MANAGEMENT OF NEEDLESTICK INJURIES AND INCIDENTS INVOLVING EXPOSURE TO BLOOD AND BODY FLUIDS

Transcription

1 MANAGEMENT OF NEEDLESTICK INJURIES AND INCIDENTS INVOLVING EXPOSURE TO BLOOD AND BODY FLUIDS Authorising Officer Version: 4 Ratified By: Infection Control Committee Date Ratified: 13 th July 2011 Name of originator/author: Infection Control Team Name of responsible committee/lead HPFT Infection Control Committee individual: Date issued: 19 th July 2011 Review date: 19 th July 2014 Summary: Minimise the risks of members of staff and users of Trust services from receiving an accidental inoculation injury. Target audience: All members of staff Hertfordshire Partnership NHS Foundation Trust is committed to providing an environment where all staff, service users and carers enjoy equality of opportunity. The Trust works to eliminate all forms of discrimination and recognise that this requires, not only a commitment to remove discrimination, but also action through positive policies to redress inequalities. Providing equality of opportunity means understanding and appreciating the diversity of our staff, service users & carers and ensuring a supportive environment free from harassment. Because of this Hertfordshire Partnership NHS Foundation Trust actively encourages its staff to challenge discrimination and promote equality of opportunity for all. Page 1 of 35 Hertfordshire Partnership NHS Foundation Trust June 2011

2 Version Control Version Date Author Status Comment V2 V3 November 2005 September 2008 Superseded Archived Current ICC approved 16 th July V4 June 2011 Ratified 13/07/2011 Trust Executive approved National Health Litigation Authority Risk Management Standards Standard 3 Safe Environment Level The organisation has approved documentation which describes the process for managing the risks associated with inoculation incidents. Level The organisation can demonstrate implementation of the approved documentation which descries the process for managing the risks associated with inoculation incidents. The organisation can demonstrate compliance with the process for when a service user: Reporting arrangements in relation to inoculation incidents Process for the immediate management of an inoculation incident (including prophylaxis) Comments and Feedback on this document were obtained from: Infection Control Team Infection Control Committee Page 2 of 35 Hertfordshire Partnership NHS Foundation Trust June 2011

3 C O N T E N T S Section Page 1. Introduction 4 2. Purpose 4 3. Process for Immediate Management of an Inoculation Incident Summary of management of occupational exposure to blood/body 5 fluids Summary of management of inoculation injury to a service user Background Information Courses of action after exposure to blood/body fluid Action to be taken by the injured service user Action to be taken by the injured employee Action to be taken by the Line Manager/Supervisor 10 Source Patient Risk Assessment Form Action to be taken by A&E and OHD 13 Rapid PEP Assessment Form 14 Flow Chart 1 Management of all significant injuries during 15 Occupational Exposure Guidance notes for Flow Chart Post-exposure Prophylactic agents (PEP) DRUGS Follow-up Support for the member of staff Duties Training in the prevention of sharp s injury and safe sharp s practice Consultation, Approval and Ratification Process Process for monitoring compliance with this document and the 20 effectiveness of prevention of sharp s injury and safe sharp s practice 8. Process for reviewing, approving and archiving this document Dissemination, Implementation and Access to this document References Associated Documentation 21 Appendix 1 Contact Numbers 22 Appendix 2 Information on PEP drugs for prescribers 23 Appendix 3a Source patient information sheet following a contamination 25 incident involving a member of staff that requires blood test for HIV, Hepatitis B and Hepatitis C Appendix 3b - Check List for pre-test discussion with source patient (following a 26 contamination incident involving a member of staff) Appendix 3c - Consent for HIV, HBV and HCV Blood Test 28 Appendix 3d - Laboratory Testing and Reporting Arrangements: 29 Appendix 4 - Calculating the risk of HIV transmission following an exposure 30 Appendix 5 - Prevention, Promotion And Process For Monitoring The 31 Effectiveness Of Safe Sharps Practice And The Prevention Of Sharp s Injury Appendix 6 HPFT Accidental Inoculation Injury Procedure 33 Equality Impact Assessment Stage One 34 Page 3 of 35 Hertfordshire Partnership NHS Foundation Trust June 2011

4 1. Introduction Sharps injuries occur frequently among healthcare workers and are often not reported. Service users 1 and their relatives/friends may also receive an accidental inoculation injury. Therefore, it is vital that all members of staff minimise the risks of either themselves; their colleagues or their service users/relatives from receiving an accidental inoculation injury in the workplace. At least 40% of the injuries could be prevented by the adoption of safer sharps handling practice. Recapping of used needles causes approximately one-third of injuries; sharps not discarded after use causes one-quarter of the injuries and a further 10% are associated with overfilled sharps bins. The Department of Health circular EC(91)2 states that under the Health and Safety at Work Act 1974, employers have a responsibility to ensure the safe handling and disposal of sharp items and to ensure that staff are trained in these procedures. The Control of Substances Hazardous to Health (COSHH) Regulations (1994), states that employers are required to assess the risks associated with the handling of hazardous substances, including pathogenic micro-organisms. Hertfordshire Partnership NHS Foundation Trust is committed to fulfilling these responsibilities. Definition A sharp may be defined as any object or instrument, which may cause a puncture or incisional wound in the skin. The term includes glass ampoules, hypodermic and suture needles, blades and sharp edges of human tissue, e.g. bone, nail and teeth. Injuries from sharps, when contaminated with blood or other body fluids (see page 6), carry the risk of transmitting hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). Other diseases might also be transmitted through percutaneous injury include syphilis and malaria. 2. Purpose This policy outlines the management procedure of needlestick injuries and incidents involving exposure to blood and other body fluids. It also highlights the recommendations for the safe use and disposal of sharps in all areas within Hertfordshire Partnership NHS Foundation Trust. 1 The terms service user and patient are both used in this document as applicable to the context. Page 4 of 35 Hertfordshire Partnership NHS Foundation Trust June 2011

