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Source: Health, Safety and Risk Manager Status: Approved Page 1 of 16 Issue Date: August 2019 Review: July 2022 Document Ref: P(19)083 Trust Policy and Procedure Document Ref No: PP (19)083 Sharps Injury (Safe Handling and Disposal of Sharps) Policy For use in: All areas of the Trust For use by: All Trust staff For use for: The Management of sharp devices Document owner: Health & Safety Committee Status: Approved Purpose of this document To provide comprehensive guidance to all West Suffolk NHS Foundation Trust (WSFT) staff on the safe handling and disposal of sharps. Aim of the policy and procedure: To ensure that the WSFT complies with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. Minimise the risk of sharps injuries and blood borne virus exposure to WSFT staff through the correct handling and disposal of sharps. To ensure all relevant clinical staff are trained in the safe use, disposal and what to do in the event of a sharps injury. To ensure that all injuries and exposure incidents are reported on Datix to enable investigation and action to reduce a recurrence. To ensure safety sharps are used where it is reasonably practicable to do so. If you are clinically assessing a patient or staff member for possible blood borne virus exposure or needle sharp type injury click here to access the assessment guidelines Contents Pages 1. Introduction 2 2. Definitions 2 3. Causes of Sharps injuries 2-3 4. Roles and Responsibilities 3-5 5. Safe handling and disposal of sharps 5-7 6. Procedure to be taken following a sharps injury to staff 7 7. Procedure to be taken by Occi Health or the Emergency Dept following a staff sharps injury 8 8. Assessing the Risk 8 9. Post Exposure Prophylaxis (PEP) 9 10. Risk of Hepatitis B 9-10 11. Risk of Hepatitis C 10-11 12. Occupational Health Follow Up 11 13. Training 11 14. Reporting 11 15. Monitoring and Review 12 16. Development of the Policy 12 17. Distribution and Implementation 12 Appendix 1- Generic risk assessment 14 Appendix 2- Flow chart 15

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Page 1: Sharps Injury (Safe Handling and Disposal of Sharps) Policy · 2020-01-15 · virus exposure or needle sharp type injury click here to access the assessment guidelines Contents Pages

Source: Health, Safety and Risk Manager Status: Approved Page 1 of 16 Issue Date: August 2019 Review: July 2022 Document Ref: P(19)083

Trust Policy and Procedure Document Ref No: PP (19)083 Sharps Injury (Safe Handling and Disposal of Sharps) Policy

For use in: All areas of the Trust

For use by: All Trust staff

For use for: The Management of sharp devices

Document owner: Health & Safety Committee

Status: Approved

Purpose of this document To provide comprehensive guidance to all West Suffolk NHS Foundation Trust (WSFT) staff on the safe handling and disposal of sharps. Aim of the policy and procedure:

To ensure that the WSFT complies with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

Minimise the risk of sharps injuries and blood borne virus exposure to WSFT staff through the correct handling and disposal of sharps.

To ensure all relevant clinical staff are trained in the safe use, disposal and what to do in the event of a sharps injury.

To ensure that all injuries and exposure incidents are reported on Datix to enable investigation and action to reduce a recurrence.

To ensure safety sharps are used where it is reasonably practicable to do so. If you are clinically assessing a patient or staff member for possible blood borne virus exposure or needle sharp type injury click here to access the assessment guidelines

Contents Pages

1. Introduction 2

2. Definitions 2

3. Causes of Sharps injuries 2-3

4. Roles and Responsibilities 3-5

5. Safe handling and disposal of sharps 5-7

6. Procedure to be taken following a sharps injury to staff 7

7. Procedure to be taken by Occi Health or the Emergency Dept following a staff sharps injury

8

8. Assessing the Risk 8

9. Post Exposure Prophylaxis (PEP) 9

10. Risk of Hepatitis B 9-10

11. Risk of Hepatitis C 10-11

12. Occupational Health Follow Up 11

13. Training 11

14. Reporting 11

15. Monitoring and Review 12

16. Development of the Policy 12

17. Distribution and Implementation 12

Appendix 1- Generic risk assessment 14

Appendix 2- Flow chart 15

Page 2: Sharps Injury (Safe Handling and Disposal of Sharps) Policy · 2020-01-15 · virus exposure or needle sharp type injury click here to access the assessment guidelines Contents Pages

Source: Health, Safety and Risk Manager Status: Approved Page 2 of 16 Issue Date: August 2019 Review: July 2022 Document Ref: P(19)083

1. Introduction Sharp injuries are a well-known risk within the NHS, the true nature of the problem is difficult to know as many incidents go unreported each year. It is estimated that around 40,000 needlestick injuries are reported each year but it is recognised that the true figure may be twice this. The risk of infection from an infected patient following exposure to a patient’s blood by a sharp or needlestick injury is estimated to be 1 in 3 for Hepatitis B, 1 in 30 for Hepatitis C and 1 in 300 for HIV. Healthcare Workers (HCW) are most at risk from exposure to a blood borne virus (BBV) following a contaminated sharp injury. However anyone working in healthcare can be at risk. This includes housekeepers, catering staff and porters. The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 came into force on 11 May 2013 to reduce the risk of sharps injuries and exposure to blood borne viruses. The regulations place a duty on the Trust to:

Avoid the use of unnecessary sharps

Substitute traditional unprotected medical sharps with a ‘safer sharp’ where it is reasonably practicable to do so

Prevent recapping of needles

Place secure containers and instructions for safe disposal of medical sharps close to the work area

