Burton Hospitals NHS Foundation Trust. Corporate / Directorate. Clinical / Non Clinical. Department Responsible for Review:

Transcription

1 POLICY DOCUMENT Burton Hospitals NHS Foundation Trust Approved by: INOCULATION / SHARPS INJURY POLICY Clinical Management Board On: 13 February 2014 Review Date: January 2017 Corporate / Directorate Clinical / Non Clinical Department Responsible for Review: Distribution: Essential Reading for: Information for: Policy Number: Version Number: Corporate Clinical Occupational Health and Well Being All Clinical Staff Department Managers 76 6 Inoculation / Sharps Injury Policy / Version 6 / February 2014

2 Burton Hospitals NHS Foundation Trust POLICY INDEX SHEET Title: Inoculation / Sharps Injury Policy Original Issue Date: September 2006 Date of Last Review: January 2014 Reason for amendment: Update to reporting procedures for Community Hospitals Responsibility: Occupational Health Manager Stored: Intranet Linked Trust Policies: Risk Management Strategy and Policy Policy for Reporting and Management Adverse Incidents and Near Misses Health and Safety Policy Learning and Development policy E & D Impact assessed EIA 122 The following infection control guidelines: Inoculation Risk and linked pages within those guidelines located on Intranet Consulted Executive Management Team Occupational Health Manager Infection Control Clinical Risk Manager Health and Safety Manager Associate Directors Head Nurses Professional Forum

3 REVIEW AND AMENDMENT LOG Version Type of change Date Description of Change 6 Review & Update 08/07/2013 Update to reporting procedures for Community Hospitals NHSLA review

4 Burton Hospitals NHS Foundation Trust INOCULATION / SHARPS INJURY POLICY If you have sustained an inoculation injury: Needlestick injury Sharps injury Splash injury Or other contamination incident Involving a body fluid Please go straight to Appendix 1 Needlestick / Splash Injury Immediate Actions

5 INOCULATION / SHARPS INJURY POLICY CONTENTS PAGE Paragraph Number Subject Page Number 1 Introduction 1 2 Scope of the Policy 1 3 Policy Statement 1 4 Organisation Duties and Responsibilities 2 5 Safe Sharps Practice 4 6 Disposal of Sharps 4 7 Circumstances of Exposure 5 8 Reporting arrangements for Sharps Injuries 5 9 Risk Assessment 6 10 Training 7 11 Counselling, Help and Further Advice 7 12 Policy Effectiveness 7 13 Review 8 14 References 8 Appendix 1 Immediate actions to be taken following an injury 9 Appendix 2 Guidance for Accident and Emergency staff Actions to be taken following a sharps injury to the public Appendix 3 Inoculation Injury Advice 11 Appendix 4 Report form for staff without access to HISS 12 Appendix 5 Monitoring matrix 13 10

6 Burton Hospitals NHS Foundation Trust INOCULATION / SHARPS INJURY POLICY 1. INTRODUCTION 1.1 Inoculation risk infections are primarily blood-borne and they pose a risk to those in whom blood to blood contact occurs to include Hepatitis B, Hepatitis C and HIV. 1.2 An Inoculation incident can occur to any person, staff member, patient, visitor or contractor. This Policy is to be followed if such an event occurs. Where significant exposure to a patient may have occurred it must be managed appropriately to control the risk of infection of a Blood Borne Virus (BBV) from the attending health care worker e.g. incidents occurring during surgical procedures. 1.3 Definition of Inoculation incidents Sharp injury: Exposure to blood or body fluids caused by laceration, puncture of the skin, bite or scratch by a sharp. Sharps include needles, scalpels, broken glass or other items that may lacerate or puncture the skin. Splash Incident: Where blood or body fluids comes into contact with the eyes, mouth, broken skin or mucous membranes. Blood-borne viruses (BBV): Hepatitis B virus (HBV), Hepatitis C virus (HCV) or Human Immuno-deficiency Virus (HIV). Blood or Body fluids: Blood, Cerebrospinal fluid, peritoneal fluid, pleural fluid, pericardial fluid, synovial fluid, amniotic fluid, semen, vaginal secretions and breast milk. Any other body fluid containing visible blood e.g. saliva, urine. 2. SCOPE OF THE POLICY This document applies to all employees of the Trust and extends to patients, contractors, volunteers and others carrying out activities within Burton Hospitals NHS Foundation Trust. 3. POLICY STATEMENT Burton Hospitals NHS Foundation Trust aims to minimise the risks to employees, volunteers, members of the public, patients, visitors and contractors and those affected by their work practices of contracting a Blood Borne Virus (BBV) in the workplace.

