SHARPS SAFETY POLICY INCLUDING PREVENTION AND MANAGEMENT OF INOCULATION OR CONTAMINATION INCIDENTS (e.g. sharps, bites, scratches or cuts)

Transcription

1 SHARPS SAFETY POLICY INCLUDING OR CONTAMINATION INCIDENTS (e.g. sharps, bites, scratches or cuts) Solent NHS Trust policies can only be considered to be valid and up-to-date if viewed on the intranet. Please visit the intranet for the latest version. Purpose of Agreement Document Type This policy provides a clear, evidence-based framework to ensure safe practice when sharps are used, thereby minimising injuries caused by contaminated sharps. It is applicable to all staff who handle sharp items during the course of their employment, and applies at all times, in all situations. It provides a framework to ensure that when inoculation or contamination incidents do occur; the incident is promptly risk assessed and the healthcare worker/patient is offered appropriate treatment to reduce the risk of infection and counselling support to reduce distress. x Policy SOP Guideline Reference Number Solent NHST /Policy/IPC 04 Version Version 3 Name of Approving Committees/Groups Operational Date June 2015 Document Review Date June 2018 Infection Prevention Control Committee Risk Health & Safety Committee Document Sponsor (Name & Job Title) Document Manager (Name & Job Title) Document developed in consultation with Intranet Location Website Location Keywords (for website/intranet uploading) Julie Pennycook, Director of HR Gill Ward, Lead Nurse, Occupational Health Occupational Health & Wellbeing team Infection Prevention and Control team Sexual Health team Health& Safety team Solent Policies Location in FOI Publication Scheme Our Policies and procedures Policy, sharps, inoculation, contamination, HIV, PEP, Ratification, NHSLA SHARPS SAFETY POLICY INCLUDING 1 of 31 Version 3

2 Table Of Contents SECTION CONTENT PAGE 1. Introduction 3 2. Scope & Definition 5 3. Roles & Responsibilities 6 4. Safe Sharps Practice 8 5. Safe Handling 8 6. Use and Standardisation Of Sharps Bins 9 7. Safety Devices Operational Management Of Incident Post Exposure Prophylaxis Recovery Of Sharp Equipment On Or Near Hospital Sites Training Review References Table of amendments Links To Other Policies Appendix 1 Poster Guidelines and Information To Help Risk Assessment 22 Appendix 2 Full Risk Assessment Of Three Main Blood-Borne Viruses 23 Appendix 3 Occupational Health Risk Assessment Following Inoculation/ 25 Contamination Incident Appendix 4 PEP Treatment 28 Appendix 5 Recovery Of Needless/Sharp Equipment On Or Near Hospital Sites 29 Appendix 6 Contact Numbers for the following Hospitals and A&E departments 30 Appendix 7 Equality and Human Rights and Mental Capacity Act Impact Assessment SHARPS SAFETY POLICY INCLUDING 2 of 31 Version 3

3 1. INTRODUCTION 1.1 This Policy will discuss sharps safety and the operational management of adverse events resulting in injuries which may happen to healthcare workers whilst delivering care in any care setting. 1.2 There are three types of exposure in health care settings associated with significant risk, these are: Percutaneous injury (from needles, instruments, bone fragments, significant bites which break the skin etc). (Often referred to as sharps.) Exposure of broken skin (abrasions, cuts, eczema etc.) Exposure of mucous membranes including the eye. 1.3 Blood borne virus infections may be transmitted from infected patients to staff members. All blood and body fluids and tissues should be regarded as potentially infectious. This type of injury can also happen on rare occasions to patients they care for and the key principles of managing the incident will be the same. 1.4 A sharps injury is defined as an injury where a needle or other sharp medical device contaminated with blood or other body fluid penetrates the skin. This also includes human bites and scratches that break the skin. Syringe needles, scalpel blades and many other sharp devices are routinely used as part of healthcare practice in acute and primary care settings. 1.5 The Trust recognises the importance of providing a clear reporting system including out of hours; to ensure that all employees understand their responsibilities. This will ensure the individuals receive timely assessment, appropriate treatment and health surveillance to reduce the likelihood of transmission of a blood borne pathogen. The Trust further recognises the distress that this type of injury can cause to the individual and provides specialist counselling services to support them throughout this period. 1.6 This policy provides a clear, evidence-based framework to ensure safe practice when sharps are used, including the use of personal protective equipment; thereby minimising injuries caused by contaminated sharps. It is applicable to all staff who handle and dispose of sharp items during the course of their employment and applies at all times, in all situations. 1.7 Legal Requirement Under existing Health and Safety legislation (Health and Safety at Work etc Act 1974): All employers should provide suitable and sufficient training to ensure the safety of their staff while on the employer s business The Management of Health and Safety at Work Regulations, 1999: Employers must undertake suitable and sufficient risk assessments of all significant hazards in the workplace. Risk assessments should be extended to dangers to others on the employer s premises, including patients, visitors and contractors. Legislation also requires that employees have a duty to cooperate with the employer on all matters associated with health and safety and to abide by local safe systems of work Health and Safety Sharp Instruments in Healthcare ( Regulations 2013 the Sharps Regulations). Employers must ensure that risks from sharps injuries are adequately assessed and appropriate control measures are in place. SHARPS SAFETY POLICY INCLUDING 3 of 31 Version 3

