A member of: Association of UK University Hospitals Sharps Management Protocol Infection Prevention and Control Procedure 1
Date of Issue: January 2016 Next Review Date: Version: 1 Last Review Date: Author: Deputy Director of Nursing Standards and Safety Directorate: Governance January 2017 Approval Route: Medical Devices and Infection Control Group Approved By: Executive Director of Nursing Date approved:pending and Quality and DIPC Health and Safety Committee Medical Devices Group Links or overlaps with other policies: Infection Prevention and Control Policy Health and Safety Policy Waste Management Policy Management of Needle Sticks & Contamination Injuries to Healthcare Workers Procedure :ICP 21 - Management of Occupational Exposure to Blood Borne Viruses (BBVs) and Post Exposure Prophylaxis (PEP) Controlled document. It should not be altered in any way without the express permission of the author or their representative. On receipt of a new version, please destroy all previous versions. Amendment History Status and Author Draft Jayne Bruce Date 25 January 2016 Reason for Change New Protocol Authorised Protocol Location Infection Prevention and Control Policy Bundle 2
Contents Contents...3 Policy Statement.4 Purpose/Introduction..4/5 Roles and responsibilities..5/6 Sharps Management 6/7/8 Appendix 1 Management of Occupational Exposure to Blood Borne Viruses (BBVs) and Post Exposure Prophylaxis...9/10 If you require this document in another format such as large print, audio or other community language please contact the Governance Support Team on 01903 845735 or email Governance.support@sussexpartnership.nhs.uk 3
1.0 Policy Statement Sussex Partnership NHS Foundation Trust (SPFT) is committed to ensuring safe practice by effective sharps management in accordance with the Health and Safety (Sharp Instruments in Healthcare) Regs.2013 Prevention from sharp injuries in the hospital and healthcare sector, has formed part of national legislation since 11th May 2013. The Control of Substances Hazardous to Health Regulations (COSHH) states that all Trusts shall assess the risk of exposure to biological hazards including blood-borne viruses and risk of sharps injuries from procedures and activities. These regulations require, so far as is reasonably practicable, that sharps are avoided otherwise safer sharps be used so far as is reasonably practicable. That Trusts will substitute traditional, unprotected medical sharps with a safer sharp where it is reasonably practicable to do so. If a suitable safer sharp is not available to reduce the risk of injury, all Trusts will ensure that safe procedures and assessment for working and disposal of the sharp are in place. Needle safe procedures especially for disposal will also be in place for disposal of safer sharps. SPFT fully endorses the introduction of syringe devices, with engineered safety mechanisms to reduce incidents of needle stick injuries. As part of The Safer Sharps implementation plan all Staff are expected to use retractable needles or other devices with engineered safety mechanisms, to administer injectable medicines. Conventional needles should only be used in exceptional circumstances and a Risk Assessment for each sharp must be completed with control measures identified, recorded and regularly reviewed. This policy applies to all staff and must be implemented as a minimum standard in all services throughout the Trust Sussex Partnership NHS Foundation Trust is committed to ensuring peoples safety while at work. It aims to do this by: Providing a safe working environment which, as far as is reasonably practicable, reduces the risk of harm occurring to staff and anyone else who may be affected by their activities Implementing and maintaining a proactive approach to risk assessment to identify where risks need to be controlled Ensuring sufficient information, instruction and supervision is available to staff to enable them to work safely Raising awareness on the safe and compliant assembly, storage, and disposal of sharps containers 2. Purpose/Introduction The Health and Safety (Sharp Instruments in Healthcare) Regs.2013 were introduced in May 2013 in order to implement the framework agreement on the prevention of sharps injuries. For 4