5 3. Process for Immediate Management of an Inoculation Incident 3.1 Summary of management of occupational exposure to blood/body fluids Occupational Exposure to blood/body fluids Injured employee reports to 1. Line manager 2. OHD Injured employee completes staff incident form Line manager organises Risk assessment on source patient (refer to page 11) Blood tests for HIV Antibody/Hepatitis B surface Antigen/Hepatitis C Antibody from source patient (A pretest discussion and informed consent will be required) Further management for injured employee at OHD/SLA Management of source patient according to results OHD / A&E Undertake Risk Assessment and further action using Rapid PEP Assessment form and Flow Chart 1 (refer to page 13 and 14 ) Organise follow up in GUM for those on PEP Send copies of completed Rapid PEP Assessment form and Flow Chart 1to GUM (and OHD if seen in A&E) OHD Follow up source patient s results and take appropriate action GUM organises PEP follow up and feedback to OHD Action following exposure from a HCW infected with BBV 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 OHD/GUM Dept for advice Page 5 of 35 Hertfordshire Partnership NHS Foundation Trust June 2011

6 3.1.1 Summary of management of service user exposed to blood/body fluids Service user exposure to blood/body fluids Injured service user gets reported to 1. Manager in charge of the unit 2. Medical officer in charge of the unit Manager/medical officer organises Risk assessment on source individual (refer to page 11) Blood tests for HIV Antibody/Hepatitis B surface Antigen/Hepatitis C Antibody from source person (A pretest discussion and informed consent will be required) Management of service user according to results A&E /Infection Control Doctor Undertake Risk Assessment and further action using Rapid PEP Assessment form and Flow Chart 1 (refer to page 13 and 14 ) Organise appropriate follow up for those on PEP Send copies of completed Rapid PEP Assessment form and Flow Chart 1 to Medical officer in charge of the service user Care team support service user according to the results. Refer to Section Appendix 1 for link to support organisations Page 6 of 35 Hertfordshire Partnership NHS Foundation Trust June 2011

7 3.2 Background Information The blood-borne viruses (BBV) Hepatitis B, Hepatitis C and HIV can be acquired following occupational exposure to infected body fluids or blood. Hepatitis B Virus The risk of infection with Hepatitis B (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 positive1. Hepatitis C Virus The risk of infection to an individual following a needlestick injury from a Hepatitis C (HCV) positive patient is in the order of 1 in 30 (3%)1. HIV The risk of seroconversion following significant percutaneous exposure has been estimated as one infection in every 300 exposures (0.33%). HIV infection associated with contamination of the mouth or eyes is very rare mucous membrane exposure risk is approximately one in a thousand (0.1%)2. Other Other diseases that might also be transmitted through percutaneous injury include syphilis and malaria. Body fluids that may transmit blood borne viruses Blood Vaginal fluid Semen Cerebro-spinal fluid Amniotic fluid Pericardial fluid Human breast milk 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 Body fluids such as urine, vomit, faeces, sputum and saliva are not normally considered a risk unless visibly stained with blood. There is good evidence that taking appropriate prophylaxis after an accidental exposure to infected blood reduces the risk of being infected. The following sections explain the necessary actions, and the relevant information. Page 7 of 35 Hertfordshire Partnership NHS Foundation Trust June 2011

8 3.3 Courses of action after exposure to blood/body fluid Action to be taken when a service user exposed to blood/body fluids Immediate first aid Percutaneous injuries: Encourage bleeding, preferably under running water, but not by sucking Then wash the wound with soap and water without scrubbing for at least five minutes. Antiseptics and skin washes should not be used. Dry and cover the wound with a waterproof plaster. Splashes onto non-intact skin (e.g. abrasions, cuts, and eczema): Wash liberally with water. Splashes into the eyes, mouth or other mucous membranes: Irrigate with copious amounts of clean water. If contact lenses are worn, eye irrigation should take place before and after removing the lenses. Ensure completion of Serious Untoward Incident Form Complete the Source Patient Risk Assessment form (page 11). For high risk individuals please obtain further advice from A&E or the Infection control Doctor If required, organise blood tests for Hepatitis B surface antigen, Hepatitis C antibody and HIV antibody from source individual. Informed written consent must be obtained from the source patient prior to blood test (refer to appendix 3(a-c) for further details) The source patient should be approached by one of the members of the clinical team caring for the patient, or the doctor/nurse manager who is oncall for that patient out of hours. The injured service user must not approach the source patient. Write source patient in sharps incident on the request form Pre-test discussion with consent to testing from the source patient should be carried out as soon as possible. If the source patient is unable to give consent, refer to GMC guidelines in appendix 3b and discuss with GUM staff if necessary The information provided must meet the individual s communication needs, e.g. people with physical, sensory or learning disabilities or people who do not speak or read English. The Trust Policy On Communicating With Service Users From Diverse Communities provides guidance on communication needs and the procedure on accessing the interpreting service. Page 8 of 35 Hertfordshire Partnership NHS Foundation Trust June 2011

