Download Sharps Safety Policy 2015

‘SHARPS’ SAFETY POLICY
INCLUDING PREVENTION AND MANAGEMENT OF INOCULATION OR CONTAMINATION INCIDENTS (e.g.
sharps, bites, scratches or cuts)
Solent NHS Trust policies can only be considered to be valid and up-to-date if viewed
on the intranet. Please visit the intranet for the latest version.
Purpose of Agreement
Document Type
This policy provides a clear, evidence-based
framework to ensure safe practice when sharps are
used, thereby minimising injuries caused by
contaminated sharps. It is applicable to all staff who
handle sharp items during the course of their
employment, and applies at all times, in all
situations. It provides a framework to ensure that
when inoculation or contamination incidents do
occur; the incident is promptly risk assessed and the
healthcare worker/patient is offered appropriate
treatment to reduce the risk of infection and
counselling support to reduce distress.
x
Policy
SOP
Guideline
Reference Number
Solent NHST /Policy/IPC 04
Version
Version 3
Name of Approving Committees/Groups
Infection Prevention Control Committee
Risk Health & Safety Committee
Operational Date
June 2015
Document Review Date
June 2018
Document Sponsor (Name & Job Title)
Julie Pennycook, Director of HR
Document Manager (Name & Job Title)
Gill Ward, Lead Nurse, Occupational Health
Document developed in consultation with
Occupational Health & Wellbeing team
Infection Prevention and Control team
Sexual Health team
Health& Safety team
Intranet Location
Solent Policies
Website Location
Keywords (for website/intranet uploading)
‘SHARPS’ SAFETY POLICY – INCLUDING
PREVENTION AND MANAGEMENT OF INOCULATION
OR CONTAMINATION INCIDENTS (e.g. sharps, bites,
scratches or cuts). Version 3
Location in FOI Publication Scheme
Our Policies and procedures
Policy, sharps, inoculation, contamination, HIV, PEP,
Ratification, NHSLA
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Table Of Contents
SECTION
1.
CONTENT
PAGE
3
Introduction
2.
Scope & Definition
5
3.
Roles & Responsibilities
6
4.
Safe Sharps Practice
8
5.
Safe Handling
8
6.
Use and Standardisation Of Sharps Bins
9
7.
Safety Devices
10
8.
Operational Management Of Incident
10
9.
Post Exposure Prophylaxis
15
10.
Recovery Of Sharp Equipment On Or Near Hospital Sites
18
11.
Training
18
12.
Review
19
13.
References
19
14.
Table of amendments
20
Links To Other Policies
Appendix 1
Poster Guidelines and Information To Help Risk Assessment
22
Appendix 2
Full Risk Assessment Of Three Main Blood-Borne Viruses
23
Appendix 3
25
Appendix 4
Occupational Health Risk Assessment Following Inoculation/
Contamination Incident
PEP Treatment
Appendix 5
Recovery Of Needless/Sharp Equipment On Or Near Hospital Sites
29
Appendix 6
Contact Numbers for the following Hospitals and A&E departments
30
Appendix 7
Equality and Human Rights and Mental Capacity Act Impact Assessment
31
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1.
INTRODUCTION
1.1
This Policy will discuss sharps safety and the operational management of adverse events resulting
in injuries which may happen to healthcare workers whilst delivering care in any care setting.
1.2
There are three types of exposure in health care settings associated with significant risk, these
are:
Percutaneous injury (from needles, instruments, bone fragments, significant bites which
break the skin etc). (Often referred to as sharps.)
Exposure of broken skin (abrasions, cuts, eczema etc.)
Exposure of mucous membranes including the eye.
1.3
Blood borne virus infections may be transmitted from infected patients to staff members. All
blood and body fluids and tissues should be regarded as potentially infectious. This type of injury
can also happen on rare occasions to patients they care for and the key principles of managing the
incident will be the same.
1.4
A sharps injury is defined as an injury where a needle or other sharp medical device contaminated
with blood or other body fluid penetrates the skin. This also includes human bites and scratches
that break the skin. Syringe needles, scalpel blades and many other sharp devices are routinely
used as part of healthcare practice in acute and primary care settings.
1.5
The Trust recognises the importance of providing a clear reporting system including out of hours;
to ensure that all employees understand their responsibilities. This will ensure the individuals
receive timely assessment, appropriate treatment and health surveillance to reduce the likelihood
of transmission of a blood borne pathogen. The Trust further recognises the distress that this
type of injury can cause to the individual and provides specialist counselling services to support
them throughout this period.
1.6
This policy provides a clear, evidence-based framework to ensure safe practice when sharps are
used, including the use of personal protective equipment; thereby minimising injuries caused by
contaminated sharps. It is applicable to all staff who handle and dispose of sharp items during the
course of their employment and applies at all times, in all situations.
1.7
Legal Requirement
1.7.1 Under existing Health and Safety legislation (Health and Safety at Work etc Act 1974):
All employers should provide suitable and sufficient training to ensure the safety of their staff
while on the employer’s business.
1.7.2 The Management of Health and Safety at Work Regulations, 1999:
Employers must undertake suitable and sufficient risk assessments of all significant hazards in
the workplace. Risk assessments should be extended to dangers to others on the employer’s
premises, including patients, visitors and contractors. Legislation also requires that
employees have a duty to cooperate with the employer on all matters associated with health
and safety and to abide by local safe systems of work.
1.7.3 Health and Safety Sharp Instruments in Healthcare ( Regulations 2013 the Sharps Regulations).
Employers must ensure that risks from sharps injuries are adequately assessed and
appropriate control measures are in place.
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Avoid the unnecessary use of sharps, needle- free equipment should be available and used
where reasonably practicable to do so.
Use ‘safer sharps’ (incorporating protection mechanism) where reasonably practicable to do
so.
1.7.4 The Control of Substances Hazardous to Health (COSHH) Regulations 2002:
Employers must undertake suitable and sufficient risk assessments of all significant hazardous
substances, including micro organisms and further ensure that significant findings are
recorded.
1.7.5 The Personal protective equipment at work (second edition) regulations 1992 (as amended);
All equipment (including clothing affording protection against weather), which is intended to
be worn or held by a person at work and which protects him against one or more risks to his
health or safety.
Personal protective equipment provide barriers and filters between the worker and the
hazard and should be worn where risk is indicated; gloves and eye protection will prevent
exposure to blood splashes but will not prevent needlestick injuries.
1.7.6 Provision and Use of Work Equipment Regulations 1998:
Employers must provide work equipment that is suitable for the intended job, maintained
and which can be used safely.
1.7.7 The Health and Safety Regulations, 1981:
Employers must provide adequate first aid facilities and first aid treatment.
1.7.8 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013:
Employers must report all injury, accidents that result in serious injury and/or occupationally
acquired disease to the Health and Safety Executive (HSE) e.g. (Exposure to HIV, hepatitis B
and hepatitis C are reportable to HSE as a dangerous occurrence).
1.7.9 The Health and Social Care Act 2008 – Code of Practice:
The Care Quality Commission assesses performance against cleanliness and infection control
requirements stated in the Code. The Code specifically addresses the need to prevent
exposure to blood-borne viruses including prevention of sharps injuries.
Criterion 5:
Ensure that people who have or develop an infection are identified
promptly and receive the appropriate treatment and care to reduce the risk of passing on the
infection to other people.
Criterion 6:
Ensure that all staff and those employed to provide care in all settings are
fully involved in the process of preventing and controlling infection.
Criterion 9: Have and adhere to policies, designed for the individual’s care and provider
organisations that will help to prevent and control infections.
Criterion 10:
Ensure, so far as is reasonably practicable, that care workers are free of
and are protected from exposure to infections that can be caught at work and that all staff
are suitably educated in the prevention and
control of infections associated with the
provision of health and social care.
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1.4
Epidemiology
The major blood-borne pathogens of concern associated with needlestick injuries
are:
Hepatitis B (HBV)
Hepatitis C (HCV)
Human immunodeficiency virus (HIV)
However, other infectious agents also have the potential for transmission through a sharps injury and
may be indicated by risk assessment.
2.
SCOPE & DEFINITIONS
This policy applies to all directly and indirectly employed staff and other persons working within the
Trust in line with Solent NHS Trust’s Equal Opportunities Document. This Document is also
recommended to Independent contractors as good practice.