7 4. ORGANISATION DUTIES AND RESPONSIBILITIES Arrangements and general responsibilities for Health and Safety are outlined in the Trust s Health and Safety Policy. 4.1 Chief Executive The Chief Executive has overall and ultimate responsibility for Health and Safety within the Trust and will ensure that this Policy is implemented and that the effectiveness is monitored and reviewed as necessary. 4.2 Board of Directors The Board of Directors has a corporate responsibility for ensuring that the Trust provides a safe environment and systems of work for staff, patients and visitors, as far as is reasonably practicable Procedures will be constantly reviewed to support the reduction in the use of sharps or the use of safer devices so far as is reasonably practicable. 4.3 Executive, Clinical and Associate Directors Executive, Clinical and Associate Directors have responsibility for the coordination of health and safety activities within the Trust and for ensuring that decisions are implemented in accordance with this Policy within their directorates. 4.4 Occupational Health The Occupational Health Service will: Check first aid treatment has been followed Review Hepatitis B status and update as necessary in accordance with the Occupational Health procedure Advise that a sample of clotted blood is obtained for Hepatitis C storage from the recipient, this sample can be taken in either the clinical area, phlebotomy or the Queen s Hospital Accident & Emergency Department. Advise that a blood sample be obtained from the source patient for Hepatitis C antibodies, with informed consent Ensure necessary follow up procedures are undertaken as required for monitoring of possible infection Offer or arrange alternative advice and support to employees 4.5 Consultant Medical Microbiologist will: Give expert advice on management of incidents on an individual basis

8 4.6 Accident & Emergency If out of hours confirm first aid treatment has been carried out and follow up as necessary as per Appendix 1 if a member of staff is affected. Appendix 2 applies at all times for sharps injuries affecting a member of the general public Advise staff to contact OH during normal office hours, or on the first working day following the incident. Contact the Consultant Medical Microbiologist on call for expert advice Deliver treatment promptly if required 4.7 Genito-Urinary Medicine (GUM) Department Responsibilities To ensure specialist management is available for source clients of incidents when HIV testing is proposed 4.8 Managers The Manager or senior person on duty must ensure that the recipient has received the appropriate First Aid attention and that the appropriate documentation is completed. 4.9 Employees Employees have a duty to practice safely thus reducing the risk of injury. In the event of an incident employees should carry out first aid treatment and follow the ACTION TO BE TAKEN FOLLOWING INJURY (Appendix 1) Attending Medical Officer The source patient should be counselled regarding the incident and informed consent as per the Consent Policy obtained prior to taking necessary blood samples. Unless the patient is in an at risk group this blood is a 7ml clotted specimen taken for Hepatitis C antibodies. If designated as in an at risk group then the inoculation risk guideline on the infection control pages of the intranet must be followed. See Risk assessment at paragraph 7 below. N.B: If the attending medical officer is the recipient of the injury then the risk assessment and consent must be carried out by another member of the clinical team Learning and Development Learning and Development are responsible for ensuring relevant training is provided and attendance monitored. Training covering this subject is incorporated into the Trust s Induction Training as part of the Infection Protection and Control session that every employee attends. An information and advice leaflet is also provided at Trust Induction.

9 5. SAFE SHARPS PRACTICE The following highlights the key elements of safe sharps practices: Assess clinical/nursing practice so that, where possible, sharps usage can be replaced with other instruments or procedures Never leave sharps lying around Sharps must not be passed from hand to hand Non-safety needles must not be recapped Safe sharp devices must be used in accordance with EU Directive 2010/32/EU Risk Assessments should be in place for the use of any non-safe sharp devices Any practice or device which requires the practitioner to move their hand towards a needle point or a needle point towards the hand cannot be regarded as safe practice. Staff should seek assistance when taking blood from or giving injections or infusion therapy to uncooperative patients. 6. DISPOSAL OF SHARPS Sharps bins must be used correctly and never be filled beyond the fill line It is the personal responsibility of the individual using a sharp to dispose of the item safely Sharps must not be left for disposal by other people. Where circumstance prevents the user from personally disposing of a sharp, they retain overall responsibility for safe disposal Sharps must be placed into a sharps container at the point of use Needles and syringes should be discarded as a single unit Vacutainer collecting systems should be discarded as a single unit Adequate numbers of sharps containers must be placed at/near sites of treatment Sharps containers should be taken to the site of use of a sharp for its disposal, not the used sharp to a sharps container Sharps containers should be kept in a location that excludes injury to patients, visitors and staff