9 File the HIV test consent form in source patients notes The medical staff responsible for obtaining consent for the blood sample is responsible for ensuring that service user receives the result of the tests in a timely fashion. If the consent/blood test is obtained out of hours or the results are available the following day, the medical staff should inform the medical staff who are responsible for the service user the following day of the incident and ask them to give the results to the service user. ACTION FOLLOWING EXPOSURE FROM A HCW INFECTED WITH BBV TO ANOTHER INDIVIDUAL If exposure occurs from a HCW under-taking an exposure prone procedure to a service user 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 OHD/GUM Dept for advice Action to be taken by the injured employee Immediate first aid Percutaneous injuries: Encourage bleeding, preferably under running water, but not by sucking Then wash the wound with soap and water without scrubbing for at least five minutes. Antiseptics and skin washes should not be used. Dry and cover the wound with a waterproof plaster. Splashes onto non-intact skin (e.g. abrasions, cuts, and eczema): Wash liberally with water. Splashes into the eyes, mouth or other mucous membranes: Irrigate with copious amounts of clean water. If contact lenses are worn, eye irrigation should take place before and after removing the lenses. Next step Inform the Line Manager/Supervisor of your clinical team; she/he should organise completion of source patient risk assessment form. Complete a STAFF INCIDENT FORM. The information should include: o the name and hospital number of the source patient, if known. o The information regarding the level of injury i.e if the skin has been broken. o The action that has been taken eg accidental inoculation injury procedure carried out; attended occupational health etc. If there is a high risk of HIV transmission, post-exposure prophylaxis (PEP) needs to be commenced ideally within an hour of injury. o Phone the OHD IMMEDIATELY. Opening hours: WGH and HHGH -8am-4pm- Monday Friday ( ). Page 9 of 35 Hertfordshire Partnership NHS Foundation Trust June 2011

10 Norwich Occupational Health 9am-5pm Monday Friday ( ) North East Essex Occupational Health 9am-5pm Monday-Friday If OHD is closed then go to the Accident and Emergency Department (A&E) IMMEDIATELY. You should be seen as high priority in A&E, usually within 45 minutes Take a copy of the source patient risk assessment form to OHD/A&E. The OHD adviser or A&E Department will assess the significance and risks of the exposure and arrange for further action if required. Injured employee after receiving PEP will be managed by GUM Clinic Action to be taken by the Line Manager/Supervisor Ensure completion of Staff Incident Form Complete the Source Patient Risk Assessment form (page 11) Organise blood tests for Hepatitis B surface antigen, Hepatitis C antibody and HIV antibody from source patient. Informed written consent must be obtained from the source patient prior to blood test (refer to appendix 3(a-c) for further details) including explanation of the window period. The source patient should be approached by one of the members of the clinical team caring for the patient, or the doctor/nurse manager who is oncall for that patient out of hours. The injured healthcare worker must not approach the source patient. Write source patient in sharps incident on the request form and request a copy of the result to be sent to OHD Pre-test discussion with consent to testing from the source patient should be carried out as soon as possible. If the source patient is unable to give consent, refer to GMC guidelines in appendix 2c and discuss with GUM staff if necessary The information provided must meet the individual s communication needs, e.g. people with physical, sensory or learning disabilities or people who do not speak or read English. Refer to the Trust Policy On Communicating With Service Users From Diverse Communities for further guidance on communication and the procedure for accessing the interpreting service. File the HIV test consent form in source patients notes Contact OHD/A&E and inform them an accidental inoculation injury has occurred. Give a copy of the Source Patient Risk Assessment form to the injured employee to take to OHD or A&E. Page 10 of 35 Hertfordshire Partnership NHS Foundation Trust June 2011

11 The medical staff responsible for obtaining consent for the blood sample is responsible for ensuring that service user receives the result of the tests in a timely fashion. If the consent/blood test is obtained out of hours or the results are available the following day, the medical staff should inform the medical staff who are responsible for the service user the following day of the incident and ask them to give the results to the service user. ACTION FOLLOWING EXPOSURE FROM A HCW INFECTED WITH BBV TO ANOTHER INDIVIDUAL If exposure occurs from a HCW under-taking an exposure prone procedure to a service user 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 OHD/GUM Dept for advice. Page 11 of 35 Hertfordshire Partnership NHS Foundation Trust June 2011

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13 3.3.4 Action to be taken by A&E and OHD Complete the Rapid PEP Assessment Form (page 13) If using the authorised documentation, the injury is categorised as being a significant risk for infection of blood-borne viruses follow guidance in Flow Chart 1 and tick checklist (page 14) Send copies of the above to OHD if seen first in A&E and to GUM if PEP follow up indicated Page 13 of 35 May 2008