Type
Incidents- can happen
occupationally in 3 ways
Definition
1. Percutaneous exposure
Inoculation incidents from sharps: e.g. needles, sharp edged instruments,
broken glass contaminated with blood/body fluids including pathology
specimens or sharp spicules of bone or teeth.
Blood borne viruses are potentially transmittable by human bite;
if the bite breaks the skin of the person bitten the risk of Hepatitis B
contamination is high in this instance but minimal for HIV.
Deep scratches where the skin has been broken have the potential to be
infected from others nails, especially when contaminated by blood/body
fluids
Contamination incidents from spraying of blood/body fluids onto broken
skin (abrasions, cuts, eczema etc) although the risk of HIV contamination
in this instance is low. There is no evidence that blood born virus (es) can
be
transmitted by contaminated blood onto ‘intact skin’
Contamination incidents from blood/body fluids into eyes, up the nose or
into the mouth.
2. Cutaneous exposure
3. Mucous Membrane
Exposure:
Type
Blood Borne Virus
HBV
HCV
HIV
HIV PEP
Donor
Definition
A virus which is carried in the blood of an infected individual
and which can be transmitted to another person exposed to the individual’s
blood
Hepatitis B virus
Hepatitis C virus
Human Immunodeficiency Virus
HIV (Post Exposure Prophylaxis): HIV treatment medication given after a
sharps injury from a known/highly suspected to
be a high risk HIV positive source to reduce the risk of seroconversion to
HIV. HIV PEP is prescribed by the local Emergency Department or Sexual
Health Department.
In staff incidents: a donor is the patient/client. However in incidents where
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Source
Recipient
Safer sharps
3.
the patient may have been contaminated with staff blood, the donor is the
staff member.
A source is the cause of the incident e.g. incident from unknown needle
would be referred to as the source
In staff incidents the recipient is the healthcare worker who sustained the
injury; however on rare occasions the patient may have been contaminated
with the healthcare worker’s blood or body fluid they would be the recipient
These are devices that incorporate engineered controls to reduce risk of
sharps injury. There are two categories of safer devices:
1. Needless systems such as intravenous connectors
2. Sharps with engineered sharp injury protection
ROLES & RESPONSIBILITIES
3.1 Duties of the Trust:
3.1.1
Solent NHS Trust referred to throughout this policy as the Trust recognises and accepts its
duties and responsibilities to provide staff with a safe and healthy working environment and
will ensure that the necessary management systems are in place to enable implementation of
all policies.
3.1.2
These duties include provision of information, instruction and training; provision of personal
protective equipment, ensuring that safer sharp medical devices are used when available and
providing first aid, treatment and support to those who have sustained an inoculation or
contamination injury. This is to prevent/reduce the risk of health care acquired infection
through inoculation or contamination incidents (sharps, bites, scratches, cuts or blood/blood
stained body fluids) at work.
3.2
The Chief Executive has ultimate accountability for the strategic and operational management
of the organisation, including ensuring all policies are adhered to.
3.3
Directors, Operational Directors and Line Managers have a duty to ensure that the
requirements of this policy are met and that responsibilities for prevention and control of
infection are reflected in all staff members’ job descriptions.
3.4
Line managers have a responsibility to operate this policy, as follows:
Display the Poster Guidance (Appendix 1) in their area(s)
Ensure staff are aware of this policy and their responsibilities to comply with first aid
procedures, and to report any inoculation/contamination.
Ensure that all staff receives induction training in line with Trust requirements and
implementation this policy.
Ensure staff are aware of how to protect themselves at work, including provision of
information and training on blood borne viruses and accidental exposure.
Carry out local risk assessment, which identify hazards and ways to protect themselves;
Standard Precautions and safe working practice, including use of personal protective
equipment and use of safer needles and other medical devices. See (Appendix 2). Full Risk
Assessment of the three main blood borne viruses (HIV, hepatitis and hepatitis C)
Be aware of required screening and immunisation programmes, available through the
Occupational Health Service to protect staff in the workplace.
They should also ensure that all inoculation or contamination injuries are reported
through the Trust reporting system so that trends may be highlighted which may indicate
training needs.
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3.5
Provide support for staff who have sustained an injury, this is especially important when
the incident is a high risk of HIV and post exposure prophylaxis treatment has been
prescribed.
Report incidents with a high risk of transmission of blood borne viruses to the Health &
Safety Team so that they may be reported under RIDDOR.
Ensure consent is obtained from the patient, for appropriate blood tests to be taken (HIV,
hepatitis B, and hepatitis C) and that bloods are taken and dispatched urgently to the
Pathology Laboratory. The Trust does recognise that there may be occasions when taking
blood from the source/donor patient is not possible; under these circumstances the risk
assessment must include what the likelihood of risk is see (Appendix 2)
Investigate incidents in a timely manner to prevent re-occurrence, adding those incidents
to their departmental risk register, appropriately.
Share learning outcomes with their teams to prevent re-occurrence and promote safe
working practices and procedures.
To ensure that all staff attend mandatory training and updates in relation to infection
prevention and control issues as advised by the Infection Prevention and Control Team
(IPCT).
Staff have a responsibility to:
Familiarise themselves with this Policy to ensure that, should an incident occur to
themselves or their patient, they understand their own personal responsibility to comply
with first aid action and reporting procedure to follow.
Be aware of their responsibility in avoiding needlestick injuries.
Comply with Standard Precautions, including wearing appropriate and suitable protective
clothing, follow safe working practice, specifically when handling and disposing of sharps
to prevent injuries to themselves and others at work.
Be aware of the potential for occupational exposure, including sharps injuries, which can
and do occur while delivering care in any care setting.
Attend mandatory training courses and updates in health and safety/infection control
procedures; follow good practice to protect themselves from injuries at work.
Attend Occupational Health & Wellbeing for prophylactic vaccinations to protect them as
far as reasonably practicable against serious communicable disease and specifically blood
borne viruses. Comply with treatment or monitoring procedures outlined in this policy, to
try to protect them/detect health problems at an early stage.
Seek counselling support when they have concerns which may affect their health and
wellbeing.
3.6
Occupational Health Wellbeing (OH): have a responsibility to operate this policy; provide
advice, treatment, support and counselling; referring individual to specialist counselling and
Consultant Hepatologist, as appropriate.
To provide a screening and vaccination service to the Trust in line with current
Department Health Guidance and best practice.
To monitor incidents and provide health surveillance to detect any early health
changes.
To provide assistance to both staff and managers in making an initial risk/ongoing risk
assessment. (See Appendix 3).
To liaise with the Virology/Microbiology/Pathology/Sexual Health Department and the
Emergency Department, as required.
To document the incident in individual’s confidential occupational health records and
use anonymised statistics for audit purposes.
To liaise with IPCT to promote safe working practices including safer needles and
other devices.
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To share the Inoculation / Contamination audit with the IPCT and the Trust Health &
Safety Committees. This information may be used to highlight awareness of the
Principles of Standard Precautions and safe systems of work, to prevent injury and
transmission of serious communicable diseases.
3.7
The Health & Safety Team: has a responsibility to develop/maintain a reporting system for
the Trust to ensure that all staff are aware of their responsibilities under this policy to
report:
Incidents which involve a source or a patient known or highly suspected to be
a carrier of HIV/hepatitis B/hepatitis C must be reported under RIDDOR. This
duty may also be undertaken by the Risk Management Team.
The Trust Risk Register is maintained and risk is incorporated into staff training.
The Safeguard reporting system is maintained and that statistics are produced
quarterly and shared with the Trust.
3.8
Local Emergency Departments (ED): have a responsibility:
To provide assessment and treatment to staff who have suffered inoculation or
contamination injuries when OH is closed or where it is geographical difficult for the
member of staff to get to OH department in a timely way e.g. travel distance In the
case of high risk HIV incidents recognise this as a medical emergency and assess staff
urgently.
Provide starter packs of post exposure prophylaxis as indicated.
3.9
Sexual Health Department : has a responsibility:
Provide specialist advice, support and ongoing treatment (post exposure prophylaxis)
to staff who have suffered contamination incidents, when there has been a known or
highly suspected risk of HIV.
To provide advice and support to OH and the local ED.
To provide specialist treatment, advice and support when appropriate to recipients
who have suffered a contamination incident where there is a high risk of HIV.
