Download Exposure Prone Procedures (EPPs) and Blood Borne Viruses (BBVs

SH CP 157
Exposure Prone Procedures (EPPs) and
Blood Borne Viruses (BBVs)- Management
of the Infected Healthcare Worker
Version: 2
Summary:
This document provides guidance for clinicians and administrative
staff managing cases where healthcare workers (HCW) who
undertake exposure prone procedures (EPP) and HCWs infected
with a blood borne virus
Keywords:
Hepatitis B, Hepatitis C, HIV, Blood Borne Virus. Infected Health
Care Worker
Target Audience:
Staff performing surgical procedures or scrub for surgical
procedures; staff working in MIU’s and podiatry staff who perform
exposure prone procedures.
Next Review Date:
March 2020
Approved &
Ratified by:
Infection Prevention & Control &
Decontamination Group
Date issued:
March 2016
Author:
Theresa Lewis – Lead Nurse Infection Prevention and Control
Jacky Hunt – Infection Prevention Nurse
Lorna Straine – OH Assist Occupational Health Specialist
Practitioner Clinical Lead - Immunisations & BBV's
Sara Courtney – Interim Executive Director of Nursing, AHP and
Quality
Director:
Date of meeting:
11 February 2016
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Version Control
Change Record
Date
Author
06.02.14
Theresa Lewis
and Carol
Hargreaves - OH
Assist
Jacky Hunt
Lorna Strain
Theresa Lewis
22.12.15
Version
Page
Reason for Change
1
New Policy
2
Previous policy due to expire
Reviewers/contributors
Name
IP&C Team
Carol Hargreaves
IP&C Group Members
Clinical Directors and Professional
Leads
Louise Jones
Nick Sargeant
IPC Team
Lorna Strain – OH Assist Immunisation
Lead
Louise Jones
Position
OH Assist
HR Manager
Acute Care Pathway Manager - AMH
Lorna Straine – OH Assist Occupational
Health Specialist Practitioner
Clinical Lead - Immunisations & BBV's
Senior HR manager
Version Reviewed
& Date
20.01.14 & 19.03.14
10.01.14 & 06.03.14
07.04.14
07.04.14
28.04.14
22.04.14
29.12.15
29.12.15
29.12.15
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Quick Reference Guide
For quick reference, this page summarises the actions required by this policy. This does not
negate the need to be aware of and to follow the further detail provided in this policy.
The purpose of this policy is to restrict healthcare workers infected with blood bourne viruses
from the workplace if their infection poses a risk to the patients in their care.
Exposure Prone Procedures (EPP): invasive procedures where there is a risk that injury to
the worker may result in the exposure of the patient’s open tissues to the blood of the worker
(‘bleed-back’). These include procedures where the worker’s gloved hands may be in
contact with sharp instruments, needle tips or sharp tissues (e.g. spiccules of bone or teeth)
inside a patient’s open body cavity, wound or confined anatomical space where the hands or
fingertips may not be completely visible at all times. Other situations, such as pre-hospital
trauma care should be considered to be EPP.
Procedures where the hands and finger tips of the worker are visible and outside the
patient’s body at all times, and internal examinations or procedures that do not involve
possible injury to the worker’s gloved hands from sharp instruments and/or tissues, are
considered not to be exposure prone provided routine infection control procedures are
adhered to at all times.
Examples of staff that perform EPP include:

All surgeons

FY1 and FY2 doctors who rotate into EPP areas

Theatre staff who scrub

Midwives

Doctors and nurses in Emergency Department

Podiatric surgeons
Further information on what constitutes an EPP is available in the Immunisation Policy SH
HR 59
Staff with a blood borne infection will be restricted from performing EPP unless they meet
specific criteria as outlined in section 5 of this policy
Routine blood testing for HIV hepatitis C and hepatitis B is required for EPP clearance for :

All EPP workers who enter training of EPP dependant specialities

All EPP workers new to the NHS or returnees to the NHS in EPP dependent
specialities

All EPP workers who believe they have been exposed to a blood borne virus where
there is a risk of transmission e.g. HCW has had a needle stick injury from a hepatitis
positive HCW.

