Download Blood Borne Viruses Source CA4003 v 5 id 1260

Trust Guideline for the Management of Incidents which have the potential to transmit Blood
Borne Viruses
A clinical guideline recommended for use
For Use in:
By:
For:
Division responsible for document:
Key words:
Name and job titles of document
author:
Name and job title of document
author’s Line Manager:
Workplace Health & Wellbeing, Accident & Emergency
Department, iCaSH Norfolk
Trust Managers & Supervisors
All Health Care Workers
Any patient (bleed back incident) or Health Care Worker
who may have been put at risk of blood borne virus
transmission (Hepatitis B, Hepatitis C and HIV)
Corporate
Hepatitis B, Hepatitis C, HIV, Occupational Exposure,
Source, Recipient, Risk Assessment, Post Exposure
Prophylaxis (PEP) Blood Borne Viruses (BBV), Bleed Back
Incident, needlestick, Blood and Body Fluid Exposure
Incident, Inoculation injury, Other Potential Infectious
Material (OPIM), Non Infectious Materials (NIM)
Hilary Winch, Head of Workplace Health, Safety &
Wellbeing
Dr Mark Ferris, Specialty Doctor, Occupational Health
Supported by:
Portia Jackson, Highly Specialist Pharmacist HIV
Dr J Evans, Consultant, iCaSH Norfolk
Dr T Daynes, Consultant in Accident & Emergency
Dr S Dervisevic, Consultant Virologist
Assessed and approved by the:
Chairs Action approval given 17/09/2015 and reported
to Clinical Guidelines Assessment Panel (CGAP)
23/09/2015
Date of approval:
17/09/2015
Ratified by or reported as approved
to (if applicable):
Clinical Standards Group and Effectiveness Sub-Board
To be reviewed before:
This document remains current after this 17/09/2018
date but will be under review
To be reviewed by:
Workplace Health & Wellbeing Manager
Reference and / or Trust Docs ID No:
CA4003 id 1260
Version No:
5
Description of changes:
Amendment made as GUM changed to iCaSH
Compliance links: (is there any NICE
related to guidance)
If Yes - does the strategy/policy
deviate from the recommendations
of NICE? If so why?
None
This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and management of relevant
patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline must be interpreted
and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional judgement,
knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the
patient's case notes.
The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare through
sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of this document.
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/ 2015
Guideline Ref No: CA4003 / V5 id 1260
Page 1 of 36
Trust Guideline for the Management of Incidents which have the potential to transmit Blood
Borne Viruses
Contents
Quick reference pages:1. Management of Staff Blood and Body Fluid Exposure Incidents
2. Source Testing in Blood and Body Fluid Exposure Incidents
3. Blood Exposure Management - A&E Department
4. A&E Department Check List for Assessing High Risk Blood &
Body Fluid Risk Incidents
5. A&E Department Hepatitis B Assessment Algorithm
6. A&E Department HIV Assessment Algorithm
7. Important Contact Numbers
8. Definitions
Additional information on the following can be found in
sections:Objective / Rationale
Immediate management of a Blood or Body Fluid Exposure Incident
Management responsibility
Source consent and blood testing
The Role of Workplace Health & Wellbeing
Role of the Accident & Emergency Department
Role of Integrated Contraception and Sexual health, Norfolk (iCaSH)
Bleed Back Incidents
Clinical audit standards
Guideline development and consultation process
Page
3
4
5
6
7
8
9
10
12
12
12
13
14
15
16
16
17
17
Appendices
1 - Patient Information leaflet for Post Exposure Prophylaxis (PEP) against HIV
2 - Drug Interactions
3 - Recipient consent form for PEP against HIV infection
4 - Patient consent form for Source Testing
5 - Parent/guardian consent form for Source Testing
6 - Advice Sheet for staff
7 - PEP Proforma
8 - Background information for Health Care Workers on Blood Borne Viruses.
References
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/ 2015
Guideline Ref No: CA4003 / V5 id 1260
Page 2 of 36
Trust Guideline for the Management of Incidents which have the potential to transmit Blood
Borne Viruses
Quick Reference Guide 1 - Management of Staff Blood and Body Fluid Exposure
Incident
Immediate Management:

Bleed / Wash / Cover

Inform "person in charge" of
ward / department
17.00 -08.30 +
Weekends & Bank Holidays
Time of Incident?
A&E assessment
Staff member (recipient)
attend with details of
"source"
"Person in Charge" to
facilitate investigation of
incident and source (Refer
to source testing
algorithm)
08.30 -17.00 Weekdays
Contact Workplace
Health & Wellbeing at
earliest oppurtunity
Who is the "Person in Charge"?



The most senior staff member on shift where the source patient is
being cared for at the time of the incident.
If this person is also the recipient then they should contact the
Operational Practitioner who will assume this role.
It is the responsibility of the "person in charge" to ensure that the
source testing process is undertaken - either by a nurse or a doctor.
NB: If the source patient moves location shortly after the incident, then it
is the responsibility of the original senior staff member to inform the
new location and ensure source blood testing is commenced.
Workplace Health & Wellbeing
Telephone (01603) 287035 Int. x3035
Fax (01603) 287026
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/ 2015
Guideline Ref No: CA4003 / V5 id 1260
Page 3 of 36
Trust Guideline for the Management of Incidents which have the potential to transmit Blood
Borne Viruses
Quick Reference Guide 2 Source Testing after Blood & Body Fluid
Exposure Incidents
"Source"
Identified?
Inform Workplace
Health &
Wellbeing at
earliest
opportunity
No/ Unable
Yes
Use Consent form
Appendix 4 or 5
Consent for
blood testing?
Yes
No/ Unable
Document in hospital
notes that patient is
unable or unwilling to
consent to blood borne
virus testing
Arrange for appropriate blood tests