4 Avoid the unnecessary use of sharps, needle- free equipment should be available and used where reasonably practicable to do so. Use safer sharps (incorporating protection mechanism) where reasonably practicable to do so The Control of Substances Hazardous to Health (COSHH) Regulations 2002: Employers must undertake suitable and sufficient risk assessments of all significant hazardous substances, including micro organisms and further ensure that significant findings are recorded The Personal protective equipment at work (second edition) regulations 1992 (as amended); All equipment (including clothing affording protection against weather), which is intended to be worn or held by a person at work and which protects him against one or more risks to his health or safety. Personal protective equipment provide barriers and filters between the worker and the hazard and should be worn where risk is indicated; gloves and eye protection will prevent exposure to blood splashes but will not prevent needlestick injuries Provision and Use of Work Equipment Regulations 1998: Employers must provide work equipment that is suitable for the intended job, maintained and which can be used safely The Health and Safety Regulations, 1981: Employers must provide adequate first aid facilities and first aid treatment Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013: Employers must report all injury, accidents that result in serious injury and/or occupationally acquired disease to the Health and Safety Executive (HSE) e.g. (Exposure to HIV, hepatitis B and hepatitis C are reportable to HSE as a dangerous occurrence) The Health and Social Care Act 2008 Code of Practice: The Care Quality Commission assesses performance against cleanliness and infection control requirements stated in the Code. The Code specifically addresses the need to prevent exposure to blood-borne viruses including prevention of sharps injuries. Criterion 5: Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people. Criterion 6: Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection. Criterion 9: Have and adhere to policies, designed for the individual s care and provider organisations that will help to prevent and control infections. Criterion 10: Ensure, so far as is reasonably practicable, that care workers are free of and are protected from exposure to infections that can be caught at work and that all staff are suitably educated in the prevention and control of infections associated with the provision of health and social care. SHARPS SAFETY POLICY INCLUDING 4 of 31 Version 3

5 1.4 Epidemiology The major blood-borne pathogens of concern associated with needlestick injuries are: Hepatitis B (HBV) Hepatitis C (HCV) Human immunodeficiency virus (HIV) However, other infectious agents also have the potential for transmission through a sharps injury and may be indicated by risk assessment. 2. SCOPE & DEFINITIONS This policy applies to all directly and indirectly employed staff and other persons working within the Trust in line with Solent NHS Trust s Equal Opportunities Document. This Document is also recommended to Independent contractors as good practice. Type Incidents- can happen occupationally in 3 ways Definition 1. Percutaneous exposure Inoculation incidents from sharps: e.g. needles, sharp edged instruments, broken glass contaminated with blood/body fluids including pathology specimens or sharp spicules of bone or teeth. Blood borne viruses are potentially transmittable by human bite; if the bite breaks the skin of the person bitten the risk of Hepatitis B contamination is high in this instance but minimal for HIV. Deep scratches where the skin has been broken have the potential to be infected from others nails, especially when contaminated by blood/body fluids 2. Cutaneous exposure Contamination incidents from spraying of blood/body fluids onto broken skin (abrasions, cuts, eczema etc) although the risk of HIV contamination in this instance is low. There is no evidence that blood born virus (es) can be transmitted by contaminated blood onto intact skin 3. Mucous Membrane Exposure: Contamination incidents from blood/body fluids into eyes, up the nose or into the mouth. Type Blood Borne Virus HBV HCV HIV HIV PEP Donor Definition A virus which is carried in the blood of an infected individual and which can be transmitted to another person exposed to the individual s blood Hepatitis B virus Hepatitis C virus Human Immunodeficiency Virus HIV (Post Exposure Prophylaxis): HIV treatment medication given after a sharps injury from a known/highly suspected to be a high risk HIV positive source to reduce the risk of seroconversion to HIV. HIV PEP is prescribed by the local Emergency Department or Sexual Health Department. In staff incidents: a donor is the patient/client. However in incidents where SHARPS SAFETY POLICY INCLUDING 5 of 31 Version 3

6 Source Recipient Safer sharps the patient may have been contaminated with staff blood, the donor is the staff member. A source is the cause of the incident e.g. incident from unknown needle would be referred to as the source In staff incidents the recipient is the healthcare worker who sustained the injury; however on rare occasions the patient may have been contaminated with the healthcare worker s blood or body fluid they would be the recipient These are devices that incorporate engineered controls to reduce risk of sharps injury. There are two categories of safer devices: 1. Needless systems such as intravenous connectors 2. Sharps with engineered sharp injury protection 3. ROLES & RESPONSIBILITIES 3.1 Duties of the Trust: Solent NHS Trust referred to throughout this policy as the Trust recognises and accepts its duties and responsibilities to provide staff with a safe and healthy working environment and will ensure that the necessary management systems are in place to enable implementation of all policies These duties include provision of information, instruction and training; provision of personal protective equipment, ensuring that safer sharp medical devices are used when available and providing first aid, treatment and support to those who have sustained an inoculation or contamination injury. This is to prevent/reduce the risk of health care acquired infection through inoculation or contamination incidents (sharps, bites, scratches, cuts or blood/blood stained body fluids) at work. 3.2 The Chief Executive has ultimate accountability for the strategic and operational management of the organisation, including ensuring all policies are adhered to. 3.3 Directors, Operational Directors and Line Managers have a duty to ensure that the requirements of this policy are met and that responsibilities for prevention and control of infection are reflected in all staff members job descriptions. 3.4 Line managers have a responsibility to operate this policy, as follows: Display the Poster Guidance (Appendix 1) in their area(s) Ensure staff are aware of this policy and their responsibilities to comply with first aid procedures, and to report any inoculation/contamination. Ensure that all staff receives induction training in line with Trust requirements and implementation this policy. Ensure staff are aware of how to protect themselves at work, including provision of information and training on blood borne viruses and accidental exposure. Carry out local risk assessment, which identify hazards and ways to protect themselves; Standard Precautions and safe working practice, including use of personal protective equipment and use of safer needles and other medical devices. See (Appendix 2). Full Risk Assessment of the three main blood borne viruses (HIV, hepatitis and hepatitis C) Be aware of required screening and immunisation programmes, available through the Occupational Health Service to protect staff in the workplace. They should also ensure that all inoculation or contamination injuries are reported through the Trust reporting system so that trends may be highlighted which may indicate training needs. SHARPS SAFETY POLICY INCLUDING 6 of 31 Version 3