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17 3.3.5 Post-exposure Prophylactic agents (PEP) DRUGS Current choice of drugs is Combivir 1 tablet b.d plus Kaletra 2 tablets b.d. If source is known HIV positive and is currently on treatment the injured employee may require a different combination due to possible resistance. Obtain treatment details and discuss with GUM staff PEP drugs can be prescribed by the following medical staff A&E doctors OHD advisers who can prescribe under PGD (in process) GUM doctors FOLLOW UP All recipient exposures must be reported to OHD as soon as possible, either immediately or if the injury occurs out of hours, on the next working day. If source service user tested HIV negative, and gives no history of high-risk behaviour (or possible contaminated blood supply) within the last 3 months, OHD contact injured employee and advise to cease PEP. All injured employees continuing PEP should be followed up in GUM. OHD/A&E staff to give copies of completed rapid assessment form to injured employees and advise them to telephone GUM clinic to arrange appointment. All low risk / moderate risk exposures should have follow up HIV / Hepatitis C antibody tests at 3 months and 6 months at OHD Support for the member of staff It is vital that the Trust keeps in regular contact with the member of staff who has been affected by the accidental inoculation injury to ensure the member of staff receives appropriate support. The Occupational Health Department to maintain formal records of the treatment that has been carried out. The member of staff is requested to keep in regular contact with their line manager and to keep him or her up to date with regard to treatment and progress. The line manager has the responsibility to ensure the employee is debriefed following the injury and is provided with any ongoing support that is required. Any lessons learnt from the incident must be actioned by the line manager including training requirements. The following Trust policies provide further direction in enabling this process: Attendance Management Stress Management Policy Debriefing Policy Refer to Section Appendix 1 for link to support organisations 4. Duties, Organisation and responsibilities Page 17 of 35 May 2008

18 Chief Executive The Chief Executives will have responsibility for the implementation of this policy and ensure its effectiveness is continually reviewed. Executive/Clinical Directors Executive and Clinical Directors have the responsibility for the coordination of health and safety activities within the Trusts and for ensuring that the decisions are implemented in accordance with this policy within their directorates. Occupational Health Departments To ensure that the Hepatitis B vaccination offered to any member of staff assessed on pre-employment to be at risk of exposure. To maintain the Hepatitis B Database including follow-up booster after 5 years or sooner if appropriate To see employees presenting following exposure incidents during office hours and manage them according to Flow Chart 1 To liaise with Consultant Medical Microbiologists, GUM Consultants, as appropriate for ongoing advice and follow-up To ensure appropriate samples from employees are obtained and forwarded to the appropriate microbiology laboratory departments for storage. To maintain a database of injuries and accidents and report to the ICC To follow source patients blood results and take action appropriately in a timed fashion patients blood results To ensure all medical staff within the department are aware of the action and treatment required following an inoculation injury and the urgency with which it should be dealt with. To ensure the training of appropriate staff on administration of PEP under patient group direction Consultant Medical Microbiologists The Consultant Medical Microbiologists will organise same day HIV testing for source patients during office hours and report the results to the requesting clinical team and OHD A&E To see employees out of hours and other service users presenting following exposure incidents. To commence PEP when clinically indicated following a risk assessment To arrange PEP follow up at GUM and send copies of rapid PEP assessment and Flow chart 1 via the injured staff To ensure all medical staff within the department are aware of the action and treatment required following an inoculation injury and the urgency with which it should be dealt with. Genito-Urinary Medicine Departments (GUM) To provide specialist advice To undertake specialist counselling HIV positive source clients To undertake follow up for HCW who are on PEP Provide non-identifiable data, as required to meet Public Health requirements To undertake administration of PEP during normal working hours at the request of OHD Page 18 of 35 May 2008

19 Line Managers / Supervisors Refer to Section 3.1 To provide support to the affected employee as required. Employees Employees are responsible for following the procedures in this and associated policies. 5. Training in the prevention of sharp s injury and safe sharp s practice The organisation s expectations in relation to which staff need this training is identified in the Risk Management Training Prospectus The relevant section from Appendix 1 is included below: Section 4 of the Risk Management Training Prospectus , also describes the process for checking that all relevant staff groups complete the training they need, and the process for following up those who fail to attend this, or any such training Course For Renewal Period Delivery Mode Contact Information Infection Control (Incorporates Hand Hygiene and Inoculations Training) All front Line Staff Annually E-learning, DVD & workbook, taught course or team based training by special arrangement staff should complete a taught course every other year Link to the e-learning here Link to the workbook here, all ward/site managers have been sent the DVD. For taught courses check for future dates here and contact the Learning Team to request a place: Tel: Consultation, Approval and Ratification Process This policy has been circulated for comments within Trust services via the Heads of Services and Lead Clinicians. The document has been approved and Ratified by the Trust Page 19 of 35 May 2008