All EPP workers who are newly employed by the Trust where their role involves EPP
and cannot provide Occupational Health their complete EPP documentation that meets
UK Department of Health standards, may require to undergo further EPP serology
testing. Occupational Health will make the decision if this is required or not depending
on the documentation provided.
Managers

Managers are responsible for ensuring that staff are aware of this policy.

Managers are responsible to ensure that the OHS is made aware of any HCW whose
role includes EPP
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
If Occupational Health advises that the HCW is not fit to undertake EPP’s a risk
assessment of the role will need to be undertaken by OHS. This will identify if the
HCW can continue in the role if EPP’s are excluded. Managers are then responsible
for ensuring that adherence to any restrictions made by Occupational Health are
followed and must make every effort to arrange suitable alternative work and retraining
opportunities, or where appropriate, early retirement for infected employees, where
indicated after Occupational Health input.
Healthcare Workers

All healthcare workers who have direct clinical care of patients, have a duty to keep
themselves informed and updated on the codes of professional conduct and guidelines
on working with a blood borne infection laid down by their regulatory bodies and any
relevant guidance issued by the Department of Health.

A healthcare worker who has any reason to believe they may have been exposed to
infection with HIV, in whatever circumstances, must promptly seek and follow
confidential professional advice on whether they should be tested for HIV. Failure to do
so may breach the duty of care to patients.

Healthcare workers who know or have good reason to believe (having taken steps to
confirm the facts as far as practicable) that a medical colleague or healthcare worker
who has, or may have, a serious communicable disease (such as hepatitis B, hepatitis
C or HIV), is practicing, or has practiced, in a way which places patients at risk, they
must inform an appropriate person in the healthcare worker’s employing authority, for
example an Occupational Health Physician, the Trust’s medical director, the Director of
Public Health or where appropriate the relevant regulatory body. Healthcare workers
may wish to seek advice from their regulatory and professional bodies before passing
on such information; such cases are likely to arise very rarely. Wherever possible, the
healthcare worker should be informed before information is passed to an employer or
regulatory body.

HCW’s have a duty to comply with this policy and undertake any appropriate screening
deemed necessary for the position.

