Infection Prevention and Control Policy Prevention and Management of Occupational Exposure to Blood-Borne Viruses (BBVs) and Post-Exposure Prophylaxis

Transcription

1 Infection Prevention and Control Policy Exposure to Blood-Borne Viruses (BBVs) and Post-Exposure Prophylaxis Document Summary To ensure that staff understand how persons in clinical practice will be cared for. DOCUMENT NUMBER CL/POL/001/042/006 DATE RATIFIED 27 th April 2011 DATE IMPLEMENTED April 2011 NEXT REVIEW DATE April 2013 ACCOUNTABLE DIRECTOR POLICY AUTHOR Director of Operations and Executive Nurse Head of Nursing and Infection Prevention and Control Important Note: The Intranet version of this document is the only version that is maintained. Any printed copies should therefore be viewed as uncontrolled and, as such, may not necessarily contain the latest updates and amendments.

2 TABLE OF CONTENTS 1 SCOPE INTRODUCTION STATEMENT OF INTENT DEFINITIONS DUTIES OCCUPATIONAL EXPOSURE TO BLOOD-BORNE VIRUSES TRAINING MONITORING COMPLIANCE WITH THIS POLICY REFERENCES/ BIBLIOGRAPHY RELATED TRUST POLICY/PROCEDURES APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX Exposure to Blood-Borne Viruses Policy Page 2 of 23 Our Ref: CL/POL/001/042/006

3 1 SCOPE This policy applies to healthcare personnel working within the Cumbria Partnership NHS Foundation Trust. It also applies to private contractors working on the premises including GPs, agency staff, trainees, students and volunteers. Each member of staff has a personal responsibility to ensure they comply with these guidelines. 2 INTRODUCTION This guidance should be followed to minimise risk of transmission of infection from service user/client to health care workers, health care workers to service user/clients and service user/client to service user/client. Most clinical procedures, including many which are invasive, do not provide opportunity for the blood of the health care worker to come into contact with the service user/clients open tissues, provided that the general measures to prevent occupational BBV transmission are adhered to at all times. Procedures where an opportunity does exist are described as exposure prone. 3 STATEMENT OF INTENT This policy aims to provide guidance to staff about the prevention and management of the risk associated with acquiring a blood borne virus (BBV) occupationally. 4 DEFINITIONS A&E - Accident and Emergency Department at local Acute Trust hospital. BBVs - Blood Bourne Virus, virus that can be spread through the medium of the blood or other bodily fluids. HBV - Hepatitis B Virus, a blood-borne virus that infects the liver and is passed from one person to another by blood and body fluids. It is one of the most common infectious diseases in the world. Infection can be either acute or chronic, it may last from a few weeks to a few months and you may recover yourself. As chronic hepatitis B the disease may remain for life and can lead to serious liver disease, including cancer. HCV - Hepatitis C Virus, a blood-borne ribonucleic acid (RNA) virus that exists as a number of different strains (genotypes), an important cause of liver disease. The effects of infection vary from one individual to the next. Some people will remain symptom free, some will develop cirrhosis and others will develop liver failure or cancer. HIV - Human Immunodeficiency Virus, a member of a group of viruses called retroviruses, it infects the human cells and uses the energy and nutrients provided by those sells to grow and reproduce. The virus lives and multiplies primarily in the white blood cells; these are immune cells and normally protect us from disease. The Exposure to Blood-Borne Viruses Policy Page 3 of 23 Our Ref: CL/POL/001/042/006

4 virus will damage or kill these and other cells, weakening the immune system and leaving a person vulnerable to various opportunistic infections and other illnesses ranging from pneumonia to cancer. OH - Occupational Health Provider, Atos Healthcare, the provider employed by the Trust to ensure that the health of it s workers are sufficiently monitored and cared for. PEP - Post Exposure Prophylaxis, treatment to prevent the possible transmission of an infection following a contact with the blood or other bodily fluids of a known or suspected carrier. 5 DUTIES Refer to POL/001/042, Infection Prevention and Control Policy, Overview Trust Board The Trust Board will ensure that the Policy is implemented. The Chief Executive Ensures there are effective and adequately resourced arrangements for infection prevention and control within the organisation. Director of Infection Prevention and Control The DIPC will oversee local control of infection policies and their implementation and that the effectiveness is monitored and reviewed as necessary. Senior Managers Senior managers include network managers, Service Managers and on call managers out of hours. They are responsible for ensuring all staff receives appropriate training to support the implementation of this policy. The senior managers are responsible across the Trust for the co-ordination of Health and Safety activities and for ensuring that decisions are implemented in accordance with this policy and associated guidelines. Infection Control Committee The Infection Control Committee has a responsibility to ensure that this Policy allows the Trust to comply with advice and guidance from the Department of Health and other bodies. These guidelines will be binding on employees under Health & Safety Legislation and the Health and Social care Act Exposure to Blood-Borne Viruses Policy Page 4 of 23 Our Ref: CL/POL/001/042/006

