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Sharps Safety Policy Version: 5

Date Issued: 24 October 2017 Review Date: 24 October 2020 Document Type: Policy

Contents Page

Paragraph Executive Summary 2 1 Introduction 3 2 Scope 3 3 Purpose 3-4 4 Definitions 4 5 Related Trust Policies 4 6 Roles and Responsibilities or Duties 4-5 7 Principles to be Followed 5-7 8 Implementation (including training and dissemination) 7-8 9 Process for Monitoring Compliance/Effectiveness 8 10 Arrangements for Review of the Policy 9 11 References and additional reading 9

Appendices Page

Appendix A Flow Chart – If a sharps injury does occur 10 Appendix B Safe Practice Guide 11

Separate Document

Sharps Safety Policy Quick Reference Guide Separate document on Staffnet

Document Status

This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet.

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Executive Summary

Syringe needles, scalpel blades and many other sharp devices are routinely used as part of healthcare practice in acute and primary care settings. Every year numerous staff sustain injuries from contaminated sharps. These injuries pose a significant risk to the physical and mental health of the staff member, cost the healthcare organisation time and resources, and have the potential to result in costly litigation.

All staff are informed of the correct and safe procedures for the management of sharps both at induction and during refresher training. Staff are made aware of the action to take should a sharps injury occur, including the appropriate reporting of the incident.

Many sharps injuries can be avoided by adherence to the principles of safe practice. However it is recognised that some injuries are complete accidents. It is possible to reduce the risk of these happening by the use of safety devices.

Safety devices have been pro-actively introduced throughout the organisation.

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1 Introduction

Sharps like syringe needles, scalpel blades and many other sharp devices are routinely used as part of healthcare practice in acute and primary care settings. Every year numerous staff sustain injuries from contaminated sharps. These injuries pose a significant risk to the physical and mental health of the staff member, cost the healthcare organisation time and resources, and have the potential to result in costly litigation. All employers are required under existing health and safety law (see Reference A) to ensure that risks from sharps injuries are adequately assessed and appropriate control measures are in place. The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 (Reference B) build on the existing law and provide specific detail on requirements that must be taken by healthcare employers and their contractors. Reference B follows the principles of the hierarchy of preventative control measures, set out in the Control of Substances Hazardous to Health Regulations (COSHH) (Reference C). This policy provides a clear, evidence-based framework to ensure safe practice when sharps are used, thereby minimising injuries caused by contaminated sharps. It is applicable to all staff who handle sharp items during the course of their employment, and applies at all times, in all situations. 2 Scope This Policy is for all Trust staff (including students, agency etc) working on all Trust sites on the safe management of sharps. The policy includes:

Safe management of sharps handling in the hospital and community settings where UHS staff work.

Correct use of sharps containers.

Correct use of safety devices.

Action to be taken in the event of a sharps injury (Appendix A). This policy does not provide detailed guidance on the action to take and the management of sharps injuries. For more detailed guidance see the Management of Sharps and Contamination Incidents Policy. 3 Purpose

The objectives of this policy are:

The management of sharps is incorporated into the risk assessment process.

Suitable sharps containers are readily available and located in agreed areas i.e. bins and trays which can be taken to point of care, all bins positioned ‘waist height’ using appropriate fixation wall or trolley brackets. Specialty bins are available for specialist services sharps waste.

All staff are informed of the correct and safe procedures for the management of sharps both at induction and during refresher training.

All staff are made aware of the action to take should a sharps injury or sharps spillage occur, including appropriate reporting of the incident.

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4 Definitions

A sharp: includes items such as a needle, sharp edged instruments, broken glassware, razors, scissors, bones and teeth. Sharps injury: defined as an injury where a needle or other sharp object, contaminated with blood or other body fluid, penetrates the skin. This also includes human bites and scratches that break the skin.

5 Related Trust Policies

Management of Sharps and Contamination Incident Policy.

Standard Precautions Policy.

Council Directive 2010/32/EU Framework Agreement on prevention from sharp injuries in the hospital and healthcare sector. Incident Reporting and Management Policy.