Provide adequate information, instruction and training

To have a process for reporting and investigating sharps injuries

To ensure staff have immediate access to treatment and follow up of sharps injuries

The Control of Substances Hazardous to Health Regulations 2002 (as amended) place a duty on the employer to “protect against risks to the health of their employees, whether immediate or delayed, arising from exposure to substances”. 2. Definitions:

Sharps Injury: Sharps injuries occur when a needle or other sharp instrument (for example, scalpel blade, trochar, bone fragment or tooth) accidently penetrates the skin. This is called percutaneous exposure. If the needle or sharp instrument is contaminated with blood or other body fluid, there is the potential for transmission of infection. Other percutaneous exposure includes cuts, pinches, scratches, nicks and bites which break the skin. Exposure to body fluid: When blood or other body fluid splashes into the eyes, nose or mouth or onto broken skin, this is called mucocutaneous exposure. The risk of transmission of infection is lower for mucocutaneous exposure than for percutaneous exposures. 3. Causes of sharps injuries: In general sharp or needlestick injuries are caused by simple and preventable mistakes in handling sharp medical devices. The main device for causing most injuries is the needle and syringe. Injuries are more likely to occur if used (contaminated) needles are re-sheathed prior to disposal and when they are not disposed of at point of use. The risk of injury also increases when a sharps bin is, not available, is too far away, or, is overfilled. Sharps injures can and do also occur to non-clinical staff, e.g. porters and housekeepers.

Page 3: Sharps Injury (Safe Handling and Disposal of Sharps) Policy · 2020-01-15 · virus exposure or needle sharp type injury click here to access the assessment guidelines Contents Pages

Source: Health, Safety and Risk Manager Status: Approved Page 3 of 16 Issue Date: August 2019 Review: July 2022 Document Ref: P(19)083

Other causes of sharps injuries:

When there is a lack of personal protective equipment, safety devices, and sharps disposal containers

Lack of procedures for sharps injury reporting

Lack of awareness with occupational hazards

Insufficiently trained staff

Staff working under increased pressure so take short cuts

Reduced staffing levels

Passing sharp instruments from hand-to-hand in the operating suite

Unpredictable medical incidents

Unexpected patient reactions

Staff in a hurry when undertaking their tasks

Staff moved to areas with which they are unfamiliar

The time of day, particularly post lunch and during the night shift 4. Roles and Responsibilities The overall accountability for effective Management of Risk associated with the safe handling and disposal of sharps for the WSFT lies with the Chief Executive. At an operational level, the Executive Chief Nurse has responsibility for Governance and Risk Management. They will liaise with the Executive Medical Director for medical issues relating to Clinical Risk Management. The Trusts Governance structure for Managing risk and the roles and responsibilities of other Managerial and clinical staff are outlined in the document “Strategy and Policy for Risk Management” (PP093). The responsibilities of all employees to maintain a safe working environment and exercise care for their safety and that of others are detailed in the “Health, Safety and Welfare Policy” (PP018). Of particular relevance to the Management of risk associated with the Safe Handling and Disposal of Sharps: a) Chief Executive is to ensure that:

Any WSFT tasks and activities carried out are safe and without risks to health and welfare of the employees

The mechanisms are in place to ensure that employees working for the WSFT are made aware of their responsibilities under this policy.

The effectiveness of this policy is monitored by the Health and Safety Committee b) The Executive Chief Nurse is to:

Assist in ensuring high standards of health and safety including the safe handling and disposal of sharps are achieved within the WSFT and is responsible for monitoring the Trust’s health and safety performance while promoting health and safety at an Executive level.

c) Executive Directors are to:

Ensure that Clinical Directors and General Managers are made aware of this policy and support in implementing and enforcing the policy within their areas of responsibility.

Page 4: Sharps Injury (Safe Handling and Disposal of Sharps) Policy · 2020-01-15 · virus exposure or needle sharp type injury click here to access the assessment guidelines Contents Pages

Source: Health, Safety and Risk Manager Status: Approved Page 4 of 16 Issue Date: August 2019 Review: July 2022 Document Ref: P(19)083

d) ADO’s , Senior Operations Managers, lead Clinicians, Service Managers, Matrons, Ward Managers and Heads of Department are to ensure:

That all staff are made aware of the requirements of the safe handling and disposal of sharps policy and comply with the safe systems that are contained within it

That all staff receives the appropriate information, instruction, training and supervision to enable them to utilise the appropriate safe systems for the safe handling and disposal of sharps.

Standard Operating Procedures (SOP’s) are in place especially for high risk areas (Theatres, Obstetrics and Emergency Care).

That where safety devices have been provided that all relevant members of staff have been trained in their use and make use of all safety devices provided.

That the practice of re-sheathing needles is prohibited unless working in the Pharmacy or Nuclear Medicine Departments (until such time alternative safety devices are available).

A risk assessment has been undertaken for any departments who want to use non-safety sharps. The risk assessment must be put on Datix risk register and include appropriate control measures to reduce the likelihood of an incident occurring.

That there are a sufficient number of Sharpsmart containers to take to the point of use to enable the immediate disposal of sharps.

Adequate stocks of appropriate Personal Protective Equipment (PPE –gloves, goggles, aprons and masks) are available and worn by staff.

An incident form is completed on Datix for every needlestick and near miss incident occurring on site. These forms must be completed according to the Trusts incident policy and procedure (PP105 and 105b).

