Needlestick Policy and Actions to be taken after Exposure to Blood and Body Fluids (including HIV Post- Exposure Prophylaxis).

Transcription

1 LTHT Infection Control Policies Needlestick Policy and Actions to be taken after Exposure to Blood and Body Fluids (including HIV Post- Exposure Prophylaxis). This policy covers the immediate actions to be taken following percutaneous or mucocutaneous exposure to blood and body fluids. Scope of policy This policy applies to: All patients at LTHT All staff working on LTHT property either on a permanent or temporary basis. Policy contents: Body fluids that may transmit blood borne viruses pg 2 What is meant by exposure pg 2 Immediate first aid following exposure to blood/body fluids pg 2 Hepatitis B, Hepatitis C and HIV pg 3 Action following exposure from source patient pg 4 Action following exposure from HCW to another individual pg 5 Who provides specialist advice pg 5 Appendix 1 risk assessment pg 7, 8 Appendix 2 action following exposure pg 9 Appendix 3 PEP information and advice pg 10 Appendix 4 Out of Hours Needlestick Checklist Form pg 11 Appendix 5 - Example Microbiology Forms pg 12 Key Points Each health care worker (HCW) needs to be aware of the actions they should take if exposure has occurred; both for their own benefit and if they are involved in the immediate management of exposed workers. If significant exposure has taken place and HIV post exposure prophylaxis (PEP) is indicated then ideally it should be commenced within one hour.(see appendix 3) 1

2 Body fluids that may transmit blood borne viruses Blood Saliva (associated with dentistry) Cerebro-spinal fluid Pericardial fluid Peritoneal fluid Pleural fluid Synovial fluid Unfixed human tissues and organs Exudate or tissue fluid from burns/wounds Any other body fluid if visibly blood stained. Vaginal fluid Semen Amniotic fluid Human breast milk What is meant by exposure? Percutaneous injuries e.g. from used needles, bites and other wounds from sharp items. Mucocutaneous exposure e.g. splashes into the mouth, eyes etc, or splashes onto broken skin e.g. existing cuts, eczema etc. Exposure to low risk body fluids e.g. urine, vomit, faeces, sputum and saliva (except when associated with dental work) is not normally considered a risk unless visibly stained with blood. Exposure of unbroken skin to blood and body fluids has not been associated with blood borne virus transmission. Injuries with unused needles or sharps should be washed and covered with a waterproof plaster. A record of the injury should be made on an IR 1 form but there is no requirement to inform Occupational Health Services or the Site Matron. Immediate first aid following exposure to blood/body fluids. Percutaneous injuries from used needles, bites, cuts from sharp objects etc, should be gently encouraged to bleed. Do NOT suck the wound. The wound should then be washed with soap and water, dried and covered with a waterproof plaster. Splashes onto non-intact skin (e.g. abrasions, cuts, and eczema) should be cleaned liberally with water. Splashes into the eyes, mouth or other mucous membranes should be irrigated with copious amounts of clean water. If contact lenses are worn, eye irrigation should take place before and after removing the lenses. The injury/incident should then be reported to the person in charge of the ward or area and a written record made on an IR 1 form. 2

3 Protection against Hepatitis B Virus The risk of infection with HBV in unimmunised individuals following a sharps or splash injury from a HBV positive source patient is in the region of 1 in 50, rising to 1 in 2.5 to 1 in 3 if the source patient is also e antigen positive (DoH 1998, Gerberdring 1995). The action needed in the immediate post exposure period to protect the health care worker against hepatitis B is dependent on the vaccination status of the health care worker and (where known) the hepatitis B surface antigen status of the source patient. This will be managed by the OHS. For details of what action is necessary out of hours see page 4 (action following exposure from a source patient). Please note, if hepatitis B immunoglobulin is required this is available from the Health Protection Agency (HPA) at Seacroft (tel or out of hours via Seacroft Lodge ). Protection against Hepatitis C Virus Currently there is no vaccination or post exposure prophylaxis against hepatitis C. The risk of infection to an individual following a needlestick injury from a HCV positive patient is 1 in 30 (DoH 1998). If the source patient is found or known to be hepatitis C positive, then the exposed individual will require follow up by Occupational Health Services (OHS). Treatment in the early stages of infection has been shown to be very successful.the source patient should be referred to an appropriate specialist where necessary. Protection issues against HIV Currently there is no vaccination, however post exposure prophylaxis is available. Studies have indicated that the average risk for HIV transmission after percutaneous exposure to HIV infected blood in health care settings is about 0.3% or 3 per 1000 injuries (Department of Health 2000). However some factors are associated with increased risk of HIV infection, these include :- Deep injury Visible blood on the device which caused the injury Injury with a needle that had been in the source patient s artery or vein Terminal HIV related illness in the source patient The initial risk assessment is based on the potential for viral transmission, i.e. the type of body fluid involved, the route and severity of exposure. For example, some occupational exposures after careful assessment may not be considered to be significant, that is they do not have potential for HIV transmission i.e. splashes onto intact skin. In such circumstances PEP is not indicated. Further information pertaining to PEP including access to and prescribing of can be found in appendix 3. 3

