1. health and fitness
2. disease
3. aids and hiv

Protection against Blood Borne Virus
Infections and Management of Sharps
and Contamination Incidents
Reference Number:
614
Author & Title:
Dr Colin Payton, Consultant Occupational
Physician
Stephen Roberts, Occupational Health Manager
Responsible Directorate:
Human Resources
Review Date:
January 2015
Ratified by (committee):
Health and Safety Committee
Date Ratified:
January 2012
Version:
4
Related Policies
•
•
•
•
•
•
•
Incident reporting and Management policy
and procedure; including the management
of Serious Untoward Incidents
Waste Policy
Linen Policy
Decontamination Policy
Sharps Injury Action Pack
Universal Infection Control Policy
Isolation Policy
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 1 of 48
Contents
1.
Introduction ........................................................................................................................ 4
2.
Purpose of this Policy ..................................................................................................... 5
3.
Aims and Objectives of this policy .............................................................................. 5
4.
Definitions .......................................................................................................................... 5
5.
Blood borne viruses ........................................................................................................ 6
5.1 Human immunodeficiency virus (HIV) _________________________________ 6
5.2 Hepatitis B virus (HBV) _____________________________________________ 6
5.3 Hepatitis C virus (HCV) _____________________________________________ 7
5.4 Hepatitis D virus (HDV) _____________________________________________ 7
5.5 Viral Haemorrhagic Fevers __________________________________________ 7
6.
Risks of Transmissions of BBVS ................................................................................. 8
6.1 Risk of infection ___________________________________________________ 8
6.2 Known infected patients ____________________________________________ 8
6.3 Use of Protective Clothing___________________________________________ 9
6.4 Disposal __________________________________________________________ 9
7.
Pathology Specimens and venepuncture .................................................................. 9
7.1 All specimens _____________________________________________________ 9
7.2 Specimens from infected patients ____________________________________ 9
7.3 Venepuncture ____________________________________________________ 10
7.4 Arterial sampling__________________________________________________ 11
7.5 Venesection ______________________________________________________ 11
8.
Testing Deceased Patients for Blood Borne Infections ....................................... 11
8.1 Procedures Following the Death of the Patient ________________________ 11
8.2 All patients with uncontrollable leakage of blood or body fluids __________ 11
8.3 Patients infected with a blood-borne infection or Hazard Group 3 infections12
9.
Sharps Injury and Contamination Incident Action Pack...................................... 12
10. Exposure Prone Procedures ....................................................................................... 12
10.1
Exposure prone procedures ____________________________________ 12
10.2
Examples of procedures that are not exposure prone include: _______ 13
11. Responsibilities .............................................................................................................. 14
11.1
Role of Director of Infection Prevention and Control________________ 14
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 2 of 48
11.2
Role of the Head of Health & Safety ______________________________ 14
11.3
The Manager _________________________________________________ 14
11.4
Members of Staff______________________________________________ 15
11.5
Occupational Health Department ________________________________ 15
11.6
Role of Infection control _______________________________________ 16
11.7
Role of Trade unions __________________________________________ 16
12. Training ............................................................................................................................. 16
13. Monitoring compliance ................................................................................................. 17
14. References........................................................................................................................ 18
Appendix 1:
Consultant Checklist ................................................................................... 20
Appendix 2:
Sharps and Contamination Incident Action Pack ............................... 21
Appendix 3
Patient Consent ............................................................................................ 33
Appendix 4:
Information collected by occupational health...................................... 35
Appendix 5:
Reducing the risk of sharps and contamination injury ..................... 38
Appendix 6:
Protocol for healthcare works exposure to HIV................................... 41
Appendix 7:
Root Cause Analysis Following Blood or Body Fluid Exposure .... 42
Appendix 8:
Risk categories for Viral Haemorrhagic Fevers ................................... 45
Appendix 9:
Rural African** Risk Assessment – Triage Form................................. 46
Equality Impact Assessment Tool ....................................................................................... 47
Ratification Checklist .............................................................................................................. 48
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 3 of 48
1. Introduction
Infections can be transmitted by inoculation of blood and other body fluids from infected
patients. In the Health Service, precautions must be taken to protect staff and patients
from this risk, while ensuring that infected patients receive the treatment and care they
need. For this reason the Trust has adopted the policy of taking 'universal precautions'
with blood and body fluids.
The key to preventing transmission of blood-borne viruses (BBVs) is the strict
observance of infection control measures which treat all blood, body fluids and body
tissues from all patients as potentially infectious at all times.
The BBVs which present most cross-infection hazard to health care workers (HCWs)
are those associated with a carrier state with persistent replication of the virus in the
human host and persistent viraemia. These include HIV and several hepatitis viruses,
considered separately in the following paragraphs. Viral Haemorrhagic Fevers will also
be considered briefly. For other rarer potentially blood-borne viruses, specialist
microbiological/ virological advice should be sought.
Any health care worker who is known to be carrying a blood borne virus or who
suspects they may be a carrier MUST NOT undertake exposure prone procedures
except under certain circumstances in the case of Hepatitis B carriers (DH, 2007).
These individuals must be referred to Occupational Health for an assessment of their
fitness to work, counselling and testing.
For all patients and staff with blood-borne infections the normal rules of medical
confidentiality apply. Personal health data relating to him/her must not be disclosed
without their agreement to anyone for any purposes other than the health care of that
patient. Adequate safeguards to protect against unauthorised disclosure must be
adopted. Only in exceptional circumstances can confidentiality be breached e.g.
infected healthcare worker continuing to undertake exposure prone procedures or
seizure of medical records by court order. Consequently, patients should also be
advised that confidentiality is not absolute and that doctors may be legally bound to
disclose HIV status information.
Should a patient be exposed to blood from an infected health care worker, the incident
should be managed without revealing which member of the clinical team is infected.
When a known infected patient is admitted to a ward, the clinician looking after the
patient should only inform those nursing and medical colleagues who need to know in
order to provide the necessary counselling, support and clinical care. Other staff do not
need to know a patient has a BBV. All staff should be protecting themselves against
BBV by adhering to safe working practices and the infection control policy.
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 4 of 48
2. Purpose of this Policy
This policy is primarily to guide against the transmission of Blood-borne Viruses from
patient to health care worker however, it is equally applicable to patients where
exposure to them from a health care worker’s body fluids occurs.
3. Aims and Objectives of this policy
The policy aims to make explicit the principles of infection prevention and control which will
minimise exposure to and the transmission of micro-organisms.
4. Definitions
Percutaneous exposure
Needle or other sharp object contaminated with blood or body fluids causing injury, a
bite causing visible bleeding, or other visible skin puncture
Contamination via mucous membrane
Blood or body fluid splashes to the eyes, nose, or mouth
Contamination via broken skin
Blood or body fluids entering cuts, abrasions, or patches of eczema
Source patient
The person from whom the blood or body fluid originates
Injured recipient
The person exposed to blood or body fluids that have the potential to be infected with a
blood borne virus
Standard Principles of Infection Control
All blood and body fluids are potentially infectious. Precautions are necessary to
prevent exposure to them. These routine procedures are called Standard Principles of
Infection Control (or Universal Precautions). The trust policy on infection control
provides guidance on precautions that should be applied by all healthcare workers.
Each member of staff is accountable for his/her actions and must follow safe practices.
Standard Principles of Infection Control include:
• Hand Hygiene and Skin Care
• Protective Clothing
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 5 of 48
•
Safe Handling of Sharps (including Sharps Injury Management).
5. Blood borne viruses
5.1
Human immunodeficiency virus (HIV)
HIV has been isolated from blood, semen, vaginal secretions, saliva,
tears, urine, breast milk, and cerebrospinal, synovial and amniotic fluids.
However, only blood, blood products, semen, vaginal secretions, donor
organs and tissues and breast milk have been implicated in the
transmission of infection. There is no evidence that HIV is spread by close
social contact even when this is prolonged, as in a family setting.
Although HIV transmission may occur in health care settings, most HIV
transmission occurs:
• By unprotected penetrative sexual intercourse with an infected
person (between men or between man and woman);
• By inoculation of infected blood. At present in the UK this results
mainly from drug users sharing blood contaminated injecting
equipment;
• From an infected mother to her baby before or during birth or
through breast feeding.
There is at present no vaccine to prevent HIV infection.
