IPC 4.4 Accidental exposure to bloodborne viruses
Contents
Introduction
Definitions
Duties
Employment issues
Monitoring
Legislation and compliance
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6
Appendix 7
Appendix 8
Appendix 9
Appendix 10
References / Source documents
Introduction
1. This policy covers the protection of Nottinghamshire Healthcare Trust staff against occupationally acquiring a blood borne viral (BBV) infection and the action to be taken should an incident occur where transfer of a BBV could take place.
The greatest risk of transmission of BBVs from patient to healthcare worker (HCW) is usually from a 'sharps' injury including bites 'Contamination incidents' (The 'Contamination incidents' document is available on the Connect site). There is also a lower risk from a splash to the eyes and mouth or skin. The risk to the HCW depends upon the prevalence of the virus in the population served, the infectious status of the patient, and the risk inherent in the procedure being carried out.
2. The protection of patients in the instance of patient-to-patient cross-contamination through e.g. medication errors when single patient use injections are accidentally used for two patients, bite wounds, razor sharing etc.
3. There is a negligible risk of transmission from a HCW to a patient as exposure prone procedures do not commonly take place within Nottinghamshire Healthcare Trust.
Definitions
Blood Borne Viruses (BBV)
Hepatitis B (HBV) and Hepatitis C (HCV) are viral infections that attack the liver and can lead to serious liver disease. Human Immunodeficiency Virus (HIV) is viral infection that attacks the body's natural defence mechanisms (your immunity to disease). They are present in blood and other body fluids.
COSHH Substances
These are substances and preparations that are covered by the Control of Substances Hazardous to Health Regulations 2002 (COSHH) that have the potential to cause harm if they are inhaled, ingested or come into contact with or absorbed through the skin. They include chemicals such as cleaning materials and biological agents such as viruses.
Exposure Prone Procedures (EPP)
Exposure Prone Procedures occur mainly in surgical procedures. They are procedures where there is a risk that injury to the HCW could result in that person's blood contaminating a patient's open tissues adding where the workers gloved hands maybe in contact with sharp instruments needle tips or sharp tissues (e.g. bone or teeth) inside a patient's open body cavity or wound where the hands or fingertips may not be completely visible at all times.
Contamination Incidents
The three types of exposure in healthcare settings where there is known to be significant risk are:
- Percutaneous injury (e.g. from needles, instruments, human bites)
- Exposure of broken skin (e.g. abrasions, cuts, active eczema)
- Exposure of mucous membranes, including the eye, mouth and gums
Standard Precautions
Standard Precautions are guidelines to follow to protect staff, patients and visitors from the spread of infection. This means that the HCW should assume that all body fluid containing blood is potentially infectious, and that personal protective equipment (PPE) must be worn as appropriate.
Personal Protective Equipment
Healthcare associated Infections
Healthcare Associated Infections (HAI) encompasses any infection by any infectious agent acquired as a consequence of a person's treatment by the NHS or which is acquired by a health care worker in the course of their NHS duties.
Duties
- The Trust will put in place arrangements to reduce the risk of exposure to blood borne viruses by implementing appropriate control measures such as management of clinical waste, provision of appropriate PPE engineering-controlled needle systems (shielded or retractable needles), sharp-safe devices and training in the management of violence and aggression and hand hygiene training.
- Infection Prevention and Control advice and Occupational Health Services will be available to all staff and volunteers.
- The Trust has a responsibility to make staff aware of these services through induction training, and the Occupational Health Service Leaflet.
- Line managers must make all staff aware of local arrangements for these services above by using available resources such as Trust leaflets and posters, and the BBV procedure within this policy.
Line Managers must ensure staff receive training in the use and disposal of specific sharp-safe devices used within their clinical area.
Line managers will undertake activity based risk assessments on Odyssey (The 'Odyssey' page acessed via the Connect site) to ensure that suitable controls are in place or identify additional measures for the protection of staff against BBVs.