5 The Infection Prevention and Control Team: The Infection Prevention and Control Team will review any urgent communications from the Department of Health or other bodies and decide on what action is necessary prior to the next meeting of the Infection Control Committee. Managers Managers and supervisors have a responsibility to ensure that staff are aware of their responsibilities under this Policy and associated guidelines. Managers must inform new employees of their responsibilities under this Policy. In addition they must ensure that all employees within their area of responsibility comply with this Policy and associated guidelines. Employees All employees have a responsibility to abide by this Policy and associated guidelines and any decisions arising from the implementation of them. This Policy is enforceable through Health and Safety Legislation and CPT disciplinary procedures. If employees are aware that the Policy or associated guidelines are not being complied with they must first take the issue to their line manager and if the problem is not resolved they must inform the Infection Prevention and Control Team. 6 OCCUPATIONAL EXPOSURE TO BLOOD-BORNE VIRUSES Blood and Body Fluids All service user/clients potentially present a risk of infection. Therefore, consider all blood and body fluids to be infectious, as not all individuals with blood Borne Viruses (BBVs) have had their infection diagnosed. Although the risk is much reduced with body fluids it is recommended that they should be handled with the same precautions as blood, these include: Cerebrospinal fluid. Peritoneal fluid Pleural fluid Pericardial fluid Synovial fluid Amniotic fluid Semen Exposure to Blood-Borne Viruses Policy Page 5 of 23 Our Ref: CL/POL/001/042/006

6 Vaginal secretions Breast milk Exudative or other tissue fluid from burns or skin lesions Any body fluid containing visible blood 6.1 Prevention of Exposure to Blood Borne Viruses Transmission Transmission of BBVs may result from contamination of mucous membranes of the eyes or mouth, or broken skin, with infected blood or other infectious material. The risks are lower after mucoctaneous exposure than those after a percutaneous exposure. BBVs are potentially transmissible by a human bite through mucous membrane exposure if the bite breaks the skin. Exposure Prone Procedures Exposure prone procedures are invasive procedures where there is risk that injury to the worker may result in the exposure of the service user/clients open tissues to the blood of the worker? Taking blood IV lines Minor surface suturing The incision of an abscess Routine vaginal or rectal examination The type of work that may be undertaken by an infected health care worker will be assessed on an individual basis in conjunction with a specialist occupational physician, taking into account the specific circumstances of the working practices of the worker concerned. A number of studies have advocated the use of double gloving during surgical procedures. The use of double gloving is advocated by the Expert Advisory Group on AIDS and Hepatitis (DoH, 1998), as a method reducing percutaneous exposure for surgical procedures on Service user/clients with blood borne infections and therefore healthcare workers are to consider double gloving when undertaking Exposure Prone Procedures (EPP) on Service user/clients with blood borne infection when glove puncture is likely to occur, e.g. where there has been a large blood spillage, or there is likely to be contact with a large volume of blood. This will reduce the risk of infection as a result of needle stick injury but it will not prevent it. Exposure to Blood-Borne Viruses Policy Page 6 of 23 Our Ref: CL/POL/001/042/006

7 Protecting Staff against Blood-Borne Viruses Hepatitis B Immunisation Hepatitis B immunisation is recommended for all staff that has potential contact with blood and body fluid through their work. Immunisation is available through the Occupational Health provider, Atos Healthcare. Standard Infection Control Precautions Standard infection control precautions should be followed at all times to minimise the risk of transmission of infection between service user/clients and between service user/clients and staff. Standard precautions should be followed by all staff and carers in all health care settings, including the service user/client s home. Standard infection control precautions include:- Hand hygiene Use of personal protective clothing Prevention of occupational exposure to blood-borne viruses Handling / disposal of clinical waste Laundry Blood / body fluid spillage Decontamination of equipment Standard Equipment The following equipment must be available wherever health care is delivered: Adequate supplies for effective hand decontamination, i.e. alcohol hand gel, liquid soap and paper towels. Protective clothing as required, i.e. gloves, aprons, facial protection. Suitable sharps bins. A range of sizes of sharps containers should be ordered from supplies including small containers that can be carried by community staff. Sharps containers must be assembled correctly before use so that the lid and the carry handle are securely attached and then signed by the person who does this. Supplies should be stored in a clean dry area to prevent potential soiling or contamination before use. Exposure to Blood-Borne Viruses Policy Page 7 of 23 Our Ref: CL/POL/001/042/006

