Trust Operational Policy. Infection Prevention and Control Department

Transcription

1 Trust Operational Policy Infection Prevention and Control Department Needlestick Policy - The Prevention and Management of Sharps Injuries and Mucocutaneous Exposure to Body Fluids Policy Reference: 2094 licy Reference: 2094 icy Reference: 2094 cy Reference: 2094 y Reference: 2094 Reference: 2094 Reference: 2094 eference: 2094 ference: 2094 erence: 2094 rence: 2094 ence: 2094 nce: 2094 ce: 2094 e: 2094 :

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3 Document Title Author/Contact Document Path & Filename Document Reference 2094 Document Control Needlestick Policy The Prevention and Management of Sharps Injuries and Mucocutaneous Exposure to Body Fluids Mrs Sue Redfern, Infection Control Department Quality\MyDocuments\ClinicalGovernance\ Policies\2009Policies2009\December09 Document impact assessed Yes/No Date: July 07 Version 6.0 Status Approved Publication Date Review Date Approved by (Executive) Diane Wake Date: 2/11/09 Ratified by (Relevant Group) Distribution: Risk Management Group Date: 2/11/09 Royal Liverpool and Broadgreen University Hospitals NHS Trust-intranet Please note that 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. Document History Version Date Comments Author Helen Ballinger, Denise Jim Anson Carroll 2.0 Sept 09 Helen Ballinger, Sue Sue Redfern Redfern NHSLA Monitoring Tables Helen Ballinger added Addition to use of ID and GUM as support services to Needlestick Dr minor changes no need to re-ratify Sue Redfern 3

4 Amendment made to NHSLA monitoring table to allow reporting to NHSLA Working Group H Watterson Review Process Prior to Ratification: Name of Group/Department/Specialist Committee Date Infection Control Sub Group Chairman s Approval Risk Management Group

5 Table of Contents Heading Page Number 1.0 Introduction Equality and Diversity Objectives Scope of Policy Needlestick Policy Needlestick Incidents 2 (Post-exposure and Management) and Incident Reporting 4.2 Patient Consent Guidance for Clinical Staff Primary Prevention Pre-exposure Prophylaxis against Hepatitis B Roles and Responsibilities Directorate Managers/Heads of Department Occupational Health Department Trust Staff Medical Microbiologist Infection Control Team Risk Manager Human Resources Department Associated Documentation and References Training and Resources Monitoring and Review Monitoring of Equality and Diversity Appendices Appendix A Needlestick Incident Proforma Appendix B Reporting Flowchart 5

6 1.0 Introduction There are still too many preventable occupational sharp and mucocutaneous exposures occurring in the healthcare setting. Percutaneous exposures mostly with hollow bore needles are the commonest injury sustained by healthcare workers with nurses carrying the largest burden of exposure followed by the medical profession. Most occupational exposures occur in the ward, theatre, ITU and A&E. The majority of these, such as those sustained whilst recapping needles or clearing clinical waste, are preventable with adherence to procedures for the safe handling of sharps and disposal of clinical waste. However, it is important that appropriate measures are in place to ensure clinical staff are offered vaccination against Hepatitis B and also that in the event of an exposure, the staff member is dealt with in a timely and sensitive manner, with appropriate prophylaxis and follow up offered where necessary. 1.1 Equality and Diversity The Trust is committed to an environment that promotes equality and embraces diversity in its performance as an employer and service provider. It will adhere to legal and performance requirements and will mainstream equality and diversity principles through its policies, procedures and processes. This policy should be implemented with due regard to this commitment. To ensure that the implementation of this policy does not have an adverse impact in response to the requirements of the Race Relations (Amendment Act) the Disability Discrimination Act 2005, and the Equality Act 2006 this policy has been screened for relevance during the policy development process and a full impact assessment conducted where necessary prior to consultation. The Trust will take remedial action when necessary to address any unexpected or unwarranted disparities and monitor practice to ensure that this policy is fairly implemented. This policy and procedure can be made available in alternative formats on request including large print, braille, moon, audio, and different languages. To arrange this please refer to the Trust translation and interpretation policy in the first instance. The Trust will endeavour to make reasonable adjustments to accommodate any employee/patient with particular equality and diversity requirements in implementing this policy and procedure. This may include accessibility of meeting/appointment venues, providing translation, arranging an interpreter to attend appointments/meetings, extending policy timeframes to enable translation to be undertaken, or assistance with formulating any written statements. 6