7 Provide support for staff who have sustained an injury, this is especially important when the incident is a high risk of HIV and post exposure prophylaxis treatment has been prescribed. Report incidents with a high risk of transmission of blood borne viruses to the Health & Safety Team so that they may be reported under RIDDOR. Ensure consent is obtained from the patient, for appropriate blood tests to be taken (HIV, hepatitis B, and hepatitis C) and that bloods are taken and dispatched urgently to the Pathology Laboratory. The Trust does recognise that there may be occasions when taking blood from the source/donor patient is not possible; under these circumstances the risk assessment must include what the likelihood of risk is see (Appendix 2) Investigate incidents in a timely manner to prevent re-occurrence, adding those incidents to their departmental risk register, appropriately. Share learning outcomes with their teams to prevent re-occurrence and promote safe working practices and procedures. To ensure that all staff attend mandatory training and updates in relation to infection prevention and control issues as advised by the Infection Prevention and Control Team (IPCT). 3.5 Staff have a responsibility to: Familiarise themselves with this Policy to ensure that, should an incident occur to themselves or their patient, they understand their own personal responsibility to comply with first aid action and reporting procedure to follow. Be aware of their responsibility in avoiding needlestick injuries. Comply with Standard Precautions, including wearing appropriate and suitable protective clothing, follow safe working practice, specifically when handling and disposing of sharps to prevent injuries to themselves and others at work. Be aware of the potential for occupational exposure, including sharps injuries, which can and do occur while delivering care in any care setting. Attend mandatory training courses and updates in health and safety/infection control procedures; follow good practice to protect themselves from injuries at work. Attend Occupational Health & Wellbeing for prophylactic vaccinations to protect them as far as reasonably practicable against serious communicable disease and specifically blood borne viruses. Comply with treatment or monitoring procedures outlined in this policy, to try to protect them/detect health problems at an early stage. Seek counselling support when they have concerns which may affect their health and wellbeing. 3.6 Occupational Health Wellbeing (OH): have a responsibility to operate this policy; provide advice, treatment, support and counselling; referring individual to specialist counselling and Consultant Hepatologist, as appropriate. To provide a screening and vaccination service to the Trust in line with current Department Health Guidance and best practice. To monitor incidents and provide health surveillance to detect any early health changes. To provide assistance to both staff and managers in making an initial risk/ongoing risk assessment. (See Appendix 3). To liaise with the Virology/Microbiology/Pathology/Sexual Health Department and the Emergency Department, as required. To document the incident in individual s confidential occupational health records and use anonymised statistics for audit purposes. To liaise with IPCT to promote safe working practices including safer needles and other devices. SHARPS SAFETY POLICY INCLUDING 7 of 31 Version 3

8 To share the Inoculation / Contamination audit with the IPCT and the Trust Health & Safety Committees. This information may be used to highlight awareness of the Principles of Standard Precautions and safe systems of work, to prevent injury and transmission of serious communicable diseases. 3.7 The Health & Safety Team: has a responsibility to develop/maintain a reporting system for the Trust to ensure that all staff are aware of their responsibilities under this policy to report: Incidents which involve a source or a patient known or highly suspected to be a carrier of HIV/hepatitis B/hepatitis C must be reported under RIDDOR. This duty may also be undertaken by the Risk Management Team. The Trust Risk Register is maintained and risk is incorporated into staff training. The Safeguard reporting system is maintained and that statistics are produced quarterly and shared with the Trust. 3.8 Local Emergency Departments (ED): have a responsibility: To provide assessment and treatment to staff who have suffered inoculation or contamination injuries when OH is closed or where it is geographical difficult for the member of staff to get to OH department in a timely way e.g. travel distance In the case of high risk HIV incidents recognise this as a medical emergency and assess staff urgently. Provide starter packs of post exposure prophylaxis as indicated. 3.9 Sexual Health Department : has a responsibility: Provide specialist advice, support and ongoing treatment (post exposure prophylaxis) to staff who have suffered contamination incidents, when there has been a known or highly suspected risk of HIV. To provide advice and support to OH and the local ED. To provide specialist treatment, advice and support when appropriate to recipients who have suffered a contamination incident where there is a high risk of HIV Infection Prevention and Control Team (IPCT) has a responsibility: To deliver Mandatory training in Standard Precautions in liaison with the Trust s Learning and Development Team. To develop policies and procedures to assist the Trust in its duty to protect their staff at work. Monitor effective practice through the use of audit appropriate to clinical areas. To liaise with OH and work together to promote a safe and healthy workplace. To train Link Advisors for the Trust, to raise awareness of Standard Precautions at department level so that staff may protect themselves at work. 4. SAFE SHARPS PRACTICE The use of sharps should be avoided where possible. When their use is essential, particular care is required in handling and disposal. Staff must use safer medical devices whenever possible. 5. SAFE HANDLING Sharps must always be handled carefully in accordance with the following principles: Do not re-sheath used needles. SHARPS SAFETY POLICY INCLUDING 8 of 31 Version 3