That all reported incidents involving sharp devices are fully investigated to determine the root cause. Appropriate actions with agreed timescales are put in place and fully implemented to prevent a recurrence.

Apply the generic risk assessment (Appendix 1) with any updates relevant to areas of responsibility for using sharps (inserting cannula or administration of drugs to patient via syringe / needle) to their areas and ensure control measures are fully implemented.

That appropriate action is taken when workplace inspection or general observation indicates the non-adherence to the required procedure for the safe handling and disposal of sharps in their area of responsibility.

Any member of staff who sustain sharp and or blood borne virus exposure injures are provided with appropriate advice and support.

e) Employees are to:

Use any safety device which is provided by the Trust, unless a risk assessment has been carried out and captured on datix risk register to indicate the clinical need for an alternative non-safety device.

Wear all PPE provided (gloves, goggles, aprons and masks) to reduce any potential exposure to blood or body fluids. Double glove for high risk procedures or if patient is of high risk (Hep C, Hep B or HIV positive).

Dispose of the sharp safely and securely in the Sharpsmart bin or one way burn bin at the point of use; never leave a contaminated or clean sharp device so that it could cause injury to staff, patients and visitors.

Never re- sheath a needle unless working in the Pharmacy or Nuclear Medicine Departments (until such time alternative safety devices are available).

Not use any sharp devices until appropriately trained to do so.

Attend all training provided by the Trust for the use of sharp devices.

In the event of a sharps injury or contamination with blood or body fluids, seek advice and support IMMEDIATELY from the Occupational Health and Wellbeing Service between the hours of 08:30 and 16:30. If the department is closed, then attend the Emergency Department.

Page 5: Sharps Injury (Safe Handling and Disposal of Sharps) Policy · 2020-01-15 · virus exposure or needle sharp type injury click here to access the assessment guidelines Contents Pages

Source: Health, Safety and Risk Manager Status: Approved Page 5 of 16 Issue Date: August 2019 Review: July 2022 Document Ref: P(19)083

Inform their Manager/Supervisor when a needle stick injury has occurred and complete an incident form on Datix.

Report all near misses and examples of bad practice (e.g. needles found in rubbish bags) even if they did not result in injury to their Manager / Supervisor and raise an incident form on Datix.

Be aware of and abide by the contents of this policy and procedure for reporting and follow-up in the event of a needle-stick/sharps or exposure to body fluids incident.

f) Occupational Health and Wellbeing Service will:

Be responsible for ensuring that support is provided, as appropriate, for the injured member of staff who must attend the Occupational Health and Wellbeing service on the day of the incident or the next working day.

Carry out a risk assessment and refer the injured member of staff to the GU Medicine clinic (located off site) should the need for further specialised advice, support or treatment be required.

Where a high risk injury (HIV infected patient) is identified, treatment with Post Exposure Prophylaxis must be commenced as soon as possible.

Initiate a telephone call on receipt of an incident form via Datix relating to sharps/needlestick/blood/body fluid splash to ensure the inured member of staff has followed the appropriate procedure. This personal follow-up will be documented in the member of staff’s Occupational Health record.

5) Safe handling and disposal of sharps:

An adequate number of Sharpsmart bins must be available in all clinical areas so they can be used at point of use.

The staff member who is going to be using the sharp or sharp device must ensure that it is correctly used and disposed of.

Personal Protective Equipment (PPE) must be available in all areas where sharps or sharp devices are going to be used. PPE may consist of aprons, gloves, goggles / visors and masks.

Staff must wear gloves or double gloves where exposure to blood and or body fluids is likely.

All patients should be regarded as a potential infection risk and infection prevention precautions followed. Inexperienced staff should avoid carrying out invasive procedures on patients who may be a high infection risk e.g. HIV positive patient.

The re-sheathing of needles is banned within the Trust. A majority of needle stick injuries occur whilst attempting to re-sheath a needle. However there are some exceptions to this and if a clinical practice makes this action unavoidable then a risk assessment must be undertaken with clear control measures to mitigate any risk of sharps injury occurring and captured on Datix.

Staff must never transport or carry sharps or sharp devices with the sharp exposed or without using a tray.

Staff using sharps or sharp devices must always take a Sharpsmart container or a one way burn bin to the point of use, not the sharp or sharp device to the Sharpsmart container. Any sharp or sharp devices must be placed immediately into the Sharpsmart container or one way burn bin after use.

Staff must never leave sharps to be disposed of later or to expect someone else to dispose of their sharp.

Needles and syringes must not be disconnected, but disposed of in the Sharpsmart container or one way burn bin as a complete unit.

Staff must ensure that the appropriate lid colour of the Sharpsmart container is used, prior to any procedures being carried out.

Page 6: Sharps Injury (Safe Handling and Disposal of Sharps) Policy · 2020-01-15 · virus exposure or needle sharp type injury click here to access the assessment guidelines Contents Pages

Source: Health, Safety and Risk Manager Status: Approved Page 6 of 16 Issue Date: August 2019 Review: July 2022 Document Ref: P(19)083

The yellow lidded Sharpsmart container is for the disposal of sharp and sharp devices contaminated with Medicinal & Infectious waste e.g. used needles and syringes following the administration of medication and broken medicine bottles.

The orange lidded Sharpsmart container is for the disposal of sharp or sharps devices which have not been contaminated with Medicinal waste e.g. needles from Phlebotomy or operating sharps.

