Download Management of inoculation injuries including needle stick, scratches

Document Reference: HS.IC/005/13
Title:
Management of inoculation injuries including needle stick,
scratches, bites and other bodily fluid exposure
Purpose:
The policy gives details of the clinical risk assessment and the
actions to be taken for the clinical management of staff when
they present with an inoculation or significant exposure to blood
or body fluids.
Applicable to:
Staff, including volunteers, contractors, students, agency. The
principles of management outlined also apply to exposed members
of the public.
Document Author:
Senior Occupational health Nurse Advisor. Occupational Health
adopted and reviewed and adapted by Infection Prevention and
Control PCH & CFT
Ratified by and Date:
Sharon Linter – Director of Quality and Governance / Executive
Nurse
1 May 2013
Review Date:
6 months prior to the expiry date
December 2015
Expiry Date:
See version control table
3 years after ratification unless there are any changes in legislation
or changes in clinical practice
Policy library location:
A11 Infection Prevention and Control
Related legislation
national guidance:
and  United Kingdom Surveillance of Significant Occupational
Exposures to Blood borne
 Viruses in Healthcare Workers. Health Protection Agency
November 2008
 FOM SEQOHS Standards of Accreditation D 1.1 January
2010
 HIV Post Exposure Prophylaxis : Guidance from the UK Chief
Medical Officers'
 Expert Advisory Group on AIDS. UK Health Departments. Feb
2004.
 EU Directive on the Prevention of Sharps Injuries in the Hospital
and Health Sector, The Directive becomes legally binding on May
11th 2013.
 Human Tissue Act 2004
 Reporting of Injuries, Diseases and Dangerous Occurrences
Regulations 1995 (RIDDOR),
 Code of Practice for the Prevention and Control of Healthcare
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Document Reference: HS.IC/005/13
Associated Infections (HCAI) 2008.
 Control of Substances Hazardous to Health Regulations 2002
 Health and Safety at Work Act 1974
 EFA/2013/001 Sharps and sharps containers transported in
staff vehicles
Associated Trust Policies  A11 Infection Prevention and Control
and Documents:
 Trust Incident Management Policy
 Trust Consent Policy
 Trust Capacity Policy
Equality Impact
Assessment:
The Equality Impact Assessment Form was completed on 04.11.12
Training Requirements:
Inoculation injury is part of the compulsory E-Learning package. in
accordance with the corporate training needs analysis. Completion
of training within the E-learning package is monitored electronically
through reports run by the Workforce and Learning Department. On
completion the register is sent to the Workforce and Learning
Department for recording to inform the compliance database.
Face to face practical assessment of hand hygiene also makes
reference to the management of inoculation injuries, attendance is
monitored as above.
Compliance and reporting is monitored through The Induction
Policy and One Stop Process. Non compliance is reported to line
managers and via a monthly report to the Performance Information
Monitoring Meeting to enable monitoring of teams. These
compliance reports apply for both temporary and permanent staff.
Information in regard to the reporting arrangements for all types of
inoculation injury are discussed during the hand hygiene practical
sessions.
Persistent non compliance would be a breach of contract and
therefore may result in the disciplinary process being applied.
The organisation trains staff in line with the requirements set out in
its training needs analysis and published in its Corporate
Curriculum.
Training which is categorised as statutory or essential must be
completed in line with the training needs analysis and Corporate
Curriculum.
Compliance with statutory and essential training is monitored
through the Learning and Development team with monthly
manager’s reports and staff individual training records twice yearly.
Training reports are also submitted quarterly through the Trust
Quality and Governance Committee Meeting.
Staff failing to complete this training will be accountable and could
be subject to disciplinary action.
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Document Reference: HS.IC/005/13
Monitoring Arrangements:
The effective implementation of this Policy will be monitored by the
Infection Prevention and Control Committee. Required action and
completion of tasks will also be monitored through this committee.
Areas of non compliance will be dealt with by the Director
/Associate Director for each service line.
OH will report contact from staff in regard to inoculation injuries
to the Infection Prevention and Control Committee. Trends of
high incidence will be highlighted as appropriate and brought to
the attention of the IPCT team and Associate Director for the
relevant service line.
The governance team will provide for the Infection Prevention
and Control committee a summary of incidents for analysis.
The infection Prevention and Control team will audit compliance of
this policy - using the audit tool agreed through the IP&CC in
response to incidents, at the frequency stated for each individual
service line and support services, in accordance with the annual
infection prevention programme. Audits will be submitted to the
Infection Prevention and Control Committee as tabled, stating areas
of non compliance and concern for required action.
Implementation:
The content of this policy will be highlighted through the hand
hygiene practical sessions and compulsory training.
Version Control
Version
V1
Date Reviewed
June 2007
V2
June 2009
V3
April 2011
V4
Nov 2011
V5
April 2013
June 2016
January 2017
Changes
Major review, document published
and ratified
Minor review, document published,
but not ratified by HR Director
Full review and consultation
By Whom
Dr Julian Smith OHP
Dr Julian Smith OHP
Barbara McCormack
Senior OHNA
G Dinnis
Minor review, to reflect review of
incidents
Minor review to reflect alert G Dinnis
EFA/2013/001 Sharps and sharps
containers transported in staff
vehicles and update of flow chart
Policy extended 6 months
Policy extended 6 months
EMG
This document can / cannot be released under the Freedom of Information Act.
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Document Reference: HS.IC/005/13
This document can be accessed and printed via the Intranet Document Library and
the Trust Website
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Document Reference: HS.IC/005/13
Contents
Management of Needle stick/Contamination Injury by Injured Person ............................................ 6
1.
Introduction ......................................................................................................................... 6
2.
Purpose of this Policy.......................................................................................................... 7
3.
Scope.................................................................................................................................. 7
4.
Definitions / Glossary .......................................................................................................... 7
5.
Ownership and Responsibilities .......................................................................................... 8
6.