5.2
Hepatitis B virus (HBV)
Hepatitis B virus surface antigen (HBsAg) may be found in blood and
virtually all body fluids of patients with acute hepatitis B and carriers of the
virus but blood, semen and vaginal fluids are mainly implicated in the
spread of HBV infection. Transmission usually occurs:
•
By unprotected sexual intercourse;
•
By injecting drug users sharing blood contaminated injecting
equipment;
•
Perinatally from an infected mother to her baby.
Up to 90% of babies infected perinatally and around 5% of those infected
as adults develop chronic carrier status. The persistence of the `e' antigen
correlates with a high level of viral replication and increased infectivity.
However some e antigen-negative carriers are also of high infectivity, and
such carriers have been implicated in a number of transmission events in
the healthcare setting. All HB surface antigen positive patients should be
regarded as infectious.
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 6 of 48
Immunisation, against HBV, provides protection in 90% or more of
recipients. The Department of Health strongly recommends that all HCWs
that are likely to be exposed to bodily fluids are vaccinated against HBV.
Immunisation is not a substitute for good infection control practice
since it provides no protection against infection with other BBVs.
5.3
Hepatitis C virus (HCV)
HCV is the main cause of what was previously known as parenterally
transmitted non-A non-B hepatitis. HCV is most frequently acquired by
direct blood-to-blood contact and the commonest mode of transmission in
the UK is the sharing of blood contaminated injecting equipment by
injecting drug users. Both sexual and perinatal transmission can occur but
in general these are less efficient modes of transmission. There is at
present no vaccine to prevent HCV infection.
5.4
Hepatitis D virus (HDV)
HDV causes infection only in those who have active HBV infection. HDV
infection can occur either as co-infection with HBV or as super infection of
an HBV carrier. Since HDV depends on an HBV-infected host for
replication, prevention of HBV infection by immunisation will also prevent
HDV infection.
5.5
Viral Haemorrhagic Fevers
Viral haemorrhagic fevers (VHF) are potentially life-threatening diseases
caused by a range of viruses. Most are endemic in a number of parts of
the world, most notably Africa, parts of South America and some rural
parts of the Middle East and Eastern Europe. The illness may lead to
bleeding disorders increasing the opportunity for exposure to infected
fluids.
Accidental inoculation may result from needle stick or contamination of
broken skin or mucous membranes by infected blood or body fluids. Four
agents of VHF are of concern in the UK because of possible person-toperson spread. These are Lassa, Ebola, Marburg and Crimean/Congo
haemorrhagic fevers.
Any patient suspected of having a VHF must be kept in STRICT
isolation and the Consultant Microbiologist and ICT contacted
IMMEDIATELY
The wearing of protective clothing is essential
It is difficult to make a firm diagnosis solely on clinical grounds, so
epidemiological evidence is essential in assessing a feverish patient with
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 7 of 48
a history suggestive of VHF. Clinicians should seek the help and advice of
a specialist in infectious diseases or tropical medicine.
The HPA website is also
useful: http://www.hpa.org.uk/infections/topics_az/VHF/default.htm
Experience has shown that most ill patients suspected of VHF will be
suffering from malaria. Laboratory tests to exclude or confirm malaria
should be undertaken as soon as possible. The laboratory must be
notified in advance of the suspicion of VHF. Several blood films should be
examined to exclude this diagnosis as false negative results occasionally
occur. Treatment may need to be considered in the absence of a firm
diagnosis. No laboratory work should be carried out on specimens from
these patients (other than unavoidable emergency tests) until a blood film
has been examined for the presence of malarial parasites. The blood
sample should be taken by someone experienced in phlebotomy and
should be hand delivered to the haematology biomedical scientist who
must be made fully aware of the infection risks involved.
6. Risks of Transmissions of BBVS
6.1
Risk of infection
The risk of transmission of BBVs is greater from patient to HCW than from
HCW to patient. The risk to the HCW for each virus is proportional to the
prevalence of that infection in the population served, the infectious status
of the individual source patient, which may or may not be known, and the
risk of a significant occupational exposure occurring during the procedures
undertaken. In the health care setting transmission most commonly occurs
after percutaneous exposure to a patient's blood by sharps injury. The risk
of transmission to a susceptible HCW from an infected patient following
such an injury has been shown to be around:
1. 1 in 3 when a source patient is infected with HBV and is `e' antigen
positive
2. 1 in 30 when the patient is infected with HCV
3. 1 in 300 when the patient is infected with HIV.
6.2
Known infected patients
Patients with simple chronic or acute hepatitis B, C or HIV infection do not
require routine isolation. Patients with suspected or confirmed VHF must
be isolated, ideally in specialist facilities (See Isolation Policy).
All body fluids/tissues including breast milk should be handled with the
same precautions as blood.
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 8 of 48
6.3
Use of Protective Clothing
Appropriate protective clothing must be available for use at all times and
must be worn whenever there is a risk of contamination with blood or body
fluids. Removal of all protective clothing must be followed by hand
washing (See Universal Infection Control Precautions Policy).
Allergy to latex is well recognized but uncommon. Staff should be
wearing nitrile gloves when taking blood. Advice should be sought from
Occupational Health if problems arise.
6.4
Disposal
See Disposal of Waste Policy and Infection Control Precautions Policy for
disposal of: Sharps, Contaminated Waste and Linen and Managing
spillages of blood and body fluids.
7. Pathology Specimens and venepuncture
7.1
All specimens
All specimens must be safely contained in a leak proof container and this
must be enclosed in a sealed polythene bag. The request form should be
placed in the side pocket if it is not attached to the bag. Care must also be
taken to ensure that the outside of the container and bag remain free from
contamination with blood.
Needles must never be sent attached to syringes or alone in a plastic
bag.
7.2
Specimens from infected patients
These specimens should be packaged as trust procedure but the request
form and specimen should be labelled "inoculation risk". The polythene
bag should also be labelled. These specimens must not be sent via the
vacuum tube system. If there is risk of spillage of contents then the
polythene bag should be placed inside another i.e. “double bagging”. For
individual patients/specimens advice may be sought from Infection
Control.
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 9 of 48
7.3
Venepuncture
7.3.1 Venous Blood sampling
Only staff trained in the technique of venepuncture may undertake this
procedure.
7.3.2 Vacutainer Procedure
Nitrile gloves are recommended for use when taking blood and this skill
should be developed and taught to all new practitioners.
Factors which increase the risk of exposure to BBVs include:
•
•
•
•
•
The
The
The
The
The
patient is difficult to "bleed"
carer has a cut or broken skin etc.
venepuncturist is inexperienced
patient is restless
patient is known to be infected with blood-borne viruses.
Good practice includes:
•
•
•
•
•
Always use Vacutainer as the routine blood collecting system.
Both 21g (green) and 22g (black) needles are available, plus a luer
adapter for use with butterflies or venflons.
Always take extra care to ensure bleeding has stopped after using
the Vacutainer system.
Never force blood from a traditional syringe and needle, through
the Vacutainer tube seal, as this can result in the production of
aerosols of blood and in the separation of the syringe from the
needle.
Never re-sheath a needle. Most needle stick injuries occur during
re-sheathing.
Never remove the tops off Vacutainer tubes. This is considered
poor practice and may result in blood leaking out and causing a
major contamination incident.
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 10 of 48
7.4
Arterial sampling
Due to the possibility of gross contamination this procedure should only
be performed by junior medical staff that have been taught by an
experienced senior.
Pressure must be applied to the puncture site for at least 5 minutes, until
bleeding stops.
The needle MUST be replaced before transportation to the laboratory or
blood gas analyser.
7.5
Venesection
Following venesection the bag containing the unit of blood should be
discarded into an approved sharps container.
8. Testing Deceased Patients for Blood Borne
Infections
It is the policy of the Trust that patients' blood should not be tested for HIV or Hepatitis
viruses without their consent solely for hospital control of infection purposes. This is in
keeping with national recommendations.
It is the responsibility of the clinician to see that the patient's consent is obtained before
the test is performed.
8.1
Procedures Following the Death of the Patient
Also see Universal Infection Control Precautions Policy
8.2
All patients with uncontrollable leakage of blood or
body fluids
Every effort must be taken to prevent leakage by appropriate measures
such as:
• Seal wounds and cannulation sites etc. with a waterproof dressing
• Spigot drains, catheters, other tubes etc.
• Plug orifices where necessary using cotton wool swabs
The body MUST be placed in a cadaver bag. See also Handling of
Deceased Persons Policy.