20 Infection Control Committee and has been accepted as an organisation-wide policy by the Trust Executive Committee.. 7. Process for monitoring compliance with and the effectiveness of prevention of sharp s injury and safe sharp s practice The management of needlestick injuries and incidents will be monitored for compliance by the following processes: Inoculation incidents should be reported to the Risk Department. Risk Department to send all copies of the incidents to the Occupational Health Manager and Infection Control Nu, as soon as the information arrives at the department. Monitoring through datax system in the Trust The Health and Safety Manager to report to the quarterly Trust Health and Safety meetings. Quarterly reports on inoculation injuries are part of the quarterly updates as defined within the Management of Infection Control Prevention Policy Incident statistic on sharp s injury produced by Occupational Health Department datax system.. 8. Process for reviewing, approving and archiving this document 8.1 This document will be reviewed bi annually or whenever national policy, guideline or changes required to be considered (whichever occurs first) by the Infection Control Committee following which it will be subject to re-ratification by the Infection Control Committee. 8.2 All procedural documents must be retained for a period of 10 years from the date the document is superseded as set out in the Trust Business and Corporate (Non-Health) Records Retention Schedule, which is part of the Records Management Policy (nonclinical). 8.3 A database of archived procedural documents is kept as an electronic archive by the Director of Workforce and Organisational Development. This archive is held on a central server. 9. Dissemination, Implementation and Access to this document 9.1 This policy is disseminated throughout the Trust following ratification via the policy guardians. and will be published on the HPFT staff website. Access to this document is open to all via the Trust public website. 9.2 Infection control link persons are responsible in conjunction with the ward/team manager for the dissemination of infection control information and other duties with regard to the implementation of infection control policies and procedures. For medical staff this responsibility lies with the supervising clinician. 10. References: 1. Guidance for Clinical Health Care Workers: Protection against infection with bloodborne viruses. HSC 1998/063. Page 20 of 35 May 2008

21 2. HIV Post-Exposure Prophylaxis: Guidance from the UK Chief Medical Officers Expert Advisory Group on AIDS. February Immunoglobulin Handbook. Indications and dosage for normal and specific Immunoglobulin preparations issued by the PHLS. November Ransay ME. Guidance on the investigation and management of occupational exposure to hepatitis C. Commun Dis Public Health 1999; 2: Immunisation against Infectious Disease PHLS Hepatitis subcommittee, CDR Review ,R97-R101 6.Clinical Guidelines: Preventing Hospital Acquired Infection. PHLS. July 1997 ; Control of Substances Hazardous to Health (COSHH) Regulations. (1994) 8. Health and Safety at Work Act National Institute for Occupational Safety and Health: Preventing Needlestick Injuries in Health Care Settings. U.S Department of Health and Human Services. 10. Management Of Needlestick Injuries And Incidents Involving Exposure To Blood And Body Fluids, West Hertfordshire Hospitals NHS Trust, Associated Documentation This Policy should be read in conjunction with the following Policies all available from the staff website: Management of Infection Prevention & Control Policy Learning from Adverse Events All other related Infection Control Policies as outlined within the Management of Infection Prevention & Control Policy under Section 6.2. (Please refer to Section 6.2 for the list of Policies and dates) Risk Management Training Prospectus Page 21 of 35 May 2008

22 Appendix 1 CONTACT TELEPHONE NUMBERS Accident and Emergency Departments Watford General Hospital O Ext 7758 Hemel Hempstead General Hospital Ext 2452 Lister Hospital Ext 4502 QE Ext 4133 Little Plumstead Colchester General Hospital GUM Clinics Watford Hemel Hempstead Ext 4333 Woodland Clinic Ext 5206/4571 Hertford Clinic Ext 3471 Colchester Microbiology Departments Consultants Watford General Hospital Ext 7594 Hemel Hempstead General Hospital Ext 2833 Hemel Hempstead General Hospital Ext2834 East and North Ext5913 East and North Ext 4047 East and North Ext 4580 Little Plumstead North East Essex Occupational Health Departments Watford General Hospital Hemel Hempstead General Hospital Little Plumstead North East Essex Out of hours Microbiologists Hemel Hempstead: Lister: Little Plumstead North East Essex Health and Safety Health and Safety Manager Risk Management Risk Management Department Supportive Organisations Hertfordshire Health Promotion links: For local HIC & Aids information For national organisations: Page 22 of 35 May 2008

23 Appendix 2 Information on PEP drugs for prescribers Zidovudine (active ingredient of Combivir) Side effects: Zidovudine is generally well tolerated. Common side effects are nausea, headache and muscle aches. Vomiting, abdominal pain, diarrhoea, dizziness, breathlessness, and nail and skin colour changes may also occur. Anaemia and neutropenia may occur after 4 to 6 weeks. Drug interactions: Zidovudine may interact with some anti-epileptic and anti-infective agents. Contra-indications and cautions: Liver disease, renal disease, pregnancy and breastfeeding. Administration: Zidovudine can be taken before or after food although taking after food may prevent nausea. Lamivudine (active ingredient of Combivir) Side effects: The common side effects of lamivudine are headache, insomnia, cough and nasal symptoms, nausea, vomiting, abdominal pain, diarrhoea, skin rashes, joint pain and fatigue. Rarely causes cause anaemia and neutropenia. Drug interactions: No significant drug interactions Contra-indications and cautions: Liver disease, renal disease, pregnancy and breastfeeding. Administration: Can be taken before or after food although taking after food may prevent nausea. Kaletra (lopinavir/ritonavir) Side effects: Common short-term side effects of Kaletra are diarrhoea, flatulence, nausea, abdominal pain and rash. Drug interactions: Kaletra should not be taken with St Johns Wort. Kaletra may affect blood levels of drugs that are cleared by the liver such as drugs used to lower blood cholesterol, rifampicin (used to treat tuberculosis) and phenytoin (used to treat epilepsy). Kaletra may reduce the efficacy of the oral contraceptive pill. Alternative contraceptive measures should be used. Kaletra should not be taken with drugs used to treat irregular heart rhythm or with certain drugs used to treat high blood pressure (calcium channel blockers). Contra-indications and cautions: Kaletra should be used with caution during pregnancy and use whilst breast-feeding is not recommended. Kaletra may cause diabetes or worsen pre-existing diabetes. Kaletra should be used with caution in patients with liver disease and kidney disease. Administration: Kaletra tablets can be taken with or without food. Prochlorperazine (Stemetil) Side effects: The commonly reported side effects of prochlorperazine are drowsiness, dry mouth, blocked nose, light-headedness when standing up, restlessness and uncontrolled movements. Less commonly, prochlorperazine may cause jaundice, swollen breasts or increased skin sensitivity to sunlight. Drug interactions: May interact with some types of blood pressure medicines, heart medicines and antidepressants. Page 23 of 35 May 2008

