Standards and Guidance for the
Prevention & Management of
Body Fluid Exposure Incidents for Healthcare Students on
Clinical Placements
Students enrolled onto healthcare courses at King’s College London
may undertake practical procedures on patients, including those with
potential for body fluid exposures (BFE); these carry a very small
but important risk of blood-borne virus infection. The key standards
and responsibilities outlined in this publication outline best practice,
and give practical guidance, for students to prevent and to manage
inoculation injuries or body fluid exposure incidents whilst on clinical
placement.
This booklet comprises one element of a comprehensive information
package that students on healthcare courses at King’s will be
introduced to, and will be revisited during their programme of study.
The exact content of the teaching package may differ according the
health discipline being studied however all share the same standards
and responsibilities for the University and Faculties, students, partner
organisations and occupational health.
King’s takes your safety very seriously. Please familiarise yourself with
the contents of this booklet so as to both reduce your likelihood of an
inoculation injury or body fluid exposure, and to enable you to respond
swiftly and effectively should this happen.
Introduction
Responsibilities of students in the prevention & management of body fluid exposures
Introduction
Students on clinical placements may be at risk of exposure to blood
borne viruses through accidental injury from medical sharps/ splashes
of blood or body fluids. Students should do all that they can to reduce
the risk of this occurring.
Students must:
1. Attend all required statutory, mandatory and timetabled teaching
related to the safe use of medical sharps (including completing
e-learning), and the prevention and management of body
fluid exposures, and practice in accordance with the teaching
received.
2. Only undertake procedures involving the use of medical sharps
when you have completed the required learning cited above.
3. Ensure that you are aware of and practice in accordance with
local organisational policy relating to safer use of medical sharps
and the prevention and management of body fluid exposures
when on clinical placement. This includes being aware of and
adhering to local policy regarding the use of personal protective
equipment when undertaking tasks that may result in body fluid
exposure
4. Always consider whether it is safe for you to participate in any
procedure involving contact with medical sharps or body fluids.
You should consider the needs of the patient, your competence,
the environment and suitability of supervision available (see (5)
below).
5. In clinical placement only undertake procedures involving
medical sharps under the supervision of a registered / qualified
practitioner. The level of supervision may vary according to your
level of training but ONLY undertake the procedure if you feel it
is safe to do so.
6. Students may onlytake bloods or cannulate patients known to
have blood borne virus when they have been deemed competent
to do so by their faculty. (DH 1998)
7. If at any time you are concerned that your own or anyone else’s
safety is being put at risk through unsafe practice relating to
medical sharps or body fluid exposure in clinical practice you
should inform your clinical supervisor and your university
representative immediately.
8. If you sustain an inoculation injury or body fluid exposure report
it immediately to your clinical supervisor and then follow the
local emergency procedure for management of a inoculation
injury or body fluid exposure (see also page 19 of this booklet).
9. You must also complete the placement organisation and the
university Airsweb incident reporting process (http://www.kcl.
ac.uk/ai-report). You must also inform Student Occupational
Health even if others have said that they will do this for you.
10. Arrange with Student Occupational Health for appropriate
follow up.
11. Attend a debrief discussion following an inoculation injury or
body fluid exposure with an identified member of university staff
to ensure that your wellbeing is promoted.
Responsibilities of partner healthcare organisations in the prevention & management of body fluid exposures
Introduction
Partner healthcare organisations such as Trusts, General Medical &
Dental Practice Clinics and private and voluntary healthcare providers
have responsibilities which relate to the prevention and management
of body fluid exposures. They must, as part of their contractual
commitments, have appropriate standards of practice and supervision
for the teaching of students in the clinical environment. The majority
of these standards will be met by existing organisational policy and
contractual agreements
Partner healthcare organisations must:
1. Through their educational administration teams and local
managers
• know which students are on their site
• provide an induction session for students new to the site within
48 hours of the students commencing on the site / placement.
This must include information in relation to BFE risks, and on the
emergency procedures to follow if involved in a BFE incident.
• have a risk assessment for all types of placement in relation to
training and procedures that may place students at risk, and a
strategy to minimise risk.
• identify any students who have insufficient background (e.g.
classroom- based) training for the tasks which they are likely to
undertake; and in such cases liaise with the relevant education
provider to review their training; and in certain cases provide
relevant training.