Standards and Practice ....................................................................................................... 9
Appendix 1 – Minimising the Risks of Needle stick Injuries/Incidents ............................................ 14
Appendix 2 – Assessing „source patient‟ risk by manager/ nominated person and how to ask for
consent to take bloods from the source. ....................................................................................... 17
Identification and Risk of Transmission ......................................................................................... 18
Appendix 3 – Royal Cornwall Hospital NHS Trust Needle stick/Contamination Reporting Form ... 22
Appendix 4 – Examples of Completed Microbiology Forms .......................................................... 25
Appendix 5 – Table for testing blood from Needle stick Recipient/HCW ....................................... 26
Appendix 6 – Needle stick injury conclusion letter ........................................................................ 27
Appendix 7 – Management of Needle stick / sharp / contamination injury by injured person ......... 28
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Document Reference: HS.IC/005/13
Management of Needle stick/Contamination Injury by Injured Person
It is essential that you follow this procedure with the minimum delay – if HIV post exposure
prophylaxis (PEP) is required, this should, if at all possible be started within one hour of
the Needle stick/body fluid exposure incident
Body Fluid
Exposure Incident
FIRST AID
Splash contamination injuries to eyes and mouth –
Wash site immediately and thoroughly with water.
Splash or injury to skin –
Wash site immediately and thoroughly with soap and
water. Do NOT scrub the injured area and do not use
antiseptics.
Gently encourage puncture wounds to bleed by pinching
skin around the site of injury. Do NOT suck injury site
under ANY circumstances.
Needle stick
injury
Injury from
broken glass,
crockery,
razors used to
self arm
Spitting that
has entered
into eyes or
mouth, or onto
face.
A scratch or
bite that has
broken or
reddened the
skin.
IMMEDIATELY FOLLOWING FIRST AID
Telephone: 01872 250000
Ask for Needle stick Pager/Bleep, give your telephone
number and wait for the return call
Documentation – Make a note of the name, date of birth and hospital number of the source
patient involved. If he/she cannot be identified, where was the sharp located, how was the injury
sustained and which exact area of your body was injured/splashed
Inform Line Manager
Record on the electronic
incident reporting system
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Document Reference: HS.IC/005/13
1.
Introduction
Under Health and Safety legislation, Cornwall Partnership NHS Trust has a statutory responsibility
to minimise the risk of staff acquiring blood borne virus infection (BBV) following a significant
exposure to infected blood or body fluid.
This policy is aimed at all Trust employees who may experience a significant exposure to infected
blood and body fluids in the course of their duties, for example nursing staff, medical staff,
professions allied to medicine, laboratory staff, ancillary staff and facilities staff.
Under current Health and Safety legislation, staff who could be exposed to infection with blood
borne viruses should be subject to a risk assessment which should be documented and include
means to reduce the risks of such an incident occurring and reduce the potential for adverse
consequences developing from the incident. Inoculation and needle stick incidences will be
reviewed and reported via the Trust incident reporting system.
2.
Purpose of this Policy
The policy gives details of the clinical risk assessment and the actions to be taken for the
clinical management of staff when they present with an inoculation or significant exposure to
blood or body fluids.
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All Trust staff will have 24 hour access to competent staff that are able to assess
needle stick/inoculation injuries and exposures to body fluids, and give appropriate
advice.
All Trust staff will have 24 hour access to appropriate post exposure prophylaxis.
All Trust staff at risk of blood and body fluid exposures will be made aware of the
procedures to be followed after needle stick/inoculation injury or significant exposure
incident.
Occupational Health (OH), Hospital Infection Prevention and Control (HIC)
Microbiology, GU Medicine Department (GUM) and Emergency Department (ED) will
work together as a team to provide optimal care for the exposed member of staff.
Scope
This policy is aimed at all members of staff who have sustained a needle stick injury or body fluid
exposure incident (also known as „contamination or inoculation injury`) during the course of their
work, regardless of location. There is also guidance to minimise the risk of inoculation injury
occurring.
4.
Definitions / Glossary
Blood borne viruses (BBV’s) are viruses which are transmitted in the blood which may cause
disease in other people. The most common BBV‟s are Hepatitis B, Hepatitis C and Human
Immunodeficiency Virus (HIV).
Body fluid. This refers to any human secretion which could act as a source of blood borne
viruses. All exposures, whether through a penetrating injury or by splash onto eyes, mucosal
surfaces or abrasions will be defined as a „needle stick injury/body fluid exposure incident‟.
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Document Reference: HS.IC/005/13
The Needle stick/inoculation Injury is where a needle or sharp object, contaminated with blood
or other body fluid, penetrates the skin. For the purpose of this policy, this also includes human
bites and scratches that break the skin and mucosal surfaces, such as eye or mouth.
HIV Post Exposure Prophylaxis (PEP) This is treatment given to individuals who have had a
high risk incident involving blood or body fluids from a source known to be infected with HIV or
who is very likely to be infected with HIV.
Exposure Prone Procedures (EPP’s) are defined as any invasive procedure where risk of injury
to the person carrying out such a procedure could result in the patient‟s tissue being exposed to
the blood of the worker for example Theatre staff, Dentists etc.
Source/donor This refers to the human origin of the blood or body fluid.
Recipient This refers to the individual, Health Care Worker (HCW) who has experienced the injury
or exposure.
Sharps include; syringes, needles, scalpels, razor blades, broken glass or any other sharp
implement with the potential to cause a penetrating injury if not handled in a safe manner. For the
purpose of this policy it will also include bites and scratches.
Transmission is the passing of a micro-organism from an infected individual to a previously
uninfected individual.
5.
Ownership and Responsibilities
The Chief Executive is ultimately responsible for the Health and Safety and Welfare of the
personal working in the organisation and to others who may be affected by its undertakings. The
Chief Executive is responsible to the Board for compliance with this policy and has ultimate
responsibility for reducing risks to the organisation.