9 a. Always get help when using sharps with a confused or agitated patient b. Never pass sharps from person to person by hand use an injection tray or clear field to place them in c. Never walk around with sharps in your hand d. Never leave sharps lying around dispose of them yourself e. Dispose of sharps at the point of use take a sharps bin and an injection tray with you f. Dispose of syringes and needles as a single unit do not remove the needle first g. Use needleless intravenous devices whenever possible, where available h. Always wear gloves when carrying out phlebotomy, cannulation etc. You do not have to wear gloves when giving routine intradermal, subcutaneous and intramuscular injections. You may wear gloves if a risk assessment indicates it is best to do so e.g. the patient s skin is not intact, your skin is not intact. 6. USE AND STANDARDISATION OF SHARPS BINS 6.1 The Trust has taken the decision to standardise on a range of sharps bins from a single manufacturer. They have been selected as the bins are easy to use and have been well evaluated by clinical staff in practice. Standardisation will ensure that staff working in multiple locations are familiar with the bins in use, and aims to help reduce the number of avoidable sharps injuries related to incorrect assembly and disposal of sharps bins. Safe use of sharps bins Sharps must only be disposed of in designated sharps bins that meet the requirements and in accordance with HTM Safe Management of Healthcare Waste (DH,2011) provides a framework for good practice to all producers of healthcare waste on the development and management arrangements for the safe, economic disposal of healthcare waste. Page 203 Sub Section 8409 Sharps Containers. Use appropriate designated sharps bins for specific types of waste e.g. yellow sharps bin with yellow lid, or yellow sharps bin with purple lid Always assemble sharps bins correctly Lid on properly click into place Label completed with time, date and initials of person assembling the sharps bin Placed in suitable, safe location Ensure sharps bins are of an appropriate size for the clinical activity do not select excessively large sharps bins, or those that are too small for the size needle/syringes you use Sharps bins should be available at the point of use of the sharp they should be taken to the bedside, placed on drug and cardiac arrest trolleys, and be carried by all staff who use sharps as part of their work in the community Wall and trolley brackets should be used, as appropriate Sharps bins must be located at approximately waist height, and never placed on the floor, on top of high surfaces, or where children or confused adults can tamper with them Between uses use the temporary closure device on the bin to prevent accidental spillage of sharps if the bin is knocked over. Always carry a sharps bin by the handle, or using the carry tray provided for smaller bins never place it against your body. Never overfill a sharps bin replace it when filled to the line mark or when it is two thirds full. Ensure sharps bins are closed and locked before disposal, and complete the label on the bin. SHARPS SAFETY POLICY INCLUDING 9 of 31 Version 3

10 Do not place sharps containers in orange bags for disposal community staff may place them inside a clear plastic bag during transport in their vehicles in order to prevent leakage Used sharps bins must be stored in a locked, segregated cupboard or clinical waste bin provided for the purpose 7. SAFETY DEVICES Note: sharps bins should be disposed of after 3 months even if not full. 7.1 Many sharps injuries can be avoided by adherence to the principles of safe practice. However it is recognised that some injuries are complete accidents. It is possible to reduce the risk of these happening by the use of safety devices as available and appropriate for the task. 7.2 Safer sharps and other safer medical devices incorporate a built-in safety feature in their design, which is intended to reduce the risk of sharps injury. An integrated safety feature is part of the basic design of the device that cannot be removed. A passive safety feature is one that does not require the user to activate it and remains effective before, during and after use. 7.3 Staff should consider the use of safety devices in preference to standard devices wherever possible. In areas where venepuncture and cannulation are carried out, safer sharps should be used whenever possible. 8. OPERATIONAL MANAGEMENT OF ALL INOCULATION/CONTAMINATION INCIDENTS 8.1 Immediate Action First Aid: see Poster Guidance - Flow Chart (Appendix 1). 8.2 Trust Reporting Procedure (Inoculation or contamination incident). Inform manager/person in charge and ensure Adverse Event form is completed and sent to the Risk Health & Safety Team. If source/patient is HIV/hepatitis B/ hepatitis C positive, managers should ensure the Incident is reported under RIDDOR via the Trust Health & Safety team to the Health Protection Agency at Communicable Diseases Surveillance Centre. 8.3 Reporting and Local Risk Assessment It is vital that staff report incidents immediately to OH and out of hours to the local ED, so that a local risk assessment can be made. See Poster Guidance - Flow Chart (Appendix 1). 8.4 Information at local level to inform risk assessment. Information to assist with the risk assessment should be promptly collated at local level see Poster Guidance - Flow Chart (Appendix 1). Information Needed Patient s name or origin of source. DOB, address GP/Consultant treatment and diagnosis if known. SHARPS SAFETY POLICY INCLUDING 10 of 31 Version 3

11 All incidents must be given priority and assessed immediately. QUESTIONS TO ASK: WHO Who was involved, date and time of incident HOW How did it happen WHAT What is the risk The WHY did it happen can wait until the incident has been dealt with, and the individual involved has been given appropriate treatment. QUESTION: Is the patient/source known to be HIV positive or highly likely to be HIV positive? UNKNOWN SOURCE Examples: You have been stabbed by a dirty needle, but don t know which patient the needle came from or you have been stabbed by a needle in sharps box. In this instance the risk assessment must assess all potential source patients and the likelihood that they may be infected with a blood borne virus. A more comprehensive risk assessment can be undertaken once the initial risk has been made (Appendix 2). Risk of HIV: time is crucial when there is a known or higher risk of HIV Out of hours: when there is a known or highly like risk of exposure to HIV the recipient should attend ED ideally within one hour of the incident. The manager/person in charge should assist by telephoning through to advise them that this is a medical emergency and provide the information in Section Out of hours: when OH is closed: The above information will need to be given to the local ED to assist in risk assessment. If the recipient works in e.g. community area, their managers may be able to assist by telephoning the information through to the relevant department. If staff member has no transport they should go by a taxi (the Trust will reimburse the fare; on production of a receipt). 8.6 Guidelines for Obtaining Source Patient s Blood in Sharps Injuries Pre Test discussion with patient prior to taking blood The source patient/client will need a pre-test discussion and informed consent obtained, before standard blood tests can be taken. The following guidance should be followed: All source patients must be tested for HBV, HCV & HIV to comply with Department Health recommendations. This helps prevent discrimination of individual patients. The consent is verbal and ideally must not be taken by the recipient, but by a colleague or member of staff in the clinical area and documented in the notes. Inform the patient that an inoculation or contamination incident has taken place and that specific BBV (HBV, HCV and HIV) can be transmitted after this type of incident. Enquire as to whether there is any possibility of carriage or exposure to these viruses in the past. SHARPS SAFETY POLICY INCLUDING 11 of 31 Version 3