The purple lidded Sharpsmart container is for the disposal of sharp or sharp devices which have been contaminated with Cytotoxic / Cytostatic Medicines e.g. used needles and syringes following administration of Chemotherapy.

Access plus (no flip tray) Sharpsmart containers are available for the disposal of large sharps in designated areas only. They must NOT be located in public areas.

The Sharpsmart container must be opened prior to use and closed when not in use or un-attended.

The Sharpsmart container must be labeled with the following: o Ward / Department o Date of Opening o Date of Closure

The Sharpsmart container must only be filled to their designated fill level to ensure compliance with audits. Once filled or when opened for 90 days the container must be locked and the label completed by the person who locks the container.

The Sharpsmart container must not be used for any purpose other than that for which they were intended e.g. do not dispose of paper waste into the Sharpsmart container.

Filled and locked Sharpsmart containers must be stored safely ready for collection from clinical areas.

5.1) Sharps and sharps containers transported in staff vehicles

All community staff should be issued with sharps boxes that meet the standards to transport in vehicles.

Sharps containers that are used at multiple sites, used by Community teams, should never be left at a patient’s home.

A sharps container that is left at a patient’s own home for their own use needs to be risk assessed and consideration taken for position and storage. Community healthcare workers must follow the environmental regulations in place which cover the disposal of hazardous health care waste such as sharps in a community setting. The issuer of the sharps box must ensure that there is provision for disposal of the sharps waste, as per local agreement.

Healthcare workers who travel in the community and carry sharps (used or unused) in the course of their work should follow a safe system of working at all times, dispose of sharps immediately after use in a sharps container suitable for transport, close the lid immediately after use and secure the container in the vehicle to avoid tipping.

In the event of a sharps container being spilled in a Healthcare workers vehicle, the vehicle should be cleared and cleaned as soon as possible without compromising safety, e.g. using a torch, a special tool / devices to avoid hand contact and wearing appropriate Personal Protective Equipment (PPE), care must be taken for any sharps which may have fallen into crevices and fabrics.

5.2) Disposing of discarded sharps

In the event of finding an unprotected or used sharp which has not been disposed of into a Sharpsmart container or if there has been a sharps spillage incident, it must be dealt with quickly. If the user of that sharp is nearby then they must be asked to dispose of it. If the user is not available then ensure that a Sharpsmart bin is next to the sharp and wearing disposable gloves, the sharp/ sharps should be picked up using a pair of forceps or similar piece of equipment if available and placed in the Sharpsmart bin.

Page 7: Sharps Injury (Safe Handling and Disposal of Sharps) Policy · 2020-01-15 · virus exposure or needle sharp type injury click here to access the assessment guidelines Contents Pages

Source: Health, Safety and Risk Manager Status: Approved Page 7 of 16 Issue Date: August 2019 Review: July 2022 Document Ref: P(19)083

Do not physically handle the sharp, use a dustpan and brush to manipulate the sharps if forceps are unavailable or a large spillage is encountered. The incident should then be reported to the senior clinician on duty and a datix incident form submitted.

5.3) Reducing the risk of percutaneous injury during surgical procedures

The following measures may help to reduce the risk of percutaneous exposure and should be considered where practicable:

Have no more than one person working in an open wound/body cavity at any time (unless essential to the safe outcome of the procedure).

Use a ‘hands free’ technique where the same sharp instrument is not touched by more than one person at the same time, prohibit hand to hand passing of sharp instruments during a procedure.

Assure safer passage of necessary sharp needles and instruments via a ‘neutral zone’ and announce when a sharp instrument is placed there. The ‘neutral zone’ may be a tray, kidney dish or an identified area in the operative field.

Ensure that scalpels and sharp needles are not left exposed in the operative field, but always removed promptly having been deposited in the neutral zone by the operator or assistant.

Use instruments rather than fingers for retraction, and for holding tissue while suturing.

Let falling objects fall. Don’t try to catch falling instruments and stand well clear of them. It’s better to clean up a mess or replace an instrument than to risk injury and infection.

Use appropriate instruments to handle needles and to remove scalpel blades

Direct sharp needles and instruments away from own non-dominant or assistants hand.

Remove sharp suture needles before tying suture, tie suture with instruments rather than fingers.

Avoid scalpel injuries associated with assembly/disassembly, by using scalpels which are either disposable, have retractable blades or which incorporate a blade release device.

Consider double gloving with a larger pair of gloves innermost for optimum comfort.

Double gloving does not prevent sharps injury but has been shown to effect up to a six fold decrease in inner glove puncture. In the event of percutaneous injury, the volume of blood transmitted may also be reduced due to the enhanced wiping effect of two layers of glove.

Consider the use of blunt-tipped needles, stapling devices or skin glue as they are all safer alternatives to sharp suture needles.

Use a sharps disposal device (e.g. sharps pad) for checking /counting of all sutures ad scalpel blades during procedures.

All trays/sets used for minor/major surgical procedures must be thoroughly checked on completion of the procedure to ensure all sharps have been removed prior to their return to SSD (Sterile Services Department).

5.4) Patient-administered injections (i.e. insulin) and finger-prick tests (e.g. blood

glucose monitoring)

In-patients with diabetes may continue to use their own pen devices to deliver insulin, providing they can attach and remove the pen needle independently, and discard it in the Sharpsmart container. If the patient is self-administering medication/testing they must dispose of the sharps themselves and therefore have a Sharpsmart container made available to them. On discharge, patients must be provided with a small sharps box for their safe disposal of sharps at home.