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 11 of 48
8.3
Patients infected with a blood-borne infection or
Hazard Group 3 infections
The body MUST be placed in a cadaver bag and a yellow 'Danger of
Infection' sticker attached to the outside of the bag. The appropriate
information must be secured on the OUTSIDE of the cadaver bag for
mortuary staff protection.
9. Sharps Injury and Contamination Incident Action
Pack
The Sharps and Contamination Incident Action Pack (available via the intranet under
Occupational Health) gives staff clear guidance on the procedure they should follow in
the event of a sharps or contamination incident (see Appendix 2). These are classified
as incidents where you are exposed to blood, serum or other body fluids. Incidents
include:
•
•
•
•
•
Percutaneous injuries such as needle stick injuries or sharps injuries
Bites (blood drawn
Scratches (blood drawn)
Contamination of the mucous membrane (through the mouth & nose) or
conjunctivae (through the eye)
Minor cuts, abrasions and other open skin lesions which become contaminated
Managers in clinical departments should make all staff aware of the procedure. The
document can be accessed on the intranet – Staff resources, Occupational Health
10. Exposure Prone Procedures
10.1
Exposure prone procedures
Exposure prone procedures are those invasive procedures where there is
a risk that injury to the worker may result in the exposure of the patient’s
open tissues to the blood of the worker. These include procedures where
the worker’s gloved hands may be in contact with sharp instruments,
needle tips or sharp tissues (e.g. spicules of bone or teeth) inside a
patient’s open body cavity, wound or confined anatomical space where
the hands or fingertips may not be completely visible at all times.
However, other situations, such as pre-hospital trauma care and care of
patients where the risk of biting is regular and predictable, should be
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 12 of 48
avoided by health care workers restricted from performing exposure prone
procedures.
When there is any doubt about whether a procedure is exposure prone or
not, advice should be sought in the first instance from a consultant
occupational health physician who may in turn wish to consult the UK
Advisory Panel for Health Care Workers Infected with Blood-borne
Viruses (UKAP). Some examples of advice given by UKAP about
exposure prone procedures are provided in Guidance on the management
of HIV/AIDS infected health care workers and patient notification (issued
under cover of Health Service Circular 1998/226). These may serve as a
guide but cannot be seen as necessarily generally applicable as the
working practices of individual health care workers vary.
Procedures where the hands and fingertips of the worker are visible and
outside the patient’s body at all times, and internal examinations or
procedures that do not involve possible injury to the worker’s gloved
hands from sharp instruments and/or tissues, are considered not to be
exposure prone provided routine infection control procedures are adhered
to at all times.
10.2
Examples of procedures that are not exposure
prone include:
•
•
•
•
•
•
Taking blood (venepuncture);
Setting up and maintaining IV lines or central lines (provided any skin
tunnelling procedure used for the latter is performed in a non-exposure
prone manner i.e. without the operator’s fingers being at any time
concealed in the patient’s tissues in the presence of a sharp
instrument);
Minor surface suturing;
The incision of external abscesses;
Routine vaginal or rectal examinations;
Simple endoscopic procedures.
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 13 of 48
11. Responsibilities
11.1
Role of Director of Infection Prevention and Control
•
•
•
•
•
•
11.2
Role of the Head of Health & Safety
•
•
•
•
11.3
Promote a safety first culture in the trust and challenge poor practice.
To ensure there are safe systems of work in place to comply with the
relevant aspects of the Hygiene Code to minimise the risk of health
care associated Infections to staff, patients, and visitors.
To ensure that the Trust has an approved documented process for
managing the risks associated with inoculation incidents that is
implemented and monitored.
To ensure that sufficient resources are made available to replace
conventional medical sharps with sharp-safe devices so far as is
reasonably practical.
To be advised on all matters relating to sharps and contamination
incident, especially major incidents and kept fully informed of changes
in health and safety legislation which might significantly affect safe
working practices
To receive annual reports on progress, performance and
implementation of this policy.
To support Divisions and Directorates in ensuring that appropriate
action is taken as a result of a sharps incident
To ensure any RIDDOR reportable incidents are reported to the Health
and Safety Executive within the appropriate timeframe
To liaise with the Complaints and Claims Manager when there has
been an incident that has the potential to result in a claim
To facilitate a formal investigation into high risk incidents and report
findings to the Safer Staff Group each quarter.
The Manager
•
•
•
•
See Sharps Injury Pack for the management of workers following a
sharps injury
Follow the guidance in this document and maintain and promote a safe
work place.
Prevent exposure to sharps so far as is reasonably practical. For
example: Where possible, replace the use of sharps with sharp safety
devices or safer techniques
Actively support the introduction of needle free systems and medical
devices with sharps protection mechanisms
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 14 of 48
•
•
•
•
•
11.4
Members of Staff
•
•
•
•
•
•
•
•
•
•
•
•
11.5
Ensure all staff [including medical/nursing students, visitors, agency
and bank staff] are trained to use sharps safely and dispose of them
correctly
Investigate all sharps incidents; allocating sufficient resources to
prevent further incidences occurring and reviewing the effectiveness of
measures taken. See Appendix - Root Cause Analysis
Ensure all sharps incidents are communicated to the Health and Safety
team within the required time frames
Ensure the guidance in the Sharps Injury Pack [See Appendix] is
followed. Timely testing of the source patient in these instances is vital
to minimise any unnecessary anxiety in the healthcare work [HCW]
and to reduce unnecessary use of antiretroviral drugs
Provide feedback to staff on trends, serious incidents, results of
investigations, learning opportunities and any necessary risk reduction
activities required within your sphere of influence.
See Sharps Injury Pack for the management of workers following a
sharps injury
Attend the appropriate training and refresher sessions
Avoid passing sharps from hand to hand. Use a receiver so that the
same sharp device is not touched by more than one person at the
same time
Employ a ‘no touch’ technique e.g. using forceps rather than fingers for
steadying and separating tissues while stitching
Avoid handling suture needles
Try to stitch away from yourself
Assemble devices with care and dispose of as a single unit [i.e. syringe
and needle]
Be especially vigilant during emergency procedures
Ask for assistance when taking blood from or giving injections or
infusion therapy to uncooperative patients
Wear appropriate personal protective equipment [see universal
infection control precautions policy]
Dispose of the sharp immediately following its use. Never leave sharps
lying around.
Report all accidents, poor practice and near misses.
Occupational Health Department
•
See Sharps Injury Pack for the management of workers following a
sharps injury
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 15 of 48
•
•
11.6
Provide a comprehensive hepatitis B vaccination programme for all
healthcare workers exposed to blood and other body fluids at work at
pre-employment and following a sharps or contamination incident
Maintain an occupational health record of clinical care given to staff
Role of Infection control
Arrange annual site surveys of sharps bins to establish whether or not
staff are adhering to Trust policy and disposing of sharps in a safe manner
Inform senior management and department managers of the findings and
recommendations to improve practice
11.7
Role of Trade unions
Employers and workers' representatives shall work together at the
appropriate level to eliminate and prevent risks, protect workers´ health
and safety, and create a safe working environment, including consultation
on the choice and use of safe equipment, identifying how best to carry out
training, information and awareness-raising processes.
12. Training
It is the responsibility of managers to ensure that all staff working in their area of
responsibility have received suitable and adequate training and information about the
infection control, safe handling and disposal of sharps. Staff should be supervised until
they can demonstrate:
• Safe method of working in line with the policy
• The correct use of medical devices in current practice including those that
incorporate sharps protection mechanisms where used
• The correct disposal of sharps
• Action to take in the event of an injury
Infection control and sharps safety training incorporating the issues detailed above will
be provided during the following sessions:
• Occupation health Trust induction
• Infection control Trust induction
• Medical staff Induction and annual updates
• Mandatory infection control annual update
• All training sessions involving the use of sharps [i.e. venepuncture and
cannulation]
• Introduction of new equipment/systems that involve the use of sharps
Staff training records can be located centrally via learning management system.
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 16 of 48
13. Monitoring compliance
Compliance with this policy is monitored by Safer Staff Group, as part of their regular
review of inoculation and other medical sharps incidents data and trends analysis.
Health and Safety, Occupational Health will collate sharps and contamination
information for the Safer Staff Group. Information will include: location of incident; date
and time; role of person injured, details about the incident and details of the number of
incidents in each department per month.