7 2.0 Objectives To avoid preventable sharps injuries and mucocutaneous exposures to body fluids within the Trust by ensuring safe use and disposal of sharps and safe containment of body fluids. To have all staff working in clinical areas immune against Hepatitis B (pre-exposure prophylaxis). To give the minority of individuals in whom this cannot be achieved a clear awareness of their susceptibility to infection so that prompt effective post-exposure prophylaxis measures may be instituted. To achieve immediate reporting of all incidents to a specialist doctor (Medical Microbiologist) so that effective medical management is given to members of staff who have potentially been exposed to blood- borne virus. To record fully, with due regard to patient confidentiality, relevant details of all incidents (actual exposures or near misses) to allow systematic audit against explicit standards in order to target education and training. To ensure that staff behave with due regard for the health and safety of others. To protect the Trust against legal claims. 3.0 Scope of Policy The policy applies to all Trust and Contracted Staff. 4.0 Needlestick Policy 4.1 Needlestick Incidents When a needlestick incident occurs the staff member must report the incident on the Datix Incident Reporting System. Contact Needlestick Dr for treatment 4.2 (Post-exposure and Management) and Incident Reporting Needlestick incidents seldom give rise to actual infection but are a source of great anxiety for the individual who has sustained the injury. A Medical Microbiologist (the Needlestick Doctor) will be on call 24 hours a day, 7 days a week, to offer direct and immediate clinical advice and help to any member of staff who has been, or who is thought to have been, involved in potential exposure to a blood-borne virus. The hospital Switchboard will have a rota giving the name of the Needlestick Doctor on-call. If a member of staff receives an injury from a used clinical sharp, or if blood or any other body fluid contaminates their face, eyes or broken skin, follow up and treatment can be offered, in appropriate 7

8 circumstances, for Hepatitis B and HIV. Follow up can be offered for Hepatitis C exposure. The first stage is to rinse the affected part under running tap water whilst squeezing any injury from a sharp to encourage it to bleed. Wash liberally with soap and water but do not scrub the wound. The member of staff should then contact the hospital Switchboard without delay and ask to be put through to the Medical Microbiologist. The risk associated without the injury will be assessed and explained to the needlestick victim by the Medical Microbiologist. The Medical Microbiologist will elicit a systematic history of the incident and record it on a pre-printed tick box record pro-forma, which will serve both as the medical record and as an audit tool. (Copy of proforma at Appendix A). The risk assessment which is recorded on the pre printed record proforma, is copied anonymously to the Risk Management and Legal Department, in order for lessons to be learned from the incident and assessment findings. The Medical Microbiologist will either re-assure the needlestick victim that there is no danger of a blood-borne viral infection (based on risk assessment of the injury sustained) and explain that further action is not required, or that there has been potential exposure to a bloodborne virus, in which case the Needlestick Doctor will arrange appropriate investigations on the donor (if identifiable) to determine if they are carrying a blood-borne virus and will arrange appropriate referrals, e.g. to Occupational Health, GU Medicine Department or the Infectious Diseases Unit. The referral to GU Medicine Department or the Infectious Diseases Unit Clinicians, is made when post exposure prophylaxis is consider to be potentially necessary. The staff member will be referred into the service and the assessment will be undertaken, actioned and recorded of a Needlestick Database, which will record, contact details, details of incident, outcome of assessment and treatment provided. Where prophylaxis is appropriate the staff member will be referred to the team as a outpatient and will be followed up the post exposure prophylaxis outpatient clinic. The Medical Microbiologist will liaise closely with Occupational Health regarding decisions about management and follow-up. Members of staff who are aware of the patient status can refer directly to Infectious Diseases or GU Medicine Department direct. An incident form should be complete post advice. 8