The Occupational Health (OH) through a SLA owns this policy and has the responsibility for
the operational implementation of the policy, including aftercare for staff who have sustained a
needle stick injury, auditing and providing reports for management.
The Emergency Department (ED) play an integral part in supporting Trust staff (out of OH
opening hours) who have sustained a needle stick injury giving appropriate advice/treatment
following risk assessment.
The GU Medicine Department (GUM) play an integral part in assessing members of staff
following a high risk needle stick injury and offer HIV (PEP) as appropriate and including ongoing
care. GUM also informs OH and ED about HIV PEP policy changes and offer training for ED and
OH on prophylaxis matters.
The Department of Microbiology will process blood samples from the recipient and donor in all
cases of needle stick injuries when required, alerting OH to positive blood results in relation to HIV,
Hepatitis C and Hepatitis B. To give advice to ED (out of hours) if deemed necessary, e.g. HIV
PEP and Hepatitis B Immunoglobulin. Advising ED (out of hours) if deemed necessary, e.g. HIV
PEP & Hepatitis B Immunoglobulin.
Infection Prevention and Control (IPC) offer advice to OH on the infection control risks involved
in High risk incidents as required.
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Document Reference: HS.IC/005/13
The Pharmacy Department (RCHT) will ensure that emergency HIV PEP packs are kept within
RCHT hospitals are in date and contain appropriate drugs.
Role of the Managers
Line managers are responsible for:
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Ensuring that staff are aware of, and adhere to, this policy and that it is implemented
into clinical practice at all times.
Ensuring staff know how to access this policy.
Informing staff without electronic access to the policy on how to access it.
Ensuring that staff are given adequate protected time to access the immediate action
necessary to receive support from OH, GUM or ED in the event of an injury/incident.
Arranging and funding transport to GUM/ED/OH for needle stick recipients to avoid
delay as required.
Carry out an initial risk assessment of source/donor.
Acquiring consent from donor/source and arranging for bloods to be taken from donor
(This should not be done by the needle stick recipients). This role can be delegated to
an appropriate designated person.
Ensure that ongoing support is available for staff.
Ensuring that staff attends the mandatory annual Infection Prevention and Control
training.
Ensure that staff are minimising the risk of Needle stick injuries as advised in Appendix
1.
See also page 11 - Action by Manager/nominated person following a body fluid exposure
incident:
The Role of Individual Staff
All staff are responsible for:
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6.
Demonstrating adherence to this policy at all times.
Behaving in a safe and responsible manner taking all appropriate steps to minimise the
risks of transmission of Blood Borne Viruses (BBV‟s) See Appendix 1 for information
and advice.
Attending annual Infection Prevention and Control training.
In the event of sustaining a needle stick injury/body fluid incident follow the guidance
outlined in the Standards and Practice section below (All staff – Immediate Action
following a Needle stick injury/incident).
Recording incidents on Trust incident system.
All staff have a professional responsibility not to put patients at risk because of their
Blood borne virus status (E.g. HIV positive, HCV positive and HBV positive). This is
particularly relevant to staff who undertake Exposure Prone Procedures (EEP‟s)
Standards and Practice
The Action and Process outlined below must be followed in the event of a needle stick incident
occurring.
All Staff – Immediate Action Following a Needle stick Injury/incident
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Document Reference: HS.IC/005/13
Refer to Appendix 2 for Flow chart for the immediate management of a Needle stick injury/incident.
It is essential that you follow the following procedure with the minimum delay – if HIV post
exposure prophylaxis (PEP) is required, this should, if at all possible, be started within one
hour of the needle stick/body fluid exposure incident.
If you sustain a Needle stick/body fluid exposure during the course of work and are asked to
attend an ED, GUM or OH Department away from your site, arranging appropriate transport must
be made without delay. Funding to be approved by your immediate manager.
Carry out first aid immediately to reduce the risk of acquiring an infection as below:
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For splash contamination in the eyes or mouth wash the site immediately
thoroughly with water.
Where there has been a splash or injury to the skin, wash the site thoroughly with soap
and water.
Do NOT scrub the injured area and do not use antiseptics.
Gently encourage puncture wounds to bleed by pinching skin around the site of injury.
Do NOT suck injury site under ANY circumstances.
Phone 01872 250000 and ask for the ‘needle stick pager/bleep’. Give your
telephone number and await the return call.
Inform your line manager or appropriately qualified member of staff or nominated
person. They will assess the injury to determine whether it is significant, i.e. could
BBV‟s have been transmitted by this injury? If injury is significant, they will carry out a
risk assessment of the source patient see Appendix 3. In exceptional circumstances,
e.g. when nobody who is appropriately qualified is present this risk assessment may be
carried out by the recipient.
Make a note of the name, date of birth and hospital number of the source patient
involved. If he/she cannot be identified, make a note of where the needle stick/sharps
was, where it may have come from, how the injury was sustained, circumstances of
incident and any other information you consider may be relevant. You can use the
Needle stick/Contamination Reporting Form Appendix 4 to help prompt you for the
relevant details and can be used to help determine risk factors. This form will be
completed by ED or OH.
Inform OH/ED of the nominated person risk assessing the source patient.
You will be offered advice/treatment via ED/OH on appropriate management
dependant on risk factors.
During normal working hours OH will contact the individual to follow up the incident as
appropriate. Out of usual working hours and at the weekend the exposed member of
staff will be asked to contact ED for initial management of the incident.
You will be required to have a blood sample taken for storage and save; this can be
taken by an appropriately qualified nurse/doctor/phlebotomist. See appendix 6 for
instructions and an example of the microbiology form. (Use 5-10ml clotted yellow/buff
topped bottle).
Record the incident on the trust risk management system as soon as possible following
the incident/injury.
You will be contacted by OH the next available day that OH is open, if you have
previously been managed through ED and they will inform you of the next stage of the
process which will be in accordance with your source donor risk factors, you will also
be offered counselling.