Any HCW who is involved in EPP’s and refuses to follow the policy will not be allowed
to undertake EPP’s. The Manager will be informed that the HCW is not fit to undertake
EPP’s. Failure by staff to comply with this policy may be regarded as gross misconduct
and may lead to Disciplinary Action.
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Contents
Section
Title
Quick reference guide
Page
3
1.
Introduction
6
2.
Who does this policy apply to?
6
3.
Definitions
6
4.
Duties and responsibilities
8
5.
Main policy content
9
6.
Training requirements
12
7.
Policy review
13
8.
Associated trust documents
13
9.
Supporting references
13
Appendices
Appendix 1
Equality Impact Assessment Tool
14
Appendix 2
Hepatitis B Infected HCW and Anti-Virals - Best
Practice Guidance
15
Appendix 3
Hepatitis C Infected HCW – Best Practice
Guidance
15
Appendix 4
Proforma for Testing Blood Samples
15
Appendix 5
DoH Health Clearance for Tuberculosis, Hepatitis
B, Hepatitis C and HIV: New Healthcare Workers –
Best Practice Guidance
Management of HIV infected Healthcare Workers
who perform exposure prone procedures: updated
guidance January 2014 (PHE 2014)
15
Appendix 6
15
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Exposure Prone Procedures (EPPs) and Blood Borne Viruses (BBVs) Management of the Infected Healthcare Worker
1.
Introduction
The overall aim of this policy is to control the risk to patients from healthcare workers
infected with blood borne viruses (BBV).
The purpose is also to restrict healthcare workers infected with blood borne viruses
from the workplace if their infection poses a risk to the patients in their care
This guidance recommends that all new healthcare workers have checks for
tuberculosis disease/immunity and are offered hepatitis B immunisation, with postimmunisation testing of response and the offer of tests for hepatitis C and HIV. These
standard health clearance checks should be completed on appointment (See
Immunisation Policy SH HR 59)
For new healthcare workers who will perform exposure-prone procedures (EPPs),
additional health clearance should also be undertaken. Additional health clearance
means being non-infectious for HIV, hepatitis B (surface antigen negative or, if
positive, e-antigen negative with a viral load of 103 genome equivalents/ml or less) and
hepatitis C (antibody negative or, if positive, negative for hepatitis C RNA). These
checks should be completed before confirmation of an appointment to an EPP post, as
the healthcare worker will be ineligible if found to be infectious.
This guidance does not apply to healthcare workers who are already employed in the
NHS, with the exception of those moving to a post requiring the performance of EPPs
for the first time in their career. This guidance is supplementary to routine occupational
health checks/immunisations for other infectious diseases (eg for rubella and varicella
as outlined in Immunisation policy SH HR 59) (Department of Health (2007) Health
Clearance for tuberculosis, hepatitis B, hepatitis C and HIV: New Healthcare Workers).
2.
Who does this policy apply to?
This policy applies to all healthcare workers (HCWs) who would be performing
exposure prone procedures for the first time. This would include existing HCWs who
are moving post or training that involves EPPs and those returning to the NHS
dependent on what activities they have engaged in while away from the NHS.
This policy does not apply to HCWs who are already employed in the Trust with the
exception of those moving to a post requiring performance of EPPs for the first time in
their career.
3.
Definitions
New Health Care Worker – for the purpose of this policy a new healthcare worker
(HCW) is defined as an individual who has direct clinical contact with Trust patients,
whether as an employee or with Trust agreement (visiting fellow, student placement)
for the first time. Existing healthcare workers who are moving to a post or training that
involves exposure prone procedures (EPP) are also considered new. Returning
healthcare workers may also be regarded as ‘new’ depending on what activities they
have engaged in while away from the NHS.
Exposure Prone Procedures (EPP): invasive procedures where there is a risk that
injury to the worker may result in the exposure of the patient’s open tissues to the
blood of the worker (‘bleed-back’). These include procedures where the worker’s
gloved hands may be in contact with sharp instruments, needle tips or sharp tissues
(e.g. spiccules of bone or teeth) inside a patient’s open body cavity, wound or confined
anatomical space where the hands or fingertips may not be completely visible at all
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times. Other situations, such as pre-hospital trauma care should be considered to be
EPP.
Procedures where the hands and finger tips of the worker are visible and outside the
patient’s body at all times, and internal examinations or procedures that do not involve
possible injury to the worker’s gloved hands from sharp instruments and/or tissues, are
considered not to be exposure prone provided routine infection control procedures are
adhered to at all times.
Examples of such non-EPP procedures include:
 Taking blood