9 The needlestick victim must complete an incident report form in accordance with the Trust s Incident Reporting Policy. The Risk Manager or Health and Safety Manager, may request an investigation into the incident or the process involved. A flow chart summarising the reporting, recording and audit procedure of needlestick incidents is attached at Appendix B. 4.2 Patient Consent Guidance for Clinical Staff - Adapted from DOH, HIV Post-Exposure Prophylaxis: Guidance from the UK Chief Medical Officers Expert Advisory Group on AIDS, UK Health Dept, July 2000). If the initial assessment by the Medical Microbiologist indicates that an exposure has been significant (i.e. potential transmission of bloodborne viruses) and it is not possible to ascertain from the medical records that a source patient has established viral infection, the clinical team will be advised by the microbiologist to obtain informed agreement to blood-borne viruses (Hepatitis B, C and HIV) testing. A doctor from the patient s clinical team should normally approach the patient whose viral status is unknown. The person who received the needlestick injury should not undertake this. When a source patient is asked to agree to be tested for blood-borne viruses (including HIV antibodies) careful pre-test discussion will be needed, as will fully informed consent. The discussion should be undertaken sensitively and an explanation of the incident and a reason for the test should be given. (i.e. the clinical management of the recipient relies on donor test results). Where a patient lacks capacity refer to the Trusts Consent to Treatment and Examination Policy. The patient can be informed that testing is routine in these circumstances and the confidentiality of the test and the result should be stressed. Pre-test discussion and informed consent must be documented in the patient s medical records by the doctor (or delegated nurse) who has carried it out. It is very unusual for patients to refuse testing provided the above are followed. Further guidance is available in the Trust policy Guidelines for HIV Testing by Generalists. In the unlikely event that a patient refuses testing the medical microbiologist must be contacted, further advice will be provided. 9

10 Although the prevalence of HIV is low in this area, occasionally there may be a reason to believe that HIV infection of the source patient is likely on the bases of personal (including sexual) history, or the circumstances of the source patient are unusual or complex. In these situations it may be advisable to contact GUM health advisor on Ext 2622/3 to carry out pre-test counselling. If the source patient is unconscious when the injury occurs consent should be sought once the patient has regained full consciousness (if appropriate, the injured person can take prophylactic treatment until consent has been obtained and the test result if known). If the patient is unable to give or withhold consent because of mental illness or disability, or does not regain full consciousness within 48 hours the severity of the risk should be reconsidered by the medical microbiologist. In exceptional circumstances e.g. if there is good reason to think that the patient has HIV, the microbiologist after consulting with an experienced colleague may arrange to test an existing blood sample. If it is decided to test without consent, the person must be informed at the earliest opportunity. In these exceptional circumstances the fact that the test has been undertaken should be entered in the patient s medical record, however the results should not be entered in the patient s medical record, without the patient s consent. If the patient dies you may test for a serious communicable disease if you have good reason to think that the patient may have been infected, and the health care worker has been exposed to the patient s blood or other body fluids. You should usually seek the agreement of a relative before testing. 4.3 Primary Prevention All staff have a responsibility to comply with good working practices to preserve their own health and safety and that of their colleagues. This applies to the proper disposal of clinical waste in general and particularly to the disposal of clinical sharps (used needles and blades). Disregard for the health and safety of other staff may lead to disciplinary action or possible prosecution of individuals by the Health and Safety Executive. It is the responsibility of all staff to both avoid accidents, report them if they happen and to keep up with the immunisation schedule recommended by Occupational Health. The Infection Control Nursing Team, supported by Clinical Governance structures will have responsibility to develop and co-ordinate an effective education and training programme for staff throughout the Trust 10