8 Safe Practice when Handling Blood and Body Fluids Use of Gloves Refer to the Hand hygiene Policy (POL/001/042/016) Suitable gloves must always be worn when handling blood and body fluid. Gloves cannot prevent percutaneous injury but they may reduce the risk of acquiring a blood-borne viral infection. Although punctured gloves allow blood to contaminate the hand, the wiping effect of the glove can reduce the volume of blood to which the worker s hand is exposed and also the volume inoculated in the event of a sharps injury. Safe use of Sharps Refer to the Safe Handling and Disposal of Sharps Policy (POL/001/042/005) The use of sharps should be avoided where possible. Where sharps usage is essential, particular care should be exercised in handling and disposal. It is the responsibility of the individual using the device to dispose of it safely. Sharps should never be left lying around. The following principles should be adhered to: Open footwear should not be worn when carrying out clinical procedures. Sharps should be disposed of immediately after use, at the point of use, by the person who carried out the procedure. Where there are two healthcare workers working together, sharps must not be passed from one person to the other. Responsibilities should be clearly defined. Extra care should be taken when undertaking procedures with confused service user/clients. Needles should not be bent or broken prior to use or disposal. Needles should not be re-capped or re-sheathed by hand during use and prior to disposal. Sharps MUST never be left unattended Needles and syringes MUST not be disassembled prior to disposal Sharps containers must be signed and dated prior to use Exposure to Blood-Borne Viruses Policy Page 8 of 23 Our Ref: CL/POL/001/042/006

9 Sharps container must be located in a safe position away from public access Sharps containers must not be filled more than ¾ full The lid must be closed and locked before disposal Sharps container must not be placed in any kind of disposal bag Sharps containers must not be shaken Items should never be retrieved from sharps containers Sharps containers must be in the temporary closure position when not in use Prevention of Mucocutaneous Exposure Safety Devices Protective eyewear should be worn for procedures which carry a risk of splashing to the eyes. Eyewear should prevent splashing (including lateral splashes) without discomfort or loss of visual acuity. Face visors may be considered appropriate for procedures that involve a risk of splashing of blood, including aerosols. National and local statistics regarding sharps injuries indicate that the majority of such injuries happen after use and prior to disposal of a contaminated sharp. However, the risks may be reduced by the use of safety devices. These devices must conform to the Medical Devices Regulations and carry a CE mark. A safety device should incorporate the following features: Integrated and passive safety features, which are likely to have the greatest impact on preventing sharps injuries. The integrated safety feature should be part of the basic design of the device - it cannot be removed and is not an accessory feature. The device should provide a barrier between hands and needle after use. The device should require worker s hands to remain behind the needle at all times. The device should have safety features that cannot be deactivated and remain protective throughout disposal to protect downstream workers. Exposure to Blood-Borne Viruses Policy Page 9 of 23 Our Ref: CL/POL/001/042/006

10 The device should be simple and self-evident to operate and require little or no training for effective use. The device should be appropriate to the procedure to be undertaken and chosen following a risk assessment. 6.2 Management of Exposure to Blood Borne Viruses Immediate Action An inoculation / bite injury action sheet can be found at Appendix 1 Quick guidance on what to do after a needlestick or body fluid contamination incident STEP 1 - First Aid Squeeze a sharps injury to make it bleed (DO NOT SUCK), and then wash with soap and water (NOT antiseptic or skin wash solution) Wash a scratch or bite with soap and water (NOT antiseptic or skin wash solution) Rinse the area of splash [e.g. eye, mouth] with water until clear of body fluids. (DO NOT SWOLLOW) Cover broken skin with a waterproof dressing STEP 2 - Report the Incident to the Line Manager Report the incident to the line manager in charge of the ward or work area IMMEDIATELY do not delay, a risk assessment needs to be done quickly. STEP 3 - Complete a Risk Assessment. Please use Appendix 2 to help you to conduct a risk assessment and complete the source risk record found in Appendix 3. A possible risk of transmission of a BBV exists if the injured HCW / recipient; Suffers a penetrating injury with a sharp object that has previously been used in a clinical procedure or has been in contact with a service user/client s blood or other body fluid, or has sustained a splash of body fluid into the eyes, mouth, or onto broken skin (including cracked eczema), or has sustained a bite which breaks the skin, or has received a scratch that breaks the skin, and is contaminated with service user/client s blood or body fluid. Exposure to Blood-Borne Viruses Policy Page 10 of 23 Our Ref: CL/POL/001/042/006