• Provide all students with a named clinical supervisor
2. Ensure that relevant professionally-qualified staff in receiving
wards, departments and clinics, and other staff or contractors
involved with training particular students, are suitable to train
others, and are aware of their responsibilities with regards
to student supervision and practice in relation to BFE risks.
Students who visit a wide range of clinical areas and perform
clinical examinations and procedures should also be informed
during induction (as above) of their own responsibility to
appreciate the importance of their background training needs,
competency and awareness of BFE risks.
3. Be aware that students may only take bloods or cannulate
patients known to have blood borne virus when they have been
deemed competent to do so by their faculty (DH, 1998).
4. Ensure appropriate and adequate levels of supervision of students
during their training until they are deemed to be at the relevant
level of competency.
5. Risk assess the activities and training processes students
undertake to ensure appropriate controls and record the results
and any remedial actions identified.
6. Where contractually required to provide them, ensure that
clinical skills training facilities are adequate for classroom-based
teaching of their students.
7. Ensure that adequate personal protective equipment and
approved safer sharps devices are available, demonstrated and
provided to students when required in the clinical environment.
8. Demonstrate a commitment to safer sharps management in
accordance with the Health and Safety (Sharps Instruments in
Healthcare) Regulations 2013, by ensuring that organisational
policy outlines the requirement to:
• avoid the unnecessary use of sharps
• use safer sharps devices where possible
• prevent the recapping of needles
• place secure containers and instructions for safe disposal of
medical sharps close to the work area
9. Ensure that there is an adequate procedure for dealing with a
BFE of a student, which is aligned to the same procedures for all
staff
10. Refer to Local Security Management Specialist (LSMS)
if the incident occurred in the context of violence/ assault.
Consideration should be given to the need for counselling/
psychological support, and incident recording and reporting.
11. Ensure that in the case of students on placement, any incident is
re-ported to the university’s Health & Safety Services using the
electronic web-based system (http://www.kcl.ac.uk/ai-report).
This is done either directly by the student and/or a supervisor, or
via the local Occupational Health & Safety Department, or via
the Student Occupational Health Service.
12. Work in partnership with the university Health & Safety
Services in the investigation of any BFE incident when requested
to do so, and ensure that lessons learned are applied across the
organisation and not just in the location where the incident
occurred.
Responsibilities of Occupational Health (OH)in the prevention & management of body fluid exposures
Introduction
The immediate management of a student who sustains a BFE
rests with the Occupational Health Service (OHS) or Emergency
department of the healthcare organisation where the student is on
placement. Student OHS has responsibility to prepare King’s students
regarding the risks of BFE prior to placement, and to follow up any
student who sustains a BFE during the healthcare programme.
Local OHS
1. Ensure that, on notification of a student having sustained a
BFE, the student is given explicit instruction on the immediate
action to be taken (first aid, obtaining source details, attending
OH/A&E).
2. Ensure that a full risk assessment is undertaken, including access
to a doctor for HIV PEP if appropriate, within one hour of the
incident, in adherence to the OHS Protocol for the Management
of BFE.
3. Ensure that the medical team looking after the source patient is
contacted as soon as possible with regard to risk assessment and
consent of the source for blood testing, and that the student is
informed of results.
Student OHS
1. Ensure that students are made aware of the risks of BFE prior
to their first clinical placement. Ensure that, during their
New Starter Check appointment students are provided with
information on the use of safe sharps, appropriate PPE, correct
disposal of sharps, immediate first aid to be performed and the
reporting procedures to be followed.
2. Ensure that clear arrangements are made with the student for
follow-up where necessary (in cases where source unidentifiable,
not tested, positive for BBV, or student on PEP).
3. Ensure that, where a student has sustained a BFE, contact
with OH in these organisations is made to arrange appropriate
assessment and follow-up.
4. Ensure that reporting to the Health and Safety Executive
(HSE) in accordance with Reporting of Injuries, Diseases and
Dangerous Occurrances Regulations 2013 (RIDDOR) and
Public Health England (PHE)
following high risk exposures (source positive for BBV) is
undertaken.
5. Provide the schools with figures of BFEs sustained by students
within the quarterly OH reports to King’s.
Responsibilities of the University / Faculty in the prevention & management of body fluid exposures
1. It is important to note that the university’s legal, moral and
ethical obligations relevant to items such as Duty of Care,
health and safety, insurance, risk management and equality and
diversity legislation also apply to students on placement.
2. There must be clear written information and guidelines on the
placement in the form of a written agreement and this must be
disseminated to providers and students.