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Document Reference: HS.IC/005/13
Action by the Emergency Department following a Needle stick incident
(From 4.15pm – 8.00am weekdays, Weekends & Bank Holidays)
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Hold the needle stick pager between 4.15pm – 8am, weekends and Bank Holidays.
See, assess and treat all needle stick recipients within the above hours.
Low Risk needle stick injuries – Take appropriate bloods for storage, See Appendix 5
for how to complete the microbiology form and ask the staff member to contact OH as
soon as possible within OH opening times for follow up.
High Risk incident – Offer PEP and counselling support. HIV PEP can give given by
GUM in normal working hours. ED should inform GUM at the earliest opportunity if
PEP has been started.
If PEP is commenced out of usual working hours, ED will inform the recipient that GUM
will be involved in their follow up case and ask them to contact GUM on the next
working day. This should be supported by a secure fax communication from ED to the
GUM.
Action by Occupational Health following a Needle stick incident
Occupational Health staff are responsible for:
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Answering the bleep in OH opening hours (8 am – 4.15 pm, Monday to Friday excluding
Bank Holidays.
Undertaking a risk assessment via see Appendix 3 to determine relevant risk factors.
Referring those at high risk of HIV to GUM urgently during normal working hours.
( within 1 hour)
Arrange for a blood sample from the recipient as soon as possible for storage and save.
See appendix 5 for completion of microbiology form.
Assess psychological impact of needlestick injury and offer counselling/support as
appropriate.
The appropriate prophylaxis for Hepatitis B vaccinations or HBIG will be offered in
accordance with the „HBV prophylaxis for reported exposure incidents‟ (found in the Green
book 2006), outlining if Hepatitis B vaccination or HBIG is more appropriate according to
the status of the exposed person and the source of the donor below.
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Document Reference: HS.IC/005/13
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Seek advice from the on-call Consultant Microbiologist or GU Medicine Consultant, as
required.
Blood tests from the recipient/HCW for Hepatitis B, C and HIV status will carry out in
accordance with Appendix 6.
In the event that the Needlestick injury is known to be a HIV high risk case, OH will
consult with the GUM clinic for specialist advice.
In the event that the Needlestick injury is known to be a HCV or HBV high risk case,
OH will consult with the relevant Gastroenterology Consultant for specialist advice.
Follow up telephone consultation to deliver the blood results from the source/donor and
recipient. (If negative).
If blood results from the recipient are positive (these must not be given via telephone)
arrange an immediate appointment for the member of staff to be seen by the OH
Consultant/Senior OHN Advisor and arrange an appointment with the relevant
Specialist such as GUM. The GUM Department may offer PEP following assessment
and will carry out any further treatments as deemed necessary in the case of high risk
HIV incidents. Staff undertaking EEP‟s will be assessed and advised for fitness for work
as appropriate.
OH will review as appropriate and in accordance with advice from the relevant GU
Medicine Consultant.
Final Outcome/Completion of actions: Send a letter to the member of staff to confirm
the needlestick assessment process is complete. (Appendix 7).
Recording and reporting body fluid exposure incidents are undertaken by the OH
department, this will include clinical and statistical analysis.
Under the requirements of Reporting of Injuries, Diseases and Dangerous Occurrences
Regulations (RIDDOR) 1995.
ED staff will be kept up to date on revised actions/current OH risk assessment
approaches in line with this policy or any other guidance.
Action by Microbiology
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Document Reference: HS.IC/005/13
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Process blood samples from the recipient and donor in all cases of Needlestick injuries
when required in accordance with Appendix 6
Alert OH to positive blood results in relation to HIV, Hepatitis C and Hepatitis B.
Advise ED (out of hours) if deemed necessary, e.g. RE HIV PEP, Hepatitis B
Immunoglobulin.
Inform OH as soon as possible should there be a positive result of HIV/Hepatitis B and
Hepatitis C from Donor.
Action of the Department of Genitourinary Medicine (This service is available Mon-Fri 9am –
5pm)
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Following OH referral, offer urgent advice on the clinical management and follow-up of
the exposed member of staff considered at high risk of HIV in line with current national
guidelines. Outside working hours, this immediate service will be provided by ED.
Referral could be via phone call or secure fax and the member of staff should be
advised to contact GU medicine as soon as possible to arrange an appointment.
Where appropriate, advise on the most appropriate choice of HIV PEP, taking into
account previous treatment of the source patient, and any other medical conditions or
medication taken by the exposed member of staff.
Providing follow-up at the earliest opportunity and ongoing care when required.
Undertake follow up blood testing for recipients as required, if the member of staff
requests this.
Support the nominated person in assessment and testing of source patient when
needed, especially if at higher risk of HIV.
Help in giving positive HIV diagnoses when required.
Action by Manager/nominated person following a body fluid exposure incident:
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Ensure that the member of staff (Recipient/HCW) has followed the immediate
management as outlined in All Staff Responsibilities and the flow chart Appendix 2.
Ensure that member of staff reports the incident via the needlestick pager/bleep which
can be accessed by Telephone 01872 250000.
If the member of staff is required to attend ED, GUM or OH Department, ensure
transport is arranged without delay.
Obtain informed consent from source patient for BBV screening. See appendix 3.
Arrange for a blood sample to be taken from the source patient for the following test:
• Hepatitis B surface Antigen (HbsAg)
• HIV antibody
• HCV antibody
Consent must then be obtained prior to testing for the above BBV‟s and storage of the
serum for subsequent confirmatory tests in line in accordance with this policy. See
Appendix 6 for example of completion of microbiology form and instructions.
An entry must be made in the source patient case notes of action/advice given. The
entry must be dated and signed by the member of staff.
Ensure that the exposed member of staff also completes an incident form as soon as
possible.