11 If none of these applies, then there can be no significant risk of transmission of a BBV, and therefore the risk assessment can be halted. For example, a simple scratch that has not been contaminated with a service user/client s blood or body fluid, or a splash of body fluid onto intact skin does not carry any significant risk of transmission of infection. If in doubt, advice can be obtained from the OH or A&E. N.B If none of the body fluids listed in section 6 above are implicated, then the risk of transmission of a BBV is negligible. Note also that likelihood of transmission of infection from faeces or urine in the absence of visible blood is remote. Exposure to Discarded Needle/Unknown Source Where it is not possible to identify the source service user/client (e.g. needle stick injury caused by a discarded needle), a risk assessment should be conducted to determine whether the exposure was significant. This will be informed by considering the circumstances of the exposure and the epidemiological likelihood of HIV in the source. The viruses concerned are very delicate and degrade quickly away from the body so an infecting dose is unlikely to survive to the incident. The use of PEP is unlikely to be justified in the majority of such exposures. We would define a needle stick from an unknown source as low-moderate risk in the majority of cases, each being assessed on an individual basis. N.B Where the source service user/client cannot be identified, it is still necessary to report the incident to either Occupational Health (ATOS Healthcare) or A&E so the incident can be documented and the appropriate action taken. STEP 4 - Acquire Blood Sample Contact the clinical team caring for the service user/client (source) who must obtain TWO consented 3.5ml samples of blood in gold bottle from the service user/client (source) for Hep B sag, Hep C and HIV. Contact OH (Atos Healthcare) (or go to the A&E out of hours) taking completed form Appendix 3 with you. This form will indicate if the service user/client [source] is high risk for BBV. OH / or A&E will always as a minimum take a sample of blood from you for storage STEP 5 Report Incident To Occupational Health (Atos Healthcare) Even If You Attend A&E. You will require a Hepatitis Booster within 72 hours if you ve not had one within 12 months. If you are non-immune you may require Hep B immunoglobulin (HBIG). If you are unsure, Occupational Health (Atos Healthcare) or A&E will help you. OH CIC FGH WCH Atos Healthcare Accident & Emergency Microbiology Exposure to Blood-Borne Viruses Policy Page 11 of 23 Our Ref: CL/POL/001/042/006

12 The Source Service User/Client Where the source user/client is known, it is the responsibility of the person in charge at the time of the injury to liaise, as soon as possible, with the doctor in charge of the source user/client, to ascertain the risk of this user/client being infected with a bloodborne virus. This information should be forwarded to the person dealing with the risk assessment for the member of staff. In the case of a source user/client being infected with HIV or strongly suspected of being infected with HIV, PEP should be given as soon as possible after the incident, preferably within the hour. Thus there is a need for urgent assessment of source user/client. After an inoculation injury all source service user/clients will be approached and asked to supply a specimen of blood to be tested for Hepatitis B, Hepatitis C and HIV. The user/client s consent will be required for this. Blood from the source service user/client will be tested during laboratory working hours. If the incident occurs outside normal hours it will be tested the next working day. The laboratory must be informed about the incident and notified about the specimen. Forms must be clearly labelled. Service user/clients Care Information Leaflet in appendix 4 provides information for the source service user/client explaining the need and repercussions of providing a blood test. Educating service user/clients and carers regarding safe handling of sharps is an important part of community and primary health care. An information leaflet is available on the following website - This includes information about: Infection control Hand hygiene Protective clothing Sharps Prevention of infection for people who need a urinary catheter, enteral feeding, or a central venous catheter. Exposure to Blood-Borne Viruses Policy Page 12 of 23 Our Ref: CL/POL/001/042/006