24 Should not be taken with alcohol. Contra-indications and cautions: Taking prochlorperazine during pregnancy or whilst breastfeeding is not recommended. Prochlorperazine should be used with caution in patients with history of epilepsy or kidney, liver or heart disease. Administration: Prochlorperazine tablets should be swallowed whole with some water. The treatment regimen 2 Kaletra tablets and 1 Combivir tablet every twelve hours for four weeks. You can take one or two tablets of Prochlorperazine two or three times a day if the medication is making you feel sick. Page 24 of 35 May 2008

25 Appendix 3(a) Source patient information sheet following a contamination incident involving a member of staff that requires blood test for HIV, Hepatitis B and Hepatitis C Background A member of staff has been accidentally exposed to your blood or body fluids in a way, which could pose a risk to their health if you are infected with Hepatitis B, Hepatitis C or HIV. In order to allay the anxiety of the injured staff and if necessary to ensure appropriate treatment, we need to test your blood to see if you are infected with these viruses. It is consistent with the Trust Policy but you have the right to refuse the tests. The blood will be specifically analysed for evidence of infection with Hepatitis B, Hepatitis C and HIV. Hepatitis B, Hepatitis C and HIV are not common illnesses but it is possible to be infected with them without knowing or being ill. If you are infected with these viruses it is important for you to know this, as there are treatments available for these conditions. These viruses are transmitted by exposure to blood and some body fluids, most commonly by sexual contact with an infected person or by sharing of needles between injecting users. People who are at higher risk of being infected are: Men who have sex with men Injecting drug users Sexual partners of the above Sexual partners of people who has lived in an area of high endemicity (Sub- Saharan Africa, South America, Far East) Sexual partners of HIV infected people Patients who have had blood transfusions before 1985 in the UK, or at any time in developing countries HIV, Hepatitis B and Hepatitis C tests are performed on a blood test, which is taken like any other blood test, but which is analysed specifically for the viruses of concern. The result will show whether or not you are carrying the virus, even although you may be completely unaware of it. HIV stands for Human Immuno-deficiency Virus, the virus that causes AIDS. AIDS stands for Acquired Immune Deficiency Syndrome. This consist of a number of different types of illness e.g. a rare type of pneumonia, and a rare skin cancer, which occur in people who are infected with HIV. A Senior House Officer (SHO) or another member of staff who is treating you will discuss the details of the testing arrangements and the implications of testing before your blood test is taken. We can arrange a time to provide you with the result of the blood test, if that is your wish. If you do not wish to know the result, or do not wish the results to be recorded in your records, that wish will be respected. If you are negative for these viruses, it will help to reduce anxiety in the injured doctor, nurse or other health care worker. If you are shown to be positive, it will enable appropriate treatment to be given to the injured employee with the hope that this will minimise the chance of them developing serious illness resulting from their care of you. We will also be in a position to offer you appropriate treatment, should that be your wish. Page 25 of 35 May 2008

26 Check List for pre-test discussion with source patient (following a contamination incident involving a member of staff) Appendix 3b Who can do pre-test discussion? The most recent Department of Health guidelines state that the pre-test discussion for HIV antibody testing should be considered part of mainstream clinical care. Specialist counsellors from GUM Dept are available to provide additional expertise for complex cases and for those who test positive. This pre-test discussion should be carried out by a member of the clinical team other than the injured member of staff. What to do during pre-test discussion? Identify yourself in relation to the rest of the health care team and explain what has happened, maintaining the injured employee s anonymity. Emphasise that it is Trust policy following incidents such as this to approach the source patient involved and ask for permission to test for HIV, Hepatitis B and Hepatitis C. Explain that it is their right to decline permission, but that it would be extremely helpful in allaying injured employee s fears, and if necessary in ensuring that they receive appropriate treatment. Explain that an HIV antibody test requires informed consent, which involves discussion prior to the test. Stress confidentiality. Establish that the source patient understands the meaning of the test i.e. that it is not a test for AIDS. It is a test that picks up whether someone had been infected with HIV. If the service user does not have the capacity to agree to the test the requirements of the Mental Capacity Act 2005 should be followed. Refer to the Trust Mental Capacity Act Policy. See also the Extract From Serious Communicable Diseases: General Medical Council 1998 below. The information provided must meet the individual s communication needs, e.g. people with physical, sensory or learning disabilities or people who do not speak or read English. The Trust Policy On Communicating With Service Users From Diverse Communities provides guidance on communication needs and the procedure on accessing the interpreting service. Discuss methods of transmission of HIV (and HBV and HCV if relevant): unprotected sex, IV drug use, blood transfusions (prior to 1985 in the UK), vertical transmission, needlestick injuries. Discuss that some groups have a higher prevalence and there could be a higher risk. Discuss the practical implications of the test and its result (especially if positive) e.g. for life insurance/mortgage (the insurance companies have been currently advised not to ask people to disclose whether an HIV test has been taken, although, they can ask if you ve had a positive result), sexual relationships, work situations and medical follow-up. It is important to remain sensitive to the potential stigma associated with HIV in many communities. Page 26 of 35 May 2008