Line managers will also undertake a specific risk assessment following an accidental occupational exposure to a member of staff to a blood borne virus. See Appendix 5 and Appendix 10
- Occupational Health is responsible for providing guidelines on immunisation against infectious diseases for employees of the Trust. It also provides advice to healthcare workers who believe they may have acquired a BBV, either occupationally or in other circumstances, or those known to have acquired a BBV. It will provide ongoing support to the HCW or volunteer following an accidental occupational exposure of a member of staff to a blood borne virus.
- Employees must follow guidance issue by their Professional Bodies and the Trust in respect of BBVs, and undertake clinical procedures in accordance with Trust policies and procedures.
Employment issues
- The Trust will take all reasonable action to eliminate any discrimination in recruitment against applicants, internally or externally, solely on the grounds of having a BBV. The criteria for any applicant will be medical fitness to carry out the job as recommended by Occupational Health, following the pre-employment health screening, based on medical information supplied in confidence, and the nature of the work to be undertaken.
- Any harassment, victimisation or discrimination directed against employees, patients or visitors by a member of staff on the basis of them having a BBV, now or in the past, may be regarded as a disciplinary offence and will be dealt with accordingly.
- Where an employee contracts a BBV, the Trust will provide reasonable arrangements to allow the employee to continue working.
- Employees who become aware of having contracted a BBV must:
- Take particular personal responsibility to ensure they take every practical precaution to protect patients and colleagues from the spread of infection.
- Not feel isolated, and for personal and professional reasons they must discuss the matter with Occupational Health and/or the Infection Prevention and Control Nurse who will deal with the information in strict confidence in accordance with procedure.
- Where redeployment as a medical necessity is advised by the Occupational Health Physician, the appropriate General Manager/Head of Service or equivalent, should be advised accordingly and the appropriateness of redeployment will be considered. Knowledge of infection will be treated in strict confidence and disclosed only with the employee's permission, except on medical advice where disclosure is necessary to protect the safety of others.
- Redeployment at the employee's request as a result of having a BBV, will be considered following discussion between the manager, the employee and Occupational Health/Infection Prevention and Control.
- The Trust recognises that flexible working arrangements can be crucial to the continued employment of staff that develop, or are recovering from, long term illness. Absence of staff will be managed in accordance with Trust Policy 10.01 Sickness Absence Management.
- No patient will be denied the care to which they are entitled because of infection with a BBV. Refusal to care for such a patient may lead to disciplinary action. As part of the overall consideration of such a refusal, further help, counselling, and training will be available to the employees.
Monitoring
- The effectiveness of the policy will be monitored by The Trust Wide Infection Control Group. The Care Group Matrons will provide a written quarterly report to the Trust Wide Operational Group on needle stick / sharps injuries that have been reported via the Trusts Incident Reporting system. The Occupational Health Service will provide a written quarterly report to the Trust's Health and Safety Committee on needlestick/sharps injuries that have been reported to and managed by the Occupational Health Services.
- The number of reported incidents will be reviewed by each of the committees.
- The effectiveness of the procedure for the management of the injuries will be reviewed by a written quarterly report from the Occupational Health Service.
Legislation and compliance
- Health and Social Care Act 2008: code of practice on the prevention and control of infections and related guidance (Department of Health and Social Care, 2022)
- Control of Substances Hazardous to Health Regulations 2002
- The Health and Safety at Work (etc) Act 1974
- Management of Health and Safety at Work Regulations 1999
- Guidance for Clinical and Healthcare Workers: Protection against Infection with Blood-Borne Viruses (Department of Health and Social Care, 1998)
- Needlestick injuries and blood-borne viruses: decisions about testing adults who lack the capacity to consent (BMA, 2016)
Appendix 1
Procedure for the Prevention of Infection with a BBV
- Because not all patients with BBVs have their infections diagnosed, it is essential that all blood and body fluids are regarded as potentially infectious and therefore high risk, so healthcare workers should adopt Standard Precautions to avoid contact with them. This means they should assume that all blood-containing fluid is potentially infectious and that appropriate control measures identified in the general risk assessment should always be in place.
- When the wearing of PPE such as gloves, aprons, masks and goggles is identified as a control measure, they must be worn and disposed of correctly.