13 Incident out of hours When an incident occurs out of hours staff should follow the flow chart in appendix 1. OH (ATOS Healthcare) Blood Borne Virus Exposure help line can be reach on Any further treatment or follow-up will be through ATOS Healthcare. Follow up testing will be undertaken through OH (ATOS Healthcare). Staff can also contact the Body Fluid Injury Helpline for advice. 6.3 Treatment of an Inoculation Incident Human Immunodeficiency Virus The risk of acquiring HIV from a contamination accident is approximately 1 in 300. The highest risk is associated with injuries caused by a hollow-bore needle containing HIV positive blood. Accidents where the dose is less (i.e. splashes and injuries with less contaminated sharps) carry a lower risk. Follow-up of injuries where there is a perceived or residual risk of HIV infection, especially where PEP has been initiated, will be performed through the Consultant in Genitourinary Medicine, as soon as practicable after the injury. Follow-up blood tests, other than for PEP management, will be taken by the OH at 6 weeks and three months. If the client/service user is known or strongly suspected to be HIV positive, Post- Exposure Prophylaxis (PEP) must be IMMEDIATELY requested via the Atos Healthcare or A&E. A service user/client / source may be known to be HIV positive, or may be strongly suspected to be HIV positive on the following grounds: Taking anti-viral medication appropriate for the treatment of HIV / AIDS. Has a sexual partner who is HIV positive. Has a clinical condition (e.g. tumour or infection) that is consistent with a diagnosis of AIDS. Neonate of HIV positive mother. Mother of HIV positive infant. Membership of a high risk group does not in itself indicate probable HIV infection, but should be taken into account when making a risk assessment. High risk groups include: Homosexual / bisexual male. Commercial sex workers (male or female). Intravenous drug user (past or present). Exposure to Blood-Borne Viruses Policy Page 13 of 23 Our Ref: CL/POL/001/042/006

14 Recent arrival from sub-saharan Africa (particularly if recently ill or hospitalised). Service user/clients with clotting disorders (e.g. haemophilia) who have received coagulation factor VIII and IX concentrate prior to 1986 (or abroad). HIV post exposure prophylaxis will only be recommended if the staff member has been exposed to blood or other high risk body fluids or tissue, known to be or strongly suspected of being infected HIV. Ideally, this is given within an hour of exposure and the full course lasts for four weeks. Where treatment is delayed but the source person proves to be HIV positive, PEP can be given up to 2 weeks from the time of injury. Staff should report the to Atos Health Care or A&E within one hour of the incident, if on assessment there is a significant risk of exposure the worker will then be referred for further assessment and possible commencement of PEP. If the health care worker commences PEP, then further management and treatment will be followed and monitored through Atos Healthcare. Hepatitis B Virus The risk of acquiring Hepatitis B from a contamination accident is up to 1 in 3, where the client/service users blood is Hepatitis B positive (HBsAg positive) and the recipient (HCW) is not immune. It is possible to provide passive immune protection in the event of a high risk incident where the client/service user is HBsAg positive, but this will require the approval and assistance of the Consultant Microbiologist on call. Follow up of injuries where there is a perceived or residual risk of Hepatitis B infection will be done through the Atos Heathcare as soon as practicable after the incident and at 6 weeks, three months and six months in the case of the HCW / recipient. Table 1 below gives guidance on what action to take if the risk assessment indicates that Hepatitis B transmission is possible Table 1- Prophylaxis Following Exposure Incidents EXPOSURE STATUS OF SERVICE USER/CLIENT/ SOURCE Hep B status of Healthcare worker HBsAg positive source Unknown source HBsAg negative source 1 dose HB vaccine pre-exposure Accelerated course of HB vaccine* HBIG x 1** Accelerated course of HB vaccine* Initiate course of HB vaccine 2 doses HB vaccine pre-exposure (immune status not One dose of HB vaccine followed by second dose 1 One dose of HB vaccine Complete course of HB vaccine Exposure to Blood-Borne Viruses Policy Page 14 of 23 Our Ref: CL/POL/001/042/006