 Setting up and maintaining intravenous lines or central lines (provided any skin
tunneling procedure used for the latter is performed in a non-exposure prone
manner)
 Minor surface suturing
 Incision of external abscesses
 Routine vaginal or rectal examinations
 Simple endoscopic procedures
Examples staff that perform EPP include:
 All surgeons
 FY1 and FY2 doctors who rotate into EPP areas
 Theatre staff who scrub
 Midwives
 Doctors and nurses in Emergency Department
 Podiatric surgeons
Further information on what constitutes an EPP is available in the Immunisation Policy
SH HR 59
Blood Borne Virus (BBV): viruses that are carried in the blood and may cause severe
disease in certain people and few or no symptoms in others. The main BBVs of
concern are:
 Hepatitis B virus (HBV) and Hepatitis C (HCV) which cause hepatitis, a disease of
the liver
 Human Immunodeficiency Virus (HIV) which causes Acquired Immune Deficiency
Syndrome (AIDS), affecting the immune system of the body.
United Kingdom Advisory Panel for Health Care Workers infected with Blood
Borne Viruses (UKAP). UKAP gives advice on guidance on healthcare workers
infected with HIV, hepatitis B and hepatitis C. The panel also provides support for local
incident management teams and maintains a register of infected healthcare workers.
See www.gov.uk email contact [email protected]
Health Care Worker (HCW): all staff including medical and nursing staff as well as
others who may have direct patient contact,
Viral Load – Viral load, also known as viral burden or viral titre, is a measure of the
severity of an active viral infection, and can be calculated by estimating the live
amount of virus in an involved body fluid.
cART – Combination antiretroviral therapy
Identified Validated Sample (IVS) - is defined by Association of NHS Occupational
Physicians (ANHOPS) and the Association of NHS Occupational Health Nurses
(ANHONS) as meeting the following criteria:
(a) The HCW must show a proof of identity with a photograph - Trust identity badge,
new driver’s licence, passport or national identity card - when sample is taken;
(b) The sample of blood must be taken in the occupational health department;
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(c) Samples must be delivered to the laboratory in the usual manner, not transported
by the healthcare worker;
(d) When the results are received from the laboratory, the clinical notes must be
checked for a record that the sample was sent by the occupational health department,
at the relevant time.
Elite Controller– is defined as a person living with HIV who is not receiving
antiretroviral therapy and who has maintained their viral load below the limits of assay
detection for at least 12 months, based on at least three separate viral load
measurements.
4.
Duties and responsibilities
Chief Executive
The chief executive has overall responsibility for ensuring that the Trust meets its
statutory and non-statutory obligations for staff health clearance for Hepatitis B,
Hepatitis C and HIV of the HCW.
Director of Human Resources
Director of Human Resources is responsible for ensuring that the requirements of this
policy are effectively managed via the Occupational Health Department.
Giving assurance that healthcare workers’ infected with HIV hepatitis B or C status and
rights as employees will be safeguarded so far as practicable
Occupational Health
 Occupational Health is responsible for the implementation and monitoring of this
Policy.
 Occupational Health has a responsibility to ensure that prior to any blood tests
being undertaken that the HCW understands what tests are being undertaken and
why.
 Occupational Health has a responsibility to ensure the HCW is fully informed of any
implications on their role in the event of a positive test; so that the HCW must give
informed consent.
 Occupational Health will be responsible for advising the Manager of any role
exclusions that are required.
 Occupational Health will be responsible for considering the impact of HIV positivity
on the individual’s resistance to infection when advising on suitability for particular
posts, especially if the duties involve exposure to known or undiagnosed TB
Managers
 Managers are responsible for ensuring that staff are aware of this policy.
 Managers are responsible to ensure that the OHS is made aware of any HCW
whose role includes EPP
 If Occupational Health advises that the HCW is not fit to undertake EPP’s a risk
assessment of the role will need to be undertaken by OHS. This will identify if the
HCW can continue in the role, if EPP’s are excluded. Managers are then
responsible for ensuring that adherence to any restrictions made by Occupational
Health are followed and must make every effort to arrange suitable alternative work
and retraining opportunities, or where appropriate, early retirement for infected
employees, where indicated after Occupational Health input.
Healthcare Workers
 All healthcare workers who have direct clinical care of patients, have a duty to keep
themselves informed and updated on the codes of professional conduct and
guidelines on working with a blood borne infection laid down by their regulatory
bodies and any relevant guidance issued by the Department of Health. The General