Personal Protective Equipment
Handwashing
- Always wash hands thoroughly following removal of protective clothing
Occupational Health will offer vaccination to all healthcare workers (including students and trainees who are involved in healthcare of patients of the Trust) against HBV if they are doing work that might involve contact with blood or body fluids. Non-responders (non sero-converters) to vaccination will be investigated for HBV infection.
Non-responders to HBV vaccination are at risk of acquiring HBV through their work or other source. It is the responsibility of Occupational Health to inform them and their manager of this risk and ensure they are aware of correct action to take in the event of a sharp's injury.
The Appointing Officer will inform the Occupational Health Department when employees are appointed, so that immunisation status can be determined.
Occupational Health is responsible for administering the immunisation programme. It keeps a register of staff immunised and organises blood tests to establish immunity status. Occupational Health is also responsible for informing employees of their individual immunity status. It is a manager's responsibility to ensure that employees attend for HBV immunisation.
Appendix 2
Procedure for the Action to be taken following an Occupational Exposure to a Blood Borne Virus (injured/exposed staff member)
For patient-to-patient injuries/exposures, the below measures and procedures also apply.
Introduction
This procedure describes the action to be taken following accidental/occupational exposure to the risk of infection with a BBV.
National infection prevention and control manual for England (NHS England, 2024): Appendix 10 Best practice - management of occupational exposure incidents
What to do if you have a 'Sharps/Needlestick or Blood/Body Fluids Splash Injury or Bite?' (The document is available from the 'IPC 4.4 Occupational exposure to bloodborne viruses' page on the Connect site)
Definitions of Occupational Exposure (Link to the Contamination Incidents definition)
National infection prevention and control manual for England (NHS England, 2024): Chapter 1.10 Occupational safety: prevention of exposure (including sharps injuries)
Responsibility
It is the responsibility of the individual to carry out first aid, report to person in charge immediately, and complete an incident report (Ulysses).
It is the responsibility of the person charge of shift, to ensure the member of staff can seek advice from Occupational Health or out of hours service (Emergency Department) and to complete the IR1 if necessary. They must also undertake a specific risk assessment using the table in Appendix 5 and complete the Risk Assessment Tool as per Appendix 10. The risk assessment will provide guidance on the urgency with which investigation and treatment needs to be undertaken, and the completed tool should be taken by the injured person to Emergency Department or sent to Occupational Health.
It is the responsibility of the manager, in conjunction with the Infection Prevention and Control Team, to investigate all contaminated sharps incidents, ensure the incident report (Ulysses) and outcome have been completed, complete a Serious Incident form if necessary and to review the risk assessments as appropriate.
Where an incident is reportable under The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR), the Occupational Health will contact the Health and Safety Team to advise it is reportable and the Health and Safety Team will report it.
Where an incident is reportable under RIDDOR, the manager will be required to undertake an RCA in Ulysses, which will be allocated to them following being reported under RIDDOR.
- It is the responsibility of the local manager with relevant support, such as the Health and Safety Team, to investigate device failures and near miss incidents, as well as provide guidance and support with regards the development and monitoring of risk assessments.
- It is the responsibility of Occupational Health to arrange investigation and treatment, if necessary, of the healthcare worker as soon as is reasonably practicable after the incident, having established the level of risk.
- It is the responsibility of the doctor in charge of the patient to consider whether to approach the source patient to obtain consent for testing for BBVs, and if appropriate, to arrange for the test to be carried out.
Appendix 3
| ACTION BY INDIVIDUAL | ACTION BY PERSON IN CHARGE OF SHIFT | ACTION BY MANAGER | ACTION BY OCCUPATIONAL HEALTH DEPARTMENT (OHD) |
|
First Aid If the skin has been broken, encourage the wound to bleed. Wash well and cover with a waterproof dressing. If the eyes, mouth or skin have been contaminated, wash thoroughly for at least ten minutes. |
Support the staff member and ensure they are able to contact the OHD immediately by phone and to attend OHD as advised by Occupational Health. Undertake specific risk assessment using Appendix 5. |
Ensure IR1 and IR2 are completed. Exposure incidents should be reviewed by the appropriate line manager or senior manager of the area concerned to see if future recurrences can be prevented. |
During open hours Follow local OH service arrangements for the management of HCW following exposure to BBVs including ongoing support and follow up tests as appropriate. |
|
Inform the person in charge of the shift.