10 Sharps containers must be closed using the locking device and disposed of when the fill line is reached 7. CIRCUMSTANCES OF EXPOSURE The three types of exposure in healthcare settings where there is known to be sufficient risk when the healthcare worker has been exposed to blood or other high risk body fluids or tissues are: Percutaneous injury (from needles, glass, instruments, bone fragments, significant bites which break the skin, etc) Exposure of broken skin (abrasions, cuts, eczema, etc) Exposure of mucous membranes including the eye 8. REPORTING ARRANGEMENTS FOR SHARPS INJURIES Incidents must be reported to the Line Manager and Occupational Health Service if any of the following occur: Needle stick or sharp injury with a contaminated object Body fluids over uncovered cuts/or breaks in the skin Bites and scratches Splashes in the eye and/or mouth Needlestick / Sharps injuries posters can be found on all wards and departments. Guidance is also available on the Infection Control pages of the Trust intranet site. The injured staff member must report the incident to the manager on duty immediately. The most senior person on duty responsible for the source patient (if known) must assess the risk of that patient being high-risk Hepatitis B, Hepatitis C, or HIV infected. If the source patient is not known, the senior person must assess the risk of any of the patients in the area being high risk. The incident must be reported via the HISS system, copies are automatically forwarded to Occupational Health and Clinical Governance. Community Hospital staff who do not have access to the HISS system should phone Occupational Health between 8.30am and 4.45pm Monday to Thursday (4.00pm on Friday). Alternatively using Appendix 4 the information can be

11 submitted to the department by fax ( ) or to the Occupational Health generic . All sections must be completed. A web based Incident Report Form must also be completed giving full details of how the injury occurred, reasons why it occurred and the immediate treatment given. 9. RISK ASSESSMENT IF SOURCE PATIENT IS KNOWN OR HIGHLY SUSPECTED TO BE HIV POSITIVE, THEN THE POST EXPOSURE PROPHYLAXIS GUIDELINES MUST BE FOLLOWED IMMEDIATELY. These guidelines are located in the infection control pages of the Trust Intranet: The table below is a guide for assessing risk for all potential blood borne virus exposure. Criteria for Risk Hep B HIV Hep C 1. Patients with known or suspected Acquired Immune Deficiency Syndrome (AIDS) or AIDS related complex (ARC) High risk in needlestick/sharps injuries Patients who are HIV antibody positive High risk in needlestick/sharps injuries Patients who are HBsAg positive or have been so in the past 3 months, (or more than 3 months ago and not subsequently re-tested and found negative, and who are, or were, anti-hbe negative or not tested for anti-hbe) 4. Patients who have had acute Hepatitis in the past 6 weeks Patients with chronic active Hepatitis or cirrhosis Patients who are or have been in residential accommodation for the mentally handicapped 7. Patients who have spent their childhood outside Northern Europe, North America, Australia or New Zealand Haemophiliacs receiving blood products Patients who have visited Central Africa in the past 10 years Patients who have received tissue, semen, etc donations from HIV positive donors 11. Sexual partners of inoculation risk patients + + -

12 12. Patients who are or have recently been in prison Drug addicts who use injections Male homosexuals and bisexuals Babies of inoculation risk parents TRAINING All new staff, whether permanent, temporary or volunteers are required to undertake an Organisational Induction programme. The Infection Prevention and Control session includes reporting inoculation injuries on HISS. Written guidance on inoculation injuries is included in the Induction Pack. See Appendix 3, Attendance at Organisational Induction is monitored by departmental managers and Learning and Development. 11. COUNSELLING, HELP AND FURTHER ADVICE The Occupational Health Department is responsible for providing or arranging appropriate expert advice/counselling to those members of staff who acquire a needlestick/sharps injury. Assistance may also be sought from the Consultant Medical Microbiologist. Additional information is available on the Trust intranet. Confidential sources of advice can be obtained from: Occupational Health Department - Ext 2370 GUM Department - Ext POLICY EFFECTIVENESS It is essential that this Policy is adequately monitored and accurately evaluated in order to ensure its continued effectiveness. This will primarily be done in the following ways: - Quarterly Occupational Health reports to the Infection Prevention Board which includes the following: o Running total of reported incidents over the financial year o Numbers by Directorate o Blood on blood incidents