The Safer Staff Sub-group is a sub-group of the Health & Safety Committee. It is
responsible for:
• Reviewing inoculation and medical sharps incident data and trends analysis,
against the required legal, regulatory and internal standards and identify areas of
non-compliance.
• Identifying required actions to achieve compliance and assess the implications of
these actions for the Trust.
• Identifying these actions to the accountable organisational lead and their
Executive Director. Wherever possible this should be via the relevant sub-group
member.
• Identifying any significant risks and reporting these to the Health & Safety
Committee.
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14. References
Chief Medical Officers’ Expert Advisory Group on AIDS, London, Department of
Health MMWR Supplement (1987) “Recommendations for Prevention of HIV
transmission in health-care settings” Aug 21 vol 36: no 2
Department of Health guidance on HIV PEP.
Http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/
digitalasset/dh_4083640.pdf
Department of Health (2005) HIV Infected Health Care Workers: guidance on
management and patient notification.
http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/HIV/fs/en
Department of Health (2006) Immunisation against Infectious Disease. Online
Department of Health (2008) HIV Post-exposure prophylaxis. Guidance from the UK
DOH AIDS/HIV Infected Health Care Workers: Guidance on the Management of
Infected Health Care Workers and Patient Notification..
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGu
idance/DH_4116415
Expert Advisory Group on AIDS (1998) Guidance for Clinical Health Care Workers –
Protection against Infection with Blood-borne
Viruses http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Healthser
vicecirculars/DH_4003818
Health & Safety Executive Advisory Committee on Dangerous Pathogens (2008)
Protection against blood borne infections in the workplace: HIV and Hepatitis.
Hepatitis C Infected Health Care Workers HSC 2002/010
http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Healthservicecirc
ulars/DH_4004561
Hepatitis B Infected Health Care Workers. HSC 2000/020.
http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Healthservicecirc
ulars/DH_4004553
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HIV testing for patients attending general medical services NATIONAL GUIDELINES
Clinical Effectiveness and Evaluation Unit Royal College of Physicians 2005
The epic Project: Developing National Evidence-based Guidelines for Preventing
Healthcare Associated Infections. JHI; 47:S1-S82
Working Party of the British Orthopaedic Association (1991) Guidelines for the
Prevention of Cross Infection between Patients and Staff in Operating Theatres with
special Reference to HIV and the Blood-borne Hepatitis Viruses London: British
Orthopaedic Association
U.K Health Departments (1998). Health Service Circular (HSC 1998/266) AIDS/HIV
Infected Health Care Workers: Guidance on the Management of Infected Health Care
Workers and Patient Notification.
Health & Safety Executive. [1995]. Reporting of Injuries, Diseases and Dangerous
Occurrences Regulations [RIDDOR Explained, Version 6], Suffolk: Health and Safety
Executive. Available at: http://www.hse.gov.uk/riddor/index.htm
Healthcare Commission. [2008]. The annual health check 2008/09 Assessing and rating
the NHS. London: Healthcare Commission. Available at:
http://www.healthcarecommission.org.uk/publicationslibrary
Department of Health. Hepatitis B, Chapter 18, The Green Book. London: Department
of Health, November 2009
The management of health, safety and welfare issues for NHS staff. The Blue Book.
2005
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Appendix 1: Consultant Checklist
Name and Title of Individual
Date Consulted
Sharon Bonson, Assistant Director of Nursing
Head of Health and Safety
Head of Risk and Assurance
Senior Infection Control Nurse
A Ibbotson Senior Occupational Health Nurse
Kim Gupta, Consultant
Lors Alford, RCN Representative
18.03.2011
18.03.2011
18.03.2011
18.03.2011
18.03.2011
18.03.2011
12.08.2011
16.06.2011
Name of Committee/Group
Date of meeting
Health & Safety Committee
31.01.12
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Appendix 2: Sharps and Contamination Incident
Action Pack
SHARPS INJURY AND CONTAMINATION INCIDENT
ACTION PACK
1.0
Introduction
‘A combination of training, safer working practices and the use of medical devices
incorporating sharps protection mechanisms can prevent more than 80 per cent of
needlestick and sharps injuries’ [The Blue Book, 2005]
It is the responsibility of managers to ensure that all staff working in their area of
responsibility have received suitable and adequate training and information about the
safe handling and disposal of sharps. Staff should be supervised until they can
demonstrate:
• Safe working practices following training
• The correct use of medical devices in current practice including those that
incorporate sharps protection mechanisms where used
• The correct disposal of sharps
• Action to take in the event of an injury
All staff, patients and visitors involved in a sharps or contamination incident should
follow this procedure.
2.0
Definitions
A blood or body fluid exposure incident refers to an incident where there is:
•
•
•
•
•
•
3.0
Percutaneous injuries such as sharps injuries caused by medical devices
Bites (blood drawn)
Scratches (blood drawn)
Contamination of the mucous membrane (through the mouth & nose) or
conjunctivae (through the eye)
Minor cuts, abrasions and other open skin lesions which become contaminated
First aid
The responsibility for compliance with these instructions lies with the injured employee
and his / her immediate manager.
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3.1
Immediate action to be taken by the employee (Recipient)
Puncture wound, cut, scratch or broken skin:
• Encourage bleeding but the wound should not be sucked.
• Run site of exposure / injury under warm water then wash the site liberally with
soap and warm water but without scrubbing.
• Cover with dressing/plaster, if the wound is larger and/or requires medical
attention contact the Occupational Health Department, during opening hours or
attend A+E.
Exposed mucous membranes or conjunctivae
• Should be irrigated with copious amounts of water.
4.0
4.1
Reporting procedure
Notify department manager / person in charge immediately
•
•
•
An urgent risk assessment should be undertaken to establish the risk of
exposure to blood borne virus (see Section 7 on Risk Assessment). If you have
concerns about exposure to HIV please contact the switchboard who will put you
though to the doctor on call for HIV post exposure prophylaxis.
If a significant exposure has not occurred, e.g. a clean, uncontaminated sharps
injury, no further action is required other than completing an incident form.
The manager should make sure the patient (source) has been tested for HIV,
Hepatitis B and C infection, subject to informed consent – see section 6.
4.2
Notify Occupational Health
Report all sharps and contamination incidents to Occupational Health straight away by
phoning the Sharps Information Line Tel: 1001, External calls: 01225 821001.
If the nurse is not available you will hear the following message:
“This is the Sharps Incident Information Line at the Royal United Hospital. Please listen
to the following message:
•
•
•
•
Follow the instructions in the Sharps and Contamination Action pack for first aid
treatment and blood tests.
Please leave a message on this answerphone. Speaking clearly, give your full
name; date of birth; the place, date and time the incident occurred. Also leave
your contact telephone number, mobile number and bleep.
This answer phone will be checked each day Monday to Friday. You will be
contacted as soon as possible.
If you have serious concerns about blood borne infection and are unable to talk
to an Occupational Health nurse please contact the Emergency Department and
ask for an urgent assessment tor HIV post exposure prophylaxis (PEP). Lastly,
the initial blood sample from the injured worker should be sent for ‘storage only’.
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The patient should have samples sent, only with informed consent, for Hepatitis
B, C and HIV infection.
If the Occupational Health Nurse is unable to contact the injured worker within 48 hours
of the incident an email will be sent to the manager of the department (if known) where
the injury occurred requesting them to contact the injured worker and refer them to
Occupational Health.
5.
5.1
•
•
•
•
•
Responsibilities following an inoculation injury
Manager / Person in Charge
Carry out a risk assessment of the incident immediately. See Section 7.
If you think there may be a high risk of exposure to blood borne viruses including
HIV phone Occupational Health during working hours or the the Emergency
Department out of hours and ask for an urgent assessment tor HIV post
exposure prophylaxis (PEP). If in doubt, do not delay - phone for advice.
If the sharps incident involved a known patient ask them for their consent to test
for HIV, Hepatitis B and C infection. The person taking blood from the patient
should contact the laboratories and ask for the blood tests to be processed
quickly if there is a high risk of the injured worker being exposed to HIV, Hepatitis
C or B infection. See Section 6.
Refer the injured worker to Occupational Health to have a blood sample taken for
‘storage’; their Hepatitis B immunity checked and counselling if required.
Complete an incident form. Investigate the incident and take steps to prevent a
further sharps incident. Send the incident form to the risk management
department within the required time frame.