3.10
Infection Prevention and Control Team (IPCT) has a responsibility:
To deliver Mandatory training in Standard Precautions in liaison with the Trust’s
Learning and Development Team.
To develop policies and procedures to assist the Trust in its duty to protect their staff
at work.
Monitor effective practice through the use of audit appropriate to clinical areas.
To liaise with OH and work together to promote a safe and healthy workplace.
To train Link Advisors for the Trust, to raise awareness of Standard Precautions at
department level so that staff may protect themselves at work.
4.
SAFE SHARPS PRACTICE
The use of sharps should be avoided where possible. When their use is essential,
particular care is required in handling and disposal. Staff must use safer medical devices
whenever possible.
5.
SAFE HANDLING
Sharps must always be handled carefully in accordance with the following principles:
Do not re-sheath used needles.
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a. Always get help when using sharps with a confused or agitated patient
b. Never pass sharps from person to person by hand – use an injection tray or ‘clear field’
to place them in
c. Never walk around with sharps in your hand
d. Never leave sharps lying around – dispose of them yourself
e. Dispose of sharps at the point of use – take a sharps bin and an injection tray with you
f. Dispose of syringes and needles as a single unit – do not remove the needle first
g. Use needleless intravenous devices whenever possible, where available
h. Always wear gloves when carrying out phlebotomy, cannulation etc.
You do not have to wear gloves when giving routine intradermal, subcutaneous and
intramuscular injections. You may wear gloves if a risk assessment indicates it is best
to do so e.g. the patient’s skin is not intact, your skin is not intact.
6.
USE AND STANDARDISATION OF SHARPS BINS
6.1
The Trust has taken the decision to standardise on a range of sharps bins from a single
manufacturer. They have been selected as the bins are easy to use and have been well
evaluated by clinical staff in practice. Standardisation will ensure that staff working in
multiple locations are familiar with the bins in use, and aims to help reduce the number of
avoidable sharps injuries related to incorrect assembly and disposal of sharps bins.
Safe use of sharps bins
Sharps must only be disposed of in designated sharps bins that meet the requirements
and in accordance with HTM 07-01 Safe Management of Healthcare Waste (DH,2011)
provides a framework for good practice to all producers of healthcare waste on the
development and management arrangements for the safe, economic disposal of
healthcare waste. Page 203 Sub Section 8409 Sharps Containers.
Use appropriate designated sharps bins for specific types of waste e.g. yellow sharps
bin with yellow lid, or yellow sharps bin with purple lid
Always assemble sharps bins correctly
Lid on properly click into place
Label completed with time, date and initials of person assembling the sharps bin
Placed in suitable, safe location
Ensure sharps bins are of an appropriate size for the clinical activity – do not select
excessively large sharps bins, or those that are too small for the size needle/syringes
you use
Sharps bins should be available at the point of use of the sharp – they should be taken
to the bedside, placed on drug and cardiac arrest trolleys, and be carried by all staff
who use sharps as part of their work in the community
Wall and trolley brackets should be used, as appropriate
Sharps bins must be located at approximately waist height, and never placed on the
floor, on top of high surfaces, or where children or confused adults can tamper with
them
Between uses use the temporary closure device on the bin to prevent accidental
spillage of sharps if the bin is knocked over.
Always carry a sharps bin by the handle, or using the carry tray provided for smaller
bins – never place it against your body.
Never overfill a sharps bin – replace it when filled to the line mark or when it is two
thirds full.
Ensure sharps bins are closed and locked before disposal, and complete the label on
the bin.
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Do not place sharps containers in orange bags for disposal – community staff may
place them inside a clear plastic bag during transport in their vehicles in order to
prevent leakage
Used sharps bins must be stored in a locked, segregated cupboard or clinical waste bin
provided for the purpose
Note: sharps bins should be disposed of after 3 months even if not full.
7.
SAFETY DEVICES
7.1
Many sharps injuries can be avoided by adherence to the principles of safe practice.
However it is recognised that some injuries are complete accidents. It is possible to
reduce the risk of these happening by the use of safety devices as available and
appropriate for the task.
7.2
Safer sharps and other safer medical devices incorporate a built-in safety feature in their
design, which is intended to reduce the risk of sharps injury. An integrated safety feature
is part of the basic design of the device that cannot be removed. A passive safety feature
is one that does not require the user to activate it and remains effective before, during
and after use.
7.3
Staff should consider the use of safety devices in preference to standard devices wherever
possible. In areas where venepuncture and cannulation are carried out, safer sharps
should be used whenever possible.
8.
OPERATIONAL MANAGEMENT OF ALL INOCULATION/CONTAMINATION INCIDENTS
8.1
Immediate Action
First Aid: see Poster Guidance - Flow Chart (Appendix 1).
8.2
Trust Reporting Procedure (Inoculation or contamination incident).
Inform manager/person in charge and ensure Adverse Event form is completed and sent
to the Risk Health & Safety Team.
If source/patient is HIV/hepatitis B/ hepatitis C positive, managers should ensure the
Incident is reported under RIDDOR via the Trust Health & Safety team to the Health
Protection Agency at Communicable Diseases Surveillance Centre.
8.3
Reporting and Local Risk Assessment
It is vital that staff report incidents immediately to OH and out of hours to the local ED, so
that a local risk assessment can be made. See Poster Guidance - Flow Chart (Appendix 1).
8.4
Information at local level to inform risk assessment.
Information to assist with the risk assessment should be promptly collated at local level
see Poster Guidance - Flow Chart (Appendix 1).
Information Needed
Patient’s name or origin of source.
DOB, address
GP/Consultant treatment and diagnosis if known.
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All incidents must be given priority and assessed immediately.
QUESTIONS TO ASK:
WHO
Who was involved, date and time of incident
HOW
How did it happen
WHAT
What is the risk
The ‘WHY’ did it happen can wait until the incident has been dealt with, and the individual
involved has been given appropriate treatment.
QUESTION: Is the patient/source known to be HIV positive or highly likely to be HIV positive?
UNKNOWN SOURCE
Examples:
You have been stabbed by a dirty needle, but don’t know which patient the
needle came from or you have been stabbed by a needle in sharps box. In this
instance the risk assessment must assess all potential source patients and the
likelihood that they may be infected with a blood borne virus.
A more comprehensive risk assessment can be undertaken once the initial risk has been
made (Appendix 2).
Risk of HIV: time is crucial when there is a known or higher risk of HIV
Out of hours: when there is a known or highly like risk of exposure to HIV the recipient should
attend ED ideally within one hour of the incident.
The manager/person in charge should assist by telephoning through to advise them that this
is a medical emergency and provide the information in Section 8.
8.5
Out of hours: when OH is closed:
The above information will need to be given to the local ED to assist in risk assessment. If
the recipient works in e.g. community area, their managers may be able to assist by
telephoning the information through to the relevant department.
If staff member has no transport they should go by a taxi (the Trust will reimburse the
fare; on production of a receipt).
8.6
Guidelines for Obtaining Source Patient’s Blood in Sharps Injuries
Pre Test discussion with patient prior to taking blood
The source patient/client will need a pre-test discussion and informed consent obtained,
before standard blood tests can be taken. The following guidance should be followed:
All source patients must be tested for HBV, HCV & HIV to comply with Department
Health recommendations. This helps prevent discrimination of individual patients.
The consent is verbal and ideally must not be taken by the recipient, but by a
colleague or member of staff in the clinical area and documented in the notes.
Inform the patient that an inoculation or contamination incident has taken place and
that specific BBV (HBV, HCV and HIV) can be transmitted after this type of incident.
Enquire as to whether there is any possibility of carriage or exposure to these viruses
in the past.
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If low risk of BBV carriage proceed to blood testing. If high risk of BBV carriage
consider liaising with Sexual Health or Virologist before testing.
Inform source patient that results will be made available to OHW and recipient of
incident.
If a positive result obtained from source patient repeat the test for confirmation. If
true positive result, liaise with Sexual Health for advice on further management.
In the case of a true positive result there are many advantages to the diagnosis being
known, both to the individual and to their contacts
Where it is not possible to gain informed consent, e.g. refusal or confused/
unconscious patient, ensure recipient is managed as per Trust policy i.e. report
incident, arrange baseline blood test and OHW follow up.