Patients self-administering medication must be supervised and trained in safe practices prior to being allowed to self-medicate, including safe handling and disposal of sharps.

Some patients will be unable to administer their own insulin. Nursing staff must ensure that after administering the correct dose of insulin that the Uniguard Safety Device is used to remove the used needle and safely dispose of it in the Sharpsmart bin.

Page 8: Sharps Injury (Safe Handling and Disposal of Sharps) Policy · 2020-01-15 · virus exposure or needle sharp type injury click here to access the assessment guidelines Contents Pages

Source: Health, Safety and Risk Manager Status: Approved Page 8 of 16 Issue Date: August 2019 Review: July 2022 Document Ref: P(19)083

6) Procedure to be taken following a sharps injury and or splash exposure to staff (see Appendix 2 for flow chart)

For needlestick, sharps injury or bite immediately encourage the wound to bleed by applying gentle pressure to the area. Wash the area with soap and water or antiseptic if available, dry and apply a water proof dressing .Do not suck the wound

Exposure to blood or other body fluids to the eyes and mouth should be rinsed thoroughly with water. Contact lenses should be removed prior to rinsing. If available an eye wash can also be used.

Each incident must be reported immediately to the Manager or Supervisor of the area where the incident took place and an incident form completed on Datix as per the Incident Reporting and Management Policy PP105 and PP105b.

In the event of a sharps injury or contamination with blood or body fluids, it is the responsibility of the injured member of staff to seek advice and support IMMEDIATELY from the Occupational Health and Wellbeing Service between the hours of 08:30 and 16:30. If the department is closed then attend the Emergency Department.

If the source is known, they should be approached by a senior member of staff (other than the recipient of the injury) and asked if they would consent to a blood test for Hepatitis B, Hepatitis C and HIV.Testing MUST only be carried out with informed consent of the source patient.

If required Occupational Health or the Emergency Department can contact GU Medicine for further advice

The results of the source patient blood test will be sent to the ward to include in the patient records. The Occupational Health Nurse Advisor will be responsible for accessing the results and informing the injured member of staff.

7) Procedure to be taken following a sharps injury and or splash exposure to staff by

Occupational Health Practitioners and ED professional Staff (out of hours)

Ensure any first aid measures have been taken

Ensure a risk assessment is carried out

Take blood samples from the employee for storage.

Check the Hepatitis B status of the employee and update as required

Ensure incident form is completed on Datix with 24 hours of the incident occurring. 8) Assessing the risk as per clinical guideline CG-10223-1 8.1 Risk of HIV (also see HIV/AIDS policy for the protection of Staff and Patients from

individuals who are HIV Positive PP051)

If the source patient is known to be HIV Positive, or known to be High Risk then Post Exposure Prophylaxis (PEP) must be offered immediately.

The average risk for HIV infection from all types of reported percutaneous exposures of HIV-infected blood from patient to healthcare worker is 0.3% (one in three thousand).

It is also important to consider the risk of exposure to other blood-borne infectious diseases, including Hepatitis B and C.

Consideration must be given to the stage of the HIV disease where the source patient is HIV positive using the latest CD4 and viral load blood results. If the information is unavailable standard prophylaxis should be given, and a high viral load assumed.

The initial decision resulting from the risk assessment (of both the likely infectivity of the blood and type of exposure) is that of the advising Doctor. Further advice can be sought from GU Medicine (off site) through Occupational Health or the Emergency Department.

If however, the member of staff insists on initiation of treatment against medical advice (i.e. where risk is considered negligible) PEP may still be issued, and the recommendation of the Advising Doctor, must be noted on the consent form.

Page 9: Sharps Injury (Safe Handling and Disposal of Sharps) Policy · 2020-01-15 · virus exposure or needle sharp type injury click here to access the assessment guidelines Contents Pages

Source: Health, Safety and Risk Manager Status: Approved Page 9 of 16 Issue Date: August 2019 Review: July 2022 Document Ref: P(19)083

The member of staff must attend the Occupational Health and Wellbeing Service on the same or the next working day.

Ensure the PEP Consent form has been completed (CG-10223)

If the source is known, they should be approached by a member of staff (other than the recipient of the injury) and asked if they would consent to an HIV test. As part of the discussion, they should be asked whether they see themselves at risk, and if so the GU Medicine Clinic (off site) should be contacted to provide further advice. Testing MUST ONLY be carried out with informed consent of the source patient.

If HIV status cannot be obtained rapidly due to delay in gaining consent or access to testing, the decision to initiate PEP should be based on available information.

9) Post Exposure Prophylaxis (PEP)

Where PEP is recommended or offered, two drugs are to be used together as therapy. These drugs should be administered within one hour of exposure for four weeks if tolerated, however the optimal duration of PEP is unknown. If it is not possible to administer within one hour, the drugs may be administered up to72 hours after exposure. If further advice is required, contact GU Medicine.

N.B The Post Exposure Prophylaxis packs only contain the initial 5 days of treatment. The member of staff MUST be referred to GU Medicine to obtain further supplies to complete the course.

If in doubt the first dose should be given and reviewed at the next available GU Medicine Clinic.

o Truvada tablets: ONE to be taken ONCE a day o Raltegravir tablets: ONE tablet TWICE a day.

2 PEP Packs are kept in the Emergency Department, with 2 replacement packs kept in the “Out of Hours” Pharmacy Store. This pack includes a copy of the patient Information Leaflet for Prophylaxis Pack (CG10223).