5.2
All Staff
It is the responsibility of all health care workers to:
• Adhere to safe working practices, health and safety training and trust policies
concerning infection control and the use and disposal of clinical waste.
• Undertake Infection Prevention and Control training programmes and updates
which include Standard Precautions, Hand Hygiene, Disposal of Sharps, and
Management of Inoculation Injuries.
• Comply with the instructions in the Sharps Injury Action Pack.
• Report all sharps and contamination incidents to their manager or team leader so
a risk assessment can be carried out straight away.
• Contact Occupational Health as soon as possible so that they can review your
exposure to blood or bodily fluids and answer any concerns you may have.
• Contact Occupational Health to arrange blood tests and to check blood test
results. Blood tests normally take up to 5 working days to be processed unless
the results are urgent.
• Injured staff can arrange to have their blood tests and samples taken by another
health professional but they must follow this protocol.
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5.3.
•
•
•
Occupational Health
The Occupational Health Department will advise the manager on how to comply
with this procedure when requested to do so.
They will check the patient’s (source) results and advice the injured worker if they
require blood tests to check for HIV, Hepatitis B and C infection. Occupational
Health will not obtain blood samples from any hospital patient.
If the source patient is unknown or refuses testing the Occupational Health
Department will arrange for the employee to have the following tests:
o At 6 weeks testing for Hepatitis C virus RNA
o At 12 weeks testing for Hepatitis C virus RNA and antibody
o At 24 weeks testing for Hepatitis B, Hepatitis C virus antibodies, HIV
antibodies and a further storage sample.
NB: The fact that the injured employee has been vaccinated against Hepatitis B does
not preclude the need to take blood from the injured member of staff and the source
patient and to follow this protocol.
Virology Request Form for Injured Worker
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Use a yellow topped bottle to collect a 5 ml sample of blood. Include the following
details on the virology request form:
•
•
•
•
•
NHS Number Staff
Surname Injured worker’s name
Consultant Dr C Payton
Clinical details section Sharps injury; Name and date of birth of the patient if
known; Date and time of the sharp’s injury.
Other virology investigations First storage sample
Table: Post exposure prophylaxis HBV#
Injured Worker - History Hepatitis
B Vaccination
One or less doses of Hepatitis B
vaccine
Consider the following treatment
[Always check the latest edition of the Green
Book]
Commence an accelerated course of Hepatitis
B vaccine. HBIG x 1 dose if the patient is
Hepatitis B positive
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Partially completed a course of
Hepatitis B vaccine
Completed a course of Hepatitis B
vaccine but the Hepatitis B antibody
levels are unknown
Hepatitis B antibody levels are
11–99mIU/ml
Hepatitis B antibody levels are less
than 10mIU/ml (None responder to
Hepatitis B vaccine)
Complete the course following an accelerated
schedule. Check Hepatitis B antibody levels in 8
weeks after the last vaccine
Hepatitis B antibody test will be performed if the
last hepatitis B vaccine was less than a year
ago. Otherwise, a further Hepatitis B vaccine
will be given and antibody levels checked 8
weeks after.
Consider a booster dose Hepatitis B
HBIG x 1 dose and a 2nd dose in 1 month
Consider a booster dose Hepatitis B
#: Always check the Department of Health Green Book for up to date guidance
5.4
Medical Team / GP
If the source patient needs to be informed of a positive blood result then this will be
done by the medical team caring for the patient. Appropriate referrals will be made by
the medical team. If the patient has been discharged then the medical team will inform
the patient’s GP.
•
•
•
•
•
6.
5.5
Occupational Health Physician /Emergency Department Doctor
Risk assess the incident and the need for immediate treatment including HIV
PEP.
Arrange and provide clinical support to those requiring HIV PEP.
Review the source patient’s blood results if known and advise the worker
accordingly.
Ensure Occupational Health is notified of the incident so further blood tests and
support can be provided if required.
Consent to test the patient (source) for HIV, Hepatitis B and C virus
6.1
•
•
•
Patient (source) blood test
The injured worker must not be the person who takes the blood sample from the
source patient.
The blood test must be undertaken by a competent professional.
The source patient must be given a pre-test discussion and asked to consent to
testing for Hepatitis B Virus (HBV), Hepatitis C Virus (HCV) and HIV using a
clotted yellow topped bottle. The source patient should be provided with
appropriate information about the implications of these tests and appropriate time
to consider and discuss them (See Protection against Blood Borne Virus
Infections and Management of Sharps and Contamination Incidents Policy,
Appendix 2, Testing Information for Patients).
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•
•
Inform the patient that their blood results will be seen by Occupational Health
staff so they can determine if the injured worker requires further testing.
Occupational Health will treat this information confidentially.
If the source patient requires any further advice or information regarding the
testing, assistance can be sought from the GUM clinic.
Virology Request Form for the Patient
Use a yellow topped bottle to collect a 5 ml sample of blood. Include the following
details on the virology request form:
•
•
•
NHS Number Patient’s number
o Surname Patient’s name
o Consultant Patient’s consultant
Clinical details section Sharps injury; Name of injured worker; Date and time of
the sharp’s injury. Test for HIV, virus”. The consultant will be the patient’s
consultant.
Test Required Tick Hepatitis B and C
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•
Other virology investigations HIV test
The results of the blood test should be filed in the patient’s health record.
6.2
Unconscious patient or patient lacking capacity to consent
If the source patient is unconscious or lacks capacity to give consent, blood can only
lawfully be tested for serious communicable diseases if it is reasonably held to be in
their best interests in accordance with the Mental Capacity Act 2005.
6.3
Patient refuses consent
If the source patient refuses consent or is unable to give informed consent, under no
circumstances should testing will be carried out, even on previously stored blood.
6.4
Neonates and consent
Where the source patient is a neonate, the risk assessment will need to be based on
the mother’s risk factors for blood borne viruses. Antenatal screening results will
support your risk assessment but further testing is recommended if there is a high risk
of exposure to infection. The baby’s blood should not be tested.
6.5
Children under the age of 16
Children under the age of 16 should not be tested unless the parent/guardian gives
consent. The consent of the treating paediatrician is required before the parent/guardian
is approached.
6.6
Deceased patient
If the source patient is deceased, the taking and testing of blood samples requires
consent from a nominated representative or a close relative to the deceased.
7.0
Risk assessment
Following all sharps and contamination injuries a risk assessment should be carried out
by the department manager where the incident occurred. Managers may wish to
delegate this task to a competent person. The risk assessment will determine the
injured workers likely exposure to Hepatitis B, C or HIV infection and need for HIV PEP.
7.1
Risk factors
Type of body fluid to which the recipient has been exposed – Blood carries the
highest risk, but blood borne viruses can be transmitted by other body fluids, especially
if they are contaminated by blood.
High risk body fluids:
• Amniotic fluid, vaginal secretions, semen, human breast milk, cerebrospinal fluid,
peritoneal fluid, pleural fluid, pericardial fluid, synovial fluid, fluid from burns or
skin lesions, saliva in association with dentistry, unfixed tissues and organs.
• Low risk body fluids:
• Urine, saliva, faeces, vomit, or tears (unless they are visibly blood stained).
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Route of exposure – If the health care worker’s skin is intact it is impervious to the
three viruses. If the skin is not intact then transmission may occur. Splashes of blood or
body fluids onto mucous membranes may result in virus transmission, although the risk
is considerably lower than for percutaneous exposure.
Nature of exposure – Contaminated hollow-bore needles are more likely to transmit
viruses than solid needles. Needles that have been present in a blood vessel are more
likely to transmit viruses than needles used for intramuscular injection. Transmission is
less likely to occur from a needle containing dried blood.
Depth of injury – The risk of transmission increases depending on the depth of the
injury, a deep injury is likely to be a higher risk than a puncture wound or a surface
scratch.
Personal Protective Equipment – If gloves were worn at the time of the incident there
is a wiping effect as a needle pierces the glove, which may reduce the likelihood of
transmission. Safety glasses, goggles, or a visor would offer the health care worker
more protection in the event of a blood or body fluid splash to the eyes, nose, or mouth.
The source patient – If the source patient is known to have blood borne virus (BBV)
tests within the last year then their blood borne virus status may be ascertained from
records. If the blood borne virus status of the source patient is unknown then a 5ml
clotted blood sample should be taken for BBV test with informed consent. A risk
assessment should also be carried out to determine if the injured worker has had a
significant exposure to HIV, Hepatitis B and C infection.