When a patient has died and the risk assessments indicates that a blood tests for BBV
is indicated; medical advice should be sought. The risk assessment will also consider
the time lapse since patient’s death and validity of tests (sensitivity of the test may fall
slightly after death). In the case of a deceased patient consent must be obtained
from a relative
Circumstances when blood test cannot be taken from source/donor patient.
It is recognised that under certain circumstances it is not possible to take bloods for screening
from the source/donor patient for blood borne viruses; under these circumstances the risk
assessment should include full details of what is known about the source/patient, and the
likelihood of risk of contamination from the incident e.g. medical device involved, type of
injury sustained (deep/superficial), amount of blood involved; to inform the risk assessment.
See (Appendix 2)
8.7
Blood specimens from staff
Clinical details should be completed on virology blood test form and sent immediately, to
the local Pathology Laboratory for testing to detect blood borne virus(es). In urgent, high
risk cases the microbiology laboratory should be informed and arrangements made for
blood to be delivered immediately for testing at their local General Hospital.
A timely risk assessment of the injury and exposure should be undertaken and discussion
and support will be offered. Confidentiality will be maintained at all times.
ALL HCW’s (recipient) will be offered a blood test for ‘staff store’ and anti-HB if clinically
indicated. Staff store blood test will be offered and repeated 3 months later in OH, when
source/patient is positive to HIV and PEP has been given staff store will be offered 24
weeks following cessation of PEP.
8.8
Actions in OH / Sexual Health / ED.
Incidents where there is high risk of BBV: Managers can assist by telephoning through
these details and state incident is Medical Emergency likely to require Post Exposure
Prophylaxis.
If source/donor patient is positive for blood borne virus; the staff member should consider
using condoms during sexual intercourse until follow up is clear, as it cannot be guaranteed
there are no risks.
Staff store blood can only be tested with signed permission form the individual, it is
recommended that this blood test is stored for two years. For all source patients, the
clinical team will be asked to obtain blood for HBV, HCV and HIV testing and storage (not
to be taken by recipient). Appropriate consent must always be obtained.
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See OH risk assessment form (Appendix 3).
Significant exposure to Hepatitis B virus: (e.g. source/patient known to be a high risk of
Hepatitis B).
If the exposed person is not immune to hepatitis B, the patient should be asked to consent
for urgent blood test to screen for hepatitis B infection (HBsAg). If consent is not given or
the source/patient is known or found to be positive to HBsAg; it will only be necessary to
screen the exposed HCW if they were non-immune at the time of the incident.
Test for HBsAg at:
6 weeks
3 months
6 months
Significant exposure and HCW has not demonstrated protective levels of hepatitis
antibodies following hepatitis B vaccine. Where there is any concern a virology opinion
will be sought,
HCW has received < 1dose of vaccine pre-exposure:
Source is HBsAg positive contact Virology for advice; HCW may be offered hepatitis B
immunoglobulin and accelerated course of hepatitis B vaccine.
Source is unknown: offer accelerated course of hepatitis B vaccine.
Source HBsAg negative: initiate course of hepatitis B vaccine.
HCW has received > 2 doses of vaccine pre-exposure and anti bodies not known.
Source positive HBsAg: offer one dose of hepatitis B vaccine followed by second dose
one month later.
Source unknown: offer one dose of hepatitis B vaccine.
Source HBsAg negative: finish course of hepatitis B vaccine
HCW is known responder to vaccine (anti-HBs >10mlU/ml)
Source positive HBsAg or unknown source or source is HBsAg negative: offer booster
dose of hepatitis B vaccine
HCW is known non-responder to hepatitis B vaccine (<10mlU/ml) 2-4 months post
Immunisation:
Source positive HBsAg/ or unknown source: contact Virology for advice; HCW may be
offered hepatitis B immunoglobulin and booster dose of hepatitis B vaccine may be
recommended, with a second dose of hepatitis B immunoglobulin at one month.
Source is HBsAg negative: offer hepatitis B vaccine booster.
Exposure to hepatitis B virus that is not a significant risk
HCWs that are unprotected/ partway through their course of hepatitis B will be advised to
start or complete their course of hepatitis B vaccines.
When HCW is a non responder (<10mlU/ml) or low responder >10mlU/ml a booster
dose of hepatitis B will be offered.
(Immunisation against infectious diseases. (2011) Department Health).
Exposure indicates known risk of HIV or highly suspected risk of HIV
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When the incident is a high risk of HIV – PEP may be required; this will be started in Sexual
Health or the ED; staff who attend the ED are asked to telephone Sexual Health and speak
to a clinician to make an appointment for the next working day.
Exposure indicates known risk of hepatitis C virus
Following staff store the HCW will be offered health surveillance and counselling support.
Health surveillance is normally provided through OH.
Regime
Base line staff store
At 6 weeks post incident: HCV/RNA (PCR test) is offered.
At 3 months post incident HCV antibodies, HCV/RNA (PCR test), staff store are
offered.
At 6 months HCV antibodies test is offered.
Pathology specimens
When risk assessment indicates that incident may be high risk of a blood borne virus, the
microbiologist will be informed and arrangements for bloods to be transported to the
pathology laboratory immediately for testing.
Safe Sex
If the donor patient is positive for any blood borne virus(es) the recipient (the person who
sustained the injury or their partner) will be advised to wear condoms during sexual
intercourse until follow up blood tests are clear. The recipient should also contact OHW
the next working day and they will also be followed up and supported by the OHW team.
8.9
Health Surveillance and Support through OH
When notified that a staff member has been seen in the ED or Sexual Health, OHW will
provide health surveillance and counselling support as indicated. This may also include
completing vaccination programmes and referral to other specialist counsellors (OH
Consultant, HIV Nurse, Sexual Health or for general counselling support through the Trust's
Employee Assistance Programme).
Confidentiality will be maintained at all times
Health surveillance will include blood tests for staff store:
All staff who has sustained inoculation/contamination incidents are advised to have a
base line blood test, for storage (staff store).This test is repeated at 3 months. It is
recommended that this blood is stored for 2 years and can only be tested with the
individual’s signed permission. When the source/patient is HIV positive staff store may be
also taken 24 weeks after cessation of PEP.
Should any staff member be found to be positive to a blood borne virus they will be
offered advice and support from the Occupational Health Consultant who will refer them
to other specialists.
8.10
Counselling Support
The Trust recognises that inoculation or contamination incident can cause distress to the
individual, even when the risk of infection with a blood borne virus is low. To support the
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individual during this difficult period the Trust provides specialist support through a
variety of routes. All counselling is confidential and available through:
OHW (Nurses and Consultant)
Sexual Health / HIV Nurse Specialist
Referral to the Trust’s Employee Assistance Programme may also be advised for general
concerns.
9.
POST EXPOSURE PROPHYLAXIS (PEP)
9.1
Background to PEP
This guidance is based on the DH HIV post-exposure prophylaxis (Guidance from the UK
Chief Medical Officers’ Expert Advisory Group on AIDS. (September 2008)).
9.2
HIV and significant occupational exposure-The risk of acquiring HIV infection following
occupational exposure to HIV-infected blood is low.
Epidemiological studies have indicated that the average risk for HIV transmission in:
Percutaneous exposure (from needles, instruments, bone fragments, significant bites
which break the skin etc) to HIV-infected blood in health care settings is about 3 per
1,000 injuries.
However; if larger volumes of blood and the source patient’s viral load is high this may
be higher than 3 in 1,000.
Mucocutaneous exposure (mucous membranes including the eyes), the average risk is
estimated at less than 1 in 1,000.
Skin that is intact: it has been considered that there is no risk of HIV transmission
where intact skin is exposed to HIV-infected blood.
9.3
HIV post-exposure prophylaxis may be indicated when:
Deep injury.
Visible blood on the device which caused the injury. Injury with a needle which had
been placed in a source patient’s artery or vein.
Terminal HIV-related illness in the source patient. Where the source patient is not on
therapy and has uncontrolled/high viral load.
9.4
Risk assessment:
Following immediate first aid and prompt reporting a risk assessment should be made
to consider the circumstances of exposure. The issue of PEP should be considered after an
exposure with the potential to transmit HIV, based on the type of body fluid or substance
involved, and the route and severity of the exposure. The designated doctor or other
practitioner should first assess if the exposure reported by the HCW was a significant:
that is, with the potential to transmit HIV.
9.5
Sources of expert advice include:
Consultants working in HIV medicine, Virology, Microbiology, Infectious Diseases, Sexual
Health, OHW; and Public Health Physicians (particularly those with responsibility for
infection control such as Consultants in Communicable Disease Control).