Complete an accident/incident form (IR1) following the Trust's Incident Reporting procedures. |
When OHD is closed Contact the doctor responsible* for the patient to request that the doctor considers whether the source patient can be approached to obtain consent to provide a blood sample to be tested for BBVs Source patient bloods MUST be taken from any source identified as High Risk on risk assessment. |
Contact person in charge of ward / dept for the source patient to: Request a review of source patient's notes to determine risk factors for carriage of BBVs (see below) Request that the doctor considers whether the source patient can be approached to obtain consent to provide a sample to be tested for BBVs Source patient bloods MUST be taken from any source identified as High Risk on risk assessment. |
|
|
When the OHD is closed, go to the nearest Emergency Department and inform them that you are a HCW involved in a BBV exposure incident. Contact Occupational Health as soon as possible to report the exposure incident. |
When OHD is closed Undertake specific risk assessment using Appendix 5. Telephone the nearest Emergency Department (see contact details) and inform them that an injured staff member is expected to attend. Give details of the source patient including any known risk factors for BBVs Arrange for the injured member of staff to attend the nearest Emergency Department. |
Appendix 4
Action by the Doctor in Charge of the Patient
Obtaining consent
- Consider whether to approach the source patient to obtain consent for testing for BBVs, and if appropriate, to arrange for the test to be carried out. A Patient Information Leaflet is available (Appendix 7).
- Where the source patient is able to give informed consent, the doctor should, if appropriate, document the agreed consent in the patient's records.
- Where the source patient is unable to giveinformedconsentplease refer to the BMA guidance for doctors on; needle stick injuries and blood borne virus testing for patients who lack capacity to consent (BMA, 2016)Thedoctorshouldcontactthe patient's own consultantordutyconsultantas part of the process of obtaining consent.
- If consent is refused, this must be documented in the patient's notes, and the Occupational Health Department informed.
Taking a blood sample from the source patient
- Inform the source patient that a HCW has had accidental contact with the patient's blood or body fluids.
- Do not give the name of the HCW to the source patient.
- Explain that it will allay anxieties for the HCW and allow early treatment to be given if it can be established whether or not the source patient carries a BBV.
- Any source identified as High Risk on assessment will require a blood test.
- Explain that when the result of this test is known, the source patient will be informed if they are carrying a bloodborne virus. This information will be helpful because, if positive will enable treatment to be considered and if negative for Hepatitis B immunisation will be offered.
- Give the source patient the information and the Patient Information Leaflet below.
- Obtain consent (see above).
- Arrange for 10mls of clotted blood (gold top tube) to be taken and label the request for, 'Source patient of exposure to HCW. Please test HIV antigen / antibody, Hep C antibodies and HB Surface Antigen.
- The patient is not in seclusion (Forensic Care Group), the blood sample may be taken by the phlebotomist, or as per local arrangements, and sent to the relevant microbiology laboratory.
- If the patient is in seclusion (Forensic Care Group), the venepuncture is the responsibility of the doctor responsible for the patient.
- Ensure that the source patient is informed of the result.
- Occupational Health will inform the injured HCW of the result.
Appendix 5
Post exposure incident risk assessment
Several factors will need to be considered during the risk assessment, including: the type of body fluid to which the recipient has been exposed, nature / route of exposure and what is known about the source patient.
Where a known source patient is involved, the risk assessment should normally be conducted by the most senior member of the medical / nursing team treating the patient at the time of the injury. The risk assessment should assess risk based on information contained in the clinical record and/or discussion with the source patient.
If the source patient does not have the capacity to consent / does not consent, the blood sample cannot be taken, and the risk assessment will need to be based on information contained in the patient's clinical records.