27 If high-risk behaviour occurred within the preceding three months (they don t have to tell you what) explain the window period; 12 weeks from infection to the detection of measurable antibodies. Consider organising a follow-up test after the window period. Describe the procedure for having blood taken and arrange a time to give them the results. Refer to Section Appendix 1 for link to support organisations if appropriate. What to do next? Complete written consent form and document in source patient s notes e.g. source patient in staff blood contamination incident. Consent requested to test for HIV/HBV/HCV or blood taken following staff blood contamination incident. If source patient prefers, the results can be o not communicated to them o not recorded in their notes. o These discussions should be recorded in their consent form. In these cases the blood tests can be arranged using a code system. Use the microbiology blood form. Request HBsAg, Hepatitis C antibody and HIV antibody test. Write Source patient in sharps incident. EXTRACT FROM SERIOUS COMMUNICABLE DISEASES: GENERAL MEDICAL COUNCIL 1998 If the patient refuses testing, is unable to give or withhold consent because of mental illness or disability, or does not regain full consciousness within 48 hours, you should reconsider the severity of the risk to yourself or another injured health care worker, or to others. You should not arrange testing against the patient s wishes or without consent other than in exceptional circumstances for example where you have good reason to think that the patient may have a condition such as HIV for which prophylactic treatment is available. In such cases you may test an existing blood sample taken for other purposes, but you should consult an experienced colleague first. Hertfordshire Partnership NHS Foundation Trust Medical Director needs to approve this course of action. It is possible that a decision to test an existing blood samples without consent could be challenged in the courts, or be the subject of a complaint to your employer or the GMC. You must therefore be prepared to justify your decision. Page 27 of 35 May 2008

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29 Laboratory Testing and Reporting Arrangements: Appendix 3d 1. Same day processing and testing of the source patient's sample for Hepatitis B, C and HIV is available during working hours. It is advisable to notify the lab when a specimen is being sent. 2. For incidents that occur out of hours, the specimen from the source patient will be processed the following working day. Out of hours arrangement for such testing is not routinely in place unless there has been prior discussion with the on call Consultant Microbiologist (contacted via switchboard) and the request deemed to be valid. 3. Please ensure that the blood sample and microbiology request form are labeled appropriately providing sufficient information such as the tests requested and giving a clear indication on the form as to whether the sample is from the "source patient in sharps incident" or the "injured staff". 4. The results will be reported to the requesting clinical team and Occupational Health Department. Page 29 of 35 May 2008

30 Appendix 4 Page 30 of 35 May 2008

31 Appendix 5 PREVENTION, PROMOTION AND PROCESS FOR MONITORING THE EFFECTIVENESS OF SAFE SHARPS PRACTICE AND THE PREVENTION OF SHARP S INJURY Prevention of accidents involving sharps Preventing a sharps injury is crucial because: HBV: Only blood-borne virus for which there is a safe and effective vaccine and effective post-exposure prophylaxis (PEP), i.e. Hepatitis B immunoglobulin. ALL health care workers (HCW) should be immunised AND know their antibody status, post-vaccination. HIV: NO vaccine available. A combination of anti-retroviral agents (HIV PEP) can be offered following exposure to prevent infection. However protection is not absolute, and the agents have many side effects. HCV: NO vaccine and NO post-exposure prophylaxis available. STANDARD (UNIVERSAL) PRECAUTIONS must be practised, i.e. ALL blood, tissues and some body fluids (table 1), should be regarded as potentially infectious inoculation accidents Do wear gloves where contact with blood or body fluids can be anticipated. If there are cuts/abrasions on the hands, these should already be covered in an appropriate waterproof dressing and gloves worn before contact with blood/body fluids. Do take extreme care when handling and disposing of used sharps. Do take the responsibility of disposing of the sharp safely if you have used it. Users are responsible for disposing of their own sharps. Do discard needle and syringe as one unit, whenever possible. Do dispose of sharps into a safe container, immediately after use. Small sharps bins should be carried to the bedside so that disposal is done at the point of use. Sharps bins should conform to BS 7320 where on site disposal takes place. If to be transported off site for disposal, they must be of a type approved under the requirements of the carriage of dangerous goods and use of transportable pressure receptacles regulations Do ensure sharps bins are correctly assembled, according to manufacturer s instructions. The use of retractable needles is recommended/strongly advised if a service uers is being particularly difficult, violent or confused. The use of retractable needles is recommended/strongly advised for service users who are known or suspected of being a carrier of a blood Page 31 of 35 May 2008