11 Staff/students being trained to undertake a clinical procedure that involves use of a sharp must not be allowed to do so without direct supervision, particularly if an accident could be predicted to result in exposure to blood-borne viruses. The decision to wear gloves during any particular procedure is left to the discretion of the individual practitioner, provided they are fully informed of the risks both to the patient, (of transmitting pyogenic infection) and to themselves (of exposure to blood borne viruses). Fresh waterproof dressings must be used to cover any skin lesions at the beginning of every shift. 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 can reduce the volume of blood to which the hand is exposed and the volume inoculated in the event of a percutaneous injury. It is mandatory for staff to wear gloves in an aseptic procedure. The blood and body fluids of all patients must be regarded as bloodborne virus positive and be treated universally with the same appropriate degree of caution. Standard Precautions should be adopted as a routine each and every time there is the potential to exposure to blood or body fluid, either because of direct involvement with a patient or indirectly when dealing with excreta, clinical samples, used instruments or clinical waste. Staff should avoid direct contact with potentially infectious materials. Where appropriate, suitable protective clothing or face protection must be used. All clinical waste must be disposed of with due care and attention in accordance with Trust Policies. Staff are encouraged to ask for help and/or training from their Manager or to request protective clothing if they are in any doubt that a particular practice is unsafe or beyond their competence. 4.4 Pre-exposure prophylaxis against Hepatitis B Hepatitis B vaccination offers effective protection against this virus, which can cause severe acute illnesses and long-term liver damage. However, it does not give any protection against Hepatitis C or HIV infection. Other than in exceptional circumstances, all new trust staff working in clinical areas must be immunised as a condition of employment. Existing Trust staff working in clinical areas are strongly advised to take up immunisation. Hepatitis B immunisation will also be available to trust staff working in non-clinical areas on request. All medical students, nursing students and other student or contractor 11

12 working on the Trust premises will require to be immunised as a condition of training and presence on Trust premises. Trust staff that are non-responders will be dealt with sympathetically by the Trust and advice taken from the Occupational Health Department and the individual concerned may possibly be placed in a lower risk area of work. Medical staffing and Nursing Agencies are expected to screen and immunise their staff, as they will not be accepted for work on Trust premises without the necessary immunisation. Rotational medical staff, including SpRs are required to be immunised as a precondition of working within the Trust. All Contractors providing services to the Trust will be advised that the Trust strongly recommends that their staff be immunised and the Trust will not accept any liability for staff involved in incidents if they are not immunised. Directorate Managers must satisfy themselves that their staff are adequately trained and protected for the particular activities demanded of them. Directorate Managers will have the authority to exclude any member of staff who does not hold a valid immunisation, from at risk activities in the workplace. Any health care student starting a new placement in a clinical area must, as part of their induction/orientation by the Manager, be asked for and be able to provide a valid immunisation from their training institution. If they are unable to do so, the Manager must make a decision to either exclude the student or to allow them to remain on their clinical placement until their non-conformity has been clarified with the training institution. The Occupational Health Department will recall members of the Trust staff if their records indicate that the individual needs a booster or that their immune status is not clear. Directorate Managers are expected to encourage their staff to attend the Occupational Health Department and must release them to do so. Any delay of more than one working week to attend for a scheduled visit to the Occupational Health Department will prompt a request to the Directorate Manager to facilitate the attendance of the member of staff concerned. 5.0 Roles and Responsibilities 5.1 Directorate Managers/Heads of Department Managers will satisfy themselves, under COSHH Regulations, that all the staff for whom they have responsibility:- 12

13 Have been trained and demonstrated competency in practical procedures relevant to preventing blood borne viral infection. Have satisfactorily completed their Occupational Health Review and possess immunity or susceptibility to Hepatitis B. Know what to do in the event of an incident, including the need to complete an incident form. Failure to record and report an incident may result in disciplinary action. Directorate Managers must ensure that their staff have easy access to the full range of equipment and consumables necessary for safe clinical practice, including protective clothing, hand-decontamination preparations and point of use sharps containers. 5.2 Occupational Health Department The Occupational Health Department will undertake a programme to update its records on all staff. The Occupational Health Department is responsible for ensuring that staff throughout the Trust are kept fully immune against Hepatitis B. 5.3 Trust Staff Trust staff will: - Work within their own bounds of competency and proficiency, seeking help or training as and when required. Know what to do in the event of an incident, including seeking the advice of the Medical Microbiologist and completing an incident form. Attend appointments made for them by the Occupational Health Department for Hepatitis B immunisation. Comply with good working practices to preserve their own health and safety and that of their colleagues. Dispose of clinical waste, particularly clinical sharps in accordance with Trust policies and universal precautions. The Clinical Team looking after a patient who has been the donor source of contamination in a needlestick incident will comply fully with the request by a Needlestick Doctor to seek informed consent for testing of their patient for Hepatitis B, C and HIV. 5.4 Medical Microbiologist The Medical Microbiologist will take a detailed history of the needlestick incident and record it on the tick box pro-forma, which will serve both as the medical record and as an audit tool. They will then either re-assure the needlestick victim that there is no danger of blood-borne virus infection (based on risk management of the injury sustained) so that further action need not be taken or decide that there has been potential exposure to blood-borne virus, in which 13