3. Records of adequate legal, financial and health and safety
compliance must be documented and records kept of any
applicable cover.
4. There must be an identified point of contact at King’s for
students on placement (link lecturer/ personal tutor or other)
and an identified point of contact for the placement organisation
(Key account manager or other) to facilitate effective risk
assessment, management and incident investigation.
5. The process of placement quality assurance must include a
specific focus upon sharps safety ensuring relevant and up to
date policies are in place and that a process exists to audit their
implementation. It must also include a review of relevant sharps
safety incidents and evidence of actions taken to reduce the risk
of reoccurrence.
6. The university will provide training for staff involved in
placement learning so that staff are competent in their
understanding of student needs and are able to fulfill the relevant
requirements of their role. This should include ensuring that staff
who have contact with students regarding practice learning/
experience are aware of the correct process to follow when a
student identifies a risk related to sharps safety or experiences an
inoculation injury.
7. Each faculty/ school is responsible for providing training to
identified relevant staff (personal tutor/ link lecturer/ key
account manager) regarding the safe use of medical sharps and
the correct process students should follow in the event of an
inoculation injury.
8. Each faculty/ school must have an agreed process of reporting,
investigation and dissemination of findings following inoculation
injuries. This must include dissemination to the student, practice
partner, school/ faculty and across health schools.
Exposure Prone Procedures
What is an Exposure Prone Procedure?
EPPs are those invasive procedures where there is a risk that injury to
the worker may result in exposure of the patient’s open tissues to the
blood of the worker. These include procedures where the worker’s
gloved hands may be in contact with sharp instruments, needle tips
or sharp tissues (eg spicules 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. Such procedures
occur mainly in surgery, obstetrics and gynaecology, dentistry and
some aspects of midwifery. Most nursing duties do not involve EPPs;
exceptions include accident and emergency and theatre nursing.
Health care staff and students who perform EPP as part of their role
are required to be tested for HIV, Hepatitis B and C. Students who test
positive for any of the above may be able to perform EPP’s if they meet
specific criteria regarding regular monitoring, treatment and viral load.
Detailed advice and support will be provided by occupational health.
Only students who have been tested for blood borne viruses as part of
an EPP screening process may take part in exposure prone procedures.
Safety with Insulin Pen Devices
Needle stick injuries from insulin pen needles are one of the most
common BFE incidents. Insulin pens are designed for patient use.
They best suit the self-management needs of the patient rather than
staff safety, therefore special consideration needs to be taken when
using these devices (HSE Sharps Instruments in Healthcare, 2013).
These needles do not possess the safety features common with
standard hypodermic needles which make them particularly high risk
for inoculation injury. As a student of King’s College London you
should not use these patient use needles. If you are required to use an
insulin pen device you should use it with a specially designed safer
sharp for insulin pen needle (figure 1). If these are not available you
should use an approved insulin syringe with safer sharp needle attached
(figure 2).
Figure 1
Patient single use insulin pen needles (figure 3) should only be handled
by the patient and the needle disposed of directly into a sharps box by
the patient. In any circumstances where a healthcare practitioner is
required to assist with administering insulin using a pen needle without
a safer sharp then this must be disposed of safely and never re-sheathed
in any way. When self-management is being taught and encouraged
then a sharps box must be provided to ensure immediate disposal
of sharps. King’s College London healthcare students MAY NOT
administer insulin from insulin pens unless there is a safer needle in use.
Figure 2 Figure 3
How to reduce the risk of body fluid exposure.
The risk of sustaining a BFE can be reduced through careful
consideration prior to the procedure. So each time you are offered the
opportunity to undertake a procedure that may result in a BFE make
sure you:
STOP:
Does the procedure you are about to undertake involve the risk of
exposure to body fluids? This includes the use of sharp instruments
and potential splash injuries.
THINK:
Is this procedure necessary?
Do you need to use a sharp instrument or is there an alternative?
RISK ASSESS:
All procedures that involve the risk of body fluid exposure should be
risk assessed.
Some risk assessments will be formal written assessments but as
healthcare students you and your supervisor should assess the risk of
procedures that involve potential body fluid exposure each time you
perform them.
The ongoing assessment of risk that occurs in the clinical environment
is called a dynamic risk assessment. The purpose is to identify hazards
and take action to eliminate or reduce the risk.
What to risk assess
A range of factors should be considered which may vary depending on
the situation but as a minimum you should consider risks involving:
Supervision - What level of supervision do you need to safely
undertake the procedure?