HIV serology

Hepatitis B Surface antigen

Hepatitis C antibodies
When logging on ICE - select the
blood and body fluid expsoure option
Inform Workplace Health
& Wellbeing at earliest
opportunity
Yes
State on request - "source patient
of occupational blood / body fluid
exposure incident, written consent
obtained" + label as URGENT
sample
Copy of consent form
(Appendix 4 or 5)
place in source patient
notes (original copy)
faxed to Workplace Health
& Wellbeing
Workplace Health & Wellbeing
Telephone (01603) 287035 / int x3035
Fax Number (01603 ) 287026
Quick Reference Guide 3
Blood Exposure Incident Management - A&E
Patient presents to A/E with
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
needlestick / Blood exposure incident
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/ 2015
Guideline Ref No: CA4003 / V5 id 1260
Page 4 of 36
Trust Guideline for the Management of Incidents which have the potential to transmit Blood
Borne Viruses
*On ICE/Symphony select Microbiology /Serology then Blood and Body fluid Exposure Incident
option, this will advise on the bloods required for the recipient (staff member)
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/ 2015
Guideline Ref No: CA4003 / V5 id 1260
Page 5 of 36
Quick Ref 4 - A&E Check List for Assessing a High Risk Blood & Body Fluid Exposure Incident
NAME .............................................................…….ADDRESS ....................................………………………………………………………….
DOB……………………….…………JOB TITLE………………………………………………TEL. NO/BLEEP. ........................…………………
TRUST .................…………………LINE MANAGER…………………………………DATE & TIME OF INCIDENT…………………………….
LOCATION OF INCIDENT ...................................………………… DATE & TIME SEEN………………………………………………………..
Past Medical History including drug history …………………………………………………………………………
INCIDENT DETAILS…………………………………………………………………………………………………………………………………………………….
..............................................................................................................................................................………………………………………………………..
...............................................................................................................................................................………………………………………………………..
Percutaneous injury Y / N
Hollow bore needle? Y / N Gauge/type ...................
Used for ...................................................................…..
Other sharp? ..........................................................……
Was the contamination fresh blood?
Y/N
Was the injury: Superficial (surface scratch)? Y / N
Deep (with or without bleeding) Y / N
Were gloves worn?
Y / N if yes indicate below
Single Pair
Double Pair
Mucocutaneous exposure Y / N
Mucous membrane?
Y/N
Area ......................................……………………………………
Broken skin?
Y/N
Was the contaminate fresh blood Y / N (if N) give details
Details…………………….………………………………………….
Approx volume of body fluid………………………………………
SOURCE DETAILS
Is the source known Y
N
If N can source be traced to ward/dept if so where………………………………………….....................................
1. Patient/s Name………………………………………………..DOB ....................................……………………...Hospital / NHS No………………………...
Diagnosis ...................……………………………………………………………………………………………………………………………………………………
GP name and surgery address…………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………
Senior Nurse in charge of patient……………………………………………………Tel/Bleep……………………………………………………………………….
Clinician in charge of source case…………………………………………………..Tel/Bleep………………………………………..........................................
HIV Risk Assessment Table
Section A
Was the patient exposed to blood or Other Potential Infectious Material OPIM *
Was the exposure to non-infectious body fluid?**
Section B: Is the injury / exposure:
Blood/OPIM* contact with healthy skin?
Prolonged contact/heavy contamination with non–intact skin?
Mucocutaneous exposure? E.g. eye, mouth
Superficial or deep injury with solid instrument/ hollow bore needle with/without
visible blood?
Bite from patient causing abrasion or penetrating injury?
Section C: Age of patient
Patient under 16 years of age?
Patient over 16 years?
Section D: Is the source:
HIV positive and NEVER had antiretroviral therapy (ART)?
HIV positive on ART or taken in the past?
High-risk history for HIV***
No High-risk history for HIV?
If answer Yes:
Go to section B
Do not recommend PEP
If answer Yes:
Do not recommend PEP
Go to section C
Go to section C
Go to section C
Do not recommend PEP
If answer Yes:
Contact on call paediatrician
Go to section D
If answer Yes:
Recommend PEP
Recommend PEP. Contact GU
consultant
Recommend PEP
Do not recommend PEP
1. PEP recommended?
If yes proceed to question 2
2. Patient pregnant?
If yes, discuss PEP with GU consultant
3. Is patient under 16 years old?
If yes discuss PEP with paediatrician
4. Consent for PEP obtained?
5. PEP Info Given
6. Is the patient on any medication?
If Yes, Check drug interactions table
Hep B Immunisation
Hep B immune
Optimal response
Poor Response
Non-Responder
Hep B Booster given
Immunoglobulin
administered
Y
Y
Y
Y
N
N
N
N
Y
N
*OPIM: Amniotic fluid, vaginal secretions, semen, human breast milk, cerebrospinal fluid, peritoneal fluid, pleural fluid, pericardial fluid, synovial fluid, saliva in
association with dentistry (likely to be contaminated with blood even when not visibly so, Unfixed tissues and organs, Exudate or tissue fluids
from burns or skin lesions and any body fluid visibly blood stained
**Non-Infectious body fluids: Urine, vomit, saliva & faeces which are not visibly blood stained
***High risk for HIV infection: Men who have sex with men, Intra Venous Drug User (IVDU), Men/ women in countries where heterosexual transmission is common
(notably sub Saharan Africa), Infants born to HIV infected mothers or adults with HIV infected sexual partners, Commercial sex workers
PHOTOCOPY FORM & PLACE WITH A&E RECORD GIVE COMPLETED FORM TO THE STAFF MEMBER TO GIVE TO OH/iCaSH
Completed by name …………………………………………….……….Signature………………….Date…………………
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 6 of 36
Y
N
Y
N
Y
N
Y
Y
Y
N
N
N
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
Quick Reference 5 - A&E Hepatitis B Assessment Algorithm
Complete A&E
Checklist (3.4)
Exposure Risk?
Hepatitis B
Assessment
Contact Workplace
Health and Wellbeing
at earliest opportunity
High
sAb = serum antibodies
sAg = serum antigen
Yes
Person in charge to
facilitate investigation of
incident and source.
(refer to Source Testing
Algorithm)
No / Unknown
Low
Hepatitis B
vaccinated?
No
Take blood for
storage; Workplace
Health & Wellbeing to
request tests for
recipient sAb
Source sAg
positive?
Hepatitis B
Vaccination
Source sAg
positive?
Yes
Yes
Hepatitis B
Vaccination
Hepatitis B Booster
Vaccination & Consider
Hepatitis B Immunoglobulin
(Contact Consultant
Microbiologist)
No/ Unknown
Consider Hepatitis B
Immunoglobulin
(Contact Consultant
Microbiologist)
HIV Assessment
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 7 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
Quick Reference 6 A&E HIV Assessment Algorithm
Hepatitis B assessment (QR 5) &
A&E Checklist (QR4) completed
Patient to contact
their Occupational
Health at earliest
opportunity
HIV Risk Assessment
Yes
HIV positive or
high risk source?
No / Unknown
DO NOT
recomend postexposure
prophylaxis
Staff?
No
Yes
Patient to contact
iCaSH at earliest
opportunity
Age of
recipient?
<16 yr
Contact On-call
Paediatrician
>16 yr
Pregnant?
Yes
Contact On-call
Genitourinary
Consultant @
iCaSH
Commence post-exposure
prophylaxis if indicated (after
consultation with relevant
specialist)
No
Source patient
viral load known > 200 HIV
RNA/ml or unknown
Yes
No
Do not commence
post-exposure
prophylaxis
Commence postexposure
prophylaxis (if no
contraindications)
Staff?
Yes
No
Patient to contact
iCaSH at earliest
opportunity
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Patient to contact their
Occupational Health at
earliest opportunity
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 8 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