example, to prevent injuries and the risk of blood-borne infection to healthcare workers from sharp instruments such as needles. The purpose of the regulations is to implement the Framework Agreement to ensure that injuries of workers by all medical sharps (including needle sticks) are prevented; to protect workers at risk and to establish procedures in risk assessment; risk prevention; training, information awareness and monitoring. It is the responsibility of all Trusts employees to be aware of, and adhere to this Policy within the remit of the Health and Safety at Work Act 1974. A sharp is defined as any object, which can pierce or puncture the skin, which is potentially contaminated with blood or body fluids e.g. needles, razor blades, glass vials/ampoules, scalpels, lancets, scissors or stitch cutters. 3. Roles and Responsibilities 3.1 Board of Directors (the Board) The Trust is committed to protecting the health, safety and welfare of its staff and patients and recognises that injury and accident management is a health and safety issue and will ensure that effective systems are in place and where appropriate, ensuring that adequate resources are available to support those systems. 3.2 The Chief Executive and the Board The Chief Executive and the Board will ensure that managers are promoting incident reporting throughout the workplaces for which they are responsible, and that incident and accidents are being properly recorded, acted upon and where significant risks are identified, recorded on the Trust s Risk Register. 3.3 Procurement Managers Procurement managers are responsible to ensure that non-safer sharps are only procured if a Sharps Risk Assessment for the use within this clinical department has been completed. They must also maintain a list of the non-safer sharps permitted, and for which department, within the Trusts Central Ordering System 3.4 Clinical Leads The use of non-safer sharps is only permitted if a suitable safer sharp is not available, or a risk assessment shows that there is clear clinical reason why a safer sharp cannot be used. The Clinical Leads for each Care Delivery Service are responsible to ensure that where a safer sharp is not being used a risk assessment has been carried out, control measures identified and implemented and that these risk assessments are reviewed and updated as necessary. Risk assessments should be completed using the Safeguard web risk module. 3.5 Managers The Health and Safety (Sharp Instruments in Healthcare) Regs.2013 and COSHH states that where medical devices provide a risk of sharps injury a formal risk assessment should be undertaken by the manager of the service, the exposure should be eliminated if possible, and if unable to be eliminated the safest type of equipment/medical device should be used. This process will ensure the hierarchy of controls are followed (i.e. elimination, substitute) with the safer sharps device being the default position. Therefore, all managers shall ensure that a Safer Sharps risk assessment is be undertaken wherever clinical activity involves the use of 5
sharps. This should include the selection of equipment, including personal protective equipment and the safe placement of sharps containers in addition to ensuring correct assembly and disposal. All sharps incidents must be investigated as per regulation 7 (1) (b) to identify the cause of any incidents and to ensure that learning is shared throughout the trust and that actions are implemented to prevent reoccurrence. 3.6 All Staff All staff have a responsibility to: Familiarise themselves with this policy regarding the management of sharps Adhere to safe working practices in order not to harm either themselves or others Undertake mandatory infection prevention and control training and ensure this kept up to date Be aware of the necessary action to take in the event of a sharps injury as per the Infection Prevention and Control Policy Management of Occupational Exposure to Blood Borne Viruses (BBVs) and Post Exposure Prophylaxis (PEP) NUMBER: ICP 21 http://policies.sussexpartnership.nhs.uk/clinical-3/infection-control-policy-proc edure Report all incidents to line manager including near misses, of sharps injury immediately they occur and complete an incident form. 4. Sharps Management 4.1 Safety Precautions when Using and Disposing of Sharps Staff involved in providing care should adhere to hand decontamination and use standard precautions to include the use of gloves and aprons in conjunction with the safe use and disposal of sharps. Select the relevant size and colour of sharps container most appropriate to your needs (this aims to avoid prolonged uses and non-compliant waste). Refer to waste guidance if necessary. Discard sharps directly into a sharps container immediately after and at the point of use. Do not attempt to re-sheath a needle under any circumstances Dispose of needle and syringe as a complete unit never detach unit by hand unless a risk assessment has been completed. Do not pass sharps directly from hand to hand, or pass to another person handling should be kept to a minimum. Only the person using the sharps must dispose of them, unless risk assessed procedures state a different process 6