9.6
Confidentiality:
All information about the health care worker and the source patient should be kept
confidential.
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9.7
Specialist counselling:
The importance of specialist counselling support is recognised as crucial throughout this
period. Some HCW may have had occupational exposures which, after careful
assessment, are not considered significant – i.e. they do not have the potential for HIV
transmission. Such workers should be advised that the potential side effects and toxicity
of taking PEP outweigh the negligible risk of transmission posed by the type of exposure
because it is considered insignificant, whether or not the source patient is known or
considered likely to be HIV infected.
9.8
Assessment and testing of the source patient.
If initial assessment indicates that an exposure has been significant – that is, with the
potential for HIV transmission– consideration should then be given to the HIV status
of the source patient. It may be possible to ascertain from the medical record that a
source patient has established HIV infection:
Results from animal studies suggest that HIV PEP is most likely to be efficacious if
started within the hour. An urgent preliminary risk assessment therefore should
assess if it is appropriate to recommend taking the first dose of PEP and certainly
within 48/72 hours.
A more thorough risk assessment should be undertaken to inform a decision about
whether to continue the regime.
9.9
The source patient should be asked for consent to take bloods; this should not be
requested by the exposed worker but by another member of the team:
A universal approach to asking source patients to agree to have an HIV test avoids the
need to make difficult judgments, simplifies and normalises the process and avoids
potential discrimination against people perceived as belonging to groups associated
with higher than average HIV prevalence
9.10
When a source patient is asked to agree to undergo HIV testing, careful pre-test discussion
and risk assessment will be needed, which should include disclosure of their test result to
the occupational health service and to the HCW. This pre-test discussion can be provided
by any appropriately trained and competent health care worker.
9.11
Testing of source patients’ blood should be conducted urgently. This is to minimise
exposure to antiretroviral medication and to allay anxiety of the exposed individual:
It is recommended good practice that all hospitals have the capacity to obtain an HIV
test result ideally within 8 hours and not more than 24 hours after source blood is taken.
This will be monitored:
A & E Departments send a copy of their risk assessment and treatment to OHW.
By direct feedback when individual notifies their incident to OHW on their next
working day as required by policy.
9.12
Starting PEP, where appropriate, should not be delayed to await the result of source
patient testing. (See Appendix 4- Standard Regime for PEP (Starter Packs)).
9.13
Any source patient who is newly diagnosed HIV positive as a result of this
process
will need immediate access to specialist post-test counselling and assurances about
confidentiality. Close support and clinical management will be needed on an ongoing
basis. Source patients should also be informed promptly of HIV negative results, with any
post-test discussion appropriate to individual circumstances (e.g. to address an ongoing
risk identified through pre-test discussion and as a reminder about the window period
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(see below) if there has been recent personal risk). The possibility of a window period
infection in the source patient should be addressed as part of the risk assessment, and PEP
for the exposed worker may be recommended.
The window period is the period immediately following the incident, when infection can
develop and antibodies to HIV may be detected. If the individual has been infected with
HIV the antibodies usually begin to appear within a few weeks after infection, but may
take longer in some individuals (typically around 6 months).
9.14
Where it is not possible to identify the source patient (e.g. needlestick injury caused by a
discarded needle), a risk of HIV post-exposure prophylaxis assessment should be
conducted to determine whether the exposure was significant and the likelihood of HIV
from the source. The use of PEP is unlikely to be justified in the majority of such
exposures.
9.15
Prescribing PEP: PEP is available through ED or Sexual Health and should be recommended
to HCW if they have had a significant occupational exposure from a patient or other
source either known to be HIV infected, or considered to be at high risk of HIV infection,
but where the result of an HIV test has not or cannot be obtained, for whatever reason.
9.16
Starter packs of the recommended drugs are kept in: ED and Sexual Health. Each pack
should contain a minimum 3-day course of the drugs, sufficient to cover weekends and
bank holidays. PEP should normally be continued for 4 weeks. Every effort should be
made to facilitate adherence to a full 4-week regimen. Anti nausea and anti-motility drugs
(reduce diarrhoea) may also be prescribed.
9.17
PEP should not be offered after exposure through any route with low-risk materials (e.g.
urine, vomit, saliva, faeces) unless they are visibly bloodstained (e.g.
saliva
in
association with dentistry). Also, PEP should not be offered where testing has shown that
the source is HIV negative, or if risk assessment has concluded that HIV infection of the
source is highly unlikely. Exceptionally, PEP may be indicated following a negative test if
there is reason to suspect the source may be seroconverting (i.e. in the window period).
9.18
When offering PEP it is important to take into account any views of the exposed HCW.
Depending on the outcome of the preliminary risk assessment, if the exposure was
significant, the exposed health care worker may wish to consider starting PEP until further
information is available about the source patient. Changes can be made to the PEP
regimen, including cessation, if further information becomes available.
9.19
If the HIV status of the source cannot be established, the exposed HCW should have the
opportunity to consider whether or not to continue PEP. Their decision should be
informed by all that is known about the source patient in terms of past exposure to risk of
HIV infection and also the nature and severity of the exposure. These HIV post-exposure
prophylaxis aspects should be considered together with the potential for unpleasant
short-term adverse effects and unknown long term effects of taking PEP drugs.
9.20
Pregnancy: The use of PEP drugs in pregnancy are not precluded, however expert advice
should always be obtained. When there is a possibility that a healthcare worker could be
pregnant; urgent pregnancy testing should be arranged, as this will affect the evaluation
and allow the individual to reach an informed decision about starting PEP. The pregnant
HCW should be counseled about the risk of HIV infection and the risk of transmission to
her baby and about what is known and not known about the potential benefits and risks
of antiretroviral therapy for her and her baby. The British HIV Association has published
guidelines for prescribing antiretroviral therapy in pregnancy.
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9.21
Drug resistance: For known positive sources, information about drug resistances should be
used to guide decisions about PEP. A combination of drugs are recommended in starter
pack and will retain useful activity against the most common resistant viruses in the UK
and concerns over resistance should not delay standard PEP, which should be given as
soon as possible after the incident
9.22
Making PEP available: immediate access
PEP is available through the ED and through Sexual Health clinics.
9.23
OH practitioners may choose to refer exposed HCW to HIV, Sexual Health or Infectious
Disease departments for regular medical follow-up during the period of PEP, to monitor
possible toxicity and adherence to the antiretroviral regimen. Frequent close follow-up
and encouragement; as advised by clinician experienced in prescribing antiretroviral
therapy is likely to help improve adherence and deal promptly with concerns and
complications.
9.24
Where HCW follow-up is conducted outside of OH for example by the Sexual Health or
Infectious Diseases (ID) department, the HCW should also arrange a meeting/updates with
OHW. The HCW may also consent for Sexual health/ID to provide the follow-up
information to OHW. This will ensure records are complete for local review of PEP practice
and for reporting to surveillance systems, e.g. what drugs were prescribed, tolerability of
the regimen, side effects, premature discontinuation and results of any post exposure
testing.
9.25
Recommended schedule of serological screening:
Expert Advisory Group Aids (EAGA) has recommended that follow-up testing of HCWs be
performed at 12 and 24 weeks post-exposure (or 24 weeks after cessation of PEP if
prescribed. A baseline sample should be taken for storage.
Serological testing at 6 weeks is not routinely warranted as a negative serology result at
this stage is inconclusive.
HIV seroconversion: If, during the follow-up period, HIV infection is diagnosed, the HCW
should be advised and managed in line with EAGA recommendations.
9.26.
Sickness absence
Individuals, who experience adverse effects associated with PEP drugs following an
occupational exposure to HIV, may require sickness absence. Although this will be
recorded as sickness absence it should not be used for monitoring and absence control
purposes.
10.
RECOVERING AND SAFELY DISPOSING OF SHARPS OR POTENTIALLY HARMFUL
EQUIPMENT FOUND ON OR NEAR HOSPITAL SITES.
10.1
All areas should be aware of the need for a safe recovery and disposal procedure to be in
place when others have carelessly or maliciously discarded needles/sharps or other
potentially harmful equipment. (See Appendix 5) Recovering Sharps & Other Medical
Equipment Or Contaminated Equipment Found On OR Near Hospital Sites.
11.
