and infrmed decisin making. Any deviatin frm a Trust guidance dcument, alng with the reasns why, must be dcumented in the Health Recrds. 3.3 Clinical Pathway / Standard Operating Prcedure (SOP) A Clinical Pathway / SOP is a wrking dcument detailing the current agreed wrking practice that takes accunt f all the areas that are applicable t the management f a prcess in an individual setting 4 Assciated Dcuments U.K. Health Departments Guidance fr Clinical Health Care Wrkers: Prtectin against Infectin with Bld brne Viruses: Recmmendatins f the Expert Advisry Grup n AIDS and the Advisry Grup n Hepatitis (HSC 1998/063) AIDS/HIV infected Health Care Wrkers: Guidance n the management f infected Health Care Wrkers and Patient Ntificatin: UK Health Departments Nvember Health Service Circular (HSC) 2202/010 Hepatitis C Infected Health Care wrkers. Department f Health: Clearance fr TB, Hep B, Hep C and HIV fr New Healthcare Wrkers Department f Health, Guidance frm UK Chief Medical Officers Advisry Grup n AIDS, HIV Pst-expsure prphylaxis, 2008 Her Majesty s Statinery Office, Human Tissue Act Health and Safety Executive, Health and Safety (Sharps Instruments in Healthcare) Regulatins 2013 Mersey, Cheshire and Nrth Wales HIV Managed Care Netwrk, Guidelines fr Pst Expsure Prphylaxis fr HIV Fllwing Occupatinal r Sexual Expsure versin 3 And with the fllwing Infectin Preventin and Cntrl and Occupatinal Health Plicies/Prcedures: Infectin Preventin and Cntrl Gd Practice guidelines Universal Precautins Prtcl Safer Handling f Sharps Prtcl Occupatinal Vaccinatin Plicy HIV Emplyment Plicy Hepatitis Emplyment Plicy 5 Duties Duties within the Organisatin Occupatinal Health Department The Occupatinal Health Clinical Lead Nurse is respnsible fr the review f this plicy and ensuring it is implemented satisfactrily bth during ffice hurs and ut-f-hurs. The Occupatinal Health department will prvide specialist knwledge and will instruct apprpriately regarding any expsure incident and will instigate necessary treatments either directly r via third parties. Will assess initially via telephne the likely transmissin f bld brne virus: Hepatitis B (Hep B), Hepatitis C (Hep C), and Human Immundeficiency Virus (HIV) when an injury ccurs. Page 20 f 40

21 Offer advice n the apprpriate fllw-up and bld tests required fr the recipient healthcare wrker and the surce patient. Arrange fr any cunselling f the recipient healthcare wrker. Advise (where apprpriate) clinicians n the testing requirements fr the surce and recipient and ensure results fr bth are crss-referenced and reprted t Occupatinal Health. Ensure managing team f dnr patient is infrmed f any Hep B, Hep C r HIV psitive results s apprpriate fllw-up can be initiated. Manage the fllw-up care fr all ptential expsures t Hep B, Hep C and HIV and refer t specialists fr advice and treatment if necessary. Maintain all dcumentatin relating t any injury and ensure cnfidentiality f all infrmatin. Maintain a database f all accidental inculatin injuries fr the purpse f audit. Reprt all high-risk expsures that have resulted in pst expsure prphylaxis under RIDDOR. Refer t Geniturinary Medicine (GUM)/ Infectius diseases (ID) specialists fr high-risk ptential expsures t HIV fr specialist fllw-up and care. Occupatinal Health will fllw-up all recipient healthcare wrkers under the care f GUM/HIV/ID specialists teams t assess and mnitr fitness fr wrk. Ensure immediate HIV pst expsure prphylaxis starter-packs are issued (in cnsultatin with the Cnsultant Micrbilgist and pharmacy) t recipient healthcare wrkers fllwing high-risk expsure incidents. Ensure that Hepatitis B immunglbulin is administered t high-risk hepatitis B expsures, accrding t risk assessment. Prvide apprpriate training fr Accident and Emergency medical and nursing staff in the management f sharps injuries. Ensure that preventin and management f sharps injuries is