High risk body fluids:
- Blood
- Amniotic Fluid
- Human Breast Milk
- Cerebrospinal Fluid
- Pericardial Fluid
- Peritoneal Fluid
- Pleural Fluid
- Semen
- Synovial Fluid
- Vaginal Secretions
- Tissue exudate from burns or skin lesions
- Unfixed human tissue and organs
- Saliva associated with dentistry (likely to be contaminated with blood even if not visibly so
Low risk body fluids:
- Saliva
- Stool
- Urine
- Vomit
High Risk Source Patients (Examples, this is not an exhaustive list)
- Known to be HIV, Hep C or Hep B positive
- Possible HIV related illness
- Source from an area of high HIV prevalence, particularly sub-Saharan Africa
- Source has had blood transfusions or blood products outside of the UK
- Source past / present IV Drug user with needle / equipment sharing
- Source has had unprotected / unsafe sexual practices with a high-risk partner
- Been a recipient of blood products in the UK prior to 1986
- Been a recipient of organ or tissue transplants or transfused blood the UK before 1992 or outside of the UK
Higher Risk Incidents/exposures:
- A break in the skin by a sharp object (including needles, scalpels, or broken glassware) that is contaminated with blood, visibly blood-stained body fluid, or other potentially infectious material.
- Bite from a patient with visible bleeding in the mouth that causes bleeding / broken skin to the exposed worker.
- Splash of blood, visibly blood-stained body fluid, or other potentially infectious material to the mouth, nose, or eyes (mucosal surface) or broken skin (e.g. eczema, dermatitis, cuts, chapped skin, abrasion, scratches or open wound)
Low risk incident/exposure:
- Exposure to blood or body fluids on to intact skin
Post-exposure prophylaxis (PEP)
For some high-risk incidents where post-exposure prophylaxis (PEP) medication may be required, for example in case of known or suspected HIV, this should be commenced as soon as possible after the incident and ideally within the hour.
This decision to offer PEP will be made by the Occupational Health Physician during normal working hours or Accident and Emergency Department at all other times.
The risk assessment information will be required by Occupational Health (and Emergency Department if injury has occurred out of hours). This should be provided by the person who undertook the risk assessment and can be provided verbally or by email to occupational health.
When PEP would be considered
Post-exposure prophylaxis is not considered necessary following contact through any route with low risk materials (e.g. urine, vomit, saliva, faeces) unless they are visibly blood stained.
Post-exposure Prophylaxis should be considered whenever the healthcare worker has been exposed to blood or other high risk body fluids or tissues* known to be, or strongly suspected to be, infected with HIV.
Amniotic fluid, vaginal secretions, semen, human breast milk, cerebrospinal fluid, peritoneal fluid, pleural fluid, pericardial fluid, synovial fluid, saliva in association with dentistry, unfixed tissues and organs.
To be most effective, post-exposure prophylaxis medication should be commenced as soon as possible after the incident and ideally within the hour, and no more than 72 hours afterwards.
The decision to offer PEP is by either the Occupational Health Physician (based in the OH Service where they have the facility to prescribe the medication) or by the Medical Microbiologist on call in the Accident and Emergency Department.
What is PEP?
There is evidence that in HIV infected persons the use of combinations of antiretroviral drugs suppresses viral replication. This, together with the knowledge of antiretroviral resistance in this population, has led to the introduction of antiretroviral drug combinations for prophylaxis following occupational exposure to HIV.
At present the recommended antiretroviral drugs for post-exposure prophylaxis are Raltegravir 1200mg od with tenofovir/emtricitabine one tablet od. They are taken for four weeks.
Appendix 6
Contact details
Occupational Health service to Nottinghamshire Healthcare NHS Trust
Nottinghamshire Healthcare NHS Trust
Occupational Health Service
Duncan Macmillan House
The Resource
Porchester Road
Nottingham NG3 6AA
Tel: 0115 955 5373
Monday to Friday 8:30am to 4pm (excluding Bank holidays)
At all other times attend local Emergency Department so that if required the appropriate prophylaxis can be given in a timely manner. Please report incident to Occupational Health the next working day so that follow-up care / checks can be arranged as necessary.
Appendix 7
Patient information leaflet-blood testing for hepatitis B, C and HIV
What is Hepatitis?