7.2
•
•
•
•
High risk patients
Known to have or be a carrier of a blood borne virus.
A known close contact of a Hepatitis B, Hepatitis C, or HIV positive individual.
Had unprotected sex with someone who has a blood borne virus.
Sharing injecting equipment with someone who has a blood borne virus.
The following factors are associated with increased risk of occupationally acquired
Hepatitis C infection:
• History of intravenous drug misuse and or multiple sexual partners
• History of a blood transfusion in the UK before 1992
• Received a blood transfusion or injections abroad
The following factors are associated with increased risk of occupationally acquired HIV
infection:
• Deep injury
• Visible blood on the device which caused the injury
• Injury with a needle which had been placed in the source patient's artery or vein
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•
7.3
•
•
•
•
Terminal HIV-related illness in the source patient
Medium risk patients
Had multiple sexual partners
Had unprotected sex abroad (may be at high risk if had unprotected sex in
countries with high prevalence of HIV)
Born outside the UK or the Republic of Ireland – people from certain parts of the
world have a high risk of HIV
If the incident arose from an unknown source, a risk assessment may still be
possible in the light of local knowledge of the prevalence of blood borne virus
infections.
7.4
Hepatitis B status of the health care worker
Health workers should contact Occupational Health to check they are fully immune to
the hepatitis B virus. A further hepatitis B vaccine may be advisable following a sharp’s
injury.
8.0
Sharps incidents involving the public
•
•
•
•
•
Provide first aid and send the member of the public to the emergency department
to be risk assessed for exposure to HIV, Hepatitis B and C infection.
Complete an incident form. Document the date and time of injury, location and
nature of injury.
Consider the need for vaccination against Hepatitis B infection. If required obtain
the injured person’s consent and commence an accelerated course of Hepatitis B
vaccine (0, 1, 2 and 12 months). The first dose should be given immediately.
Subsequent doses should be organised through the G.P.
With the patient’s consent take a baseline 5 ml clotted blood sample and label
“Sharps Injury to a Member of the Public”.
The injured person’s blood form should state:
NHS Number Injured person’s hospital number
Surname Injured person’s name
Consultant ED consultant
Clinical details section Sharps injury to Member of the Public; Name and
date of birth of the patient (source) if known; Date, time and location of the
sharp’s injury.
o Other virology investigations First Storage Sample
o
o
o
o
•
•
Further counselling may be offered via the G.P or the Genito-Urinary Medicine
Department.
If the source of the sharp is known obtain blood from the source patient for
testing for blood-borne viruses (consent required). High risk source patients
should be discussed with the On Call Doctor for HIV PEP.
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•
If the source of the injury is unknown, a blood test is refuses or the source patient
is positive to the above infections arrange for the member of public to have the
following tests via their GP:
o At 6 weeks testing for Hepatitis C virus RNA
o At 12 weeks testing for Hepatitis C virus RNA and antibody
o At 24 weeks testing for Hepatitis B, Hepatitis C virus antibodies, HIV
antibodies and a further storage sample.
Please do not send any results to Occupational Health.
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FIRST AID
SHARPS INJURY
Encourage
bleeding,
squeeze the
wound gently
but do not suck
Wash well with
soap under
running water
but do not
scrub
Cover the
wound using a
clean, dry,
waterproof
dressing
SPLASHED WITH
BODY FLUID
Eyes: Wash in
plenty of running
water (before
and after
removal of
contact lenses if
worn)
Mouth: Spit, do
not swallow,
rinse many times
with running
water
Skin: Wash in
plenty of
running water
REPORTING AN INCIDENT
DEPARTMENT
MANAGER OR
PERSON IN
CHARGE
INJURED
WORKER
REPORT THE
INCIDENT
IMMEDIATELY
OCCUPATIONA
L HEALTH
Phone 1001
COMPLETE
INCIDENT FORM
High Risk Exposure to Blood Borne
Viruses Including HIV?
RISK ASSESSMENT
OF INJURY
PHONE SWITCHBOARD
Occupational Health Physician or
Doctor on call for HIV PEP
IF THE PATIENT IS
KNOWN AND
GIVES INFORMED
CONSENT - Blood
Test for HIV,
Hepatitis B and C
Virus
REVIEW RISK
ASSESSMENT
CHECK PATIENT'S
BLOOD RESULTS
REVIEW IMMUNITY
TO HEPATITIS B
RECOMMEND THE
INJURED PERSON
HAS A BLOOD
SAMPLE TAKEN FOR
STORAGE
Report Incident to
Occupational Health
High Risk Exposure to Blood Borne
Viruses Including HIV?
Refer to Occupational Health Physician
Counselling and advice for
injured worker
Sharps injury from unknown source,
unconsenting patient or the patient has
Hepatitis B, C or HIV infection. Blood tests:
6 weeks - Hepatitis C RNA
12 weeks - Hepatitis C RNA and antibodies
24 weeks - Hepatitis C and HIV, antibodies
,Hepatitis B virus and blood sample for
storage
Offer Vaccination or Immunoglobulin if
Required
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Appendix 3 Patient Consent
Obtaining Consent for Testing Source Patients for Blood Borne Viruses and
Patient Information
Testing information for patients
A member of staff has been accidentally exposed to your blood or body fluids during the
course of their work. We are requesting to test your blood in order to assist the member
of staff. There are three specific viruses that are covered in this information sheet. All
three viruses can be present in your body without your knowledge. We ask patients in
this situation if we can test them for:
• HIV (Human Immunodeficiency Virus): A virus that can be transmitted through
blood, body fluids, and sexual exposure. Examples include sharing needles,
syringes or equipment for drugs, tattoos, body piercing, through unscreened
blood transfusions, and from mother to baby.
• Hepatitis B: A virus that affects the liver and is passed on in the same way as
HIV.
• Hepatitis C: A virus that affects the liver and is usually passed on through blood
or sharing needles or other equipment during recreational drug injecting. Other
examples include tattoos, body piercing, and unscreened blood transfusions.
What does the test involve?
A 5 ml sample of blood will be taken from your arm. If any of the results are positive, the
test will be repeated to confirm the result.
Who will know my test result?
The result will be given to you in confidence and your own doctor will be informed. The
doctor looking after the member of staff affected will be informed, unless you request
otherwise.
What if I am found to have one of these viruses?
If the test shows that you have one of these viruses, you will be offered care, support,
and treatment.
What are the benefits of having these tests now?
You can have these viruses with or without any symptoms. If you have Hepatitis B or
Hepatitis C virus, treatment can often help to cure you and reduce the damage to your
liver. New treatments are available for individuals with HIV. The treatment for HIV may
be more effective if it is given before any serious illness develops.
How can this help the member of staff who has been exposed to my blood?
If you are carrying a blood borne virus the member of staff affected can be followed up
to see if the virus has been transmitted to them and treated if necessary.
Will having the HIV test affect my chances of getting life insurance?
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Doctors do not need to report negative HIV tests when writing insurance reports.
Insurance companies should no longer ask whether you have had an HIV test, they
should only ask whether or not you are HIV positive (As agreed by the Association of
British Insurers 1994).
What are the drawbacks of having the HIV test?
If you do have HIV, the benefits of knowing usually outweigh the disadvantages, which
may include difficulties in relationships with family and friends or, for some, employment
issues. Travel to some countries is currently restricted for people who know they have
HIV.
CONSENT
If you have any further questions, please do not hesitate to ask a member of staff.
When you have read this information sheet and asked any questions please sign below.
You may have a copy of this information sheet.
I fully understand the information given to me and have had the opportunity to ask
questions regarding the tests.
I agree/do not agree to have my blood tested for HIV, Hepatitis B, and Hepatitis C.
Signed………………………………………………… Date…………………….
Document name: Protection against blood borne virus infections and
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Page 34 of 48
Appendix 4: Information collected by occupational
health
1.
Details of Incident
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 35 of 48
2.
Personal Information
3.