12 If low risk of BBV carriage proceed to blood testing. If high risk of BBV carriage consider liaising with Sexual Health or Virologist before testing. Inform source patient that results will be made available to OHW and recipient of incident. If a positive result obtained from source patient repeat the test for confirmation. If true positive result, liaise with Sexual Health for advice on further management. In the case of a true positive result there are many advantages to the diagnosis being known, both to the individual and to their contacts Where it is not possible to gain informed consent, e.g. refusal or confused/ unconscious patient, ensure recipient is managed as per Trust policy i.e. report incident, arrange baseline blood test and OHW follow up. When a patient has died and the risk assessments indicates that a blood tests for BBV is indicated; medical advice should be sought. The risk assessment will also consider the time lapse since patient s death and validity of tests (sensitivity of the test may fall slightly after death). In the case of a deceased patient consent must be obtained from a relative Circumstances when blood test cannot be taken from source/donor patient. It is recognised that under certain circumstances it is not possible to take bloods for screening from the source/donor patient for blood borne viruses; under these circumstances the risk assessment should include full details of what is known about the source/patient, and the likelihood of risk of contamination from the incident e.g. medical device involved, type of injury sustained (deep/superficial), amount of blood involved; to inform the risk assessment. See (Appendix 2) 8.7 Blood specimens from staff Clinical details should be completed on virology blood test form and sent immediately, to the local Pathology Laboratory for testing to detect blood borne virus(es). In urgent, high risk cases the microbiology laboratory should be informed and arrangements made for blood to be delivered immediately for testing at their local General Hospital. A timely risk assessment of the injury and exposure should be undertaken and discussion and support will be offered. Confidentiality will be maintained at all times. ALL HCW s (recipient) will be offered a blood test for staff store and anti-hb if clinically indicated. Staff store blood test will be offered and repeated 3 months later in OH, when source/patient is positive to HIV and PEP has been given staff store will be offered 24 weeks following cessation of PEP. 8.8 Actions in OH / Sexual Health / ED. Incidents where there is high risk of BBV: Managers can assist by telephoning through these details and state incident is Medical Emergency likely to require Post Exposure Prophylaxis. If source/donor patient is positive for blood borne virus; the staff member should consider using condoms during sexual intercourse until follow up is clear, as it cannot be guaranteed there are no risks. Staff store blood can only be tested with signed permission form the individual, it is recommended that this blood test is stored for two years. For all source patients, the clinical team will be asked to obtain blood for HBV, HCV and HIV testing and storage (not to be taken by recipient). Appropriate consent must always be obtained. SHARPS SAFETY POLICY INCLUDING 12 of 31 Version 3

13 See OH risk assessment form (Appendix 3). Significant exposure to Hepatitis B virus: (e.g. source/patient known to be a high risk of Hepatitis B). If the exposed person is not immune to hepatitis B, the patient should be asked to consent for urgent blood test to screen for hepatitis B infection (HBsAg). If consent is not given or the source/patient is known or found to be positive to HBsAg; it will only be necessary to screen the exposed HCW if they were non-immune at the time of the incident. Test for HBsAg at: 6 weeks 3 months 6 months Significant exposure and HCW has not demonstrated protective levels of hepatitis antibodies following hepatitis B vaccine. Where there is any concern a virology opinion will be sought, HCW has received < 1dose of vaccine pre-exposure: Source is HBsAg positive contact Virology for advice; HCW may be offered hepatitis B immunoglobulin and accelerated course of hepatitis B vaccine. Source is unknown: offer accelerated course of hepatitis B vaccine. Source HBsAg negative: initiate course of hepatitis B vaccine. HCW has received > 2 doses of vaccine pre-exposure and anti bodies not known. Source positive HBsAg: offer one dose of hepatitis B vaccine followed by second dose one month later. Source unknown: offer one dose of hepatitis B vaccine. Source HBsAg negative: finish course of hepatitis B vaccine HCW is known responder to vaccine (anti-hbs >10mlU/ml) Source positive HBsAg or unknown source or source is HBsAg negative: offer booster dose of hepatitis B vaccine HCW is known non-responder to hepatitis B vaccine (<10mlU/ml) 2-4 months post Immunisation: Source positive HBsAg/ or unknown source: contact Virology for advice; HCW may be offered hepatitis B immunoglobulin and booster dose of hepatitis B vaccine may be recommended, with a second dose of hepatitis B immunoglobulin at one month. Source is HBsAg negative: offer hepatitis B vaccine booster. Exposure to hepatitis B virus that is not a significant risk HCWs that are unprotected/ partway through their course of hepatitis B will be advised to start or complete their course of hepatitis B vaccines. When HCW is a non responder (<10mlU/ml) or low responder >10mlU/ml a booster dose of hepatitis B will be offered. (Immunisation against infectious diseases. (2011) Department Health). Exposure indicates known risk of HIV or highly suspected risk of HIV SHARPS SAFETY POLICY INCLUDING 13 of 31 Version 3