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Document Reference: HS.IC/005/13
Appendix 1 – Minimising the Risks of Needle stick Injuries/Incidents
Proactive Measures
The Trust recognises the ethical and economic reasons for improving healthcare worker safety
and are working towards implementation of the EU Directive on the Prevention of Sharps Injuries
in the Hospital and Health Sector, The Directive becomes legally binding on May 11 th 2013. As a
result of this the Trust is about to undertake trials of safety engineered devices that have proven to
greatly minimise the risk of Needle stick injuries. This is also supported by ensuring that all staff
receives training on the policy and procedure associated with sharps injury prevention.
The OH department are also committed to ensuring that staff is aware and have access to
appropriate preventative immunisation.
Minimising the risks to mental wellbeing for Needle stick recipients
All Needle stick recipients will be offered counselling and advice via OH immediately following an
incident and will have direct access to counsellors. Should prophylaxis treatment be necessary in
the event that the incident was identified as being high risk counselling support can be provided in
conjunction with the GUM Department.
Safe Disposal of Sharps
Sharps must always be handled carefully
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Discard needle and syringe as one unit, whenever possible. If disassembly is
necessary it must not be done by hand.
Needle Safety Devices must be used where there are clear indications that they will
provide safer systems of working.
Staff are informed of the systems to ensure the segregation, handling, transport and
disposal of waste are properly managed.
Needles should never be re-sheathed. Re-sheathing needles is a common cause of
needle stick injury. Needles must not be bent, broken or dissembled, before use or
disposal.
Sharps should never be passed hand to hand, place directly into the box.
All sharps should be disposed of carefully at the point of care by the user. This means
that suitable sharps containers (conforming to British Standard BS 7320) should be
portable enough to take to the site of a procedure, and designed specifically to allow
needles and sharp instruments to be disposed of easily and safely at the point of use. It
is not acceptable, particularly for cost reasons, to reduce the number of sharps bins to
such an extent that staff are forced to carry used needles to the sharps bin to dispose
of them.
When retrieving broken cutlery / glass, brush up with dustpan and brush and place into
a sharps container.
Staff should be aware of the risk from retrieving items that have been used with the
intention to self harm.
Bins
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Sharps bins should not be overfilled as this creates a risk of puncture of the container
and the bin not being able to be closed. These must not be filled above the line, stating
DO NOT FILL ABOVE THIS LINE.
The temporary and permanent closures should be used appropriately, to reduce the
risk of accidental spillage of contents.
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Document Reference: HS.IC/005/13
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Containers must be located in a safe position, and must not be placed on the floor or in
a place where they may be knocked over and the contents spill.
The box should be assembled correctly ensuring the lid is securely in place. The
information on the label, hospital, area, date assembled/closed, should be completed.
Then this information will assist the assessment for the risk to that person of
transmission of a blood borne virus, should somebody sustain an injury from a needle
in this bin.
All staff should be aware of their requirements ie type of temporary closure, needle
remover, size and ensure that they carry the correct box for purpose.
Community staff should risk assess regarding the safe storage and transport of the
sharps bin. Sharps bins are collected from the community building and the individual is
responsible for ensuring their safe disposal.
Sharps bins should be replaced 3 monthly or when full.
Ensure correct colour coding is used.
Staff
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Departmental procedures should be reviewed at regular intervals to reduce the risk of
incidence.
It is the responsibility of the person using the sharp to dispose of it safely.
A risk assessment should be completed, with due consideration to the hazards and
risks posed by the environment in which the injection is to be given ie space, lighting,
access to hand washing, pets. Amenities should be available for the safe preparation
and disposal of the sharps. Clients who present a greater risk should have an
individual risk assessment completed.
Infection prevention advice clearly dictates that a bare below the elbow approach
should be undertaken for effective hand hygiene. In areas where there is a risk of
scratching and biting staff may wear long sleeves to provide protection. Sleeves must
be worn that can be pulled up to administer effect hand hygiene when required.
Personal protective equipment should be worn when dealing with blood or body fluids.
Although a needle or sharp instrument can easily penetrate a glove, the risk of
transmission of infection is significantly reduced. The glove material will remove up to
86 per cent of the blood on the outside of a needle.
Staff should be offered immunisation against hepatitis B, and be aware of their status.
Cuts and grazes should be covered with waterproof dressings. Non-intact skin is a
potential route of entry for blood-borne transmissible agents through contact with
infected body fluids.
Eye protection is important wherever blood or other body fluids could splash into the
eye. Ordinary prescription spectacles offer some, but inadequate, protection, as they
are not generally designed for this purpose.
Vehicles
Exposed or inadequately protected sharps left in healthcare staff vehicles put occupants and
service personnel at risk of needle stick injury.

Staff who travel in the community and carry sharps (used or unused) in the course of
their work should follow a safe system of working at all times, in line with their local
clinical and waste disposal policies. Sharps should always be stored safely and
securely.
Page 15 of 28
Document Reference: HS.IC/005/13






dispose of sharps immediately after use in the designated sharps box, use the clip to
close the box , place within the designated bag.
follow instructions for the assembly and use of sharps containers, including the use of
lid closing and locking mechanisms;
report any lid closing and locking mechanisms problems so that the suitability of the
container can be reviewed;
check the container at the end of each shift to ensure no sharps have been dropped or
spilled in the vehicle. If sharps have been spilled, do not use the affected area and, if
necessary, the whole vehicle until made safe;
report any difficulty following a safe system of working.
Contaminated vehicles should be cleared as soon as possible without compromising
safety, e.g. using a torch, a special tool / device to avoid hand contact, and Personal
Protective Equipment (PPE), being wary of sharps hidden in crevices and fabrics.
Page 16 of 28
Document Reference: HS.IC/005/13
Appendix 2 – Assessing ‘source patient’ risk by manager/ nominated person and how to
ask for consent to take bloods from the source.
You may be asked to establish the likelihood that a source patient is infected with HBV, HCV or HIV.
ED, GUM or OH staff will discuss any relevant information required of you as part of their incident
risk assessment.