4.2 Sharps Containers All staff must ensure that: Containers are correctly and securely assembled (follow manufacturers instructions) assembly, signature of staff member and department/ward this also identifies source and enables an audit trail Dispose of container when it is three-quarters full (shown by a fillline on each container) Ensure secure closure and locking, and ensure the label is fully completed. Sharps bins should never be placed in any waste bags or waste bins other than those designated for the collection of full rigid sharps containers prior to their consignment for disposal Fluids of any sort are not discharged into bags or containers Containers are not stored on the floor Avoid prolonged use of sharps containers maximum period of use three months Always store in a safe, designated, secure area eg: in a locked area, containers should never be placed in corridors or areas with access to the general public unless a specific risk assessment identifies the need. Sharps containers that are used at multiple sites and used by community teams should never be left at a patient s home and closed after each use A sharps container that is left at patients own home for their own use, needs to be risk assessed and consideration taken for positioning and storage Whenever possible, when a sharps container is not in use it should be stored securely/wall mounted to prevent risk of spillages Ideally the sharps container should be taken to the point of care (unless this is identified as a risk) to ensure that the sharp is disposed of immediately following use Disposal of Sharps containers to be completed safely in accordance with the Trusts procedures Sharps containers should be stored with the lid in the temporary closed position to prevent spillage of sharps if the container is knocked over. 4.3 Information The Health and Safety (Sharp Instruments in Healthcare) Regs.2013 require all Trusts to provide health and safety information to staff. It is important that the Trust co-operates with staff side representation in developing and promoting the information: The information provided must cover Sharps Management Policy The risks from injuries involving medical sharps and legal requirements 7
Relevant legal duties on employers and employees Good practice in preventing injury The benefits and drawbacks of vaccination/non vaccination The support available to an injured person 4.4Training Under the regulations the training provided to staff must cover: The correct use of sharps Safe use and disposal of medical sharps What to do in the event of a sharps injury The Trusts arrangements for health surveillance and other procedures 4.5 Injuries The Sharps Regulations require NHS Trusts to have procedures in place to ensure that they can respond effectively when an injury occurs. Staff who receive a Sharps injury at work must report it on the incident reporting system as soon as practicable, and adhere to the Needle stick Injury Protocol Management of Occupational Exposure to Blood Borne Viruses (BBVs) and Post Exposure Prophylaxis (PEP) NUMBER: ICP 21 http://policies.sussexpartnership.nhs.uk/clinical-3/infection-control-policy-proc edure The Trust must investigate the circumstances and causes of any incidents and take any action required. Learning from incidents must be widely disseminated and any changes to practice implemented to prevent reoccurrence. Any RIDDOR reportable incidents will be reported via the Trust Risk and Safety team as per the regulations and Trust incident reporting policy. References European Council Directive 2010/32/EU Management of Health and Safety at Work Regulations Health and Safety (Sharps Instruments in Healthcare) Regulations 2013 Sharps Safety RCN guidance Management of Needle Stick & Contamination Injuries SCT OH Guidance Health and Safety at Work Act 1974 8
Appendix 1 Sussex Partnership NHS Foundation Trust INFECTION CONTROL PROCEDURE NUMBER: ICP 21 - Management of Occupational Exposure to Blood Borne Viruses (BBVs) and Post Exposure Prophylaxis (PEP) INTRODUCTION: Prevention of occupational exposure to blood-borne viruses is of prime importance. Many exposures result from a failure to follow recommended procedures, including the safe handling and disposal of needles and syringes, or to wear personal protective clothing where appropriate. BACKGROUND: Health care workers should be informed and educated about the possible risks from occupational exposure and should be aware of the importance of seeking urgent advice following any needlestick injury or other occupational exposure. Post exposure prophylaxis for HIV will be considered and recommended after a full risk assessment of the injury has been carried out. AIM: Staff are able to access 24-hour