14 case he will be responsible for arranging appropriate investigations and referrals. Appropriate information on RIDDOR cases will be submitted to the Health and Safety Executive. 5.5 Infection Prevention and Control Team Will co-ordinate the development and implementation of appropriate education and training programmes and to ensure its delivery to all Trust staff, through Induction and Mandatory Training. 5.6 Health and Safety Manager Following receipt of an incident report form, the Health and Safety Manager will initiate/undertake an investigation of the needlestick incident in accordance with the Trust s Incident Reporting Policy, liaising as appropriate with the Medical Microbiologist and Local Managers. 5.7 Human Resources Department The Trust will advise the Universities and the Medical Staffing and Nursing Agencies that students and Agency staff working in clinical areas require the necessary Hepatitis B immunisation as a precondition of working on Trust premises. 6.0 Associated documentation and references Guidance for Clinical Healthcare Workers: Protection Against Infection with Bloodborne Viruses. London: Department of Health, March Health clearance for serious communicable disease: New healthcare workers. London: Department of Health, January 2003 Reporting of injuries, diseases and dangerous occurrences regulations 1995 (RIDDOR). HIV infected Health Care Workers: Guidance on Management and Patient Notification. London: Department of Health, July HIV Post-Exposure Prophylaxis: Guidance from the United Kingdom Chief Medical Officer s Expert Advisory Group on AIDS. London: Department of Health, February Immunisation against infectious disease, Hepatitis B, Chapter 18, The Green Book. London: Department of Health, August Hepatitis B Infected Health Care Workers Health Service Circular, HSC 2000/020. London: Department of Health,

15 Hepatitis C Infected Health Care Workers. London: Department of Health, August Guidance on the investigation and management of occupational exposure to Hepatitis C. Commun Dis Public Health 1999; 2: Trust Policy Guidelines for HIV Testing by Generalists. Health and Safety at Work Act Management of Health and Safety Regulations Control of Substances Hazardous to Health Eye of the Needle Health Protection Agency EU Council directives relating to the health and safety of workers. Merseyside and Cheshire HIV Network Post Exposure Prophylaxis for Sexual Exposure and Post Exposure Propylaxis. 7.0 Training & Resources Training in relation to the safe use and disposal of sharps and mucocutaneous exposure to body fluids is discussed at the Trust s Corporate Induction Programme and Mandatory Training Programmes. Additional training must be provided to staff during Local Induction Programmes. 8.0 Monitoring and Audit Minimum requirement to be monitored Process for monitoring e.g. audit Responsible individual/ group/ committee Frequency of monitoring Responsible individual/ group/ committee for review of results Responsible individual/ group/ committee for development of action plan Responsible individual/group/ committee for monitoring of action plan and Implementation Duties Reporting arrangements in relation to inoculation incidents Process for the management of an inoculation incident (including prophylaxis As below Annual Audit of Incident Policy and Monthly Compliance report Audit of use of Needlestick Dr Process and onward referral for prophylaxis treatment and follow Risk Manager Infection, Prevention and Control Team Leader Annual Annual NHSLA Working Group NHSLA Working Group Risk Manager Infection, Prevention and Control Team Leader And Health and Safety 15 NHSLA Working Group NHSLA Working Group

16 up Manager Organizations expectations in relation to staff training, as identified in the training needs analysis Monitoring attendance Learning Department Annual NHSLA Working Group Deputy Director for Organisational Development NHSLA Working Group In addition the following arrangements are in place to monitor the effectiveness of this policy. Occupational Health to provide regular updates to the Trust Infection Control Group on staff coverage of Hepatitis B vaccination (6 monthly). Infection Control in collaboration with Health and Safety to compile reports from incident forms on the epidemiology of needlestick exposures and treatment of injuries. The report will be produced quarterly and reported to Health and Safety Sub Committee for monitoring purposes. Safe disposal of sharps audits performed as part of the infection control audit programme on a yearly and results reported to the Infection Control Group for action. Any deficiencies noted as part of monitoring compliance of this policy will be address by the Infection Control Group or Health and Safety Sub Committee. This policy will be audited on an annual basis for its application and compliance. 16