Assessment/Consent form (CG10223) must be signed by the member of staff and forwarded to the Occupational Health Department.

The patient must be given a copy of the Patient Information leaflet for consent (CG10223) prior to signing consent, as this gives them the basic information regarding PEP.

At the formal consultation the following day, the advising Doctor in certain circumstances may change the drug regime taking account of such factors as: the drug resistance profile of HIV from the source patient, medical conditions and concurrent drug therapy of the exposed member of staff.

In the event of pregnancy or possible pregnancy, Zidovudine is to be recommended or offered as a single agent. The advice for women in the first trimester of pregnancy should be that there is no data specifically confirming that Zidovudine is harmful to the baby. However, they should be advised there is a theoretical risk.

If there is a history of renal disease await results of the U&E and urinalysis before commencing treatment, and if uncertain contact GU Medicine.

10) Risk of Hepatitis B (also see Hepatitis b Guidance for the protection of Healthcare

Workers and Patients PP024)

Heads of Department will be responsible for ensuring that all members of staff who have patient contact or are involved in patient services, attend the Occupational Health and Wellbeing Service for assessment of their Hepatitis B immune status. Hepatitis B vaccination will be offered to all staff identified at risk.

If never vaccinated (or uncertain), a course of Hepatitis B vaccination will commence with regular follow up appointments undertaken at the Occupational Health and Wellbeing Service. The follow up appointments are scheduled as follows:

o Accelerated Course: 0=1st Dose

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Source: Health, Safety and Risk Manager Status: Approved Page 10 of 16 Issue Date: August 2019 Review: July 2022 Document Ref: P(19)083

1 month=2nd dose 3 months=3rd dose

o Standard Course: 0=1st dose 1 month=2nd dose 5 months=3rd dose

If a non/poor responder then:

Following discussion those members of staff who do not develop an acceptable antibody level after vaccination and booster injection will be required to be tested for surface antigen, core antibody and possibly ‘e’ marker status.

Those staff that are true vaccine non-responders remain susceptible to infection. They may continue to perform Exposure Prone Procedures but should receive advice from Occupational Health on ways of minimising the risk of infection at work and the need to report any exposure to blood and or needle stick injuries and incidents immediately.

Annual blood tests will be carried out on non-responders by the Occupational Health and Wellbeing Service to ensure continued safety.

Contraindications to vaccines are few. Staff in whom there are genuine contraindications to vaccine or in whom completion of the course is deemed inadvisable because of a severe reaction to vaccine are in a similar position to non-responders above.

If a member of staff whose work involves Exposure Prone Procedures refuses to comply with the above then he or she shall be considered as if e-antigen positive and managed accordingly.

10.1) If source patient is known to be a Hepatitis B Carrier (i.e. HBsAG positive)

If the source patient is a known Hepatitis B carrier then consider giving specific immunoglobulin obtained through the Microbiology Department within 48 hours where member of staff is a non-responder or not immunised. Contact the (on-call) Consultant Microbiologist if required.

The member of staff must attend the Occupational Health and Wellbeing Service on the same or next working day for follow up if they have been seen in the Emergency Department.

11) Risk of Hepatitis C (also see Guidance for the Prevention of Infection of Hepatitis C,

and the Infected Healthcare Worker PP124)

It is the responsibility of All Health Care Workers to:

To be aware of the risks and implications of contracting Blood Borne Viruses and to take responsibility for ensuring that they and their partners health is not put at risk.

To consult with the Occupational Health and Wellbeing Service in the event of possible exposure to Hepatitis C (or any other Blood Borne Viruses) and not rely on their own assessment of risk.

Any Healthcare Worker who is aware that, or has good reason to believe (having taken steps to confirm the facts, as far as practicable), that a Hepatitis C infected Healthcare Worker has not complied with the guidance or followed advice to modify practice, should inform an appropriate person (e.g. Occupational Health Physician, Trust Medical Director or Director of Public Health. (Healthcare Workers may wish to seek advice from the relevant regulatory and professional bodies before passing such information on).

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Source: Health, Safety and Risk Manager Status: Approved Page 11 of 16 Issue Date: August 2019 Review: July 2022 Document Ref: P(19)083

11.1) Responsibilities of the Infected Healthcare Worker

It is the responsibility of any Healthcare Worker, who thinks that they may have been at risk of exposure to Hepatitis C, to seek confidential professional advice promptly from the Occupational Health and Wellbeing Service on the need for testing Hepatitis C, and follow subsequent recommendations.

Any Healthcare Worker who knows that they have been, or could have been infected with Hepatitis C (i.e. who, following tests have antibodies to Hepatitis C Virus) and who carryout exposure prone procedures, must be tested for the Hepatitis C Virus RNA.

Those Healthcare Workers found to be carrying the virus (i.e. who are Hepatitis C Virus RNA Positive) will be restricted from performing exposure prone procedures.

Hepatitis C infected Healthcare Workers who have been treated with antiviral therapy and who remains Hepatitis C Virus RNA Negative for at least six months after cessation of treatment will be permitted to return to performing exposure prone procedures at that time. However a further check six months later must show them to still be Hepatitis C Virus RNA Negative.

Healthcare Workers who have the antibodies to the Hepatitis C Virus but are Hepatitis C RNA Negative can continue performing exposure prone procedures.

Healthcare Workers must take account of their regulatory bodies’ statements on professional responsibilities in relation to communicable disease.