Operator (You) - Is it appropriate for you to be doing this procedure,
with this patient at this time?
Procedure – What are the particular risks involved in the procedure?
Patient - Are there any specific patient related risks?
Environment – Is the environment as safe as it could be to work in?
Equipment – What equipment are you using or what equipment do
you need to work safely?
Think SOPPEE when risk assessing the potential for BFE.
More information on this is available on your sharps safety e-learning.
Immediate First Aid
What should I do if I experience a sharps injury?
• Encourage the wound to gently bleed, ideally holding it under
running water
• Wash the wound using running water and plenty of soap
• Don’t scrub the wound whilst you are washing it
• Don’t suck the wound
• Dry the wound and cover it with a waterproof plaster or dressing
• Report the injury to your supervisor.
• Seek urgent medical advice (see next page for where you should go)
• Complete relevant incident reports (placement provider and
university)
What should I do if I experience a body fluid exposure splash incident?
• Rinse the wound using running water
• Report the injury to your supervisor.
• Seek urgent medical advice (see next page for where you should go)
• Complete relevant incident reports (placement provider and
university)
WHAT TO DO IF YOU SUSTAIN A BODY FLUID EXPOSURE
Gently encourage bleeding, wash
area with soap and water
Sharps injuries, cuts,
abrasions and bites
Splash to eyes/mouth,
wound or non- intact skin
INFORM YOUR SUPERVISOR
Attend your placement Occupational Health Dept.
(Mon-Fri office hours)
or A&E (out of hours) IMMEDIATELY*
*If HIV PEP is needed, this should start within one hour.
Inform the triage nurse in OH or A&E
that you have sustained a body fluid exposure.
A risk assessment** will be undertaken and treatment provided***
Complete both a ‘local incident report’ and a university accident Report.
You must contact
Student Occupational Health Service (GSTFT OH)
the next working day following the incident to arrange follow up
Immediately irrigate eyes (before
and after removing contact lenses)
or mouth with water or normal
saline for at least 30 seconds
Emergency Next Steps
**Source (patient you sustained
injury from) patient’s details which
will assist with the risk assessment (if
known):
Information you can provide about the
source patient:
• Name, date of birth
• Current location
• Consultant in charge of source
patient’s care
• Ethnic origin & country of birth
Information provided by the source
patient’s clinician as per local policy.
The information listed below should
NEVER be sought by the injured
healthcare student / worker.
• Sexual history (i.e. men having sex
with men, past or present high risk
sexual behaviour, commercial sex
worker)
• Past or present IV drug use
• History of blood/plasma transfusion
• Sexual partner at risk of BBV
• Consent for BBV testing
***Information that will help
Student OH to follow you up:
• Ask placement OH/A&E to take a
“serum save” blood sample from you.
• If HIV PEP is to be started, ensure
a blood sample is taken from you for:
FBC, U&Es, LFTs, amylase, bone
profile (calcium and phosphate),
blood glucose, lipids and Gamma GT.
Urinalysis also needs to be done.
• Ask OH/A&E to give you a Hepatitis
B vaccination (if you have not had one
in the last year).
• If the source person has consented for
blood borne virus (HIV, Hep C and
Hep B) testing please ensure consent
includes the release of the results to
Student OH to assist management of
your case.
REMEMBER: Consent for BBV testing
of the source patiend should NEVER
be sought by the injured healthcare
student / worker.
Please ask for a copy of the risk
assessment and treatment received
Giving a succinct history of the incident:
To my clinical supervisor
1. What procedure or task you were doing, where and when.
2. Identify the patient you were working on (your supervisor may
check the patient’s notes to identify any risk factors).
3. Say who was supervising if it wasn’t your clinical supervisor.
To A&E or Occupational Health
To the receptionist and triage nurse:
1. State your name and say are a student medic/dentist/nurse/
midwife and where you are working.
2. State that you have received an inoculation (needlestick) injury
or body fluid exposure.
3. State if the source was from a known high-risk patient.
4. Say the time the injury or exposure occurred (to ensure you start
treatment within the “Golden Hour”).
To the attending physician
1. State you have received an inoculation (needlestick) injury or
body fluid exposure and how it was received.
2. State if the source was from a known high-risk patient.
3. Say the time the injury or exposure occurred (to ensure you
assessed and start treatment within the “Golden Hour”).
4. You MUST inform the physician if you have any underlying
health conditions or are on any medications.