Hepatitis is inflammation of the liver. Hepatitis B and hepatitis C are viral infections that attack the liver and can lead to serious liver disease.
You can be immunised against hepatitis B, but if you are exposed to hepatitis B and you have not been immunised then you can be offered a rapid course of vaccination. There is also the potential option of treatment. You cannot be immunised against hepatitis C, but if you are exposed to hepatitis C or acquire the virus then treatment is available.
What is HIV?
HIV stands for Human Immunodeficiency Virus. It is a viral infection that attacks the body's natural defence mechanisms (your immunity to disease). You cannot be immunised against HIV but if you are exposed to HIV or if you acquire the infection, it then treatment is available.
How do you catch Hepatitis or HIV?
- Having unprotected sex with a person who already has one of the viruses.
- Sharing needles with a person who already has one of the viruses.
- Unsterile body piercing and tattooing.
- Receiving a blood transfusion or organ transplant in the UK before 1986 or in countries where donors are not screened.
- Occasionally healthcare workers can catch hepatitis or HIV by accidentally injecting themselves after giving an injection to a patient who already has one of the viruses.
- A woman who already has one of the viruses can pass it to her baby during pregnancy or at birth.
What should I do if I think I have been at risk of catching Hepatitis or HIV?
If you think you might have been 'at risk' of hepatitis or HIV you can be tested for them. Ask the ward doctor for a consent form for you to sign. This gives your permission for the test to be carried out. A small sample of blood is taken from your arm and is sent away to the laboratory of the local hospital for testing.
Results
The test results should return within a week. They are strictly confidential and as well as yourself only the nursing and medical staff that look after you will know the result.
Negative result
This probably means you do not have any of the viruses - BUT if you were 'at risk' recently your body may not have reacted yet, and it may be necessary to do another test in 3-6 months.
Positive result
You will be referred to a specialist, who will examine you and discuss treatment. You may want to let your close contacts know so they can be tested also. Ask the ward staff about this.
Appendix 8
Guidance for Dealing with Blood/Body Fluid Spillage
IPC 1.8 Safe management of blood and body fluid spillages
Appendix 9
Flowchart for the Management of Blood and/or Body Fluid Exposure and Sharps Injuries (The document is available from the 'IPC 4.4 Occupational exposure to bloodborne viruses' page on the Connect site)
Appendix 10
Post Incident Risk Assessment for Sharps Injury and Mucosal Exposure Incidents (The document is available from the 'IPC 4.4 Occupational exposure to bloodborne viruses' page on the Connect site)
References / Source documents
- BMA (2016) Needlestick injuries and blood-borne viruses: decisions about testing adults who lack the capacity to consent. (Accessed: 1 July 2024).
- Department of Health and Social Care (1998) Guidance for Clinical Health Care Workers: Protection Against Infection with Blood-Borne Viruses. (Accessed: 1 July 2024).
- Department of Health and Social Care (2022) Health and Social Care Act 2008: code of practice on the prevention and control of infections and related guidance. (Accessed: 1 July 2024).
- Health and Safety at Work etc. Act 1974, c. 37. (Accessed: 1 July 2024).
- Health and Safety Executive (2024) Blood-borne viruses (BBV). (Accessed: 1 July 2024).
- NHS England (2024) National infection prevention and control manual for England. Accessed: 1 July 2024).
- NHS Executive (2000) Health Services Circular: Hepatitis B Infected Health Care Workers. (Accessed: 1 July 2024).
- Public Health England (2019) Guidance on management of potential exposure to blood-borne viruses in emergency workers: For occupational health service providers in frontline staff. (Accessed: 1 July 2024).
- The Control of Substances Hazardous to Health Regulations 2002 (SI 2002/2677). (Accessed: 1 July 2024).
- The Management of Health and Safety at Work Regulations 1999 (SI 1999/3242). (Accessed: 1 July 2024).
- The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (SI 2013/1471). (Accessed: 1 July 2024).
- UK Health Security Agency (2021) Bloodborne viruses in healthcare workers: report exposures and reduce risks. (Accessed: 1 July 2024).
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