32 borne virus. For further information refer to the Health and Safety Manager or the Infection Control Nurses. Do label sharps bins with the date assembled, date closed, name of source department and Trust. Do carry sharps bins by the handle and away from your body. Do NOT resheath used needles. If resheathing is unavoidable use a resheathing device or one-handed technique. Do NOT pass used sharps from person to person by hand, e.g. use a receiver or similar container Do not place sharps bins within reach of unauthorised persons, especially children. They must be placed above waist level in an appropriate area. Do NOT overfill sharps bins. When ¾ full sharps bins must be properly closed and sealed. It is everyone s responsibility to replace sharps bins when ¾ full. Do not place sharps bins in a yellow clinical waste bag. HPFT staff should not administer insulin using an insulin pen. Prevention of contamination of skin lesions Cuts, abrasions, chapping and eczema on the hands present a hazard and must be covered with a waterproof dressing or gloves. Anyone likely to come into contact with blood or other body fluids of any patient must wear disposable gloves. The use of gloves does not protect from inoculation injury but should heighten the awareness that a high-risk procedure is being carried out. Gloves will protect cuts and lesions on the hands from contact with blood and body fluids. It is strongly recommended that individuals with eczema/psoriasis report to Occupational Health if the condition exacerbates. Splashes of blood/body fluids onto normal, i.e. undamaged skin, does not pose a risk of transmission of blood-borne viruses. Mouth and eye contamination ( mucous membrane exposure) HBV can be transmitted through intact mucous membranes. If a procedure is likely to lead to splashing, protection should be worn (either goggles and mask, or a visor if available). HIV infection associated with contamination of the mouth or eyes is very rare mucous membrane exposure risk is approximately 1:1000 (0.1%) Page 32 of 35 May 2008

33 Appendix 6 Accidental Inoculation Injury Procedure Immediate action to be taken by the person who has sustained an accidental inoculation injury Should an accidental inoculation injury occur, the following procedure MUST be followed so that you can be protected as far as possible. Percutaneous Injury 1 Encourage bleeding, preferably under running warm water, but not by sucking. 2. Wash the site immediately with copious soap and warm water, without scrubbing for a minimum of 5 minutes. Antiseptics and skin washes should not be used. 3. Dry and cover wound with a sterile waterproof dressing. 4. Inform your Line Manager/Supervisor whenever possible. 5. Complete an untoward incident / accident form, including the name and hospital number of the source patient, if known. 6. A member of the clinical team should complete the risk assessment form 7. Contact the Occupational Health Department immediately. If out of hours attend A&E immediately (you should be seen as high priority in A&E, usually within 45 minutes) The OHD/A&E Department will assess the significance and risks of the exposure and arrange for further action if required. Immediate reporting to A&E is very important because if there is a high risk of HIV transmission, the HIV post-exposure prophylactic agents (PEP) need to be taken ideally within an hour of the injury. 8. The OHD to be informed at the earliest opportunity, if the injury occurred out of hours. Mouth and eye contamination 1. Irrigate thoroughly with water. Use eyewash, if available, for eye contamination, removing contact lenses first. 2. Follow instructions 4 8 as above. Page 33 of 35 May 2008

34 Equality Impact Assessment Stage One Policy or service being assessed: Management Of Needlestick Injuries And Incidents Involving Exposure To Blood And Body Fluids. Summary of Policy: Sharps injuries occur frequently among healthcare workers and are often not reported. This policy looks at the prevention of needlestick injuries and the steps to be taken if an injury occurs to a healthcare worker. Lead Person: Debbie Pinkney, Infection Control Nurse Person(s) responsible for carrying out the assessment (if not the Lead Person.): Date of Assessment: June Is this a new or existing policy or New: Existing: X service? 2. What is the expected outcome of the service/policy (e.g. aims, objectives and purpose of the service/policy, standards for practice) 3. Does this policy/service link to others? If yes please state link below: 4. Does the Policy/Service show that the 11 principles of mental health recovery have been taken into account? If yes, please give evidence: N/A 5. Who is intended to benefit from the policy/service: In what way. 6. How is the policy/service to be put into practice? Who is responsible? 7. How and where is information about the policy/service publicised? 8. What regular consultation do you carry out with different communities and groups re the policy/service? 9. Are there concerns that the policy/service could have an adverse impact* because of: Age Disability Gender Ethnicity Sexual Orientation Religion/Belief 10. If YES to one or more of the above please state evidence. 11. Do the differences amount to discrimination?* 12. If YES could it still be justifiable e.g. on grounds of promoting equality of opportunity for one group? I.e. Indirect discrimination can be justifiable sometimes when a service is being provided for a particular target group E.g. Asian women s breast screening, Gay men s sexual health clinic, Mental Health Services for Older People etc. The risks of sharps injuries are minimised. Prompt effective action is taken should a needlestick injury arise. Yes: X Page 34 of 35 May 2008 No: Links to Trust Infection Control Policies Yes: No: N/A Staff work within a framework for the prevention and management of needlestick injury. Infection control training for direct care staff. All direct care staff responsible for infection control. Infection control training and the policy is available on the Trust websites. The infection control teams works closely with local Trusts on infection control issues. Yes: No: N/A Yes: Yes: X X X X X X No: N/A No: N/A