TRAINING
11.1
Training needed to implement the policy and any ongoing training is provided by the IPCT
as identified by a ‘training needs analysis’.
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11.2
The IPCT meet all staff at Corporate Induction to present on the Principles of Standard
Precautions. As part of this teaching session staff are advised of the emergency action to
be taken when a sharps injury occurs. This includes first aid, reporting, recording
procedures and safety in recovering sharps and other medical or contaminated equipment
found on or near hospital sites. (See Appendix 5)
11.3
Other injuries are addressed; scratches, splashes, bites and cuts. Annual updates via elearning are mandatory and additional training may be facilitated by the IPCT / Link
Advisors or Occupational Health as required.
11.4
All training undertaken must be recorded on the Organisational Learning Module (OLM) of
the Electronic Staff Record (ESR) taken from signing in sheets. Monitoring of training
attendance will be carried out by the Learning & Development Department. Please refer
to the Induction & Mandatory Training Policy. Nonattendance will be managed according
to the procedure detailed in the Learning and Development Policy.
11.5
The OH team provide education and raise awareness of first aid procedures, following an
Incident involving a bite, scratch, cut or splash from blood or blood stained body fluids.
Reporting the Incident is re-enforced at Corporate Induction for all staff.
11.6
11.7
Following an incident OH will provide one to one support and education to reduce the risk
of a similar incident re-occurring.
Managers are also responsible to ensure that all new staff are inducted into local areas
and made aware of this policy, first aid action to take in the event of an injury and Trust
reporting procedures.
12.
REVIEW
12.1
This Policy may be reviewed at any time at the request of either staff side or management,
but will automatically be reviewed every three years unless organisational changes,
legislation, guidance or non-compliance prompt an earlier review.
13.
REFERENCES
o
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o
In relation to this policy the following references have been used:
Department of Health (2006) Essential Steps to Safe, Clean Care
Health Technical Memorandum. (DH 2011). Safe Management of Healthcare Waste.
Pratt et al (2007) Epic 2: National Evidence Based Guidelines for Preventing Healthcare
Associated Infections in NHS Hospitals in England
Scottish Executive (2001) Needlestick injuries: Sharpen your awareness: Report on the
short life working group on needlestick injuries in the NHS Scotland. Scottish
Executive.
DH (July 2005) HIV Infected Health Care Workers, Guidance on Management and
Patient Notification.www.dh.gov.uk/publications
DH (August 2002) Hepatitis C Infected Health Care Workers.
www.dh.gov.uk/publications
DH (2006) Immunisation of healthcare and laboratory staff, in: Immunisation against
infectious disease (the ‘Green Book’), Chapter 12,
www.dh.gov.uk/assetRoot/04/13/79/02/04137902.pdf
DH (2007) Hepatitis B infected healthcare workers and antiviral therapy,
www.dh.gov.uk/publications
DH (September 2008) HIV post-exposure prophylaxis: Guidance from the UK Chief
Medical Officers’ Expert Advisory Group on AIDS www.dh.gov.uk/publications
Health Protection Agency- Eye of the Needle 2012
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o
o
o
o
o
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o
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o
o
o
o
o
o
o
http://www.hpa.org.uk/Publications/InfectiousDiseases/BloodBorneInfections/EyeOfT
heNeedle/0811Eyeoftheneedle/
Health & Safety Executive: Needlestick injuries what is the risk
http://www.hse.gov.uk/healthservices/needlesticks/
Health & Safety Executive: RIDDOR Regulations 2013
www.hse.gov.uk/riddor/
Health & Safety Executive: The Control of Substances Hazardous to Health Regulations
2002
www.hse.gov.uk/coshh/
Health and Safety (Sharp Instruments in Healthcare) regulations 2013
www.legislation.gov.uk/uhsi/2013/645/pdf
Health & Safety Executive: Management of Health & Safety at Work Regulations 1999
www.hse.gov.uk/pubns/hsc13.pdf
Health & Safety Executive: The Personal protective equipment at work (second
edition) Regulations 1992 9as amended)
www.hse.gov.uk/pubns/priced/l25.pdf
Health & Safety Executive: Provision and Use of Work Equipment Regulations 1998
www.hse.gov.uk/pubns/indg291.pdf
Health & Safety Executive: Update on the Health & Safety (First Aid) Regulations 1981
www.hse.gov.uk/firstaid/review/dec05.htm
Health & Safety Executive CD244 - Consultation on proposed regulations to implement
Council Directive 2010/32/EU on preventing sharps injuries in the hospital and
healthcare sector http://www.hse.gov.uk/consult/condocs/cd244.htm
Health & Social Care Act (DH, 2008) Code of Practice for health and adult social care
on the prevention and control of infections and related guidance
www.dh.gov.uk/publications
M.E. Ramsey Guidance on the investigation and management of occupational
exposure to hepatitis C. 1999
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947393443
NHS Employers Sharps Injuries Framework.
www.nhsemployers.org/HealthyWorkplaces/HealthAndSafety_new/sharpsinjuriesfra
mework/Pages/ECFrameworkagreementonsharpsinjuries.aspx
NHS Employers Site Collection Documents/Needlestick
Injuryhttp://www.nhsemployers.org/SiteCollectionDocuments/Needlestick Injury (22
02
2011)
NHS Employer- Occupational Health Guide -Preventing needlestick injuries
http://www.nhsemployers.org/healthyworkplaces/occupationalhealth/Pages/Occupat
ionalHealth.aspx
NHS Employers: Implementation advice on sharps agreement - The Safer Needles
Network and the Partnership for Occupational Safety and Health in Healthcare
(POSHH) have agreed advice for the NHS on preparing for implementation of the
sharps directive.
http://www.nhsemployers.org/HealthyWorkplaces/POSHH/Pages/PreventionofSharps
InjuriesintheEuropeanHospitalandHealthcareSector.aspx
NHS Scotland. Towards A Safer Healthier Workplace. Needlestick Injuries in the NHS
Scotland http://www.sehd.scot.nhs.uk/publications/nisa/nisa.pdf
The Safer Needles Network
http://www.saferneedles.org.uk/
14. TABLE OF AMENDMENTS
Health and Safety Sharp Instraments in Health Care (regialtions 2013)
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LINKS TO RELATED SOLENT NHS TRUST DOCUMENTS
Decontamination Policy
Health & Safety Policy
First Aid At Work Policy
Data Protection Caldicott & confidentiality
Policy
Serious Incidents requiring Investigation
Policy
Reporting Adverse Incidents Policy
Infection and Prevention Control Standard
Precautions Policy
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Hand Hygiene Policy
Aseptic Technique Policy
Screening and Vaccination Policy
Management of Healthcare Worker Infected
with Blood-Borne Virus (HIV, Hepatitis B,
Hepatitis C) Policy
Sickness Absence Policy
Waste Management Policy
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APPENDIX 1
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APPENDIX 2
FULL RISK ASSESSMENT OF THE 3 MAIN BLOOD BORNE VIRUSES: (HIV, Hepatitis B and Hepatitis C).
The following should be considered when making a full risk assessment following occupational
exposure.
HIV
The body materials
which may contain
HIV in quantities
sufficient to be
infectious are:
Is there anything
that you know about
the patient which
may put them into a
higher risk group for
HIV?
Amniotic fluid
Blood
Vaginal secretions and semen
Breast milk
Cerebrospinal fluid, peritoneal fluid, pleural fluid, pericardial fluid, synovial
fluid
Saliva where there is an increased likelihood of blood being present i.e. in
association with dentistry, unfixed tissues and organs.
Individual who has been living in an area of the world with a high prevalence of HIV
e.g. Africa (South/East/Central Africa), Central Asia and eastern Europe.
Individual who may be at risk through unprotected/unsafe sex or have partners who
and participate in unsafe sexual behaviour. Risk is increased in those from high
prevalence areas.
● Individual who may be at risk through unprotected/unsafe sex or have partners who
and participates in unsafe sexual behaviour. Risk is increased in those from high
prevalence areas.
● Injecting drug user.
Blood transfusion before Oct 1985 in UK.
Mother HIV positive.
Blood transfusion abroad; where blood is not screened.
HEPATITIS B VIRUS
Hepatitis B is a vaccine preventable disease.