14 When the incident is a high risk of HIV PEP may be required; this will be started in Sexual Health or the ED; staff who attend the ED are asked to telephone Sexual Health and speak to a clinician to make an appointment for the next working day. Exposure indicates known risk of hepatitis C virus Following staff store the HCW will be offered health surveillance and counselling support. Health surveillance is normally provided through OH. Regime Base line staff store At 6 weeks post incident: HCV/RNA (PCR test) is offered. At 3 months post incident HCV antibodies, HCV/RNA (PCR test), staff store are offered. At 6 months HCV antibodies test is offered. Pathology specimens When risk assessment indicates that incident may be high risk of a blood borne virus, the microbiologist will be informed and arrangements for bloods to be transported to the pathology laboratory immediately for testing. Safe Sex If the donor patient is positive for any blood borne virus(es) the recipient (the person who sustained the injury or their partner) will be advised to wear condoms during sexual intercourse until follow up blood tests are clear. The recipient should also contact OHW the next working day and they will also be followed up and supported by the OHW team. 8.9 Health Surveillance and Support through OH When notified that a staff member has been seen in the ED or Sexual Health, OHW will provide health surveillance and counselling support as indicated. This may also include completing vaccination programmes and referral to other specialist counsellors (OH Consultant, HIV Nurse, Sexual Health or for general counselling support through the Trust's Employee Assistance Programme). Confidentiality will be maintained at all times Health surveillance will include blood tests for staff store: All staff who has sustained inoculation/contamination incidents are advised to have a base line blood test, for storage (staff store).this test is repeated at 3 months. It is recommended that this blood is stored for 2 years and can only be tested with the individual s signed permission. When the source/patient is HIV positive staff store may be also taken 24 weeks after cessation of PEP. Should any staff member be found to be positive to a blood borne virus they will be offered advice and support from the Occupational Health Consultant who will refer them to other specialists Counselling Support The Trust recognises that inoculation or contamination incident can cause distress to the individual, even when the risk of infection with a blood borne virus is low. To support the SHARPS SAFETY POLICY INCLUDING 14 of 31 Version 3

15 individual during this difficult period the Trust provides specialist support through a variety of routes. All counselling is confidential and available through: OHW (Nurses and Consultant) Sexual Health / HIV Nurse Specialist Referral to the Trust s Employee Assistance Programme may also be advised for general concerns. 9. POST EXPOSURE PROPHYLAXIS (PEP) 9.1 Background to PEP This guidance is based on the DH HIV post-exposure prophylaxis (Guidance from the UK Chief Medical Officers Expert Advisory Group on AIDS. (September 2008)). 9.2 HIV and significant occupational exposure-the risk of acquiring HIV infection following occupational exposure to HIV-infected blood is low. Epidemiological studies have indicated that the average risk for HIV transmission in: Percutaneous exposure (from needles, instruments, bone fragments, significant bites which break the skin etc) to HIV-infected blood in health care settings is about 3 per 1,000 injuries. However; if larger volumes of blood and the source patient s viral load is high this may be higher than 3 in 1,000. Mucocutaneous exposure (mucous membranes including the eyes), the average risk is estimated at less than 1 in 1,000. Skin that is intact: it has been considered that there is no risk of HIV transmission where intact skin is exposed to HIV-infected blood. 9.3 HIV post-exposure prophylaxis may be indicated when: Deep injury. Visible blood on the device which caused the injury. Injury with a needle which had been placed in a source patient s artery or vein. Terminal HIV-related illness in the source patient. Where the source patient is not on therapy and has uncontrolled/high viral load. 9.4 Risk assessment: Following immediate first aid and prompt reporting a risk assessment should be made to consider the circumstances of exposure. The issue of PEP should be considered after an exposure with the potential to transmit HIV, based on the type of body fluid or substance involved, and the route and severity of the exposure. The designated doctor or other practitioner should first assess if the exposure reported by the HCW was a significant: that is, with the potential to transmit HIV. 9.5 Sources of expert advice include: Consultants working in HIV medicine, Virology, Microbiology, Infectious Diseases, Sexual Health, OHW; and Public Health Physicians (particularly those with responsibility for infection control such as Consultants in Communicable Disease Control). 9.6 Confidentiality: All information about the health care worker and the source patient should be kept confidential. SHARPS SAFETY POLICY INCLUDING 15 of 31 Version 3

16 9.7 Specialist counselling: The importance of specialist counselling support is recognised as crucial throughout this period. Some HCW may have had occupational exposures which, after careful assessment, are not considered significant i.e. they do not have the potential for HIV transmission. Such workers should be advised that the potential side effects and toxicity of taking PEP outweigh the negligible risk of transmission posed by the type of exposure because it is considered insignificant, whether or not the source patient is known or considered likely to be HIV infected. 9.8 Assessment and testing of the source patient. If initial assessment indicates that an exposure has been significant that is, with the potential for HIV transmission consideration should then be given to the HIV status of the source patient. It may be possible to ascertain from the medical record that a source patient has established HIV infection: Results from animal studies suggest that HIV PEP is most likely to be efficacious if started within the hour. An urgent preliminary risk assessment therefore should assess if it is appropriate to recommend taking the first dose of PEP and certainly within 48/72 hours. A more thorough risk assessment should be undertaken to inform a decision about whether to continue the regime. 9.9 The source patient should be asked for consent to take bloods; this should not be requested by the exposed worker but by another member of the team: A universal approach to asking source patients to agree to have an HIV test avoids the need to make difficult judgments, simplifies and normalises the process and avoids potential discrimination against people perceived as belonging to groups associated with higher than average HIV prevalence 9.10 When a source patient is asked to agree to undergo HIV testing, careful pre-test discussion and risk assessment will be needed, which should include disclosure of their test result to the occupational health service and to the HCW. This pre-test discussion can be provided by any appropriately trained and competent health care worker Testing of source patients blood should be conducted urgently. This is to minimise exposure to antiretroviral medication and to allay anxiety of the exposed individual: It is recommended good practice that all hospitals have the capacity to obtain an HIV test result ideally within 8 hours and not more than 24 hours after source blood is taken. This will be monitored: A & E Departments send a copy of their risk assessment and treatment to OHW. By direct feedback when individual notifies their incident to OHW on their next working day as required by policy Starting PEP, where appropriate, should not be delayed to await the result of source patient testing. (See Appendix 4- Standard Regime for PEP (Starter Packs)) Any source patient who is newly diagnosed HIV positive as a result of this process will need immediate access to specialist post-test counselling and assurances about confidentiality. Close support and clinical management will be needed on an ongoing basis. Source patients should also be informed promptly of HIV negative results, with any post-test discussion appropriate to individual circumstances (e.g. to address an ongoing risk identified through pre-test discussion and as a reminder about the window period SHARPS SAFETY POLICY INCLUDING 16 of 31 Version 3