11.2) Guidance and appropriate Management following Occupational Exposure to

Blood a) Known Hepatitis C Infected Source:

o Obtain baseline serum for storage from infected Healthcare Worker o Obtain serum/EDTA for HCV RNA testing at 6 and 12 weeks o Obtain serum for anti-HCV testing at 12 and 24 weeks

b) Source known not to be infected with Hepatitis C: o Obtain baseline serum for storage from Healthcare Worker o Obtain follow-up serum if symptoms or signs of liver disease develop

c) Hepatitis C status of source unknown: o Obtain baseline serum for storage from Healthcare Worker o Designated Doctor to perform Risk Assessment

d) High risk: o Manage as known infected source

e) Low Risk o Obtain serum for anti-HCV testing at 24 weeks

Healthcare Workers found to have acquired Hepatitis C infection following occupational exposure should be referred as soon as possible for specialist assessment.

12) Occupational Health Follow-up

The member of staff must agree to be followed up by the Occupational Health and Wellbeing Service, as a condition of initiating PEP. This will ensure that the essential baseline blood tests are performed and accurate advice about the drugs etc. can be discussed.

The Occupational Health and Wellbeing Service will see the member of staff on the day of the incident or on the next working day if the incident occurred out of hours to offer support and advice. If the following day is not a working day, and the member of staff requires to be assessed then they must attend the Emergency Department where advice can be sought.

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Source: Health, Safety and Risk Manager Status: Approved Page 12 of 16 Issue Date: August 2019 Review: July 2022 Document Ref: P(19)083

Appropriate further counseling and support, as well as monitoring which includes HIV antibody blood test at 3 months and 6 months and follow up, can be carried out by the GP or the Occupational Health and Wellbeing Service and with the member of staffs consent.

13) Training

All healthcare workers must receive specific training in relation to: 1. The risks associated with blood borne and body fluid exposures 2. The correct use of medical devices in current practice including those that

incorporate sharps protection mechanisms where used 3. The correct disposal of sharps and the use of protective clothing as appropriate to

their range of duties and other circumstances 4. Action to take in the event of an injury

It is the manager’s responsibility to ensure that all new clinical staff attend both the Trust corporate and Clinical Inductions

It is the manager’s responsibility to ensure that every new employee to their department / ward is given a full and thorough induction which includes the safe handling and disposal of sharps.

It is the responsibility of all members of staff to attend training and complete their mandatory e-learning in relation to the safe handling and disposal of sharps

14) Reporting

All incidents involving sharps, needlestick, blood or body fluids will be reported as per the Incident Reporting and Management Policy and Procedure PP105 and PP105b

Under the Reporting of Injures, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013, employers are required to report to the HSE certain types of injury, some occupational disease and dangerous occurrences that ‘arise out of or in connection with work’. In relation to needle stick injuries the Trust will need to report any significant exposure to blood borne viruses. The most likely requirement, if any, may be to report a dangerous occurrence e.g. “any accident or incident which resulted or could have resulted in the release or escape of a biological agent likely to cause severe human infection or illness”.

15) Monitoring and Review a) Datix provides statistics on a monthly basis to all managers who monitor, review and investigate trends or high-risk incidents. b) Quarterly statistics are monitored by the Health and Safety Committee, Governance Steering Groups (both Medical and Surgical). c) If needed the Health and Safety Committee can at any time reconvene the Safety Needle Task and Finish Group. d) The incident investigation undertaken by the manager must consider compliance with this policy e) The Occupational Health and Wellbeing Service will monitor the number of sharps injuries and maintain data on attendances to the department due to sharps injury to ensure that the process described in this policy is complied with f) This policy will be reviewed every three years, or when national guidelines indicate, by the Health and Safety Committee, Occupational Health and Wellbeing Service or a Consultant within the Infection Prevention Service. 16) Development of the Policy 16.1 Other relevant Documents

Hepatitis B Guidance for the Protection of Health Care Workers and Patients PP027

Guidance for the Prevention of infection of Hepatitis C, and the infected Healthcare Worker PP124

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Source: Health, Safety and Risk Manager Status: Approved Page 13 of 16 Issue Date: August 2019 Review: July 2022 Document Ref: P(19)083

HIV/AIDS Policy for the Protection of Staff and Patients from individuals who are HIV Positive

Incident Reporting and Management Policy and Procedure PP105 and PP105b

Infection Prevention Manual (Pink Book- Intranet)

Occupational Health and Wellbeing Service Policy PP046

Waste Management Policy PP179

Health, Safety and Welfare Policy PP018

Strategy and Policy for Risk Management PP093

Clinical Guideline CG 10223-1 (Pink Book- Intranet) 16.2 Changes compared to previous Documents

This fully revised document contains additional content which includes: o individual responsibilities to the Chief Executive, the Executive Chief Nurse,

Directors, General Managers, Deputy General Managers, Service managers, Matrons, Ward Managers, Heads of Departments and Employees.

o a section on the safe handling and disposal of sharps

This document refers to the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 and includes the responsibility of managers and members of staff to ensure, where provided, a safety device is used unless a risk assessment recommends otherwise.

Reference is made to Clinical Guideline CG10223-1 (Risk Assessment and treatment of patients following possible exposure to blood borne viruses) for use by the Occupational Health and Wellbeing Service and the Emergency Department professional staff.