Medical Council, General Dental Council and the Nursing and Midwifery Council all
provide statements about the ethical responsibilities of healthcare workers towards
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their patients and the full statements can be obtained directly from these
organisations.
 A healthcare worker who has any reason to believe they may have been exposed to
infection with HIV, in whatever circumstances, must promptly seek and follow
confidential professional advice on whether they should be tested for HIV. Failure to
do so may breach the duty of care to patients.
 Healthcare workers who know or have good reason to believe (having taken steps
to confirm the facts as far as practicable) that a medical colleague or healthcare
worker who has, or may have, a serious communicable disease (such as hepatitis
B, hepatitis C or HIV), is practicing, or has practiced, in a way which places patients
at risk, they must inform an appropriate person in the healthcare worker’s
employing authority, for example an Occupational Health Physician, the Trust’s
medical director, the Director of Public Health or where appropriate the relevant
regulatory body. Healthcare workers may wish to seek advice from their regulatory
and professional bodies before passing on such information; such cases are likely
to arise very rarely. Wherever possible, the healthcare worker should be informed
before information is passed to an employer or regulatory body.
 All HCWs who are HIV positive and wish to perform EPP must meet the following
criteria:
 must be under the care of a designated consultant occupational physician;
 must accept that it is a condition of undertaking EPP that they consent to ongoing
monitoring while they continue to practice exposure-prone procedures, including:
a. the registration of their details and monitoring data on the UKAP-OHR
b. the release of monitoring information to the consultant occupational physician
and the treating physician
c. to provide an IVS for viral load monitoring at the appointed times
d. to seek advice if a change in health condition may affect their fitness to practise
or impair their health
e. to notify OH when they are changing their practice or their place of employment
 HCW’s have a duty to comply with this policy and undertake any appropriate
screening deemed necessary for the position.
 Any HCW who is involved in EPP’s and refuses to follow the policy will not be
allowed to undertake EPP’s. The Manager will be informed that the HCW is not fit to
undertake EPP’s. Failure by staff to comply with this policy may be regarded as
gross misconduct and may lead to Disciplinary Action.
5.
Routine testing for EPP clearance and interpretation of results
Routine testing for EPP clearance is required for:
 All EPP workers who enter training of EPP dependant specialities
 All EPP workers new to the NHS or returnees to the NHS in EPP dependent
specialities
 All EPP workers who believe they have been exposed to a blood borne virus where
there is a risk of transmission e.g. HCW has had a needle stick injury from a
hepatitis positive HCW.
5.1
Hepatitis C
Healthcare workers who are infected with the hepatitis C virus (HCV) and are RNA
positive must not perform EPPs. As there is no vaccine for hepatitis C it is not possible
to ensure permanent non-infectivity.
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All HCWs who know they are infected with HCV or believe they may have been
exposed to hepatitis C infection should seek advice from the Occupational Health
Services.
Hepatitis C screening is mandatory for:
 All EPP workers who entered in training of EPP dependant specialities from
January 2003
 All EPP workers new to the NHS or returnees to the NHS in EPP dependent
specialities from August 2007.
 All EPP workers who believe they have been exposed to hepatitis C where there is
a risk of transmission e.g. hepatitis C positive needle stick injury.
Screening consists of a hepatitis C antibody blood test (Anti HCV) and if positive
hepatitis C virus RNA blood test.
If screening tests identify an individual who is Anti HCV positive a referral will be made
to the Occupational Health Consultant.
HCWs who respond successfully to treatment with antiviral therapy will be allowed to
resume EPP work or training. Successful response is defined as remaining HCV
negative for 6 months after the cessation of treatment. There will be ongoing
assessment by the OH Consultant every 6 months until advised accordingly.
In the following cases EPP clearance will not be authorised:
 Anti HCV positive, HCV RNA positive
 Anti HCV positive, HCV RNA negative but more than 6 months since last test.
The following table indicates Occupational
Health monitoring dependent on the outcome
of the screening. Status
Anti HCV negative
Anti HCV positive, HCV RNA negative
EPP Clearance Expiry
None
6 months from date of last HCV RNA test
It is a requirement for healthcare workers new to the NHS (after March 2007) who will
be undertaking EPP and HCW new to EPPs to undergo routine blood testing prior to
employment to determine non infectivity to Hepatitis B (HBV), Hepatitis C (HCV) and
HIV. HCWs who apply for a post or training which requires the performance of EPPs