Quick Reference 7
Important Contact Numbers
24 Hour Action Line:
01603 287676 or ext: 3676
Workplace Health & Wellbeing:
01603 287035 or ext: 3035
Accident & Emergency Department:
01603 287324/5 or ext: 3324/5
Health & Safety Dept:
01603 287423 or ext: 3423
Trust Microbiology Department:
01603 284587 or ext: 4587(for
urgent samples). Out of hours via
NNUH Switchboard
ICaSH Norfolk
(integrated contraception and sexual health):
0300 300 3030
Quick Reference 8 - Definitions
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 9 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
1. Bleed Back Incident
An incident in which the blood of a health care worker comes into contact with the blood or
open tissues of a patient. The following are examples of when this could occur: Bleed back from a visible laceration to a Health Care Worker’s hand during an
Exposure Prone Procedure (e.g. during surgery).
Visible bleeding from a Health Care Worker from any site leading to significant bleed
back into a patient’s open tissues or mucous membranes.
In the unlikely event that an invasive device or product contaminated by use on one
patient is accidentally reused on another patient.
2. Blood Borne Viruses (BBV)
BBVs are viruses which can be present in blood or other body fluids and which have high
potential for transmission to another person by direct contact with their blood or
susceptible fluids. For practical purposes these are Hepatitis B (HBV), Hepatitis C (HCV),
and Human Immunodeficiency Virus (HIV).
3. Occupational Exposure
There are three types of exposure in health care settings associated with significant risk
from blood or higher risk body fluids these are:
Percutaneous injury (e.g. from needles, sharp instruments, bone fragments,
significant bites which break the skin).
Exposure of broken skin (e.g.abrasions, cuts, eczema). It is important to note that
intact skin is a safe protective barrier against BBV transmission.
Exposure of mucous membranes including eyes and mouth.
4. Post Exposure Prophylaxis (PEP)
PEP is the treatment which may be advised and supplied to the recipient following a risk
assessment from a known or high risk HIV or Hepatitis B exposure incident. The treatment
for Hepatitis B is only recommended when the recipient does not have adequate immune
protection.
5. Recipient
The individual who has been exposed to the possibility of acquiring a blood borne infection
as a result of an incident with the potential to transmit a BBV.
6. Source
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 10 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
The individual who was the source of the blood or body fluid, which made contact with the
recipient. The source will usually be a patient but may be a HCW as in a bleed back
incident.
7. Risk Assessment
The process by which the need for PEP is determined, based on the characteristics of the
potential transmission incident and the evidence on the previous behaviour of the source,
which carries the potential risk of BBV infection.
8. Other Potential Infectious Material (OPIM)
Amniotic fluid, vaginal secretions, semen, human breast milk, cerebrospinal fluid,
peritoneal fluid, pleural fluid, pericardial fluid, synovial fluid, saliva in association with
dentistry (likely to be contaminated with blood even when not visibly so, Unfixed tissues
and organs, exudate or tissue fluids from burns or skin lesions and any body fluid visibly
blood stained.
9. Non – Infectious body fluids
Urine, vomit, saliva and faeces which are not visibly blood stained.
1. Objective and Rationale
This guidance is aimed at all Health Care Workers (HCW), subcontracted HCWs, Health
Care students (including work experience) on Trust premises. This guideline is to be used
in the event of a potential occupational exposure to Blood Borne Viruses (BBV) or other
potential infectious material (OPIM), particularly those contaminated with blood.
It is essential that all staff and managers familiarise themselves with this guideline since
urgent action may be required in the event of an exposure.
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 11 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
HCWs are potentially at risk from Blood Borne Viruses (BBV) including Hepatitis B virus
(HBV), Hepatitis C virus (HCV) and Human Immunodeficiency Virus (HIV) through
exposure to blood or other higher risk body fluids. The greatest risk of transmission is
from inoculation injuries but transmission is known to have occurred following splashing
onto mucous membranes or damaged skin.
Incidents with the potential to transmit BBV comprise percutaneous injury (i.e.
needlesticks), exposure of broken skin, or exposure (often splashes) of the mucous
membranes including those of the eyes and mouth. These incidents are a medical
emergency, as prophylactic medication may need to be made available at short notice.
Every effort should be made to avoid blood and body fluid exposure incidents by the
adoption of safe systems of work. Please refer to the Trust policy for the Prevention and
Management of Needlestick and Sharps Injuries within the Trust.
2. Immediate Management of a Blood or Body Fluid Exposure Incident
First Aid Treatment
 Bleed it
 Wash it
 Cover it
 Report it – Via Datix as well as undertaking actions in Quick Reference Guide 1
3. Manager Responsibility
It is a manager’s responsibility to ensure all staff are informed of the risk of acquiring a
BBV through occupational exposure.
3.1 Line Manager
To ensure the exposed member of staff has followed the appropriate guidance and
contacted Workplace Health & Wellbeing or the A&E department depending on the time of
incident (See quick reference 1).
To ensure that the incident has been reported on Datix (incident reporting system).
To investigate all blood and body fluid exposure injuries and to ensure safe working
practices are adhered to at all times. To consider if a specific exposure incident was due to
poor practice or negligence, which may require guidance, training or even in certain cases
disciplinary procedures.
Where the Line Manager is in charge of the source patient they must follow the guidance
outlined in 3.2.
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 12 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
A case may arise where the Line Manager is not in charge of the source patient as they
have moved to another location. If this occurs the Line Manager must liaise with the
person now in charge of the source patient to implement the source testing process.
3.2 Person in charge of the department or ward where incident occurred or who is in
charge of the source patient (See Quick Reference 2)
To ensure all first aid measures have been undertaken and that the recipient has
contacted Workplace Health & Wellbeing or the A&E department as appropriate.
(See Quick Reference 1).
Obtain consent as soon as possible from the source patient for BBV blood testing (see
section 4), as the purpose of this assessment is to ascertain whether the recipient
requires URGENT referral for PEP for possible HIV and HBV exposure. Post Exposure
Prophylaxis (PEP) should be started for maximal effectiveness preferably within ONE
HOUR of the exposure / injury
If the incident occurs at night and the recipient is the person in charge of the department or
ward where the source patient is being nursed then they must contact the operational
practitioner who will take on the role of the person in charge of the source patient.
NB: Staff working at Cromer / external locations should in the first instance contact
Workplace Health & Wellbeing or the A&E department by telephone to assess the
need to travel to Norwich for further treatment.
4.Source Consent & Blood Testing (See Quick Reference 2)
Consent MUST be gained from the source patient for blood tests to be undertaken using
the appropriate Patient Consent Form – (Appendix 4 or 5), even if an appropriate sample
(taken in a plain orange-topped tube) is already available in the laboratory. The following
blood tests MUST be requested:



Hepatitis B Surface Antigen
Hepatitis C Antibodies
HIV Antigen and Antibodies
BBV testing must not be undertaken without the patient’s informed consent as otherwise
there may be a breach of the Human Tissue Act 2004 which may result in disciplinary
proceedings from the Trust or the member of staff’s professional organisation (e.g. GMC,
NMC).
If the source patient is unable to give informed consent due to physical or psychological
illness, unconsciousness or death, advice must be obtained from the Clinician in charge of
the source patient in liaison with an Occupational Health Physician. Workplace Health &
Wellbeing will undertake the initial risk assessment as if the incident occurred from an
unknown source.
The Hepatitis B,C and HIV blood tests should be requested on ICE, select
microbiology/serology and the Blood and Body Fluid Exposure Incident option (hard copy if
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 13 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
ICE not applicable state URGENT source test and “source patient of occupational
blood/body fluid exposure incident, written consent obtained”).
The patients name and date of birth should be used as identification. When requesting the
HIV tests on ICE, when the requester has reached the ‘reason for request screen’ they
should click ‘other’ and then type in ‘Source patient of blood / body fluid injury’
The Trust Microbiology department should receive the sample within 24 hours of the
incident and must be informed by telephone on ext 4587 that this is an URGENT source
test request. If the incident occurs at night then a message must be left on the answer
machine to alert Microbiology of the urgency of the request for the morning. The test
results should be requested for Workplace Health & Wellbeing and not recorded in the
patient’s notes.
Once the blood sample has been taken, Workplace Health & Wellbeing must be contacted
on ext: 3035 or 01603 287035 with the following information: Name, Date of Birth and contact number of Recipient
 Name and Hospital Number of Source patient
 Managers name and contact number
For an incident occurring between 17.00 and 08.30 Monday to Friday and at any time
during a weekend or on a Bank Holiday, fax the completed ‘Source consent form’ to
Workplace Health & Wellbeing (01603 287026). NB: the original source consent
form must be filed in patient’s hospital notes.
5. The Role of Workplace Health & Wellbeing
To provide advice, support and treatment (during the hours of 0830 and 1700, Monday to
Friday) and review all staff who have been involved in a blood or body fluid exposure
incident in line with internal Workplace Health & Wellbeing procedures and best
practice.
To liaise with the person in charge of the source patient to ensure that arrangements have
been made for a blood sample to be tested for BBV.
To liaise with the Clinician in charge of the source patient prior to Workplace Health &
Wellbeing advising the recipient about further management.
To advise the recipient of the source patient’s results once the source patient has been
informed by the Clinician in charge of their care. If the source results are positive, an
urgent appointment will be made for the recipient to see an Occupational Health Physician
at the earliest opportunity.
All source patient results will be released to Workplace Health & Wellbeing as long as the
source blood sample request has been clearly marked as indicated in section 4 - “Source
patient of occupational blood/body fluid exposure incident, written consent
obtained”.
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 14 of 36
Trust Guideline for the Management of Incidents which have the potential to
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NB: If the patient has been discharged or the results are positive, the Clinician in charge of
the patient at the time of the incident will be responsible for advising the GP of the results
and will be requested to advise the patient and arrange referral to the appropriate
specialist.
To provide information and training on the management of exposure incidents mandatory
and induction training for the Trust, and provide any other training when
requested, on all aspects of the management of blood and body fluid exposure
incidents.
To undertake ongoing audit of source testing and blood borne exposure incidents.
To provide the Trust with advice about the management of blood and body fluid exposure
incidents.
To report all high risk HIV, Hepatitis B or C blood and body fluid exposure incidents to
Public Health England (previously HPA) / Health & Safety Executive (under RIDDOR
Regulations)
6. Role of the Accident & Emergency Department
To provide emergency care for all HCWs in accordance with current Department of Health
(DoH) guidance and best practice.
To manage the member of staff in accordance with internal A&E protocols and procedures
(see quick reference guides 3, 4, & 5).
To triage as requiring urgent medical attention since HIV Post Exposure Prophylaxis
should ideally be given within one hour of exposure. However it can be commenced up to
72 hours afterwards (and on occasions longer)
To provide HIV and Hepatitis B prophylaxis when indicated. Hepatitis B Immunoglobulin is
only available from Microbiology and therefore the Consultant Microbiologist On Call will
need to be contacted to discuss the case and supply if indicated.
To provide advice to managers when the Workplace Health & Wellbeing department is
closed.
If an occupational injury to instruct the recipient to telephone their Occupational Health on
the next working day for any further treatment or advice. If the member of staff is employed
by Norfolk and Norwich University Foundation Trust they should contact Workplace Health
& Wellbeing on (01603 287035 ext: 3035)
To undertake the initial management of any blood and body fluid exposure incident
sustained by a member of the public and to refer them to the Integrated Contraception and
Sexual Health clinic (iCaSH clinic) if HIV PEP has been commenced (either for blood or
sexual exposure). For those members of the public who have attended A&E where HIV
PEP has not been commenced or who only require Hepatitis B follow up they should be
referred to their Primary Care Service.
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 15 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
7. Role of Integrated Contraception and Sexual Health (iCaSH)
To provide any follow up management for members of the public in the event of a high risk
blood and body fluid exposure incident where HIV PEP has been commenced.
To provide consultant advice via telephone for the Occupational Health Physician when
Post Exposure Prophylaxis (PEP) is indicated, but either due to health condition of source
patient or recipient of incident cannot prescribe the standard PEP starter pack.
To take a referral of an occupational health patient following a blood exposure incident
when PEP is likely to be indicated, but WHWB do not have a doctor present to assess and
prescribe. This would include a consultation and baseline bloods. WHWB would be
responsible for necessary follow up consultations and employee support. To advise
WHWB on the activity undertaken so that appropriate follow up can take place (as per
agreed SLA)
In the event where the source patient is identified as HIV positive, to advise WHWB on the
most appropriate choice of HIV PEP, taking into account previous treatment of the source
patient, and any other medical conditions or medications taken by the exposed worker.
To advise Pharmacy and A&E on the most appropriate constituents of HIV PEP Starter
packs.
8. Bleed Back Incident
Definition– see quick reference 8
In the rare event of a ‘bleed back’ incident, it is important that both the HCW and the
exposed patient have access to appropriate clinical management following the incident.
Following a ‘bleed back' incident the HCW must attend Workplace Health & Wellbeing for
counselling and blood testing for BBVs (under a code number) following appropriate
consent to do so.
If the HCW tests negative for BBVs the DoH have indicated that there is no need to inform
the patient about the incident as this would avoid causing the patient unnecessary anxiety.
If the HCW tests positive for any BBV, the patient should be notified of an ‘intra operative
episode’ without revealing which member of the clinical team is infected. PEP should only
be recommended to a patient following a positive test in the HCW for HIV or Hepatitis B
(except in very exceptional circumstances e.g. high likelihood of BBV infection). If the
HCW tests positive, the patient will be followed up with baseline blood test for (storage)
and further testing, as appropriate,. It is the responsibility of the Clinician in charge of the
patient to advise their GP that further blood tests are required.
HIV test results should, ideally be available within eight hours of the exposure incident to
maximise the benefit of PEP for the patient if indicated. However, if the ‘bleed back’
incident occurs at the weekend or on a bank holiday and the microbiology lab is not able to
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 16 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
supply the result within an eight hour period, if the source (HCW) has high risk factors for
HIV infection then the recipient (patient) should be informed of the incident and
commenced on PEP until the result has been received.
Where PEP for HIV (or Hepatitis B) is required for an exposed patient the Clinician
responsible for that patient will be advised by a the Occupational Health doctor. The
iCaSH Norfolk Consultant should be contacted to confirm the appropriate HIV treatment
regimen.
Any HCW (particularly if involved in EPP) who believes they may have been exposed to
infection with HIV, Hepatitis B or Hepatitis C should inform Workplace Health & Wellbeing,
as to whether they should be tested for these BBV infections. Failure to do so may breach
the duty of care to patients. Therefore HCWs are under continual obligation to report their
own BBV infections risks.
9. Clinical Audit Standards
To ensure that this document is compliant with the above standards, the following
monitoring processes will be undertaken:
All high risk blood & body fluid exposure incidents were reported to the HSE, Public Health
England and the Health & Safety Committee and managed appropriately according to the
guidelines.
Employees receive appropriately timed follow up testing via WHWB
10. Guideline Development and Consultation Process
Guidelines were drawn up by the authors following a review of published literature (see
references). Discussions took place with colleagues in Microbiology, A&E, iCaSH Norfolk,
Health & Safety and Infection Control.
Appendix 1
HIV POST-EXPOSURE PROPHYLAXIS (PEP) FOLLOWING OCCUPATIONAL
EXPOSURE
Department of Workplace Health and Wellbeing
You have had an injury/exposure that may have put you at risk from Human Immunodeficiency
Virus (HIV) infection. This information is aimed at hospital staff but will equally apply to a member
of the public. It is important that you read the following information before deciding whether or not to
take prophylactic treatment.
What are the risks of acquiring HIV following a potential exposure?
The risk of acquiring HIV infection following occupational exposure to HIV-infected blood is
extremely low. Studies have indicated that the average risk after percutaneous exposure (e.g.
needlestick injury) to HIV-infected blood in a healthcare setting is about 3 per 1,000 injuries (0.3%).
This risk is lower after mucous membrane exposure (e.g. exposure of the eye) or broken skin (e.g.
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 17 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
eczema) and it has been considered that there is no risk of HIV transmission when intact skin is
exposed to HIV-infected blood.
Why should I take PEP?
Although the risk of acquiring HIV in a healthcare setting is extremely low, a very small number of
healthcare workers have become infected from an occupational exposure. Taking prophylactic
treatment may significantly reduce this risk but cannot eliminate it. PEP is not a cure for HIV; rather
PEP may prevent HIV from entering the cells in your body and so prevent you from becoming
infected with HIV.
How do I make a decision when I do not know if the source was infected with HIV?
In many cases it will not be possible to find out whether the source (i.e. the person you sustained
the injury from/were exposed to) is HIV-positive when you are making the decision to start PEP.
You must discuss whether your exposure has put you at significant risk of HIV infection with the
prescribing doctor.
The Department of Health (DoH) recommends PEP for healthcare workers who have had a
significant occupational exposure to blood or other potentially infectious material from a patient or
other source known to be HIV infected or considered to be at high risk of infection. A significant
exposure is defined as:
 Percutaneous injury (e.g. from needles, instruments, significant bites which break the skin)
 Exposure of broken skin (e.g. eczema, cuts, abrasions)
 Exposure of mucous membranes, including the eye
The DoH does NOT recommend PEP:
 After an exposure through any route with low risk materials e.g. saliva, urine, faeces or vomit
unless visibly bloodstained (e.g. saliva associated with dentistry)
 If a risk assessment has concluded that HIV infection of the source is highly unlikely
 Where the source is known to be HIV-negative
 If the source is known to have an undetectable viral load (<200 copies HIV RNA/mL). However,
PEP should be offered to those who are anxious about the risk of infection.
Where a risk assessment suggests that HIV infection of the source is a potential risk, a request will
be made to test the source for HIV. However, it may not always be possible, or appropriate, to
perform a test. In this case it will be up to you to decide whether to continue treatment after further
discussion with your occupational health department (if occupational injury) or Integrated
Contraception and Sexual Health (iCaSH) Consultant. You will need to balance the relative risk of
transmission against the possibility of side effects of the medication.
If you decide not to start treatment you can still discuss this with an iCaSH Clinician or your
occupational health physician at a later date, although commencing PEP is generally not
recommended beyond 72 hours post exposure.
If it is not possible to trace the source of my injury/exposure, should I still consider taking
PEP?
In the majority of cases where the source of the exposure is completely unknown, the risk of HIV is
so low that PEP should not be recommended. If you would still prefer to take treatment then you
should discuss this with the prescribing doctor. You can always stop treatment at a later date after
further discussion with your occupational health service or an iCaSH clinician (0300 300 3030)
What is the recommend PEP regimen?
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 18 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
The current guidance from the DoH is to use the combination of Truvada® (tenofovir disoproxil and
emtricitabine) and raltegravir (Isentress®), taken as follows:
Medicine
Truvada® tablets
(Tenofovir disoproxil 245mg + emtricitabine
200mg)
Raltegravir 400mg tablets
Morning
Take ONE tablet
Evening
-
Take ONE tablet
Take ONE tablet
TWELVE HOURS apart
However, in some situations, for example if you are pregnant, it may be appropriate to use
alternative medications. In addition, if the needlestick injury/exposure was from a known HIV
patient currently on treatment for HIV, your prophylactic regimen may be different and you should
contact the local HIV specialist team to discuss the options. It is important to be aware that these
drugs are not licensed for this indication.
This medication should be started as soon as possible after exposure (preferably within ONE hour)
and it should be continued for 28 days. PEP is generally not recommended beyond 72 hours post
exposure.
How should I take this medication?
 It is important that the tablets are taken at the same time each day and try to leave 12 hours
between the morning and evening doses of raltegravir.
 Swallow the tablets whole with plenty of water. It is important that they are not chewed, crushed
or split as this may affect how the medicine works. They can be taken with or without food.
 You may drink moderate amounts of alcohol (i.e. within normal recommended safe limits) while
taking this medication
 This pack contains FIVE days supply only, but PEP will normally need to be continued for 28
days. You must arrange an appointment with your occupational health service or the iCaSH
clinic as soon as possible for further supplies and advice.
What are the possible side effects of the Truvada ® and raltegravir?
 The most common side effects of Truvada® and raltegravir are nausea, diarrhoea, headache,
dizziness and insomnia. These usually settle if you keep taking the medication as directed, but
medication to prevent sickness or diarrhoea, or simple painkillers, may help. However, if you
experience side effects, speak to your occupational health doctor or iCaSH Norfolk as it may be
possible to prescribe alternative medication.
 Serious side effects are rare and include allergic reactions. The medication may also cause liver
and kidney problems and thinning of the bones, but this usually only occurs with long-term
treatment (i.e. lasting several years).
What should I do if I forget the take the tablets or miss a dose?
It is very important that you do not miss any doses of this medication since this could reduce the
it’s effectiveness. If you do forget to take a dose, take it as soon as you remember and take the
next dose at the normal time. However, do not take two doses at once if you have missed a dose
altogether; just take the next dose at the usual time.
I am taking other medication; can I still take PEP?
Truvada® and raltegravir can interact with other medicines and it is important that you tell the
prescribing doctor all the medication you currently take. This includes anything you buy ‘over-theAuthor/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 19 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
counter’ at a pharmacy, such as any herbal or complementary medications, and also any
recreational drugs. It is also important that you check with a doctor or pharmacist before starting
on any new medicines whilst taking Truvada® and raltegravir.
Are Truvada® and raltegravir safe to take in pregnancy and breastfeeding ?
 You must tell your doctor if you are, or could be, pregnant. If you are uncertain, a pregnancy test
is recommended. If you are pregnant, or at risk of pregnancy, then a different combination of
medicines may be prescribed.
 You should not breast feed while taking these medicines.
Do I need to take any other precautions whilst on PEP?
 You should take precautions to avoid becoming pregnant, or fathering a child (e.g. using a
condom/femidon) while taking these medicines and until your follow-up with the iCaSH clinic is
complete (i.e. until you have results of the 6-month blood test to confirm your HIV status)
 You should also avoid taking part in any procedure which could place others at risk of blood
borne infections. This should be discussed with your occupational health service or with the
iCaSH clinic
 If you need any further information, or have any questions, please contact your occupational
health service (for NNUH employees Workplace Health and Wellbeing on 01603 287035or Ext.
3035 if calling internally) or the iCaSH Norfolk on 0300 300 3030.
Appendix 2: Drug Interactions
Antiretroviral medication may have potentially serious interactions with other
prescription or non-prescription drugs. This can affect patient safety and the
effectiveness of PEP.
The following tables give information on potential drug-drug interactions with raltegravir and
Truvada®, and the appropriate action to take. Please note that this list is not exhaustive and any
decision to delay PEP treatment or prescribe an alternative drug combination should be made
under the direction of a specialist clinician. Please contact the Pharmacist at iCaSH Norfolk on
0300 300 3030 or Medicines Information (Bleep 0500) or the on-call Pharmacist (out-of-hours only)
for further information regarding the appropriate management of drug-drug interactions.
Key:

Safe to give Truvada®/raltegravir

Caution. Give Truvada®/raltegravir but see warning notes and seek further
specialist advice as necessary at the earliest opportunity.

Do not give Truvada®/raltegravir. Speak to iCaSH Consultant as soon as
possible.
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 20 of 36
Trust Guideline for the Management of Incidents which have the potential to
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AntiCo-administered Drug
Retroviral
Drug
Raltegravir
Antacids
Anti-coagulants
Antiepileptics
Antimicrobials
Action Notes
Aluminium
&/or
magnesium
containing
Calcium-carbonate
containing
Warfarin
Carbamazepine
Phenobarbital/
Primidone
Phenytoin
Rifampicin
Rifabutin
H2-receptor
blockers
HCV antivirals
Famotidine
Boceprevir
Telaprevir
Hormonal
Contraceptives
Methadone
Estrogenand/or
progesterone-based
Multivitamin preparations containing
polyvalent cations












Orlistat
Proton-pump
inhibitors
St John’s Wort

Omeprazole
Anti-Retroviral Interacting Drug
Drug
Truvada® (tenofovir/ Adefovir
emtricitabine)
Acetazolamide
Analgesics
Aspirin
(NSAIDS)
Celecoxib
Diclofenac
Ibuprofen
Mefenamic acid
Naproxen
Piroxicam
Antibacterials Amikacin
Cefotaxime
Gentamicin (IV/IM)
Neomycin
Streptomycin
Tobramycin
If required, suggest switching to calciumcontaining antacid
Potential for  raltegravir plasma concentrations.
If co-administration unavoidable, seek advice from
pharmacist & consider need for therapeutic drug
monitoring of raltegravir
Plasma concentration of raltegravir .
Consideration should be given to doubling
raltegravir dose to 800mg BD. Seek advice from
pharmacist
Potential for  raltegravir plasma concentrations.
Suggest withholding multivitamin preparations
whilst taking raltegravir
Potential for  raltegravir plasma concentrations.
Suggest withholding orlistat whilst taking
raltegravir.


Action Notes

Co-administration of tenofovir with adefovir
contra-indicated

Truvada® is renally excreted; co-administration
with drugs that  renal function or compete for
active tubular secretion may  plasma
concentration of Truvada® and/or  plasma
concentration of other renally excreted drugs (
risk of side effects/toxicity). If concurrent use
unavoidable, monitor renal function closely and
monitor for  side effects/toxicity of either drug.
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
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Page 21 of 36
Trust Guideline for the Management of Incidents which have the potential to
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Vancomycin
Antifungals
Amphotericin
Flucytosine
Antiprotozoals
Antivirals
Pentamidine (IV)
Aciclovir
Cidofovir
Famciclovir
Foscarnet
Ganciclovir
Valaciclovir
Frusemide
Hydralazine
Cimetidine
Diuretics
H2-receptor
antagonists
Immunosuppressants
Penicillamine
Cytotoxics
HCV antivirals
Immunomodulating
drugs
Probenecid
Ciclosporin
Mycophenolate
Sirolimus
Tacrolimus
Carboplatin
Cisplatin
Dacarbazine
Ifosfamide
Mesna
Methotrexate
Oxaliplatin
Capecitabine/
fluorouracil
Boceprevir
Ribavirin
Simeprevir
Sofosbuvir
Telaprevir
Interferon alfa/
pegylated
interferon alfa-2a
Interleukin 2
(aldesleukin)


Monitor for  fluorouracil-associated adverse
effects


Monitor for  tenofovir-associated adverse
effects
Monitor for treatment-associated toxicities,
including hepatic decompensation and anaemia

Monitor for  tenofovir-associated adverse
effects
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 22 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
APPENDIX 3 - RECIPIENT CONSENT FORM FOR POST EXPOSURE
PROPHYLAXIS AGAINST HIV INFECTION
1. I consider that I have/have not* had a significant exposure to blood or body fluids
potentially infected with HIV.
2. I have considered the advice offered and have read the patient information leaflet and
have decided to take/not to take* Post Exposure Prophylaxis.
*Delete as appropriate
3. I have been made aware of, and have considered, the toxic effects of these drugs and I
am aware that some of the long term side effects are unknown.
4. I am aware that the drugs may significantly reduce the chance of becoming infected
with HIV but cannot eliminate it.
5. I have provided information on all medication I take (including that which has not been
prescribed by a doctor) and have been advised not to start any new medication without
discussing this with a doctor or pharmacist.
6. FEMALE STAFF ONLY (delete whichever is inappropriate)
a) I am not aware that I am pregnant and, if unsure, have been advised to test
appropriately. I will also take suitable contraceptive precautions whilst on treatment.
b) I am, or could be, pregnant and have listened to the advice offered by A&E,
Workplace Health & Wellbeing or iCaSH Norfolk.
7. I am aware of the importance of practising safer sex (use of condom/femidom) and of
the importance of avoiding taking part in procedures which could put others at risk of
HIV, until further results are available.
8. a) NHS trust staff and other Health Care Workers where support is provided
through an Occupational Health Department:
I agree to be followed up confidentially by an Occupational Health advisor on the NEXT
DAY followed by the Occupational Health doctor within the next FIVE days. I will
contact them as soon possible.
b) All other:
I agree to be followed up confidentially by the iCaSH Norfolk within the next FIVE days.
I will contact them as soon as possible.
Signed by patient………….………………………. Date (dd/mm/yyyy) ………………………
Name (please print)
……………………... Date of Birth ………… Employer
A & E: Please send this form confidentially to either Occupational Health (if NNUH staff member) or
iCaSH clinic, 1a Oak street, Norwich, NR3 3AE
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
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Page 23 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
APPENDIX 4 Source Patient Consent Form for Source Testing following a Blood Exposure Incident
Incident date:…………………………………………………... Location:………………………………………….
Introduction
It can be very frightening for health care staff when blood or body fluids contaminate them at work. Very rarely
blood contains viruses, which can be contagious if they come into contact with damaged skin or through an
accidental sharps injury (e.g. from a needle) or even from splashes to the eyes or mouth
The Help We Need
When a member of staff is contaminated with blood or body fluids they themselves may require treatment. In
deciding which treatment is best we need your help in allowing us to check your blood for three important viruses,
Hepatitis B, C and HIV.
It is Trust policy for us to approach ALL patients in this situation.
The chance of any of these viruses being present in your blood is extremely rare. However, should this be the case,
your Doctor will tell you and, if necessary, arrangements will be made for further care. Negative results will be
confirmed in writing to you.
People often worry that if they have a HIV test, this will affect any later request for life insurance etc. The position of
the Association of British Insurers is that insurance companies should not ask whether you have had an HIV test.
They should only ask if you have had a positive HIV test or are receiving treatment for HIV/Aids. Therefore a
negative HIV test taken purely because someone may have been exposed to your blood should have no impact on
a future request for insurance. Thank you for your assistance.
CONSENT
Name ………………………………………… Hosp/NHS No:……………………DOB…./……/……
Address…………………………………………………………………………………………………….
Home telephone Number…………………………..Ward number (if applicable)…………………
GP Name ……………………………………………………………………………………………………
Address …………………………………………………………………………………………………….
Have read this form and give consent to a blood sample being taken or a previous appropriate sample used and
tested for the Blood Borne Viruses:
Hepatitis B Virus, Hepatitis C Virus and Human Immunodeficiency Virus (HIV)
I understand that this request is being made only as part of the management of an incident of an individual who has
been accidentally exposed to my blood or other body fluid.
I consent to the results of these tests being made known to the injured member of staff and information recorded in
their Occupational Health record, also for my General Practitioner/Consultant to be informed.
OR
I do not consent to these blood samples being taken.
(Delete whichever statement does not apply) NB: you may withdraw your consent to this blood test at any time
Signature:………………………………………………….. Date (dd/mm/yyyy)…………………………
This form needs to be retained in the patients hospital records/case notes & a copy faxed to Workplace Health & Wellbeing on 01603
287026.
APPENDIX 5
Parent/Guardian Consent Form for Source Testing following a Blood
Exposure Incident
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
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Date of issue: 17/09/2015
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Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
Incident date: ………………………………………. Location:………………………………………..
Introduction
It can be very frightening for health care staff when blood or body fluids contaminate them at work. Very rarely blood
contains viruses, which can be contagious if they come into contact with damaged skin or through an accidental sharps
injury (e.g. from a needle) or even from splashes to the eyes or mouth.
The Help We Need
When a member of staff is contaminated with blood or body fluids they themselves may require treatment. In deciding
which treatment is best we need your help in allowing us to check your blood for three important viruses, Hepatitis B, C
and HIV.
It is Trust policy for us to approach ALL patients or Parents/Guardians in this situation.
The chance of any of these viruses being present in your child’s blood is extremely rare. However, should this be the
case, your Dr will tell you and if necessary arrangements will be made for further care. Negative results will be confirmed
in writing to you.
People often worry that if they have a HIV test, this will affect any later request for life insurance etc. The position of the
Association of British Insurers is that insurance companies should not ask whether the child had an HIV test. They should
only ask if you have had a positive HIV test or are receiving treatment for HIV/Aids. Therefore a negative HIV test taken
purely because someone may have been exposed to your blood should have no impact on a future request for insurance.
Thank you for your assistance
PARENT/ GUARDIAN CONSENT
Child……………………………………………Hosp/NHS No:…………………….DOB…./……/……
Name………………………………………Relationship to child……………………………………….
Address……………………………………………………………………………………………………..
Home telephone Number…………………………..Ward number (if applicable)………………….
GP Name ……………………………………………………………………………………………………
Address …………………………………………………………………………………………………….
I have read this form and give consent to a blood sample being taken from the above child or a previous appropriate
sample used and tested for the Blood Borne Viruses:
Hepatitis B Virus, Hepatitis C Virus and Human Immunodeficiency Virus (HIV)
I understand that this request is being made only as part of the management of an incident of an individual who has been
accidentally exposed to the above child’s blood or other body fluid.
I consent to the results of these tests being made known to the injured member of staff and information recorded in their
Occupational Health record, also for my General Practitioner/Consultant to be informed.
OR
I do not consent to these blood samples being taken.
(Delete whichever statement does not apply) NB: you may withdraw your consent to this blood test at any time
Signature:………………………………………………………………….... Date (dd/mm/yyyy)……………………
This form needs to be retained in the patients hospital records/case notes & a copy faxed to Workplace Health & Wellbeing
on 01603 287026
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 25 of 36
We recognise this may be an anxious time for you therefore if
you have any concerns please write them down and discuss
them with an Occupational Health Adviser.
Useful Telephone Numbers
ICaSH Norfolk 0300 300 3030
A&E Dept: 01603 287325
Information for staff who have
experienced a blood/body fluid
exposure incident
Preventing Blood/Body fluid exposure incidents