The assessment of risk must be undertaken as soon as possible after a body fluid exposure. Your
prompt response is essential and must be given priority – as a Colleague‟s future wellbeing may be
at stake. If you for whatever reason are not able to co-operate with the ED, GUM or OH Department
in performing a risk assessment on source, ensure that a suitable colleague is made available.
Risk Assessment Guidance
Three factors to consider:
1. Nature of accident (for list of high risk body fluids see below)
2. Infectivity of source
3. Susceptibility of injured person (have they got a lowered immunity?)
High Risk
Low Risk
Unless contaminated with blood
Blood
Urine
Cerebro-spinal fluid
Faeces
Pleural fluid
Saliva
Breast Milk
Sputum
Amniotic fluid
Tears
Vaginal & Seman secretions
Sweat
Unfixed body tissue
Vomit
Peritoneal fluid
Pericardial fluid
Synovial fluid
Human Bites
Human bites can be extremely painful and should be reported to OH for an assessment. If bitten
through clothing, the clothing undamaged, and the skin is unbroken and risk of body fluid transfer
is unlikely then occupational health should be contacted within hours. Significance is
determined by the extent of the injury, e.g. skin damaged and contaminated with saliva,
therefore in these cases the needle stick pager should be used within and out of hours.
Scratches
The first aid advised within this policy is relevant to all scratches. Staff should contact OH if the
skin is reddened or broken, scratches would then need careful assessment. If the skin is not
broken staff are to follow the first aid and contact OH within hours. Unless there are factors, which
suggests that a more urgent assessment is required.
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Document Reference: HS.IC/005/13
Identification and Risk of Transmission
The risk of transmission of blood borne viruses is greater from patients to health care worker than
from health care worker to patients. The risk to the health care worker 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 procedure undertaken.
In the health care setting transmission most commonly occurs after percutaneous exposure to a
patient‟s blood by sharps or needle sticks injury. The risk of transmission to a health care worker
from an infective patient following such an injury has been shown to be approximately:



1 in 3 when the source patient is infected with Hepatitis B virus and is “e” antigen
positive,
1 in 30 when the patient is infected with Hepatitis C.
1 in 300 when the patient is infected with HIV.
Most cases of occupationally acquired HIV have arisen from percutaneous exposure to HIV
infected material. The majority of these have followed injury from hollow needles. Transmission of
blood borne viruses may result from contamination of mucous membranes, the eyes or the mouth
or broken skin with infected blood or other infectious material. The transmission risks after a
mucocutaneous exposure are lower than those after a percutaneous exposure. The risk of
acquiring HIV after a single mucocutaneous exposure is <1 in 2000.
There is no evidence that blood borne viruses can be transmitted by blood contamination of intact
skin by inhalation or by faeco-oral contamination.
SERO-CONVERSION RATE IF DONOR POSITIVE
EXPOSURE
PERCUTANEOUS
MUCOUS
MEMBRANE
BROKEN SKIN
HBV
30%
Less than 10%
Less than 10%
HCV
3%
Less than 5%
Less than 5%
HIV
0.3%
0.1%
<0.1%
The source/donor should be informed as soon as possible that a needle stick incident has
occurred, and that it is Trust policy to test their blood for BBV‟s with their informed consent after all
such incidents.
An explanation should be given during the pre test discussion about the implication of the incident
to the source patient, and of the need for testing source blood for:



Hepatitis B surface Antigen (HbsAg)
HIV antibody
HCV antibody
Consent must then be obtained prior to testing for the above BBV‟s and storage of the serum for
subsequent confirmatory tests in line with Trust policy. The approach for testing should not be
made by the exposed worker.
Page 18 of 28
Document Reference: HS.IC/005/13
See Appendix 6 on how to complete the microbiology form and instructions for taking blood.
Notes for all healthcare staff seeking information and consent for testing from patients
following needle stick/body fluid incidents
Seeking Consent for Testing for Blood Borne Virus Infection
Remember consent must be:



Voluntary
Informed
From an individual with the capacity to make decisions – if the patient is unconscious or
otherwise unable to consent seek advice.
The Steps in Obtaining Informed Consent
Ensure privacy for discussion, and be tactful in discussion about risk factors.
Explain that:
“One of the healthcare staff looking after you has had an accidental exposure which resulted in the
healthcare worker being exposed to your blood. In this situation the Trust routinely seeks consent
from patients to take a blood sample and to test it for viral infections, which could be transmitted to
staff in this way. The purpose of the tests is to reassure staff where the results are negative as it
can be worrying for them if the results are not known. If an infection is identified there may be
some treatment we can offer the staff member to reduce the risk of them contracting the infection,
but the treatment can have side effects which means we cannot use them routinely”.
The tests are for Hepatitis B, C and HIV.
Ask about risk factors for infection:
1. Have you ever been diagnosed as having Hepatitis B, C or HIV?
2. Have you ever injected drugs? If yes, have you ever shared a needle or other
equipment?
3. Have you ever had sex with someone who has injected drugs?
4. Have you ever had medical treatment or blood transfusion in a developing country?
5. Have you ever had sex with someone who lived in a developing country?
6. For a man: Have you ever had sex with a man?
7. For a woman: Have you ever had sex with a bisexual man?
If the answers are all negative reassure the source patient that the chances of a test proving
positive are very small.
Tell them:
“The test results will be available in their medical notes and if there is a positive result
arrangements will be made for you to have specialist advice and treatment where appropriate.
There are advantages in knowing that you have these infections as there is a range of potential
treatments available, and you can take steps to avoid passing them on to others.
Page 19 of 28
Document Reference: HS.IC/005/13
However, if you were to have a positive test, this could make it more difficult to obtain life
insurance or a mortgage – this is not the case if the test is negative. You might also think about
who you would tell if a test was positive and the effect it might have on your life generally.”
N.B.
Patients are under no obligation to have the tests performed, and testing will not be carried
out without their consent. If patients ask a question and you do not know the answer, seek
advice - do not bluff!