15 known) month later Known responder to HB vaccine (anti- HBs > 10 iu/l) Booster dose of HB vaccine *** Booster dose of HB vaccine*** No further action Known nonresponder to HB vaccine (anti-hbs < 10iU/L, 2-4 months post-vaccination HBIG x 1 Booster dose of HB vaccine HBIG x 1 Booster dose of HB vaccine No HBIG Consider booster dose of HB vaccine only * Vaccine given at 0, 1 & 2 months, with booster at 12 months ** Hepatitis B immunoglobulin (HBIG) optimally given within 48 hours and no later than 7 days *** Booster not required if HBV booster given within the last 12 months NB: Anti-HBs = Hepatitis B surface antibody (indicates protection against HBV) HBIG is Hepatitis B Immunoglobulin. Where the recipient is a non-responder to vaccine, and the source is known to be Hepatitis B positive, the use of HBIG will be considered in conjunction with the Consultant Microbiologist. It should be given within 72 hours. The dosage is as follows: Hepatitis C Virus Age in years Dose Immunoglobulin iu iu > iu The risk of acquiring Hepatitis C from a contamination accident is approximately 1 in 30, where the source blood is HCV PCR positive. There have been no recorded cases of transmission where the source service user/client has been HCV antibody positive but PCR negative. There is no post-exposure treatment or prophylaxis for Hepatitis C, however there is evidence that early treatment (within 3 months of contracting infection) gives a very good chance of complete recovery. It is therefore important that the recipient is counselled on the risks of long-term liver problems related to Hepatitis C Virus and that follow-up tests to determine whether there has been a transmission of infection are carried at six weeks (PCR), three months (PCR and antibodies) and six months (antibodies only). Where testing indicates that the HCW / recipient has contracted hepatitis C, Atos Healthcare, with their consent, will arrange a referral to an appropriate specialist for further advice, investigation and consideration of treatment. Exposure to Blood-Borne Viruses Policy Page 15 of 23 Our Ref: CL/POL/001/042/006

16 Syphilis The incidence of syphilis amongst homosexual men is increasing. If a male source is known to practice sex with other men ( MSM ) advice should be taken from Atos Heathcare as to how/whether it is appropriate to approach the source for testing. CJD Recent epidemiological studies have revealed cases of CJD or vcjd being caused by blood transfusion. However, vcjd is a relatively new disease on which there are few data. Although cases of CJD/vCJD have been reported in healthcare workers, there have been no confirmed cases linked to occupational exposure. However, it is prudent to take a precautionary approach. The highest potential risk in the context of occupational exposure is from exposure to high infectivity tissues through direct inoculation [e.g. as a result of sharps injuries, puncture wounds or contamination of broken skin], and exposure of the mucous membranes (e.g. conjunctiva) should also be avoided. Standard infection control precautions and first aid actions as described should be taken. Specialist advice will be sought at the time of management of the exposure, due to the unclear severity of the risk. 6.4 Reporting and Monitoring Of Incidents (See Appendix 5) All incidents will be reported and monitored in the following way: All incidents of occupational exposure to blood-borne viruses will be reported to occupational health department (ATOS Healthcare) and the Risk Management Department using an incident form. All incidents of occupational exposure to blood-borne viruses will be monitored via occupational health department (ATOS Healthcare). All reported incidents will be discussed and monitored through the monthly Occupational Health Contracts meeting. All incidents will be report by the Head of Infection Prevention to the Senior Management Team monthly. Following acceptance of above report by senior management team the report will be submitted to the Infection Control Committee. Compliance with training is reported within the quarterly reports to the Infection Control Committee. Annual Report of the Infection Prevention and Control to Clinical Governance will report all incidents. Exposure to Blood-Borne Viruses Policy Page 16 of 23 Our Ref: CL/POL/001/042/006

17 6.5 Further Information Useful websites: Needle stick forum: PASA: 7 TRAINING Training required to fulfil this policy will be provided in accordance with the Trust s Training Needs Analysis. Management of training will be in accordance with the Trust s Learning and Development Policy. 8 MONITORING COMPLIANCE WITH THIS POLICY The table below outlines the Trusts monitoring arrangements for this policy/document. The Trust reserves the right to commission additional work or change the monitoring arrangements to meet organisational needs. Aspect of compliance or effectiveness being monitored The management of Blood Borne Virus infection is in accordance with this policy to include: duties reporting arrangements in relation to inoculation incidents process for the management of an inoculation incident (including prophylaxis) Infection Control Assurance Framework Based on the Hygiene Code Staff have completed training associated with this policy in line with TNA Monitoring method Bi monthly report to be tabled at the Infection Control Committee, to be reported to the Governance Quality and Risk Committee in the Hygiene Code Assurance Report Monthly report to be tabled at the Infection Control Committee Atos and Team Prevent provide Monthly Assurance Report, to be reported to the Governance, Quality and Risk Committee. Individual responsible for the monitoring Risk Management and Occupational Health Department via Human Resources Head of nursing and Patient Safety Risk management and occupational health department via human resources This is not an individual??? Frequency of the monitoring activity Bi-monthly Six monthly Monthly Group / committee which will receive the findings / monitoring report Infection Control Committee Governance Quality & Risk Committee IP and GQR Committee Group / committee / individual responsible for ensuring that the actions are completed Governance Quality and Risk Committee Director of Operations and Executive Nurse Director of infection prevention and control Compliance with training will be monitored in accordance with the Learning and Development Policy Exposure to Blood-Borne Viruses Policy Page 17 of 23 Our Ref: CL/POL/001/042/006