Never re-sheath a needle

Always ensure sharps bins are assembled correctly

Always ensure you have a sharps bin next to you
when you carry out a procedure on a patient

Temporarily close your sharps bin between use

Do not fill the sharps bin to more than 75% of its
capacity or above the fill line

Sharps should never be passed hand to hand

Use appropriate Personal Protective Equipment,
gloves mask or goggles

Level 1 , 20 Rouen Road, Norwich, NR1 1QQ
Tel: 01603 287035 - Fax: 01603 287026
Cover cuts and grazes with waterproof dressings
U/Draft/WS Source Testing Guideline (12)
26
This advice leaflet has been given to you because you have
experienced a blood/body fluid exposure incident.
If I have been supplied PEP what happens now?
When you contact Workplace Health & Wellbeing they
will ensure that the relevant blood tests are taken and
The Accident & Emergency Department will have already
provide you with additional advice regarding the risks
completed an initial assessment and advised you on any further
associated with Hepatitis B and C.
medication, which is called Post Exposure Prophylaxis or PEP.
You must ensure you have read your PEP information
Further Information
sheet and taken the medication as directed. If you
You can obtain further information about Blood Borne Viruses in
experience any nausea or other side effects please let
section 3.7 of the Trust Guideline for the Management of
the Occupational Health Adviser know.
Incidents which have the potential to transmit Blood Borne
Viruses (found on the Trust Intranet).
You will also be seen by Workplace Health & Wellebing
within the next working day to discuss ongoing
What else do I need to do?
medication.
You are now required to contact Workplace Health & Wellbeing
for further advice and assessment between the following times:
Will the patient’s blood be tested for Blood Borne
Viruses?
Monday – Friday excluding Bank Holidays
Yes – If the patient is able to provide informed consent
08.30 – 17.00
the source patient will be requested to have their blood
01603 287035 or ext: 3035
tested to check they are not a carrier of a Blood Borne
Virus. You will be advised of the results.
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 27 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
Appendix 7: PEP PROFORMA
Please complete and send to either Workplace Health & Wellbeing (for NNUH Trust staff) or iCaSH Norfolk,
1a Oak Street, Norwich, NR3 3AE depending on the patient. If the details are unknown, please write
unknown.
Patient Details
Name
Date of Birth
Date of Consultation
Past Medical
History
Drug History
Menstruation
& Pregnancy
(go straight to
Risk Exposure if
not applicable)
Date of Last Menstrual Period
Method of Contraception
Pregnancy testing
Has a pregnancy test been done?
Yes

No
 If YES, state result:



Positive
Risk Exposure
Negative
Type of Injury
Time & Date of Exposure
Source
Post Exposure
Prophylaxis
(PEP)
Has PEP been recommended?
Yes 
No 
 If yes, state recommended treatment: …………………………..
………………………………………………………………………..
 If no, state reason: …………………………………………………
………………………………………………………………………..
Time of 1st dose:
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 28 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
Investigations (to be completed by Workplace Health & Wellbeing or iCaSH Norfolk)
(Please tick/sign as appropriate)
Investigation
Date
3 to 28 days
Baseline
12 weeks after
PEP
completion
HIV
Hepatitis A IgG
*NR WHWB / A&E
Hepatitis B
Hepatitis C
**
Syphilis
NR WHWB / A&E
STI screen
* NR WHWB / A&E
Full Blood Count
*****
***
*****
*****
*****
*****
Liver function tests
U&E
Glucose
Lipids
Urinalysis/uPCR
Pregnancy test
*
**
***
****
*****
N/R WHWB / A&E
*****
MSM without history of vaccination
HCV RNA at 28-42 days in those with known HCV status
HCV RNA in those with known HCV exposure
If symptoms
If appropriate
Appendix 8 - Background Information for Health Care Workers (HCW) on Blood
Borne Viruses
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 29 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
Human Immunodeficiency Virus (HIV)
Source:
Found in almost all body fluids. Only blood and blood products,
semen, vaginal secretions, donor organs and tissues and breast milk
have been implicated in transmission.
UK Population
Transmission: Men who have sex with men.
Injecting drug users.
Men and women who have lived as adults in countries where
heterosexual transmission is common e.g. South, East or Central Africa
(notably Sub Saharan Africa).
Infants with HIV infected mothers or adults with HIV infected sexual
partners.
Occupational
Transmission:
To HCW
‘Average’ transmission risk for blood related sharps injury is 0.3%, for
mucous membrane exposure is 0.09% (likely even lower for non-intact
skin exposure). Risk also greater for patients with terminal HIV illness,
but viral load assessment of source patient is not established as a means
for assessing risk of transmission.
From HCW
Transmission has occurred from Health Care Workers undertaking
exposure prone procedures, but only very rarely.
Immunisation: Unavailable.
Post-exposure
prophylaxis: If source is known to be infected or considered to be at risk but not yet
tested a 4 week course of anti-HIV drugs is indicated. High likelihood of
side effects. Used only on advice of occupational physician.
Hepatitis B Virus (HBV)
Source:
Found in virtually all body fluids. Blood, semen and vaginal fluid mainly
implicated in transmission.
May survive in dried blood at room temperature for at least 1 week.
UK Population
transmission: Unprotected sexual intercourse
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 30 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
Inoculation of infected blood - shared injecting equipment amongst drug
users.
From infected mother to baby perinatally.
Occupational
Transmission:
To HCW
Sharps injury, splash onto mucous membrane (eyes or mouth), splash
onto broken skin
Risk of clinical hepatitis for sharps injury up to 30% for e-antigen positive
source, 6% for e-antigen negative source, although the risk of developing
serological evidence of infection may be substantially higher in both
groups. In a given incident risk depends on viral load of source patient
(not routinely assessed) and the extent of contact with the infected fluid.
From HCW
Transmission has occurred from HCW undertaking exposure prone
procedures and those working in renal dialysis units. Workplace Health &
Wellbeing will test the HCW (as the Source Patient) for levels of
infectivity.
Immunisation: Available and effective.
Post-exposure
prophylaxis:
For non-immune recipients If source known to be infected specific HB
immune globulin (HBIG). For all occupational incidents, whether known
infected source or not, unprotected individuals should be given
accelerated course of vaccination. Protection from HBIG or post
exposure vaccination alone up to 75%, increasing up to 95% if
combined.
Hepatitis C Virus (HCV)
Source:
Blood mainly implicated in transmission.
Data on environmental viability limited.
UK Population
Transmission:
Inoculation of infected blood - shared injecting equipment amongst drug
users. Main risk group.
Unprotected sexual intercourse (low risk).
From infected mother-to-baby perinatally (low risk).
Is identified in individuals without obvious high risk factors.
Occupational
Transmission:
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 31 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
To HCW
Sharps injury, splash onto mucous membrane (eyes or mouth), splash
onto broken skin.
‘Average’ incidence of anti-HCV seroconversion for sharps injury 1.8%.
Actual risk depends on viral load of source patient. Risk seems very low
if source has undetectable virus on PCR test.
Transmission rare from mucous membrane exposure to blood and no
transmission in HCW documented from intact or non-intact skin
exposures to blood.
High risk of infection in intravenous drug users.
From HCW
Transmission has occurred from HCW undertaking exposure prone
procedures
Immunisation:
Not available.
Post-exposure
prophylaxis:
No evidence to support an effective PEP regime. Early treatment of
established infection may result in higher ‘cure’ rate.
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 32 of 36
Trust Guideline for the Management of Incidents which have the potential to transmit Blood Borne Viruses
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 33 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
Monitoring Compliance / Effectiveness Table
Element to be
monitored
(For NHSLA
documents this must
include all Level 1
minimum
requirements)
Lead
Responsible
for
monitoring
Appendix 9 .
Monitoring
Tool /
Method of
monitoring
Frequenc
y of
monitorin
g
Lead
Responsible for
developing
action plan &
acting on
recommendation
s
Reporting
arrangements
(Title needed
& name of
individual
where
appropriate)
(Committee or
group where
monitoring
results and
action plan
progress are
reported to)
Any blood and
body fluid
exposure
incidents from a
positive HIV, Hep
B, C source will
be reported by
WHWB to HSE,
Public Health
England
Karen
Carpenter
Audit
3 yearly
Karen
Carpenter
WHWB
Clinical
Governance
All NNUH staff
who commence
PEP will be
followed up in line
with these
guidelines by
WHWB
Mark Ferris
Audit
2 yearly
Mark Ferris
WHWB
Clinical
Governance
Sharing and
disseminating
lessons learned
& recommended
changes in
practice as a
result of
monitoring
compliance with
this document
The Lead
responsible for
developing the
action plans
will
disseminate
lessons
learned via the
most
appropriate
committee e.g.
Clinical Safety
Executive
Sub-Board,
Non-Clinical
Safety
Executive
Sub-Board,
Workforce
Executive
Sub-Board,
Executive
Board or Trust
Board.
REFERENCES
Children’s HIV Association (HIVA) (2005) www.bhiva.org/chiva/
UK guideline for the use of post-exposure prophylaxis for
HIV following sexual exposure (2011)
http://www.bashh.org/documents/4076.pdf?WebsiteKey=f0a15fa5-2171-4d81-af9b110c7068d66b&hkey=faccb209-a32e-46b4-8663-a895d6cc2051&=404%3bhttp%3a%2f
%2fwww.bashh.org%3a80%2fBASHH%2fGuidelines%2fGuidelines%2fBASHH
%2fGuidelines%2fdocuments%2f4076.pdf
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 34 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
EAGA guidance on HIV post-exposure prophylaxis
Change to recommended regime for post exposure prophylaxis (sept 2014)
https://www.gov.uk/government/publications/eaga-guidance-on-hiv-post-exposureprophylaxis
EAGA guidance on HIV post-exposure prophylaxis
Recommendation for HIV post-exposure prophylaxis (PEP) following occupational
exposure to a source with undetectable HIV viral load.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/275060/EA
GA_advice_on_PEP_after_exposure_to_UD_source_Dec13.pdf
Department of Health (Revised 2008) HIV Post exposure prophylaxis: Guidance from the
UK Chief Medical Officer’s Expert Advisory Group on AIDS; Department of Health
Publications, London.
Department of Health (2002) Getting ahead of the curve: a strategy for combating
infectious diseases (including other aspects of health protection); Department of Health
Publications, London
Expert Advisory Group on AIDS (2014) Change to recommended regimen for postexposure prophylaxis (PEP). Department of Health, London
Health and Safety Executive. (1995) A guide to the Reporting of Injuries, Diseases and
Dangerous Occurrences; HSE Books, Sudbury.
Jackel et al (2001), Treatment of Acute Hepatitis C with Interferon Alfa-2b, N. Eng. J Med
Nov 15 (20); 345: pg;1452-1457.
Norfolk and Norwich University Hospital NHS Trust Guidelines: The Management of
Isolation Procedures (2005), Guideline Reg No B1, Infection Control Manual pg 6.
NHS Employers - The Management of health, safety and welfare issues for NHS staff
2005, Chapter 18. Blood Borne Viruses. www.nhsemployers.org/employment
MSD (2005) Summary of product characteristics, Indinavir, Crixivan Summary of Product
Characteristics
Public Health Laboratory Service data (2005), www.phls.co.uk
Bibliography:
Centre for Disease Control and Prevention (2001), Updated US Public Health Service
guidelines for the management of Occupational Exposures to HBV, HCV and HIV and
recommendations for Post exposure Prophylaxis. MMWR June 29, Vol 50 No: RR11 1-43.
Hawkins D et al (2005). Guidelines for Management of HIV infection in pregnant women
and prevention of Mother to child transmission of HIV. HIV Med Jul; 6 Suppl 2: pg. 107-48.
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 35 of 36
Trust Guideline for the Management of Incidents which have the potential to
transmit Blood Borne Viruses
Tokars JI, Marcus R, Culver DH, et al (1993). Surveillance of HIV infection and
Zidovudine use among health care workers after occupational exposure to HIV infected
blood. Ann Intern Med June 15; 118(12) : 913-9
Care worker exposures to HIV and recommendations for post exposure prophylaxis,
MMWR 1998; 47 (No. RR-7)
Department of Health 1996, Guidelines for pre test discussion on HIV testing, Department
of Health Publications, London.
Author/s:
Dr Hilliard, Wendy Sharp, Hilary Winch
Valid until:
17/09/2018
Document:
Incidents with the potential to transmit Blood Borne Viruses guideline
Copy of complete document available from: Trust intranet
Date of issue: 17/09/2015
Guideline Ref No: CA4003 / V5 id 1260
Page 36 of 36