13 o Blood on blood incidents with high risk patients o If PEP has been required By the Clinical Risk Manager analysing web based incident report data relating to inoculation and sharps injuries for patients as part of the Clinical Risk Manager s report to the Quality Safety Group. Monitoring of attendance at mandatory training as per Learning and Development Policy. Where deficiencies are identified, these will be discussed by the aforementioned groups and actions agreed will form part of the relevant group s action monitoring. 13. REVIEW This Policy will normally be reviewed after a period of three years or earlier if compelling reasons apply. Should the Policy not be renewed by the due date it will be deemed to remain in force until either cancelled or a revised policy is developed. 14. REFERENCES HIV Post Exposure Prophylaxis. Guidance from the UK Chief Medical Officers Expert Advisory Group on AIDS. Department of Health 2008 Guidance for Clinical Health Care Workers: Protection Against Infection with blood-borne viruses. Recommendations of the Expert Advisory Group on AIDS and Advisory group on Hepatitis. UK Health Departments 1998

14 Appendix 1 IMMEDIATE ACTIONS TO BE TAKEN FOLLOWING INJURY The site of exposure, i.e. wound or non-intact skin should be washed liberally with soap and water but without scrubbing Exposed mucous membranes including conjunctivae should be irrigated copiously with water after first removing contact lenses if present If there has been a puncture wound allow bleeding, but the wound should not be sucked Cover with waterproof plaster Dispose of sharp safely After first aid inform your manager immediately (your senior on duty) Take a sample of clotted blood for storage from staff for Hepatitis C save and store (This sample can be used for baseline for Hepatitis B if required). This can be done by ward staff, phlebotomy or Accident & Emergency (out of hours) Arrange for source person, if known, to be counselled and obtain consent to test a clotted blood sample for a Hepatitis C screen, (hepatitis B and HIV only if required) Complete needlestick screen on HISS (Order entry) on the area where the accident occurred Complete web based adverse incident report form Assess risk for Hepatitis B, Hepatitis C and HIV. This assessment should be carried out by the Clinician responsible for the patient who was the source of the injury For needlestick and blood splash injuries with known HIV positive source or strong clinical suspicion of HIV you must follow the advice given in Contact the GUM clinic immediately during daytime working hours and the Emergency Department out of hours for a decision regarding PEP During office hours advice may be obtained from Occupational Health Ext 2370 Chief BMS Microbiology Ext 4104 Or in an emergency out of hours contact the Consultant Microbiologist through switchboard.

15 Appendix 2 GUIDANCE FOR ACCIDENT AND EMERGENCY STAFF ACTIONS TO BE TAKEN FOLLOWING A SHARPS INJURY TO THE PUBLIC 1. Ensure first aid has been carried out 2. Assess type of sharp (solid/fine bore) 3. Assess type of exposure (Splash in eye/mucosa/ non intact skin) 4. Assess the source (High/Low/Unknown) HIGH UNKNOWN LOW IV DRUG USER KNOWN SEX WORKER KNOWN TO BE INFECTED WITH BLOODBORNE VIRUS NEEDLE FOUND IN A PUBLIC PLACE SOURCE REFUSES OR IS NOT ABLE TO BE TESTED FOR: HEPATITIS B HEPATITIS C HIV NO SIGNIFICANT MEDICAL HISTORY NO RISK FACTORS: E.G. NOT IV DRUG USER/SEX WORKER STEP 5 - HEPATITIS B IS THE INJURED PERSON IMMUNE TO HEP B (vaccinated / previous infection)? If more than 10iu, reassure and move on to STEP 6. Less than 10iu give booster. If vaccinated but titre level not known take blood for testing. If source high risk or known to be Hep B positive and the patient is not immune, give 1 st dose of accelerated course of Hep B vaccination. The course can be completed by patients own GP at 1 and 2 months and booster at 12 months. HIGH ASSESS RISK LOW PATIENT CAN BE REASSURED BUT OFFERED COUNSELLING VIA G.U.M WHEN NEXT OPEN STEP 6 HEPATITIS C If source is high risk or known to have Hepatitis C the patient should be advised that a blood test will need to be taken at 6, 12 and 24 weeks following the injury. This follow-up can be done via GUM along with counselling. For Injury to staff follow local policy STEP 7 HIV If source is known to be HIV positive or high risk, advice should be sought regarding commencement of HIV Post Exposure Prophylaxis (PEPs) as soon as possible. (Seek Further Advice) For Further Advice: G.U.M in hours Out of hours: COUNSELLING SHOULD BE OFFERED IN ALL INCIDENTS AND CAN BE OBTAINED VIA G.U.M. In ALL cases 10mls of clotted blood should be sent to microbiology to be stored. Tel: and ask for the on call Public Health Consultant