Department Health recommends that ALL HCWs who have direct contact with blood or blood stained body
fluids/patients’ tissues or clinical specimen are offered hepatitis B vaccination and responses to immunisation
are checked. This is available through OHW Health. (DH Green Book). Hepatitis B virus is stable on
environmental surfaces for approximately 7 days and staff should be aware that dried blood can be a potential
hazard. It is much more infectious than the HIV virus.
Body materials
Hepatitis B virus has been found in virtually all body secretions and excretions. Only
which contain
blood and serum derived fluids (saliva, semen, and vaginal fluids have been shown to
hepatitis B virus are:
be infectious).
It can be passed from infected mother to baby.
Occupational
Percutaneous exposure (sharps, bites deep scratches)
Transmission could
Cutaneous exposure to non-intact skin (spraying of blood /blood stained body fluids
result from
to broken areas of skin, (abrasions, cuts, eczema).
(examples):
Mucous exposure (into eyes, nose or mouth)
Source/patient is
The source/patient is known to be infected with hepatitis B virus (HBsAg detected in
known to be
blood).
hepatitis B positive
Injecting drug user
or thought to be in a
Individual who may be at risk of hepatitis B through unsafe sexual activity (e.g.
higher risk group of
unprotected vaginal or anal intercourse).
hepatitis B as
Individual who is having unprotected sex with hepatitis B positive partner or partner
follows:
who put themselves at risk because of their sexual behaviour.
People with hepatitis B infected mothers.
People from Africa, the middle and Far East, south east Asia and southern and
eastern Europe.
HEPATITIS C
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HCWs main protection is education in Standard Precautions, which includes appropriate personal protective
clothing and ensuring that abrasions and cuts etc. are protected by waterproof dressings. All HCWs who have
contact with blood or blood stained body fluids/ patients’ tissues or clinical specimen are offered hepatitis B
vaccination, but unfortunately there is NOT a vaccine to protect against hepatitis C. It can be passed from
infected mother to baby and there is a low risk of transmission by sexual contact.
Hepatitis C can be
Blood and plasma derivatives.
found in:
Occupation
Transmission from:
Is source/patient
known to be a risk of
hepatitis C or
thought to be in a
higher risk group, as
below?
Percutaneous exposure
The source patient/client is known to be / highly suspected, to be infected with
hepatitis C.
Received unscreened blood or untreated plasma products in the UK prior to
September 1991 (blood) and 1985 (plasma products) or has received blood/plasma
products from country where blood is not tested for hepatitis C virus.
An Injecting Drug User who has shared equipment
A health care worker or has been a patient in invasive medical, surgical, dental or
midwifery procedures in parts of the world where infection control procedures may
have been inadequate or with populations with a prevalence of hepatitis C infection
(e.g. Egypt).
The above risk of infection with ALL blood borne viruses is increased by the type of exposure
Medical Equipment:
A solid needle e.g. one used for suturing, is lower risk than a hypodermic wide
Occupational
bore needle. (Most intramuscular needles have quite a narrow bore needle).
injuries can involve
Remember-The wider the bore the greater the risk.
a variety of medical
Examples: Phlebotomy needle, venepuncture needles, trochar and cannulae,
devices:
intravenous cannulation and biopsy needles.
Medical equipment contaminated with blood e.g.: scalpels and broken vacutainer
tubes, all present a risk.
This
is
further
Percutaneous rather than mucous membrane or broken skin exposure
increased by:
Injury from a device from a source patient’s artery or vein (e.g. venepuncture).
Blood exposure rather than exposure to blood stained fluids, diluted blood (e.g. in
local anaesthetic solution)or other body fluids
Injury from hollow bore needle rather than solid bore needle
Injury from a wide gauge rather than narrow gauge needle
Deep rather than superficial injury
Visible blood on the device
No protective equipment used (e.g. gloves, eye protection)
First aid measure not implemented (washing and bleeding)
Source is co infected with more than one blood borne virus, therefore screening for all
three viruses is appropriate.
The risk of HIV is
A staff member has been contaminated with a large volume of blood (e.g. deep injury
increased:
from a large bore hollow needle, which has previously come
from a patient / source’s
vein/artery and the blood contained a higher viral load (e.g. patient / source was HIV
Example
positive with acute retroviral illness, or the patient was terminally ill with AIDS).
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PREVENTION AND MANAGEMENT OF INOCULATION
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APPENDIX 3
OCCUPATIONAL HEALTH & WELLBEING RISK ASSESSMENT: Exposure to Blood Borne
Virus(es) from Inoculation Contamination Incidents (sharps, bites, cuts, scratches splashes
1. EMPLOYER:
Solent NHS Trust
□
Care UK
□
Medirest
□
CSU/CCGs
□
Injured Person’s Name:
Source /Patient’s Name:
Date of Birth:
Date of Birth:
Job Title:
Ward Department Area/Address:
Work Base:
Work Tel No:
Hep B Status:
Home Address:
Hep C Status:
HIV Status:
Other infectious agents, if known:
Home Tel No:
Mobile:
Hep B Status:
Manager’s name
Department
2. DETAILS OF INCIDENT
Date of incident
Date & Time reported:
Department reported to:
Where incident happened:
State what happened:
Date:
OH & W □
3.TYPE of EXPOSURE
NEEDLE
Contact details:
Time (24 hour clock)
Time:
Emergency Department□
MEDICAL DEVICE
Solid needle
Type: ………………
Hollow needle
Size/colour: …………
MEDICAL DEVICE
State type: ……………………………
BONE FRAGMENT
Bone fragment
Type: …………………
BITE
Did it break skin Yes
No
SCRATCH
Was scratch deep
Superficial
WOUND FROM INJURY
Was injury Deep
Superficial
SPLASH TO FACE
Splash to: Face
Nose
‘SHARPS’ SAFETY POLICY – INCLUDING
PREVENTION AND MANAGEMENT OF INOCULATION
OR CONTAMINATION INCIDENTS (e.g. sharps, bites,
scratches or cuts). Version 3
Mouth
POTENTIAL RISK FROM BBV
Blood
Body fluids Type:. ……..
Body fluids blood stained? Yes
Blood
Body fluids
Type:
………
Body fluids blood stained? Yes
Blood
Body fluids
Type:
………
Body fluids blood stained? Yes
Did patient source have mouth/teeth
problems?
Did scratch bleed? Yes
No
Yes
Eyes
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GU (Sexual Health) □
No
Blood
Body fluids
Type: ……
Body fluids blood stained? Yes
Version 3
SPLASH TO SKIN
Was area of contaminated skin intact e.g. Blood
Body fluids
Type: ……
eczema /rash Yes
No
Body fluids blood stained? Yes
Details:
4. RISK ASSESSMENT OF KNOW RISKS FROM PATIENT SOURCE OR UNKNOWN SOURCE
Known or highly suspected Known or highly suspected Known or highly suspected
risk of HIV
risk of Hepatitis B
risk of Hepatitis C
Donor patient:
Yes
No
Yes
No
Yes
No
Unknown source Yes
No
Yes
No
Yes
No
Are any other Yes
If yes state type:
No
risks known?
Are standard bloods being taken locally?
Yes
No
Details:
(HIV/Hep B/Hepatitis C)
Risk is assessed initially to be:
High
Low
5. RECIPIENT: (Staff member)
WHAT IS THEIR HEPATITIS B STATUS?
Immune
Yes
No
Not had course
Yes
No
Part way through course Yes
No
True Non responder
Yes
No
Declined course
Yes
No
Due 5 year Booster
Yes
No
Titres:
Details:
Details:
Details:
Details:
Details:
Date:
6. TREATMENT RECIPIENT (Staff member) as recommended DH Green Book
Hep B Booster given
Date:
Hep
B
course Standard course
commenced /completed Details:
Immunoglobulin
advised:
PEP started
Date:
Accelerated
Details:
Where:
Details:
HEALTH SURVEILLANCE STARTED: (blood test)
Advised monitoring hepatitis C
Advised monitoring HIV
Yes
No
Yes
No
Staff store blood taken:
Date:
Other monitoring advised:
Details:
Is recipient pregnant/ underlying health conditions
e.g. immune compromised?
7.
Advised monitoring hepatitis B
Yes
No
Advised repeat 3 months
Advised repeat 6 months
Details:
MONITORING
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Did staff member generally follow
Policy
Was injury encouraged to bleed?
Were contact lenses worn?