17 (see below) if there has been recent personal risk). The possibility of a window period infection in the source patient should be addressed as part of the risk assessment, and PEP for the exposed worker may be recommended. The window period is the period immediately following the incident, when infection can develop and antibodies to HIV may be detected. If the individual has been infected with HIV the antibodies usually begin to appear within a few weeks after infection, but may take longer in some individuals (typically around 6 months) Where it is not possible to identify the source patient (e.g. needlestick injury caused by a discarded needle), a risk of HIV post-exposure prophylaxis assessment should be conducted to determine whether the exposure was significant and the likelihood of HIV from the source. The use of PEP is unlikely to be justified in the majority of such exposures Prescribing PEP: PEP is available through ED or Sexual Health and should be recommended to HCW if they have had a significant occupational exposure from a patient or other source either known to be HIV infected, or considered to be at high risk of HIV infection, but where the result of an HIV test has not or cannot be obtained, for whatever reason Starter packs of the recommended drugs are kept in: ED and Sexual Health. Each pack should contain a minimum 3-day course of the drugs, sufficient to cover weekends and bank holidays. PEP should normally be continued for 4 weeks. Every effort should be made to facilitate adherence to a full 4-week regimen. Anti nausea and anti-motility drugs (reduce diarrhoea) may also be prescribed PEP should not be offered after exposure through any route with low-risk materials (e.g. urine, vomit, saliva, faeces) unless they are visibly bloodstained (e.g. saliva in association with dentistry). Also, PEP should not be offered where testing has shown that the source is HIV negative, or if risk assessment has concluded that HIV infection of the source is highly unlikely. Exceptionally, PEP may be indicated following a negative test if there is reason to suspect the source may be seroconverting (i.e. in the window period) When offering PEP it is important to take into account any views of the exposed HCW. Depending on the outcome of the preliminary risk assessment, if the exposure was significant, the exposed health care worker may wish to consider starting PEP until further information is available about the source patient. Changes can be made to the PEP regimen, including cessation, if further information becomes available If the HIV status of the source cannot be established, the exposed HCW should have the opportunity to consider whether or not to continue PEP. Their decision should be informed by all that is known about the source patient in terms of past exposure to risk of HIV infection and also the nature and severity of the exposure. These HIV post-exposure prophylaxis aspects should be considered together with the potential for unpleasant short-term adverse effects and unknown long term effects of taking PEP drugs Pregnancy: The use of PEP drugs in pregnancy are not precluded, however expert advice should always be obtained. When there is a possibility that a healthcare worker could be pregnant; urgent pregnancy testing should be arranged, as this will affect the evaluation and allow the individual to reach an informed decision about starting PEP. The pregnant HCW should be counseled about the risk of HIV infection and the risk of transmission to her baby and about what is known and not known about the potential benefits and risks of antiretroviral therapy for her and her baby. The British HIV Association has published guidelines for prescribing antiretroviral therapy in pregnancy. SHARPS SAFETY POLICY INCLUDING 17 of 31 Version 3

18 9.21 Drug resistance: For known positive sources, information about drug resistances should be used to guide decisions about PEP. A combination of drugs are recommended in starter pack and will retain useful activity against the most common resistant viruses in the UK and concerns over resistance should not delay standard PEP, which should be given as soon as possible after the incident 9.22 Making PEP available: immediate access PEP is available through the ED and through Sexual Health clinics OH practitioners may choose to refer exposed HCW to HIV, Sexual Health or Infectious Disease departments for regular medical follow-up during the period of PEP, to monitor possible toxicity and adherence to the antiretroviral regimen. Frequent close follow-up and encouragement; as advised by clinician experienced in prescribing antiretroviral therapy is likely to help improve adherence and deal promptly with concerns and complications Where HCW follow-up is conducted outside of OH for example by the Sexual Health or Infectious Diseases (ID) department, the HCW should also arrange a meeting/updates with OHW. The HCW may also consent for Sexual health/id to provide the follow-up information to OHW. This will ensure records are complete for local review of PEP practice and for reporting to surveillance systems, e.g. what drugs were prescribed, tolerability of the regimen, side effects, premature discontinuation and results of any post exposure testing Recommended schedule of serological screening: Expert Advisory Group Aids (EAGA) has recommended that follow-up testing of HCWs be performed at 12 and 24 weeks post-exposure (or 24 weeks after cessation of PEP if prescribed. A baseline sample should be taken for storage. Serological testing at 6 weeks is not routinely warranted as a negative serology result at this stage is inconclusive. HIV seroconversion: If, during the follow-up period, HIV infection is diagnosed, the HCW should be advised and managed in line with EAGA recommendations Sickness absence Individuals, who experience adverse effects associated with PEP drugs following an occupational exposure to HIV, may require sickness absence. Although this will be recorded as sickness absence it should not be used for monitoring and absence control purposes. 10. RECOVERING AND SAFELY DISPOSING OF SHARPS OR POTENTIALLY HARMFUL EQUIPMENT FOUND ON OR NEAR HOSPITAL SITES All areas should be aware of the need for a safe recovery and disposal procedure to be in place when others have carelessly or maliciously discarded needles/sharps or other potentially harmful equipment. (See Appendix 5) Recovering Sharps & Other Medical Equipment Or Contaminated Equipment Found On OR Near Hospital Sites. 11. TRAINING 11.1 Training needed to implement the policy and any ongoing training is provided by the IPCT as identified by a training needs analysis. SHARPS SAFETY POLICY INCLUDING 18 of 31 Version 3