17 DESCRIPTION OF INCIDENT Needlestick Doctor = DATE: TIME: Delay in reporting: Appendix A - Needlestick Incident Proforma RISK ASSESSMENT OF INJURY transmitting BBV if DONOR +ve: Hep B: Hep C: HIV: Recipients Hep B Immune Status Gloved: yes/no Spontaneous bleeding: yes/no First aid ok: yes/no Forced bleeding: yes/no DONOR SOURCE: Untraceable/KNOWN (record details overleaf if required) ADVICE GIVEN & ACTION PLAN A. full reassurance & no further action required Reassurance accepted YES/NO Cooling off period agreed Warrants donor testing B. Definite risk of BBV transmission 1. KNOWN SOURCE warrants donor testing 2. KNOWN HIV +ve: refer to GUM immediately 3. Untraceable source: Injury poses risk of HIV transmission: refer to GUM immediately Risk of Hep C: Baselines blood & four 6-weekly follow ups Risk of Hep B: booster/primary immunisation/hbig OCCUPATIONAL HEALTH discussions Date: Action needed: Follow up required: Signed Whom with: NB Incident report reminder given? DOCUMENTED Ab > 25? Yes: when? where? No: date of appointment to Trust Vaccination history: REQUEST to TEST DONOR Sample already available in labs: NO/YES Haem/Chem/Other Request for consent/blood made to... (date) (time) Virology test result reported on (date) Hep B: Hep C: HIV: If results confirm exposure to BBV, proceed with Action plan outlined in B.3 Results passed to clinical team (with reminder to tell donor) Discussed with victim: GUM referral NO/YES Made to (date): (time): PEP advised by GUM: NO/YES RISK MANAGEMENT issues 1. HSE RIDDOR report required if donor confirmed to be BBV +ve: 2. THIRD PART injury from negligent sharps disposal 3. LACK of BASIC: Equipment/training/supervision/assistance 4. Overfilled sharps box/uncooperative patient/other 5. Occupational Health:? PREVENTABLE incident: definitely/probably/possibly/unlikely Other comment: DIRECTORATE: Line Manager Copy of this incident report forward to Risk Manager By On

18 REVIEW of OUTCOMES: NEEDLESTICK INJURY sustained by: Reported to (date): (time): NOTEPAD RECIPIENT DETAILS Full NAME: Place of work: DOB: Grade: Contact numbers: WORK HOME DONOR DETAILS (record only if testing likely to be required) NAME Age Clinical Team NO/YES= Bleeps NO/YES WARD ID Known BBV +ve Obvious Hi Risk Telephone numbers OCCUPATIONAL HEALTH: Royal 6226 (fax ) A&E: Reception 2050/2051, Minors 2056/2058 HAEMATOLOGY Routine lab 4341 (day) 4330 (on-call) Transfusion 4331 (BG lab 2286) CLINICAL CHEMISTRY Routine 4237 (day) 4235 (night) Endocrine 4242 VIROLOGY Daytime 4404 LIVERPOOL PHL (for HBIG) daytime On-call (Aintree Univ Hosp) TRUST MANAGERS Risk Manager 5657 (Helen Ballinger) Health & Safety 2149 (Bob Biggar) GUM 2620

19 Reporting, Recording and Audit of Needlestick Incidents Appendix B NEEDLESTICK VICTIM 1. Direct telephone OCCUPATIONAL HEALTH/GUM or Infectious Diseases CONFIDENTIAL Medical Record 3. Incident report Assessment advice, action NEEDLESTICK DOCTOR Tick Box Recorded Proforma 4. Accident Investigation At local level As per Incident Investigation Process 5. Anonymous Risk Assessment shared with Risk Management, Health and Safety and Legal Department RISK MANAGEMENT

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