Record the fact of this information gathering and taking blood in the patient‟s clinical notes.
Blood testing of a patient lacking mental capacity following Needle stick injury to a
healthcare worker
The following is recent advice in accordance with the terms of the Memorandum and Articles of
Association of the Medical Defence Union relating to the issue of testing a patient‟s blood for blood
borne viruses following a Needle stick injury to a healthcare worker, but in particular to the
situation where the patient lacks the capacity to give informed consent for the testing
Some of the relevant sections of the Human Tissue Act 2004 are detailed below.
The current advice from the legal department at the MDU is that the taking of specimens/samples
from live persons remains subject to the common law.
The subsequent use of (i.e. testing) and storage of tissue taken from live persons is now subject to
the Human Tissue Act 2004.
Section 1(1) of the Human Tissue Act states that certain activities are lawful if done with
appropriate consent. The activities in relation to live persons are:(d) The storage for use of a purpose specified in Part 1 of Schedule 1 of any relevant material
which has come from a human body.
(f) The use for a purpose specified in Part 1 of Schedule 1 of any relevant material which has
come from a human body.
Part 1 of Schedule 1 includes at No. 4:
“ Obtaining…medical information about a living …person which may be relevant to any other
person…”
Therefore testing of an existing sample from a patient for any serious communicable disease
following a Needle stick injury, to see if treatment of the affected healthcare worker is required, will
fall within Part 1 of Schedule 1 of the Human Tissue Act.
Before testing for a serious communicable disease in these circumstances, appropriate consent
must be obtained from the patient. This would require fully informed consent obtained from a
competent adult who is capable of understanding and giving consent, without the use of duress.
If there is no existing sample available from a competent adult, his or her consent would be
required under Common Law for the taking of the sample, and then further consent would be
required for the testing of the sample as above.
Provision is made in the Human Tissue Act under Section 6 for adults who lack capacity to give
informed consent where a decision to consent, or not consent, is not in force. Under Regulation
3(2) (a) of the Human Tissue Act where there is a lack of capacity to consent to the use of or
storage of specimens, the adult is deemed to have consented where the activity is done by a
person who is acting in what he reasonably believes to be the best interests of the patient.
Whilst not technically ruling out such testing for an adult patient lacking capacity, it may be difficult
to find a set of circumstances in which the testing of a sample following a needle stick injury to a
healthcare worker is in the patient‟s best interests. If no sample were available at the time of the
needle stick injury, then it would be difficult to see how one could be taken under Common Law.
It is possible that the Department of Health may issue new regulations regarding taking of blood
samples for the purpose of screening following a needle stick injury, but as of yet no regulations
have appeared
Page 20 of 28
Document Reference: HS.IC/005/13
In summary, the situation now is that if doctors are considering taking a new sample of blood from
an incompetent patient to test after they or others have sustained a needle stick injury, or
considering testing an existing sample for a serious communicable blood borne disease, they will
need to demonstrate that they reasonably believe it is in the patient‟s best interests to do so.
Doctors must be able to establish that the motivation behind taking and/or testing the sample is
driven by a motivation to act in the patient‟s best interests, rather than by concerns for their own
health or the health of other healthcare workers.
Page 21 of 28
Document Reference: HS.IC/005/13
Appendix 3 – Royal Cornwall Hospital NHS Trust Needle stick/Contamination Reporting
Form
This form must be completed for every case of needle/sharps injury/inoculation incidents
or when there has been contamination of blood or body fluids, by the Occupational Health
Department or the Doctor/Nurse in Emergency Department outside normal working hours.
Details of HCW/Staff member
Tel/Ext.____________
Name ______________________________________ d.o.b. _____________
□
□
Dr
Allied Health
Are you substantive
□
□
□
Nurse
Phlebotomist
Kernowflex
□ Midwife
□ Ancillary
□ Healthcare
□ Admin
□ Other ___________________
Hospital _________________________ Ward/Dept ____________________
Employer: RCHT
□ CFT □ PCT/CHS □ SWAST □ Other_____________
Date of incident:________________________Time of incident ____________
Site of injury (specify exact site e.g. right hand) ________________________
Exact location
Where incident/or discarded sharp occurred __________________________
□
Yes
□
No
*Was it blood stained? □
Yes
□
No
Immediate management, e.g. wound washed and bled?
Section A Exposure
□
1.
Accidental injection
2.
Sharp instrument/needle stick
-
hollow needle
-
suture needle
-
BM stix lancet
Other (specify)
□
□
□
□
3.
Splash to eye/mouth
4. Splash to broken skin
5.
Bite/Scratch
6.
Other (specify)
□*
□
□
□
________________________
________________________
Material
□
□
4. Saliva
□
□
1.
Blood / Plasma
2.
Serum rich fluid / CSF
3.
Other (specify) ___________________________________________
5. Urine
Page 22 of 28
Document Reference: HS.IC/005/13
How it occurred
□
□
□
□
1.
Giving medication
2.
Surgery/Delivery
3.
BM stix measurement
4.
Collecting urine sample
5.
Were you wearing gloves/goggles
Did incident occur: After procedure
□
□
□
□
6. Venepuncture
7. Re-sheathing
8. Bite/Scratch
9. Cannulation
□
□ Yes □ No
Before procedure
□ Other
□
Details of incident:
_______________________________________________________________________
_____________________________________________________
______________________________________________________________
□
□
□
Were you the one using sharps?
Yes
No
N/A
If no, were you cleaning up after someone else?