18 9 REFERENCES/ BIBLIOGRAPHY Medicines and Healthcare Products Regulatory Agency, (2001), Safe use and disposal of sharps, MDA SN (19). / Medicines and Healthcare Products Regulatory Agency, (2004), Reducing needle stick and sharps injuries, MDA Jeanes A et al, (2003) Reducing sharps injury: prevention and risk management, ICNA. NICE (2003) Infection control: prevention of healthcare-associated infection in primary and community care, Understanding NICE guidance - information for patients, their carers and the public. HSC (1998) Guidance for clinical healthcare workers: Protection against infection with blood-borne viruses, Recommendations of the Expert Advisory Group on AIDS and the Advisory Group on Hepatitis Department of Health (1998 Guidance for Clinical Health Care Workers. Protection against infection with blood borne viruses HIV Post-Exposure Prophylaxis: Guidance from the UK Chief Medical Officers Expert Advisory Group on AIDS UK Health Departments, Sept RELATED TRUST POLICY/PROCEDURES POL/001/042/001 Standard Infection Control Precautions Policy POL/001/042/002 Aseptic Technique Policy POL/001/042/005 The Safe Handling and Disposal of Sharps Policy POL/001/042/016 Hand Hygiene and Glove Policy Exposure to Blood-Borne Viruses Policy Page 18 of 23 Our Ref: CL/POL/001/042/006

19 APPENDIX 1 - INOCULATION / BITE INJURY ACTION SHEET IMMEDIATE ACTION STOP WHAT YOU ARE DOING AND ATTEND TO THE INCIDENT ENCOURAGE BLEEDING OF THE WOUND BY APPLYING GENTLE PRESSURE DO NOT SUCK IMMEDIATELY Wash well with soap under running water. Dry and apply a waterproof dressing as necessary If body fluids splash into EYES/ NOSE Irrigate with cold water If body fluids splash into MOUTH DO NOT SWALLOW Rinse out several times with cold water INJURY FROM CLEAN/ UNUSED INSTUMENT OR NEEDLE Contact Occupational Health INJURY FROM USED INSTRUMENT / NEEDLE, BITE OR SCRATCH IMMEDIATELY WITHIN 1 HOUR attend A&E for treatment and report to Occupational Health IMMEDIATELY WITHIN 1 HOUR attend A&E for treatment and report to Occupational Health IMMEDIATELY Report the incident to your manager. Complete Lilac Incident Form. Initiate investigation as to the cause of the incident and risk assess. Exposure to Blood-Borne Viruses Policy Page 19 of 23 Our Ref: CL/POL/001/042/006

20 APPENDIX 2 - SOURCE RISK ASSESSMENT FLOW CHART OF BBV EXPOSURES High Risk Exposure Incident: Percutaneous (e.g. needlestick/scratch/sharp) Mucocutaneous eg body fluid on broken skin or on mucus membrane High-risk incident? Y N High Risk Body fluid: Blood Amniotic fluid Human breast milk CSF, pleural, pericardial peritoneal Synovial fluid Saliva associated with dentistry Semen/vaginal secretions Unfixed tissues/organs Vomit, faeces, urine only when contaminated with blood High risk Body Fluid? Y N High Risk Patient/Source: Known HIV positive IV Drug user [past / present]; [especially for HCV] Risk factors for HIV: Gay / bisexual male Those from South, East or Central Africa Blood transfusions before Oct 1985 Transfusions abroad Unprotected sex with HIV+ partner or partner at risk High risk source? Y Send recipient to OH or EMERGENCY DEPARTMENT IMMEDIATELY N Ensure completion of SERVICE USER/CLIENT [SOURCE] RISK ASSESSMENT RECORD SPEAK TO OH within one hour. Complete incident / accident form & also return to Risk management a.s.a.p. Reassure & refer to OH for further follow up If splash on intact skin no further action Exposure to Blood-Borne Viruses Policy Page 20 of 23 Our Ref: CL/POL/001/042/006