Staff Details
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 36 of 48
4. Donor Details
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 37 of 48
Appendix 5: Reducing the risk of sharps and
contamination injury
Reducing the risk of sharp injuries / contamination incidents
1.0
Minimising the risk of exposure to blood borne viruses (BBVs)
•
•
•
•
•
•
•
•
•
•
•
•
•
2.0
ALWAYS adhere to safe working practices; health and safety training and
infection control procedures
ALWAYS wash hands before and after contact with each patient, and before
putting on and after removing gloves;
ALWAYS change gloves between patients and between different procedures on
the same patient;
Cover existing wounds, skin lesions and all breaks in exposed skin with
waterproof dressings. If hands are extensively affected seek advice from
Occupational Health;
ALWAYS wear gloves where contact with blood can be anticipated;
Avoid sharps usage where possible. Where sharps usage is essential, exercise
particular care in handling of all items;
Dispose of sharps immediately at the point of use using a sharps bin. Do not
carry sharps across a clinical area
Sharps bins must be correctly assembled. Do not overfill sharps containers
Avoid wearing open footwear in situations where blood may be spilt, or where
sharp instruments or needles are handled. Healthcare workers must not wear
open footwear in clinical situations;
Clear up spillage of blood promptly and disinfect surfaces wearing appropriate
protective clothing e.g. apron and gloves. If there is glass involved in the spillage
use suitable equipment to clear it up and do not pick up glass fragments by hand.
Wear gloves when cleaning equipment prior to sterilisation or disinfection, when
handling chemical disinfectant and when cleaning up spillages.
Wear eye protection in situations where splashes and aerosols may be
generated
Follow safe procedures for disposal of contaminated waste.
Reducing sharp and contamination incidents in surgery
Have no more than one person working in an open wound/body cavity at any time
[unless essential to the safe outcome of an operation]
• Use a ‘hands-free’ technique where the same sharp instrument is not touched by
more than one person at the same time, prohibit hand to hand passing of sharp
instruments during an operation
• Assure safer passage of necessary sharp needles and instruments via a ‘neutral
zone’ and announce when a sharp instrument is placed there. The ‘neutral zone’
may be a tray, kidney dish or an identified area in the operative field
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 38 of 48
•
•
•
•
•
•
•
•
•
•
•
3.0
Ensure that scalpels and sharp needles are not left exposed in the operative
field, but always removed promptly by the scrub assistant having been deposited
in the neutral zone by the operator or assistant
Use instruments rather than fingers for retraction, and for holding tissues while
suturing
Let falling objects fall. Don’t try to catch falling instruments or glassware, and
stand well clear of them. It’s better to clean up a mess or replace an instrument
than to risk injury and infection
Use appropriate instruments to handle needles and to remove scalpel blades
Direct sharp needles and instruments away from own non-dominant, or
assistant’s hand
Remove sharp suture needles before tying suture; tie suture with instruments
rather than fingers
Avoid scalpel injuries associated with assembly/disassembly, by using scalpels
which are either disposable, have retractable blades or which incorporate a blade
release device
Consider double gloving with a larger pair of gloves innermost for optimum
comfort. Double gloving does not prevent sharps injury but has been shown to
effect up to a six-fold decrease in inner glove puncture. In the event of
percutaneous injury, the volume of blood transmitted may also be reduced due to
the enhanced wiping effect of two layers of glove [HSC 1998].
Consider replacing the use of blades with laser surgery or electrocautery devices
to be used as cutting devices
Consider the use of blunt-tipped needles, stapling devices or skin glue as they
are all safer alternatives to sharp suture needles
Use a sharps disposal device [sharps pad] for checking/counting of all sutures
and scalpel blades during surgery
Patient-Administered Injections and Finger-Prick Tests
If the patient is self-administering medication/testing they must dispose of the sharps
themselves and therefore have a sharps bin available.
If a healthcare professional has to administer insulin to a patient, this should ideally be
given via a syringe. Further advice may be sought from the diabetes specialist nurses if
an insulin pen has to be used.
4.0
•
•
•
•
•
Sharps bin safety
It is the responsibility of the person using the sharp to dispose of it safely
Sharps should be placed directly into an approved sharps disposal container as
soon as possible after use
Always take a sharps disposal bin to the point of use
Needles and syringes should be discarded as a single unit, where possible
Where it is necessary to disassemble a needle and syringe, such as before
transferring blood from a syringe to a pathological specimen bottle, the needle
should be placed in the sharps container before transferring the blood
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 39 of 48
•
•
•
Vacuum collection systems should be used according to the manufacturer’s
instructions. The plastic barrels of such devices should not be reused
Re-sheathing should be avoided, as should bending/breaking needles
Staff who need to visit a patient in their own home as part of their care plan, must
ensure that all sharps waste that is generated during the visit is correctly
disposed of into a sharps bin. This bin must then be fully sealed and the label
correctly filled in. The bin must then be placed in an upright position in the vehicle
and then transported in the vehicle back to the Trust premises. The bin will be
stored in a secure location within the staff member’s department at the Trust. The
staff member must then call X4141 to arrange for a sharps waste collection.
Sharps bins must always be:
• Compliant with UN3291 and BS7320 standards
• Correctly assembled and labelled
• Available in a range of sizes to suit the devices being discarded. For example
guide wires and introducers require a deep box. [seek advice from the infection
control department]
• Available at all locations where sharps are used
• Secured to an appropriate bracket at approximately below shoulder height [so
that no staff are having to reach up to dispose of a sharp] and out of the reach of
children or carried in the appropriate sharps bin container tray [available from
infection control department or your sharps bin supplier]
• Attempts must not be made to retrieve items from a sharps container
• Sharps bins should be locked closed when two-thirds to three-quarters full.
Sharps must not be pressed or ‘shaken’ down in order to make more room
• Locked and disposed of as clinical waste in accordance with The Management
and Disposal of Waste policy [605/2008].
• Carried using the handle or in a container tray
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 40 of 48
Appendix 6: Protocol for healthcare works exposure
to HIV
Protocol for the Post Exposure Prophylaxis for Healthcare Workers
Occupationally Exposed to HIV
In the event of a member of staff sustaining a sharps injury resulting in exposure to
material suspected to be infected with HIV contact the Consultant Occupational
Physician during working hours or the Emergency Department out of hours for urgent
advice.
They will investigate the circumstances of the exposure and of the source patient and
will advise on the use of POST EXPOSURE PROPHYLAXIS drugs.
During working hours phone Occupational Health (4064). Out of hours contact The
Emergency Department
The POST EXPOSURE PROPHYLAXIS pack is held in the Emergency Department, in
the pharmacy cupboard pyxis machine and is labelled “post exposure HIV pack”.
It contains 3 days’ supply of:
One Combivir tablet b.d.
(300mg zidovudine + 150mg lamivudine) plus
Two Kaletra tablets b.d.
(Lopinavir200mg/Ritonavir50mg)
Kaletra often causes diarrhoea so the pack also includes Loperamide to counteract
this.
If the Occupational or Emergency Physician advises the use of POST EXPOSURE
PROPHYLAXIS the whole pack should be given to the member of staff who should take
the first doses of each drug as soon as possible. In potentially high risk situations the
first doses may be given pending further investigation of the incident.
This protocol also covers staff of the following organisations:
• Avon & Wiltshire Mental Health Partnership NHS Trust
• The Royal National Hospital for Rheumatic Diseases NHS Trust
• All other NHS Trusts and Primary Care Trusts in the locality
• The Bath Clinic
• Dorothy House
• Clouds House
• HM Prison Erlestoke
• Reach Out
•
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 41 of 48
Appendix 7: Root Cause Analysis Following Blood or
Body Fluid Exposure
Root Cause Analysis (RCA) provides a framework for reviewing staff safety incidents
[and claims and complaints]. Investigations can identify what, how, and why staff safety
incidents have happened. Analysis can then be used to identify areas for change,
develop recommendations and look for new solutions.
Contributing Factors to a
blood or body fluid exposure
If YES - what
contributed to
this factor
being an issue?
YES NO
Is this a
root cause
of the
event?
If YES, is an
action plan
indicated?
YES
YES
NO
1. Issues related to patient
assessment?
2. Issues related to staff
training or staff competency?
3. Equipment / device?
4. Work environment?
5. Lack of or misinterpretation
of information?
6. Communication?
7. Appropriate rules/policies/
procedures or lack thereof?
8. Worker issues
9. Supervisory issues
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 42 of 48
NO
Sample Trigger Questions for Performing a Root Cause Analysis of a Blood or
Body Fluid Exposure
1. Issues related to patient assessment
•
•
•
Was the patient agitated before the
procedure?
Was the patient cooperative before the
procedure?
Did the patient contribute in any way
toward the event?
2. Issues related to staff training or staff
competency
•
•
5. Was a lack of or misinterpretation of
information contribute to this event?