and who decline to be tested for HIV, HBV or HCV should not be cleared for EPP
work. The outcomes of significant results are as follows but please consult the
attached guidance for further detail:
Hepatitis C (HCV) RNA positive- Restrict in accordance with HSC 2002/010
guidance (Appendix 2) and refer to a liver unit for specialist intervention. Hepatitis C
infected HCWs who have been treated with antiviral therapy and who remain hepatitis
C virus RNA negative for at least 6 months after cessation of treatment may resume
EPPs following consultation with a consultant Occupational Physician.
5.2
Hepatitis B (HBV)
Healthcare workers participating in EPP must undergo testing for Hepatitis B
surface antigen (HBSAg) on an identified validated sample before being cleared
by OH Service to commence EPP.
Those who are HBSAg negative are fit to undertake EPP.
Those who are HBSAg positive should undergo further tests to assess infectivity.
Staff found to be Hepatitis B e Antigen positive, are not fit to undertake EPP.
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Staff who are e antigen negative and have viral loads of hepatitis B (HBV) DNA
levels below 200IU/ml can continue to undertake EPP as long as they are
monitored annually by the Occupational Health Service.
Sampling should entail two separate blood samples (identified and validated –IVS
standards) one week apart.
Special arrangements will be put in place by the Occupational Health Service for
HBV infected HCW with pre-treatment results of above 200IU/ml and below
20,000IU/ml.
HCW with baseline viral load above 20,000 IU/ml will be declared ineligible to
perform EPP while taking oral antiviral therapy on the grounds of patient’s safety,
by the Occupational Health service.
If the staff member discontinues antiviral treatment they have a duty to inform the
Occupational Health Service
Any healthcare worker who is associated with the transmission of Hepatitis B to a
patient must cease EPP regardless of their viral load.
Staff found to be infected with Hepatitis B will be referred for appropriate
investigation and treatment. The Occupational Health Service will advise the Trust
about necessary work restrictions and the Trust will explore temporary or
permanent job modification, redeployment or retraining as appropriate.
HCWs who refuse to comply with testing will be considered unfit for EPP.
Healthcare workers would be under a professional and ethical obligation to
immediately cease performing exposure prone procedures should they stop
treatment for any reason
5.3
HIV
HIV positive employees were all previously considered permanently unfit for EPP
work, but this advice has now changed in line with PHE guidance 2014. HCWs on
appropriate treatment and management, with plasma viral load level < 200 copies per
ml can now undertake EPP work.
HIV infected HCWs must meet the following criteria before they perform EPPs:
 be on effective combination antiretroviral therapy (cART), and
 have a plasma viral load <200 copies/ml
Or be an elite controller
And
HIV infected HCW must not rely on their own assessment of the risk they pose to
patients but must promptly seek expert medical advice. They must accept that it is a
condition of undertaking EPPs that they consent to ongoing monitoring while they
continue to practise EPP, including:
i. The registration of their details and monitoring data on the UKAP-OHR
ii. The release of monitoring information to the consultant OHP and the treating
physician
iii. The provision of an IVS for viral load monitoring at the appointed times
iv. Seeking advice if changes in their health condition may affect their fitness to
practise or impair their health
v. Notification to the Occupational Health Service when they are changing their
practice or their place of employment
NB hat by seeking to and undertaking EPPs, HIV positive staff are giving implied
consent to i and ii above and they are undertaking to satisfy iii, iv, v as well.
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Viral load monitoring and ongoing clearance by the Occupational Health Service
for HIV infected HCWs performing EPPs
 HIV infected HCWs who are cleared to perform EPPs are subject to viral load
testing every three months while continuing to perform such procedures. The three
month period should be taken from the date the previous IVS was drawn, and not
from the date the result was received.
 If a HCW’s plasma viral load rises above 1000 copies/ml, they should be restricted
immediately from carrying out EPPs until their viral load returns to being
consistently below 200 copies/ml in at least two tests done no less than three
months apart. The significance of any increase in plasma viral load above 200
copies/ml and below 1000 copies/ml should be assessed jointly by the occupational
health and treating physicians with input from local experts (eg consultant
microbiologist or virologist)
The table below sets out the expected course of action for viral load test results
below and above the level of EPP clearance (200 copies/ ml)
Viral load count test result
<50 copies/ml or below
50-200 copies/ml
>200 copies/ml but < 1000 copies/ml
1000 copies/ml or above
6.
Action
No action-retest in three months