21 APPENDIX 3 - SERVICE USER/CLIENT / SOURCE RISK ASSESSMENT RECORD Complete using flowchart (To be completed by the person in charge of the service user/client s care Ward Manager) Name of Recipient.DOB Ward/Unit Name of service user/client / source.. DOB..Sex M / F Is the service user/client / source known to be Hepatitis B positive? Is the service user/client / source known to be HIV positive? Is the service user/client / source known to be Hepatitis C positive? Is the service user/client / source in a high risk group for CJD? Is the service user/client / source a known IV drug user? Yes No Unknown Yes No Unknown Yes No Unknown Yes No Unknown Yes No Unknown Using flowchart A2 is the service user/client/ source high risk Yes No I have completed risk assessment form and on the basis of the information in the flowchart. I believe this service user/client [source] to be: HIGH RISK LOW RISK [please circle] THIS FORM SHOULD BE TAKEN REFERED TO DURING INTERVIEW WITH ATOS HEALTHCARE (OH) AND OR ACCIDENT AND EMMERGENCY If the status of the service user/client / source is unknown and they decline to give a blood sample, does the source think they could be HIV, Hep B or Hep C positive? Yes No Is the service user/client / source unconscious / unable to answer the question regarding status? Yes No Occasionally a service user/client is unable to give consent or refuses to do so. Consent cannot be given by a third party, please follow guidance in consent policy. Comments... Form completed by... Designation.Date. Exposure to Blood-Borne Viruses Policy Page 21 of 23 Our Ref: CL/POL/001/042/006

22 APPENDIX 4 - EXPOSURE TO BLOOD-BORNE VIRUSES LEAFLET THIS LEAFLET IS INTENDED FOR USE IF: A health care worker has sustained a needlestick / sharps / splash / scratch / bite injury during the course of your treatment. The nature of the injury is that there is a risk that the health care worker could have become infected with a virus you might be carrying without your knowledge. HOW DOES THIS AFFECT YOU? It is Department of Health guidance and Trust Policy that a blood test is carried out to screen you for the most common blood-borne viruses: Hepatitis B, Hepatitis C and HIV. This helps ensure that the injury sustained by the health care worker can be managed appropriately; however this can only be done with your knowledge and consent If you test negative for these viruses, it will help reduce anxiety in you and the injured health worker. If you test positive for these viruses it will enable appropriate treatment to be given to both you and the injured health care worker as soon as possible. BEFORE HAVING THE BLOOD TAKEN THE PERSON TAKING THE BLOOD SAMPLE SHOULD COVER THE FOLLOWING POINTS: Ways in which Hepatitis B, Hepatitis C and HIV viruses are transmitted, which could include sexual intercourse, intravenous drug use, receiving a blood transfusion prior to Seek agreement to the test for Hepatitis B, Hepatitis C and HIV and make clear that you have the right to decline the test. Advantages for testing you: Identification of previously unknown disease so that treatment can be started as soon as possible Opportunity to be referred to an appropriate Specialist Sexual partners may be protected Plans for the future can be made Disadvantages of testing for you: Anxiety Possible adverse impact on relationship with family Insurance difficulties, however a negative test should not affect insurance applications Management of blood tests and results including who will give you the results and how you wish to receive the blood results. If you wish you can choose not to be informed of the blood test results Medical Confidentiality will be maintained at all times Many thanks for your co-operation Exposure to Blood-Borne Viruses Policy Approved 09/06/2010 Page 22 of 23 Our Ref: CL/POL/001/042/006

23 APPENDIX 5 ASSURANCE FOR BLOOD BORNE VIRUS INCIDENTS Incident Occurrence Reported to Contact Atos Healthcare + Completion of Lilac Incident Forms Atos Healthcare; records details and informs Infection Prevention and Control Department Risk Management forward Lilac forms to Infection Prevention and Control CONTROL Occupational Health Contract Meeting All networks represented, Atos, Infection Control, representation from Compliance, Governance and Risk Management, HR Infection Control Nurse Report Senior Management Team Infection Control Committee Exposure to Blood-Borne Viruses Policy Approved 09/06/2010 Page 23 of 23 Our Ref: CL/POL/001/042/006