4 Action following exposure from a source patient After sustaining an injury, the individual concerned should perform immediate first aid as outlined on page 2. During the out of office hours period use and complete the checklist form found in appendix 4. A risk assessment of the source patient should be carried out as soon as the injury occurs. This should ideally be carried out by the clinician responsible for the patient, but may also be performed by competent other e.g. Ward/Nurse Manager when they are not available (eg out of hours). Consent for blood should be obtained by the person completing the risk assessment. Detailed advice pertaining to risk assessment can be found in appendix 1. Information pertaining to PEP if indicated can be found in appendix 3. If PEP is indicated out of hours, the recipient should report to A&E for further treatment. A sample of the source patient s blood should be obtained in a clotted sample tube and sent to Microbiology to test for Hepatitis B, Hepatitis C and HIV (see appendix 5 for example of completed microbiology form). The sample must be obtained with informed consent (either from the donor or, in the case of a minor, from their guardian), by the individual carrying out the risk assessment, and this should be documented in the patient s notes. Blood samples may not be obtained from clients who are unconscious, confused or deceased unless extenuating circumstances exist. Obtain specialist advice if required (see page 5). The recipient should provide a sample of blood in a clotted sample tube, to be sent to Microbiology (see appendix 5 for example of completed microbiology form). The HCW must be informed that the baseline blood sample will be stored for 2 years. The Hepatitis B vaccination history of the recipient should be obtained. If appropriate, the sample is tested for Hepatitis B antibodies. Blood samples may be sent from the clinical area or OHS. If the recipient has been vaccinated against Hepatitis B no further treatment is required immediately. If the recipient has no history of vaccination the first dose of vaccine should be given. In hours this will be managed by OHS, out of hours this will be prescribed and given in A&E. For further specialist advice contact the Virologist Injuries from an unknown source are usually classed as low risk. Action following exposure should include all steps except, obviously collection of donor bloods. All recipient exposures must be reported to OHS as soon as possible, either immediately or if the injury occurs out of hours, on the next working day. 4

5 (Injuries from a known HIV positive source or that have resulted in the prescription of PEP must be reported under RIDDOR by OHS). All injuries should be recorded on an IR1 form and reported to Occupational Health Services either at LGI (ext 23267) or SJUH (ext 65228). This should be done as soon as the injury occurs or, if out of office hours, on the next working day. Action following exposure from a HCW to another individual If exposure occurs from a HCW under-taking an exposure prone procedure to a patient (recipient), refer to annex G in HIV Post Exposure Prophylaxis: Guidance from the UK Chief Medical Officers' Expert Advisory Group on AIDS. UK Health Departments. Feb 2004, or contact Infection Control for advice. Who provides specialist advice? During office hours Occupational Health Services will co-ordinate immediate follow up of exposed HCWs and will contact specialists in genito-urinary medicine or infectious diseases if necessary. Outside of office hours the following can be contacted by the site matron/designated deputy or A+E for HIV specialist advice. For incidents occurring at Seacroft or St. James Hospitals contact the oncall Registrar or Consultant in Infectious Diseases via SJUH switchboard. For incidents occurring at LGI, Chapel Allerton, Wharfedale, and Cookridge Hospitals contact the on-call Registrar or Consultant in Genito- Urinary Medicine via LGI switchboard. Or Outside of office hours the following can be contacted by the site matron/designated deputy or A+E for Hepatitis B specialist advice. Contact the on call Virologist via switchboard Out of hours if PEP is indicated (PEP is indicated if the source patient is identified as high risk following completion of the risk assessment (appendix 1) which will be co-ordinated by the site matron), the A+E doctor will prescribe and dispense the necessary medicines immediately. If PEP is indicated the site matron/designated deputy must ensure the relevant HIV specialist is contacted so that urgent follow up can take place the next day. If there are any doubts or questions over whether PEP should be started the site matron should not hesitate to contact the appropriate HIV specialist. Out of hours if Hepatitis B vaccination is indicated (if the source patient is identified as high risk following completion of the risk assessment (appendix 1) and the site matron has established vaccination history), the A+E doctor is to 5

6 prescribe and dispense the necessary medicine. If there are any doubts or questions over whether the recipient requires Hepatitis B vaccination the site matron should not hesitate to contact the on call virologist References and further reading. Guidance for Clinical Health Care Workers: Protection Against Infection with Blood borne Viruses. Recommendations of the Expert Advisory Group on AIDS and the Advisory Group on Hepatitis. UK Health Departments HIV Post Exposure Prophylaxis : Guidance from the UK Chief Medical Officers' Expert Advisory Group on AIDS. UK Health Departments. Feb Gerberding JL Management of Occupational Exposures to Blood Borne Viruses. New England Journal of Medicine, Vol 332, No 7, Feb 16 th Policy Development Group Fiona Allen Janice Colbeck Anna Di Biasio Mark Farrah David Green Helen Jolly Janet Maynard Jane Minton Pam Mellor Eric Monteiro Mark Wilcox Policy Development Group Lead Gillian Hodgson Advisory members to the development group Graham Johnson Tony Hale Bill Bagnel Rachel Allsop Policy date: October 2001 Revised date: December 2004 Review date: December