A case-by-case approach based on clinical
judgement would be taken which may result in
no action (as above) or a second test may be
done 10 days later to verify the first result.
Further action would be informed by the test
result.
A second test must be automatically being
done 10 days later on a new blood sample to
verify the first result. If the count was still in
excess of 200 copies/ml, the HCW would
cease conducting EPPs until their count, in two
consecutive tests no less than three months
apart, was reduced to <200 copies/ml.
The HCW would cease conducting EPPs
immediately. A second test must be done on
a new blood sample 10 days later to verify the
first result. If the count was still in excess of
1000 copies/ml, a full risk assessment must be
initiated to determine the risk of HCW to
patient transmission. At a minimum, this will
include discussion between the consultant
OHP physician and the treating physician on
the significance of the result to the risk of HIV
transmission.
Following a risk assessment exercise, a
Patient Notification Exercise (PNE) may be
conducted. UKAP advice may be sought at this
stage.
Training requirements
All occupational immunisations and tests that are referred to within this policy are
administered by qualified Occupational Health Staff who have received appropriate
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information and training. Immunisations requirements will be covered as part of the
individual’s pre-employment health screening by Occupational Health Service.
7.
Policy review
This policy will be reviewed by the OHS and IP&C team every 4 years or earlier to
meet with national guidance
8.
Associated trust documents
Immunisation Policy SH HR 59
9.
Supporting references
Hepatitis B Infected HCW and Anti-Virals - Best
Practice Guidance (DH 2007)
Hep B infected HCW
and anti-virals.pdf
Hepatitis C Infected HCW – Best Practice Guidance
(DH 2002) HSC 2002/010
Hep C infected
healthcare workers.pdf
Proforma for Testing Blood Samples
DoH Health Clearance for Tuberculosis, Hepatitis B,
Hepatitis C and HIV: New Healthcare Workers –
Best Practice Guidance (DH 2007)
Management of HIV infected Healthcare Workers
who perform exposure prone procedures: updated
guidance January 2014 (PHE 2014)
Pre-emp
clearance.pdf
Management of HIV
Infected HWC Practicing EPP_Interim Guidelines_January 2014[1
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Appendix 1: Equality Impact Assessment
The Equality Analysis is a written record that demonstrates that you have shown due regard
to the need to eliminate unlawful discrimination, advance equality of opportunity and
foster good relations with respect to the characteristics protected by the Equality Act 2010.
Stage 1: Screening
Date of assessment:
Name of person completing the
assessment:
Job title:
Responsible department:
22.12.15
Jacky Hunt
Infection Prevention and Control
Occupational Health, Infection Prevention
and Control and Human Resources
Intended equality outcomes:
Who was involved in the consultation of
this document?
OHS, HR, H&S Officer, IPC Group,
Immunisations Group
Please describe the positive and any potential negative impact of the policy on
service users or staff.
In the case of negative impact, please indicate any measures planned to mitigate
against this by completing stage 2. Supporting Information can be found be following the
link: www.legislation.gov.uk/ukpga/2010/15/contents
Protected Characteristic
Age
Positive impact
Disability
Gender reassignment
Marriage & civil partnership
Pregnancy & maternity
Risk assessments will
be carried out by OHS
Race
Religion
Sex
Sexual orientation
Negative impact
No adverse impacts have been
identified at this stage of screening
No adverse impacts have been
identified at this stage of screening
No adverse impacts have been
identified at this stage of screening
No adverse impacts have been
identified at this stage of screening
No adverse impacts have been
identified at this stage of screening
No adverse impacts have been
identified at this stage of screening
No adverse impacts have been
identified at this stage of screening
No adverse impacts have been
identified at this stage of screening
No adverse impacts have been
identified at this stage of screening
Stage 2: Full impact assessment
What is the impact?
Mitigating actions
Monitoring of actions
14
Exposure Prone Procedures (EPPs) and Blood Borne Viruses – Management of the Infected Healthcare Worker
Version: 2
March 2016
Appendix 2
Appendix 3
Hepatitis B Infected HCW and Anti-Virals - Best
Practice Guidance (DH 2007)
Hepatitis C Infected HCW – Best Practice Guidance
(DH 2002)
Appendix 4
Proforma for Testing Blood Samples
Appendix 5
DoH Health Clearance for Tuberculosis, Hepatitis B,
Hepatitis C and HIV: New Healthcare Workers – Best
Practice Guidance (DH 2007)
Appendix 6
Management of HIV infected Healthcare Workers who
perform exposure prone procedures: updated guidance
January 2014 (PHE 2014)
Hep B infected HCW
and anti-virals.pdf
Hep C infected
healthcare workers.pdf
Pre-emp
clearance.pdf
Management of HIV
Infected HWC Practicing EPP_Interim Guideli
15
Exposure Prone Procedures (EPPs) and Blood Borne Viruses – Management of the Infected Healthcare Worker
Version: 2
March 2016