included in inductin and mandatry training. Respnsibilities f Line Manager/persn in charge at the time f the incident Ensure that all first aid recmmendatins have been fllwed. Ensure the incident reprting prcedure is fllwed. Ensure the safe and crrect dispsal f sharp causing the injury. Ensure the dnr patient is infrmed f the incident. Ensure the dnr patient s cntact details are made available t Occupatinal Health including, name, address, DOB, General Practitiner name and practice address. Under the guidance f Occupatinal Health, t rganise dnr patient bld sampling with apprpriate cnsent. Page 21 f 40

22 Ensure the recipient healthcare wrker attends Occupatinal Health r Accident & Emergency (if ut f hurs) as sn as pssible after incident. Assist with risk assessment in cnjunctin with Occupatinal Health and if necessary the Cnsultant Micrbilgist. Respnsibilities f all emplyees T fllw first aid guidelines in the event f a bdy fluid incident immediately fllwing the accident Immediately after all sharps injuries/bdy fluid cntact, will cnsult with Occupatinal Health immediately r Accident and Emergency first, (if ut f nrmal wrking hurs) r nearest Accident and Emergency Department if ut f area (Peripatetic staff) T reprt all accidental expsure t bdy fluids via the Incident Reprting Prcedure. T cntact Occupatinal Health, even if initially treated by Emergency Department T attend fllw up appintments with Occupatinal Health. Emergency Department (ED) Outside f Occupatinal Health department wrking hurs the Emergency department will assess, manage and implement this plicy and assciated prcedure. Will prvide immediate advice and care ensuring that recipient healthcare wrkers are referred n t Occupatinal Health fr fllw-up. Cmplete the Out-f-Hurs Risk Assessment Questinnaire and Fllw-up Checklist (appendix A) cpies available in the Emergency Department r via the Intranet. Out-f Hurs if pst expsure chemprphylaxis (HIV-PEP, HBIG) is indicated via cmpletin f the risk assessment the ED dctr will prescribe and dispense the necessary medicines immediately. If Pst Expsure Prphylaxis is administered will ensure that Occupatinal Health is infrmed the next wrking day fr fllw-up. Liaise with specialists in Infectius Diseases/Geniturinary Medicine / Micrbilgy as necessary. ED dctrs and nurse practitiners will attend as required apprpriate training in the management f accidental inculatin injuries and HIV pst expsure prescribing. Trust Cnsultants/ senir medical staff/ Senir Nurse Be respnsible fr arranging and verseeing the testing f dnr patients. Prvide any necessary fllw-up care assciated with the dnr patient. Page 22 f 40

23 Facilitate risk assessment f dnr patient with reference t actual r ptential HIV and viral hepatitis infectin. Admitting Cnsultants are bliged t infrm the manager f an area if a patient pses an infectin risk and the manager is respnsible fr the cascading f this infrmatin t all staff invlved in patient care. A risk assessment must be carried ut fr each task. Geniturinary Medicine Clinic Prvide specialist advice n request t the Occupatinal Health Department and ED fr high-risk incidents. Prvide fllw-up care f recipient healthcare wrkers wh have cmmenced HIV pstexpsure prphylaxis and thse wh have had a ptentially high-risk expsure t HIV. Supprt Occupatinal Health regarding risk assessment and the suitability f pst-expsure prphylaxis fr HIV. Micrbilgist/ Infectin Preventin and Cntrl Team Liaise with Occupatinal Health t ensure there is a rbust system fr managing accidental inculatin injuries. Prvide clinical advice and supprt t the Occupatinal Health Department and the Emergency Department fr the prescriptin and issue f Hepatitis B immunglbulin befre it is dispensed by pharmacy. Prvide clinical advice and supprt regarding HIV pst-expsure prphylaxis treatment. Ensure apprpriate testing and strage f bth recipient healthcare wrker and dnr patient bld samples (Micrbilgy Labratry). The Infectin cntrl and Preventin Team will cnsider any plicy and prcedural changes as and when necessary. 