19 11.2 The IPCT meet all staff at Corporate Induction to present on the Principles of Standard Precautions. As part of this teaching session staff are advised of the emergency action to be taken when a sharps injury occurs. This includes first aid, reporting, recording procedures and safety in recovering sharps and other medical or contaminated equipment found on or near hospital sites. (See Appendix 5) 11.3 Other injuries are addressed; scratches, splashes, bites and cuts. Annual updates via e- learning are mandatory and additional training may be facilitated by the IPCT / Link Advisors or Occupational Health as required All training undertaken must be recorded on the Organisational Learning Module (OLM) of the Electronic Staff Record (ESR) taken from signing in sheets. Monitoring of training attendance will be carried out by the Learning & Development Department. Please refer to the Induction & Mandatory Training Policy. Nonattendance will be managed according to the procedure detailed in the Learning and Development Policy The OH team provide education and raise awareness of first aid procedures, following an Incident involving a bite, scratch, cut or splash from blood or blood stained body fluids. Reporting the Incident is re-enforced at Corporate Induction for all staff Following an incident OH will provide one to one support and education to reduce the risk of a similar incident re-occurring Managers are also responsible to ensure that all new staff are inducted into local areas and made aware of this policy, first aid action to take in the event of an injury and Trust reporting procedures. 12. REVIEW 12.1 This Policy may be reviewed at any time at the request of either staff side or management, but will automatically be reviewed every three years unless organisational changes, legislation, guidance or non-compliance prompt an earlier review. 13. REFERENCES o In relation to this policy the following references have been used: o Department of Health (2006) Essential Steps to Safe, Clean Care o Health Technical Memorandum. (DH 2011). Safe Management of Healthcare Waste. o Pratt et al (2007) Epic 2: National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England o Scottish Executive (2001) Needlestick injuries: Sharpen your awareness: Report on the short life working group on needlestick injuries in the NHS Scotland. Scottish Executive. o DH (July 2005) HIV Infected Health Care Workers, Guidance on Management and Patient Notification. o DH (August 2002) Hepatitis C Infected Health Care Workers. o DH (2006) Immunisation of healthcare and laboratory staff, in: Immunisation against infectious disease (the Green Book ), Chapter 12, o DH (2007) Hepatitis B infected healthcare workers and antiviral therapy, o DH (September 2008) HIV post-exposure prophylaxis: Guidance from the UK Chief Medical Officers Expert Advisory Group on AIDS o Health Protection Agency- Eye of the Needle 2012 SHARPS SAFETY POLICY INCLUDING 19 of 31 Version 3

20 heneedle/0811eyeoftheneedle/ o Health & Safety Executive: Needlestick injuries what is the risk o Health & Safety Executive: RIDDOR Regulations o Health & Safety Executive: The Control of Substances Hazardous to Health Regulations o Health and Safety (Sharp Instruments in Healthcare) regulations o Health & Safety Executive: Management of Health & Safety at Work Regulations 1999 o Health & Safety Executive: The Personal protective equipment at work (second edition) Regulations as amended) o Health & Safety Executive: Provision and Use of Work Equipment Regulations o Health & Safety Executive: Update on the Health & Safety (First Aid) Regulations o o o o o o o o o Health & Safety Executive CD244 - Consultation on proposed regulations to implement Council Directive 2010/32/EU on preventing sharps injuries in the hospital and healthcare sector Health & Social Care Act (DH, 2008) Code of Practice for health and adult social care on the prevention and control of infections and related guidance M.E. Ramsey Guidance on the investigation and management of occupational exposure to hepatitis C NHS Employers Sharps Injuries Framework. mework/pages/ecframeworkagreementonsharpsinjuries.aspx NHS Employers Site Collection Documents/Needlestick Injuryhttp:// Injury ( ) NHS Employer- Occupational Health Guide -Preventing needlestick injuries ionalhealth.aspx NHS Employers: Implementation advice on sharps agreement - The Safer Needles Network and the Partnership for Occupational Safety and Health in Healthcare (POSHH) have agreed advice for the NHS on preparing for implementation of the sharps directive. InjuriesintheEuropeanHospitalandHealthcareSector.aspx NHS Scotland. Towards A Safer Healthier Workplace. Needlestick Injuries in the NHS Scotland The Safer Needles Network TABLE OF AMENDMENTS Health and Safety Sharp Instraments in Health Care (regialtions 2013) SHARPS SAFETY POLICY INCLUDING 20 of 31 Version 3

21 LINKS TO RELATED SOLENT NHS TRUST DOCUMENTS Decontamination Policy Health & Safety Policy First Aid At Work Policy Data Protection Caldicott & confidentiality Policy Serious Incidents requiring Investigation Policy Reporting Adverse Incidents Policy Infection and Prevention Control Standard Precautions Policy Hand Hygiene Policy Aseptic Technique Policy Screening and Vaccination Policy Management of Healthcare Worker Infected with Blood-Borne Virus (HIV, Hepatitis B, Hepatitis C) Policy Sickness Absence Policy Waste Management Policy SHARPS SAFETY POLICY INCLUDING 21 of 31 Version 3

22 SHARPS SAFETY POLICY INCLUDING 22 of 31 Version 3 APPENDIX 1