Was First aid followed
Was protective clothing worn
Yes
No
Yes
Yes
Yes
Gloves
No
No
No
Aprons
Eye
Protection
Mask
Other state:
8. COUNSELLING GIVEN
Initial counselling given by:
Name:
Referral to other agency for specialist counselling: Yes
Follow up appointment OH
Date:
No
Date:
Details:
Form completed by ………………………………………………………………….Date: ……………………
Title ……………………………………………………………………………………. Copy taken for Sharps Audit
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PREVENTION AND MANAGEMENT OF INOCULATION
OR CONTAMINATION INCIDENTS (e.g. sharps, bites,
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APPENDIX 4
POST EXPOSURE PROPHYLAXIS TREATMENT-FOLLOWING HIGH RISK OCCUPATIONAL EXPOSURE
TO HIV
Following occupational exposure to HIV, an urgent preliminary risk assessment will be undertaken
in the local Emergency Department (ED) and following a high risk exposure to HIV.
Antiretroviral drugs; referred to as post exposure prophylaxis (PEP) may be offered; the doctor
making the risk assessment may involve GU (Sexual Health Team). Results from animal studies
suggest that HIV PEP is most likely to be efficacious if started within the hour and certainly within
48/72 hours. Starting PEP should not be delayed to await the result of source patient testing.
Antiretroviral drugs are not licensed for PEP, so must be prescribed on a named patient basis by a
doctor.
Starter Packs of PEP
Local ED’s hold Starter Pack for PEP; each pack contains a minimum 3 day course of the drugs,
sufficient to cover weekends and bank holidays. The standard combination treatment currently
recommended by the Department Health is:
Truvada (Tenofovir disoproxil 245mg/Emtricitabine 200mg) one tab to be taken once a day
plus
Raltegravir 400mgs one tablets to be taken twice a day
This regime should be continued for 28 days; every effort should be made to facilitate adherence
to this regimen. The PEP may be modified in light of knowledge re viral resistance in source
patient. The source patient’s stage of infection CD4 + T-cell count, viral load, treatment history,
genotypic/phenotypic; drug resistance will also need to be considered.
When there is viral resistance any combination of active drugs could potentially be used.
The HCW may have existing medical conditions e.g. may be; pregnancy, breast feeding, a history
of anaemia, neutropenia, hepatic or renal failure etc which will need to be considered in the risk
assessment and decision to offer PEP.
When there is the possibility that a HCW is pregnant – urgent pregnancy testing should be
arranged as this will affect the evaluation and allow the individual to make an informed decision
about starting PEP.
Side Effects:
Antiretroviral drug can cause many unpleasant side effects; common side effects to PEP are;
diarrhoea, headaches nausea and vomiting. Anti-nausea drugs such as Domperidone and antimotility drugs which reduce diarrhoea, such as Loperamide may also be prescribed to help with
these symptoms.
Health Surveillance
The exposed person should be tested for HIV antibodies at 12 weeks and 24 weeks (with informed
consent). If the exposed person tests positive for HIV antibodies; it will be necessary to test the
stored baseline sample and refer them to a specialist in HIV medicine.
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OR CONTAMINATION INCIDENTS (e.g. sharps, bites,
scratches or cuts). Version 3
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APPENDIX 5
RECOVERING SHARPS/OTHER MEDICAL CONTAMINATED EQUIPMENT FOUND ON GROUNDS/SITES
1.
Background
All areas should be aware of safe recovery and disposal procedures when others have
carelessly or maliciously discarded needles/sharps or other potentially harmful equipment.
A risk assessment should be made considering the likely past use of equipment, risk of
potential blood borne virus(es), infection and likelihood of harm and how recovery
should be undertaken. For example: recovering a sterile needle from the floor in a ward
area will be different to recovering a potentially used needle from the car park on site.
2.
The following procedure assumes worst case scenario;
Access to the area should be limited to person recovering the sharps/equipment.
If required seek advice, from Occupational Health / Infection Prevention and Control
Team.
Gather equipment needed for disposal:
A sealable ‘sharps box’, or if one is not available a ridged plastic sandwich box.
Tongs, forceps, a ‘litter picker’ or similar (do not pick up the needle/equipment with
gloves)
Suitable protective equipment, dependent upon the situation, but as a minimum
enclosed footwear and protective gloves.
If blood has been spilt, then a suitable spillage kit will be needed.
It may be helpful to provide a plastic rigid box to keep all ‘clean up’ equipment together,
e.g. plastic tool box or similar.
3.
Recovery Procedure.
Don protective clothing and ensure the sharps box is open and ready.
Pick up sharp/equipment using tongs and place into sharps box.
Seal the sharps box.
If blood has been spilled use clean up kit (following spillage instructions).
Dispose of protective clothing and wash hands.
4.
Clean up procedure for used equipment
Suitable protective clothing should be available e.g. disposable gloves, apron a eye
protection (if splashing).
After use gloves and aprons should be disposed of in yellow clinical waste bag.
If tongs/plastic box (tool box) used, they should be cleaned wearing personal protective
equipment and using soap and water or (detergent wipe) to remove any blood/debris
and dried well; then wiped using an alcohol wipe.
Should the plastic box (tool box) become grossly contaminated it should be discarded in
the orange clinical waste bag and a replacement obtained.
4.1 For blood stained spillage on floor- please follow infection control procedure.
5.
Reporting the Incident
Report the Incident using Trust Incident reporting procedure.
It may be appropriate to inform site manager, risk manager - this will depend upon the
seriousness of the incident.
Should anyone be injured whilst disposing of used/contaminated equipment they should
follow the action in this policy.
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APPENDIX 6
Contact Numbers for the following Hospitals and A&E departments
Basingstoke:
Switchboard- 01256 473202
A&E direct-01256 314700
Southampton General:
Switchboard-023 80777222
A&E direct- 023 81206220
Winchester:
Switchboard-01962 863535
A&E direct-01962 824950
Queen Alexandra Portsmouth:
Switchboard-023 92286000
A&E direct-023 92286380
Frimley Park
Switchboard-01276 604604
A&E direct-01276 604110/01276 526123
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APPENDIX 7
Equality & Human Rights and Mental Capacity Act Impact Assessment
Policies aims
Answer
1. What are the main aims and objectives of the To ensure safe practice when sharps are used, thereby
policy?
minimising injuries caused by contaminated sharps.
To ensure that when inoculation or contamination incidents do
occur; the (24/7) the incident is promptly risk assessed and the
healthcare worker/patient is offered appropriate treatment
to reduce the risk of infection and counselling support to reduce
distress.
2. Who will be affected by it?
All employees/patients and service users
3. What are the existing performance National guidance from various sources
indicators/measures for this?
What are the Department of Health guidance
outcomes you want to achieve?
Health & Social Care Act 2008
Health & Safety at Work Etc Act 1974
Control of Substances Hazardous to Health Regulations 2002
4. What information do you already have on the Assumption that this will potentially impact on a diverse group
equality impact of this policy?
of service users
5. Are there demographic changes or trends locally Not aware of any high risk areas within the Trust which would
to be considered?
increase incidence of injury.
6. What other information do you need?
None
Assessing the Impact; consider the data and Yes
research
1. Could the policy unlawfully against any group?
2. Can any group benefit or be excluded?
3. Can any group be denied fair & equal access to
or treatment as a result of this policy?
4. Can this actively promote good relations with
and between different groups?
5. Have you carried out any consultation
internally/externally with relevant individual
groups?
6. Have you used a variety of different methods
of consultation/involvement
Mental Capacity Act implications
No
X
Answer
(Evidence)
This policy applies to all and is consistent with
current DH policy.
Of potential safety benefits to all staff and patient /
service users in prevention of injuries and treatment
to prevent infections.
This policy applies to all and is consistent with
current DH policy/Health & Safety Policy
As all staff/patients/service users are treated the
same.
Internally with Occupational Health & Wellbeing
Team/ IPC team/GU (Sexual Health) team.
X
As above
X
X
X
X
7. Will this policy require a decision to be made
by or about a service user? (Refer to the Mental
Capacity Act policy for further information)
The assessment is that there is no negative impact
‘SHARPS’ SAFETY POLICY – INCLUDING
PREVENTION AND MANAGEMENT OF INOCULATION
OR CONTAMINATION INCIDENTS (e.g. sharps, bites,
scratches or cuts). Version 3
X
This policy applies to staff and part of the aim is to
protect service users.
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