6 Cnsultatins and Cmmunicatin with Stakehlders Distributed fr cmments t: Health & Safety Lead Strategic Infectin Cntrl Cmmittee Membership Head f Nursing Infectin Preventin & Cntrl Cnsultant Micrbilgist Pharmacy Head f HR Management Accident and Emergency Cnsultant Accident and Emergency Matrn Staff side representative Cnsultant in GUM Medicine Gvernance.plicies@mcht.nhs.uk must be included in the cnsultatin prcess fr all plicies Page 23 f 40

24 Versin 4 f this plicy was sent fr cnsultatin and apprval t the membership f the Strategic Infectin Preventin and Cntrl Cmmittee at Mid Cheshire Hspitals NHS Fundatin Trust and t membership f the same cmmittee at East Cheshire NHS Trust fr infrmatin. 7 Implementatin Implementatin f this plicy is a mandatry requirement fr all Cheshire Occupatinal Health Service clinical staff and Accident and Emergency staff respnsible fr the pst expsure management f inculatin incidents. All emplyees must fllw this plicy shuld they themselves r a clleague fr whm they have management respnsibility at the time receive an inculatin injury. Directrs, managers and emplyees f the Trust and partner rganisatins must c-perate with Cheshire Occupatinal Health Service in the implementatin f this plicy, in-rder t maintain a safe envirnment fr emplyees prtecting them frm risk f bld brne virus infectin frm inculatin injuries. Implementatin f this plicy is required t ensure that the Occupatinal Health Service and the Trust meet their cllective bligatins under Health and Safety legislatin, and applicable dmestic and Eurpean law therefre reducing the chances f tribunal r legal prceedings. Implementatin f this plicy and assciated Occupatinal Health plicies and prcedures shuld ensure essential functins f the Occupatinal Health Service in prtecting public health are achieved and ensures the Trust is fllwing best practice successfully meeting NHS Emplyers, SEQOHS (Safe, effective, quality Occupatinal Health Services), Health and Safety Executive and the Care Quality Cmmissin requirements. This plicy and prcedure will be available n each Trust s intranet and senir staff and managers will be alerted by the Trust s cmmunicatin prcesses when new plicies are issued r existing plices are update and reissued. Due t the advisry and supprtive functin f the Cheshire Occupatinal Health Service the implementatin f its plicies, prcedures and prtcls is and n-ging and cnsistent prcess. 8 Educatin and Training All Occupatinal Health Staff and Accident and Emergency staff respnsible fr the pst expsure management f inculatin injuries are t adhere t this plicy and carry ut their respnsibilities under it in rder t achieve the bjectives utlined in sectin 5 f this dcument. All staff will undertake mandatry and specialised training fr n-ging persnal develpment. Training needs will be identified thrugh Knwledge Skills Framewrk assessment. The Clinical Lead fr Cheshire Occupatinal Health Service will cmmunicate changes in practice t all Occupatinal Health clinical staff thrugh mnthly clinical meetings r mre frequently if urgency dictates. The Occupatinal Health Clinical Lead will cmmunicate changes in plicy, which affect the ut-f-hurs management f expsure incidents, t the Accident and Emergency Department when necessary. Training fr Trust staff in the applicatin f this plicy will be delivered in the fllwing ways: Ad-hc Clinical Updates: cvering strategic and clinical aspects f Occupatinal Health, including natinal initiatives, Natinal Institute fr Clinical Excellence standards, Care Quality Cmmissin requirements. Accredited Curses: All Cheshire Occupatinal Health Service and Emergency Department medical and nursing staff require current registratin with their respective gverning bdies Page 24 f 40