The attending physician will assess the risks of exposure to a blood-
borne virus from the history given and may decide that post exposure
prophylaxis (PEP) is necessary. You will be told of what this consists of
and any contraindications.
To Student Occupational Health
1. State your name, that you have had a BFE, when and where.
2. Whether you have already attended OH or A&E and, if so,
provide details or any written information or advice given to you
as a result of your BFE consultation.
What happens next?
What should people be doing when I report this incident?
1. Placement organisation:
• The patient may have blood taken to assess their infection status.
The bloods must not be undertaken by the person who has
sustained the BFE.
Supervising staff will explain to the patient the need to check for any
risk factors for Hepatitis B, C or HIV and will request the patient has a
simple blood test to check for their presence
• If the patient has already left the healthcare organisation ( e.g.
they are attending as an outpatient) they will be contacted so that
the process outlined in emergency next steps can be followed.
• The student may be interviewed as part of the accident
investigation.
• There may be a follow-up review of processes at the local level of
the organisation.
• Depending on the nature of the incident and exposure, the
Health and Safety Executive may need to be informed
• The placement organisation will contact the Faculty (and
Student OH).
2. The student must attend Student OH for follow-up.
3. The university will be informed by Student OH and may need to
report the incident to the Health and Safety Executive through
the Health and Safety Services if it has not been reported by the
placement organisation.
How should I be followed up?
1. Student OH follow-up:
bloods, etc.
2. The Faculty (and
university, where
necessary) follows up with
the placement organisation
and provides pastoral care.
Sources of support
• Academic supervisor
• University representative at
placement provider
• GSTFT Occupational
Health
• Student Counselling
Centre
Guidance for International Electives
Many students have the opportunity to undertake an International
elective in the developing world. The risks of doing this in terms
of personal safety must be considered prior to undertaking this
experience. The student must familiarize themselves with the
emergency management of a BFE.
All students undertaking an international elective should be assessed
prior to departure by Student OH. OH may advise you to purchase
a PEP pack. If so, please do this and ensure you carry it with you at
all times during your elective. You will also be advised to take out
King’s travel insurance as well as comprehensive travel insurance. This
enables additional treatment medication to be flown out to you should
you sustain a BFE.
References & Relevant Reading
Department of Health (1998) Guidance for clinical health care
workers: protection against infection with blood-borne viruses.
Available at: http://webarchive.nationalarchives.gov.uk/+/
www.dh.gov.uk/en/publicationsandstatistics/publications/
publicationspolicyandguidance/dh_4002766
Department of Health. (2005) HIV Infected Health Care Workers:
guidance on management and patient notification. London:
Department of Health available at:
http://webarchive.nationalarchives.gov.uk/20130107105354/
http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@
dh/@en/documents/digitalasset/dh_4116416.pdf
Health and safety at work act (1974) available at:
http://www.hse.gov.uk/legislation/hswa.htm
HSE (2001) Blood-borne viruses in the workplace: Guidance for
employers and employees London: HSE available at:
http://www.hse.gov.uk/pUbns/indg342.pdf
Health and Safety (Sharp Instruments in Healthcare) Regulations
2013 Guidance for Employers and Employees: HSE available at:
http://www.hse.gov.uk/pubns/hsis7.pdf
King’s College London (2011) Statement of General policy,
responsibilities and arrangements in respect of health and safety
protection available at:
http://www.kcl.ac.uk/college/policyzone/assets/files/governance_
and_legal/Policy_health_statement.pdf Last accessed April 2015.
Public Health England (2014) The Management of HIV infected
Healthcare Workers who perform exposure prone procedures: updated
guidance, London: Department of Health available at:
https://www.gov.uk/government/uploads/system/uploads/
attachment_data/file/333018/Management_of_HIV_infected_
Healthcare_Workers_guidance_January_2014.pdf
RCN (2013) Sharps safety RCN Guidance to support the
implementation of The Health and Safety (Sharp Instruments in
Healthcare Regulations) Available at:
https://www.rcn.org.uk/__data/assets/pdf_file/0008/418490/004135.
UK Quality Code for Higher Education. Part B: Assuring and
enhancing academic quality.
UCEA Health and Safety Guidance for the placement of Higher
Education students.
This course, its content and all materials and methods used to deliver it or supplied in association with it in whatever
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contents, methods and materials and any representations thereof may not be re-used, repackaged, adapted, broadcast
or transmitted to third parties for use without the express prior written permission of King’s College London.