17) Distribution and implementation This document will be widely circulated within the Trust, including all Heads of Department and Ward Managers and will be made available on the Trust’s Intranet and Internet sites. Comprehensive training programmes exist including induction and mandatory training and relevant modules as detailed in the Trusts training prospectus. Specialist training will also be targeted at those with responsibility for managing those at risk of injury. References

Health and Safety (Sharp Instruments in Healthcare) Regulations 2013

DH Guidance for Clinical Health Care Workers: Protection Against Infection with Blood-borne Viruses 1998

EAGA HIV PEP Guidelines 2004 (Ref 53)

HIV Post-exposure Prophylaxis: Revised Guidance from the DOH February 2004

Tokars J I, Marcus R, Culver D H, et al. Surveillance of HIV Infection and Zidovudine use among Health Care Workers after occupational exposure to HIV infected blood. Ann Intern Med 1993; 118 913-9

CDC Case Control Study of HIV Seroconversion in Health Care Workers after Percutaneous Exposure to HIV infected Blood- France, United Kingdom and United States. January 1988-August 1994. MMWR 1995;44;929-33

CDC Notice to Readers, Update: Provisional Public Health Service Recommendations for chemoprophylaxis after Occupational Exposure to HIV, MMWR 1996;45:468-72

Minutes of Blood Borne Viruses Post Exposure Management Review meeting, Huntingdon Serious Communicable Diseases, GMC October 1997, (Protecting Patients, Guiding Doctors)

Benn P, Fisher M, Kulasegaram R et al, UK guideline for the use of post-exposure prophylaxis for HIV following sexual exposure (2011). Int STD AIDS 2011;22:295-708

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Source: Health, Safety and Risk Manager Status: Approved Page 14 of 16 Issue Date: August 2019 Review: July 2022 Document Ref: P(19)083

Author(s): Mike Dixon, Health, Safety and Risk Manager

Other contributors: Sue Pollett, Occupational Health Nurse Manager, Roger Gembis-Operational Estates and Environment Manager James Whatling-Clinical Skills and Simulation Lead

Approvals and endorsements: Health & Safety Committee Issue no: 11

File name: Sharps Injury (Safe Handling and Disposal of Sharps) PP(16)083

Supercedes: PP(16)083

Equality Assessed Yes

Implementation See Section 16

Monitoring See Section 15

Other relevant policies/documents & references:

Health, Safety and Welfare Policy PP18 Strategy and policy for risk management PP093

Additional Information:

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Appendix 1

Directorate/Service: Dept/Ward/Other: Site: West Suffolk NHS Foundation Trust Address: Hardwick Lane, BSE

Original Assessment Date: Dates on which reviews have taken place: Date of next review: Name of Assessor: Signature of Assessor…

Description of the task/activity/issue: Inserting cannula or administration of drugs to patient via syringe or needle Frequency of task/activity: Daily Please identify category of people affected: Staff Estimate of number of people affected by hazard: 1000+ Hazards identified: 1) Sharps injury to staff 2) Possible exposure to infected blood borne viruses through cuts and abrasions 3) Stress Calculate the Risk Rating without controls in place (please see matrix on following page): L (Likelihood) X C (Consequence) = Moderate x Weekly= Amber

Significant consequences: 1) Puncture to skin 2) Possible blood borne virus transmission: Hepatitis B, Hepatitis C, Hepatitis G and HIV (statistics show- Hepatitis B 1 in 3, Hepatitis C 1 in 30 and HIV 1 in 300 3) Anxiety due to the incident, sickness and absence, possible litigation against the Trust and poor publicity.

What controls are in place and used to reduce the risk: 1) Induction training / mandatory training 2) Clinical skills training 3) Employment screening 4) Vaccination programme 5) Incident reporting 6) Recording accident data 7) Audit of reporting / treatment process 8) Risk assessment post injury 9) PEP treatment available 24/7 10) Occupational Health support 11) GUM Support 12) Safety products i.e. safety cannula, safety lock for taking blood cultures, blue butterfly for sub-cutaneous medication, blue twin safety system (needle-less connection system, pre-set safety arterial blood sampling set) 13) Sharpsmart disposal bin 14) Policies on management of contaminated sharps injury and accidental exposure o body fluids including HIV infected patients 15) Policy on protecting HCW and patients from Hepatitis B 16) HIV/AIDS policy 17) Policy and guidance for Hepatitis C infected HCW Recalculate the Risk Rating with existing controls in place: L X C = Moderate x Quarterly = Amber Are the existing controls listed above satisfactory? (Yes) Completed risk assessment template to be transferred onto Datix Risk Register and finally approved by the relevant lead. Risk Assessment Form Version 8 (November 2014) Location: Intranet/Trust Info/Forms/General Forms/Risk Assessment Form

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Source: Health, Safety and Risk Manager Status: Approved Page 16 of 16 Issue Date: August 2019 Review: July 2022 Document Ref: P(19)083

Appendix 2

Procedure for Accidental Inoculation with Used Needle or other Sharp object or Splash of Blood or Body Fluid

on Mucous Membrane (e.g., mouth, eye)

Contaminated sharps injury or accidental exposure to body fluids

Bleed wound, wash thoroughly and cover

Identify patient or determine source

Immediately report to Occupational Health & Wellbeing Department, 8.30 – 16.30 or to Emergency Department out of hours

To be assessed with the trust exposure guidance tool CG10223-1

Check your hepatitis B/ HIV/Hep C risk following exposure

Check your Hepatitis B Immune Status

Take blood for storage in Microbiology

Provide urgent treatment and advice as required

Complete incident form on Datix

Arrange review by Occupational Health

and Wellbeing Department