16 Appendix 3 Inoculation Injury Advice An inoculation injury is a sharps injury which has the possibility of contamination and therefore the potential of spreading blood-borne diseases including Hepatitis B, Hepatitis C and HIV. Detailed advice is available on the intranet site as to what to do when either a staff member or member of the public suffers a sharps injury. This can be found at the following links from the intranet. Specialties Infection Control Needlestick Immediate Action to be taken following a sharps injury. Wash the site of exposure liberally with soap and water but do not scrub. Exposed mucous membranes including conjunctivae should be irrigated copiously with water after first removing contact lenses if present. If there has been a puncture wound allow bleeding but do not suck the wound. Cover with a waterproof plaster Dispose of sharp safely Inform the senior on duty (after first aid) Following first aid an appropriately qualified clinical person will:- Take a sample of clotted blood from the injured staff member (for Hepatitis C Save and Store) Arrange for source person to be counselled and obtain consent for clotted blood test for Hepatitis C antibodies. If you are the injured staff member you should arrange for another member of staff to undertake counselling. The injured staff member should Enter the incident of HISS Order Entry ask a colleague to assist if you do not know how to access this. This information is automatically sent to Infection Control, Occupational Health, and Clinical Governance. Those without access to HISS should contact Occupational Health as outlined in paragraph 8 Complete a web based Incident Report Form FOR ALL NEEDLESTICK AND BLOOD SPLASH INJURIES WITH KNOWN HIV POSITVE SOURCE OR STRONG CLINICAL SUSPICION OF HIV YOU MUST FOLLOW THE HIV POLICY.

17 Inoculation Injury Report Form where staff member does not have access to HISS Appendix 4 This form should be completed when the person reports the incident. Please tell them to follow their own Inoculation Injury policy regarding assessing the risk-factors of the source patient (if known) OR the potential for high risk if the patient is not known. SURNAME FIRST NAME ADDRESS PHONE NUMBER(S) DATE OF BIRTH JOB TITLE PLACE OF WORK MANAGER S NAME PHONE NUMBER DATE OF INCIDENT PHONE NUMBER TIME OF INCIDENT Type of incident Sharp Bite Splash (please circle as applicable) For Sharp Injury was the object contaminated with blood YES / NO FOR Splash Injury EYES MOUTH BLOOD BODY FLUID (please circle as applicable) Has staff member been vaccinated against Hepatitis B? YES / NO Immune to Hepatitis B? YES / NO (Check details on Cohort update as necessary) Have bloods been taken from staff member for Hepatitis C save and store YES / NO Advise to do so write form and ask person to collect it / post it to them About the Source Patient PATIENT S NAME DATE OF BIRTH HIGH RISK PATIENT? HEP B YES / NO HEP C YES / NO HIV YES / NO If patient is not known were there any high-risk patients in the area/clinic YES / NO Details of incident. Signed. Date.. Print name... This form to be filed in Occupational Health notes.

18 Appendix 5 Monitoring Matrix Minimum policy requirements to be monitored Process for monitoring e.g. audit Responsible Individual/ Committee/Group Frequency Responsible Individual/ Committee/Group for review of results Responsible Individual/ Committee/Group for development of the action plan Responsible Individual/ Committee/Group for monitoring of the action plan How the Trust assesses inoculation injuries Web based Incident reporting Attendance at mandatory training Quarterly OH reports Occupational Health Department Clinical Risk Manager Learning & Development Quarterly Infection Prevention Board Quality Safety Group Learning & Development Departmental managers Departmental managers