•
Did the healthcare worker misinterpret
any information about the procedure
that could have contributed to the
event?
6. Communication
•
Were there any communication barriers
that contributed to this event [e.g.,
language]
• Was communication in any way a
contributing factor in this event?
7. Appropriate policies/procedures
Did the healthcare worker receive
training on injury prevention technique
for the procedure performed?
Are there training or competency factors •
that contributed to this event?
Approximately how many procedures
of this type has the healthcare worker
•
performed in the last month/week?
Are there existing policies or procedures
that describe how this event should be
•
prevented?
Were the appropriate policies or
procedures followed?
3. Issues related to the device
• If they were not followed, why not?
• Did the type of device used contribute in 8. Worker issues
any way to this event?
• Did being right or left handed influence
• Was a “safety” device used? If not, is
the risk?
it likely that a safety device could have • On the day of the exposure, how long
prevented this event?
had the worker been working before the
4. Work environment
exposure occurred?
At the time of the exposure, could
• Did the location, fullness or lack of a
factors such as worker fatigue, hunger,
sharps container contribute to this
illness, etc. have contributed?
event?
• Did the organisation of the work
9. Employer issues
environment [e.g., placement of
supplies, position of patient] influence
• Did lack of supervision contribute to this
the risk of injury?
event?
• Was there sufficient lighting?
• Was crowding a factor?
• Was there a sense of urgency to
complete the procedure?
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 43 of 48
Action Plan - Risk Reduction Strategies
Risk Reduction Strategies
Action item #1
Measure[s] of Effectiveness Responsible Person[s]
Action item #2
Action item #3
Action item #4
Action item #5
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 44 of 48
Appendix 8: Risk categories for Viral Haemorrhagic
Fevers
Minimum risk
This category includes febrile patients who have:
• Not been in known endemic areas before the onset of illness; or
• Been in endemic areas, (or in contact with a known or suspected source of a
VHF), but in whom the onset of illness was definitely more than 21 days after their
last contact with any potential source of infection.
Moderate risk
This category includes febrile patients who have:
• Been in an endemic area during the 21 days before the onset of illness, but who
have none of the additional risk factors which would place him or her in the high
risk category; or
• Not been in a known endemic area but who may have been in adjacent areas or
countries during the 21 days before the onset of illness, and who have evidence of
severe illness with organ failure and/or haemorrhage which could be due to a VHF
and for which no alternative diagnosis is currently evident.
High risk
• This category includes febrile patients who:
• Have been in an endemic area during the three weeks before illness and have
lived in a house or stayed in a house for more than 4 hours where there were ill,
feverish persons known or strongly suspected to have a VHF; or
• took part in nursing or caring for ill, feverish patients known or strongly suspected
to have a VHF, or had contact with the body fluids, tissue or the dead body of such
a patient; or
• Are a laboratory, health or other worker who has, or has been likely to have come
into contact with the body fluids, tissues or the body of a human or animal known
or strongly suspected to have a VHF; or
• Were previously categorised as `moderate' risk, but who have developed organ
failure and/or haemorrhage.
• Have not been in an endemic area but during the three weeks before illness they
• cared for a patient or animal known or strongly suspected to have a VHF or came
into contact with the body fluids, tissues or dead body of such a patient or animal;
or
• Handled clinical specimens, tissues or laboratory cultures known or strongly
suspected to contain the agent of a VHF.
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 45 of 48
Appendix 9: Rural African** Risk Assessment – Triage
Form
Modified from the Hospital for Tropical Diseases, London
Name:
Hospital No.:
Date:
1. Has the patient been to an endemic country for VHF in the last month? Access the
website for up to date information
(http://www.hpa.org.uk/infections/topics_az/VHF/menu.htm)
Endemic countries include: Guinea (-Conakry), Sierra Leone, Liberia, Cote d’Ivoire,
Ghana, Togo, Benin, Nigeria, Mali, Burkina Faso, Niger, Central African Republic,
Cameroon, Gabon, Democratic Republic of Congo, Sudan, Uganda, Chad, Congo,
Equatorial Guinea, **the Crimean region of former USSR.
YES � go to question 2
NO � risk is minimum, Proceed with triage as normal
2. Does the patient have an illness with fever of less than 21 days’ duration that started
either while s/he was in the endemic country, or within 21 days of leaving an
endemic country?
YES � go to question 3
NO � if the illness started MORE than 21days after leaving endemic country, the risk
is minimum, Proceed with triage as normal
3. Has the patient:
• Travelled outside major cities?; Yes � No �
• Had contact with sick people or been to health care facilities?: Yes � No �
• Been in contact with rats or their excreta?: Yes � No �
• Been in direct contact with wild animals; Yes � No �
If the answer to any part of question 3 is YES, or there is another reason to suspect
VHF, then DO NOT take any specimens from the patient, and discuss with the on-call
Microbiologist. This does NOT necessarily mean that the patient is at risk of VHF,
simply that further assessment is required. Malaria exclusion is vital in all cases
however before blood is taken this must be discussed with the on-call Microbiologist
and the on-call Haematologist.
If the answer to all parts of question 3 is No, then document ‘minimal risk of VHF’ and
continue with triage as normal.
Action
Discussed with Microbiology?: Yes � No 
If yes, level of seniority: SHO � SpR  Consultant 
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 46 of 48
Equality Impact Assessment Tool
Initial Screening
1. Policy, service, strategy, procedure or function: Protection against Blood Borne
Virus Infections and Management of Sharps and Contamination Incidents Lead
(e.g. Director, Manager, Clinician): Colin Payton.
2. Person responsible for the assessment:
Name:
Colin Payton
Job Title:
Occupational Health consultant
3. Is this a new or existing policy, service strategy, procedure or function?
New
Existing
4. Who is the policy/service strategy, procedure or function aimed at?
Patients
Any other
Carers
Staff
Please specify:
Visitors
5. Are any of the following groups adversely affected by the policy?
If yes is this high, medium or low impact (see attached notes):
Group
Disabled people:
No
Race, ethnicity & nationality
No
Male/Female/transgender:
Affected?
Yes
High
Impact
Medium
Low
Yes
High
Medium
Low
No
Yes
High
Medium
Low
Age, young or older people:
No
Yes
High
Medium
Low
Sexual orientation:
No
Yes
High
Medium
Low
Religion, belief and faith:
No
Yes
High
Medium
Low
If the answer is yes to any of these proceed to full assessment.
This applies whether the impact assessment is high, medium or low.
If the answer is no to all categories, the assessment is now complete
6. Does the policy, service strategy, procedure or function
include measures which promote equality?
No
Yes
7. If yes, what are these measures?
Health and safety arrangements apply
equally to all staff including temporary workers, students and visitors exposed to medical
sharps in the work place
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Ref.: 614
Status: Approved
Page 47 of 48
Ratification Checklist
Dear Chairman
Please would you review this document at your next meeting and agree final approval and
organisational ratification.
Title of meeting:
Health and Safety Committee
Date of meeting:
31/01/2012
Title and Reference of document: Protection against Blood Borne Virus Infections and
Management of Sharps and Contamination Incidents
Name of author:
Colin Payton / Stephen Roberts
Are there any elements of this policy which present operational
issues that require further discussion? If yes, please provide a
contact name for the author.
Does the document include a training plan?
Is the policy referenced?
Are up to date National Guidelines included?
If you are the appropriate forum, have the necessary resources
been agreed to implement this document?
Is there a plan for policy implementation?
Does your meeting recommend further consultation with groups
or staff other than listed at the front of the policy?
What are the cost implications of implementing this policy?
Yes
No
N/A
Yes
No
N/A
Yes
Yes
Yes
No
No
No
N/A
N/A
N/A
Yes
No
N/A
Yes
No
N/A
Yes
NO
N/A
Yes
No
N/A
Equipment
£0
Yes
No
N/A
Staffing [additional]
£0
Yes
No
N/A
Training
£0
Yes
No
N/A
Other
£0
Yes
No
N/A
Document endorsed without further comment?
Further amendments to document suggested? Managers
guide to investigating a medical sharps incident
Yes
No
Yes
No
Name of Chair: Howard Jones
Signature: Signed following the meeting
Document name: Protection against blood borne virus infections and
management of sharps and contamination incidents
Issue date: 13 February 2012
Author: Colin Payton and Stephen Roberts
.
Date: 01.02.12
Ref.: 614
Status: Approved
Page 48 of 48