(please give details, e.g. cleared up after doctor/procedure)
details_________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Section B, Details of needle stick recipient/staff member
(Hepatitis B vaccination status)
□
□
□
Immune
Non immune
Not known
______________________________________________________________
Section C Donor / Source
Source Unknown
□
Source known
□
Patient‟s name ______________________________ d.o.b. _____________
Hospital No. ___________________________________________________
Risk Assessment - Infectivity of Donor/source
□ Yes □ No
Known Hepatitis C positive □ Yes □ No
Known HIV positive
□ Yes □ No
Or if infectious status not known
□
Known Hepatitis B positive
Who carried out Risk Assessment
□ Low □ High
Risk □ Low □ High
Risk □ Low □ High
Risk
(Please Print, must be qualified Nurse/Doctor)
Name:________________________Title: _____________ Time: __________
Page 23 of 28
Document Reference: HS.IC/005/13
Section D - Course of Action
□
□
1. Blood sample from Source(consent obtained for testing)
Yes No
Source patient bloods to include Hepatitis B Hepatitis C & HIV
□Yes □No
Blood taken from recipient/HCW for Storage (Buff/Gold top) □Yes □No
Anti HB immunoglobulin given if deemed necessary
□Yes □No
HIV post exposure prophylaxis commenced (HIV PEP)
□Yes □No
Incident form (Datix /prism) completed
□Yes □No
2. Initial counselling/support given in person/via telephone
3.
4.
5.
6.
______________________________________________________________
Please Print
Name of Nurse/Doctor completing Form______________________________
Signiture:____________________Date:____________________Time: _____
OH only Does the OHS consider the accident was due to:
Incorrect work practice
Other (please specify)
□ Yes □ No
Equipment failure
□Yes □ No
Page 24 of 28
Document Reference: HS.IC/005/13
Appendix 4 – Examples of Completed Microbiology Forms
To take blood you will need to use the 5-10ml clotted buff/yellow topped bottle
Dr J SMITH
BLOGGS
JOSEPH
17
04
RCH
32
M
D9A Z8B
BLOOD
00
06
00
STORAGE POST NSI
F
F
A
ST
ANN
30
08
R
E
B
M
E
M
Dr W CRIPPEN
12345
OTHER
50
RCH
DRAKE
F
D9A Z8B
BLOOD
OCCUPATIONAL HEALTH
00
06
00
SOURCE PATIENT POST NSI
HEP B.SAg. HEP C + HIV AntIbodies
CONSENT OBTAINED
E
C
R
U
O
S
Page 25 of 28
Document Reference: HS.IC/005/13
Appendix 5 – Table for testing blood from Needle stick Recipient/HCW
Recipient/HCW
HIV
HB
Source /Donor or
High Risk for BBV’s
0
Base line
Storage
only
6/52
Storage
Only
x
x
6/12
√
√
HIV Ab
(EIA)
HIV Ab (EIA)
√
√
HB SAg
HB SAg
x
x
x
√
√
√
HC RNA
HCV Ab
HCV Ab
Non
Immune
Storage
Only
3/12
HB
Immune
Source/Donor
negative or Low risk
for BBV
Or
Source Unknown
HC
Storage
only
HIV
Storage
Only
x
HB
Storage
Only
x
√
√
Offer HIV
Ab (EIA)
Offer HIV Ab
(EIA)
if negative at
3/12
x
Non
Immune
Storage
Only
√
Offer HB SAg
x
x
x
x
x
HB
Immune
HC
Storage
only
√
Offer HCV Ab
As the overall risk of transmission of infections is small, blood testing of
source/donor will be followed using above table.
Where testing is not recommended the recipient can request due to personal
circumstances extra testing beyond recommended table, (this will be discussed on
an individual basis with the microbiology department).
Additional testing following appropriate advice from Microbiology/GUM will be
carried out beyond the recommended table in the event that the recipient develops
symptoms that are thought to be related to BBV infection.
Page 26 of 28
Document Reference: HS.IC/005/13
Appendix 6 – Needle stick injury conclusion letter
Cornwall & Isles of Scilly Occupational Health Service
Pendeen House
Royal Cornwall Hospital
Truro
Cornwall
TR1 3LJ
Tel: 01872 252770
Our Ref:
Date
PRIVATE & CONFIDENTIAL
Dear Colleague
Re:
Recent Needle stick/Body Fluid Exposure Incident
I understand you have recently had a needle stick injury and I wish to reassure you that you are
now at the end of the Occupational Health (OH) assessment process with regard to this. OH now
plans to close your case. However, please contact this department if you have any remaining
concerns via 01872 252770, where we can offer you further support if necessary.
Yours sincerely
Dr Julian Smith
Consultant Occupational Physician
Page 27 of 28
Document Reference: HS.IC/005/13
Appendix 7 – Management of Needle stick / sharp / contamination injury by injured person
Management of Needle stick / sharp / contamination injury by injured person.
It is essential that you follow this procedure with the minimum delay – if HIV post exposure
prophylaxis (PEP) is required, this should, if at all possible be started within one hour of the needle
stick/sharp/contamination exposure incident.
Needle stick injury.
Injury from broken
glass, crockery,
razors used with
intent to self harm.
A scratch or bite that
has broken or
reddened the skin.
FIRST AID



Gently encourage puncture wounds to bleed by pinching skin
around the site of injury.
Do NOT suck injury site under ANY circumstances.
Wash site immediately and thoroughly with soap and water.
Do NOT scrub the injured area and do not use antiseptics.
If appropriate cover injury.
Blood or bodily fluid
splashes has entered
into eyes,or mouth, or
onto face, or broken
skin including spitting.
FIRST AID
Wash site
immediately and
thoroughly with
plenty of running
water
IMMEDIATELY FOLLOWING FIRST AID
Telephone: 01872 250000
Ask for Needle stick pager/bleep, give your telephone number
and wait for the return call.
Documentation – Make a note of the:
 name,
 date of birth and
 hospital number of the source patient involved.
The approach for testing should not be made by the exposed worker.
In the event of a needle stick injury where the source patient cannot be identified, provide
information on where the sharp was located and the exact details of the injury/splash.
Inform your Line Manager.
Record on the electronic incident reporting system - Safeguard using:Cause group : Infection Prevention & Control,
Cause : contact with sharps patient/staff or contact with body fluids.
Page 28 of 28