support/advice regarding actions necessary in the event of a significant exposure to blood or body fluids. RISK ASSESSMENT for PEP and ACCESS TO TREATMENT The issue of post exposure prophylaxis (PEP) should be considered after an exposure with the potential to transmit blood borne viruses, based on the type of body fluid or substance involved, and the route and severity/risk of the exposure. Some health care workers may have had occupational exposures that, after careful assessment by an experienced clinician, are not considered significant in terms of risk to the individual. It is recommended however that the exposed healthcare worker will:- Have the risk of exposure transmission assessed by an experienced clinician from Occupational Health, Sexual Health Clinic or Accident & Emergency Department. Receive expert advice on the degree of risk of the blood borne exposure from an experienced clinician as above. Be offered post exposure prophylaxis if appropriate. Be offered support and counselling. All incidences must be reported using the Trust Incident Report Form and the appropriate manager informed of the incident. BLOOD BORNE VIRUS DONOR TESTING It may be necessary to obtain information or specimens from the patient involved and attention should be paid to the means of obtaining a specimen should the need arise at the time of the incident. This can be done if the patient gives consent, following consultation and 9
consideration of a number of factors by the patient s Consultant/GP including the patient s best interests and their ability to give informed consent. POST EXPOSURE PROPHYLAXIS PEP should not be offered after exposure through any route with low risk materials e.g. urine, vomit, saliva or faeces unless they are visibly blood stained. Also PEP should not be offered where testing has shown that the source is HBV, HBC or HIV negative or if a risk assessment has concluded that infection of the source is highly unlikely. Post exposure prophylaxis treatment is commenced, where appropriate, as soon as possible after the event. Occupational Health departments, Accident and Emergency Departments and acute trust pharmacies carry starter packs of the recommended drugs ensuring their accessibility 24 hours a day. IMMEDIATE ACTION FOLLOWING EXPOSURE INCIDENT Encourage bleeding of puncture wounds by gently squeezing at the site 1. Management of a Potential Exposure Incident Immediately following a needle stick or similar injury with contaminated sharps encourage bleeding by gently squeezing the wound -DO not suck the wound. 2. Put the sharps injury under running water preferably warm water(do not use antiseptic wipes or other skin washes, there is no evidence of their efficacy and their effect on the body s defences is unknown) 3. Cover the puncture site with a clean sterile dressing or something clean If in the community. 4. Exposed mucous membranes, including the conjunctiva (eyes or mouth should be irrigated copiously with water before and after removing any contact lenses. 5. Report the injury immediately to the person in charge of the ward/unit and follow procedure for sharps injury. 6. Contact Occupational Health Sharps Line during the hours of 9-4.30pm Monday-Friday. 7. Out of hours weekdays and weekends contact you nearest A and E Department immediately and then contact Occupational Health Sharps Line on the next working day 8. It is essential a clotted blood sample is also obtained from the service user (if known) as soon as possible(ie within 24 hours) 9. This blood will be tested for Hepatitis B surface antigen(hbsag) and saved. The regimen for post exposure treatment is complex and subject to speciality management and for this reason will not be listed within this document. The purpose of this policy and procedure 10
is to ensure that in the event of an exposure incident, an affected health care worker is guided to the most appropriate course of action and advice, at any time of the day, where appropriate interventions will be planned and monitored by relevant professionals. POST EXPOSURE COUNSELLING AND SUPPORT Any person who is to be tested for HIV should be offered pre and post test counselling. The aim of the counselling is to explain and discuss the implications of the test so that the person can make an informed decision regarding the most appropriate course of action. This counselling would normally be provided through the Sexual Health Clinic which will take the lead on the management of the exposure incident. Occupational Health will advise on general support and counselling available through the Employee Assistance Programme. Reference: Department of Health (2008) Blood borne viruses in the workplace, Guidance for employers and Employees INDG342 London. HSE 11