6 Roles and Responsibilities All staff working on Trust premises, including contractor staff, agency and locum staff, are responsible for adhering to this policy and for reporting breaches of this policy to the person in charge and to their line manager. Director of Nursing (Director of Infection Prevention Control) has executive responsibility for ensuring this policy is implemented and adhered to across the Trust. Ward and Department Managers are responsible for ensuring these guidelines are implemented in their areas of responsibility and for ensuring all staff who work within the area adhere to the principles at all times. All managers are responsible for ensuring that staff have access to current training to enable them to adopt safe working practices at all times and are appropriately trained to minimise risks to themselves and others. Consultant Medical Staff are responsible for ensuring these guidelines are implemented in their areas and for ensuring all staff who work within the area adhere to the principles at all times. All managers are responsible for ensuring that staff have access to current training to enable them to adopt safe working practices at all times and are appropriately trained to minimise risks to themselves and others. Divisional and Care Group Management Teams are responsible for monitoring implementation of these guidelines and for ensuring action is taken when staff fail to comply with the guidelines. The Infection Prevention Team is responsible for providing expert advice in accordance with this policy and for supporting staff in its implementation. They are also responsible for ensuring this policy remains consistent with the evidence-base for safe practice, and for reviewing the policy on a regular basis. The Occupational Health Department (OHD) is responsible for disseminating information about the prevention and immediate management of sharps and contamination incidents, to ensure timely and appropriate management of incidents which present when the department is open. They are also responsible for co-ordinating longer term treatment follow-up and counselling of affected employees and for maintaining confidentiality during this process. Additionally, they are to train Occupational Health Department and Emergency Department nurses in the immediate assessment and management of sharps and contamination incidents. They are to report any sharps/contamination incident involving a donor source

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who is Blood Borne Virus (BBV) positive, under RIDDOR and to Public Health England, and as per the Trust Incident Reporting and Management Policy. The role of the Emergency Department is to ensure timely and appropriate management of incidents which present when the OHD is closed and to maintain confidentiality during this process. The OHD requires informing of all incidents managed out-of-hours so that follow-up can be arranged. A copy of the risk assessment must be sent to the OHD for every case. The Health and Safety Team is responsible for facilitating any formal investigations into high risk incidents reportable under RIDDOR to the Health and Safety Executive. They are also responsible for the provision of support to Care Groups in ensuring that appropriate action is taken as a result of a sharps incident. Additionally, cooperation with Trust teams in promoting sharps safety and evaluating new products is a responsibility.

ALL staff have a responsibility for good sharps practice and should feel empowered to challenge unsafe behaviour.

Non-compliance with a Trust policy, procedure or guideline may result in disciplinary

action.

7 Principles to be Followed Many sharps injuries can be avoided by adherence to the principles of safe practice highlighted: Safety Devices

It is recognised that some sharps injuries are complete accidents. It is possible to reduce the risk of these happening by the use of safety devices. These are devices that incorporate a built-in safety feature in their design, which is intended to reduce the risk of sharps injury. An integrated safety feature is part of the basic design of the device that cannot be removed. A passive safety feature is one that does not require the user to activate it, and remains effective before, during and after use. As detailed in References B and C, the employer must substitute traditional, unprotected medical sharps with a ‘safer sharp’ where it is reasonably practicable to do so. Managers should consider the supply of safety devices in preference to standard devices wherever possible. In areas that have been assessed to be higher infection risks, safety devices should be considered for use as a priority.

The following factors should be considered:

The device must not compromise patient care.

The reliability of the device.

The care-giver should be able to maintain appropriate control over the procedure.

Other safety hazards or sources of blood exposure that use of the device may introduce.

Ease of use. Safe Handling The use of sharps should be avoided where possible. When their use is essential, a safer sharp device should be used where it is reasonably practicable to do so. Safer sharps do not necessarily remove all risks associated with the use of sharps and therefore sharps must be handled with care, in accordance with the following principles:

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Use needleless intravenous devices and safer needle systems whenever possible and wherever available

Do not re-sheath used needles.

In exceptional circumstances, if re-sheathing CANNOT be avoided, use a specific needle re-sheathing/removing device.

Always get help when using sharps with a confused or agitated patient.

Never pass sharps from person to person by hand; use a receptacle or a ‘clear field’ to place them in.

Never walk around with sharps in your hand.

Never leave sharps lying around, dispose of them yourself.

Dispose of sharps at the point of use; take a sharps container with you.

Dispose of syringes and needles as a single unit; do not remove the needle first.

Needles or other sharps must not be bent.

When transporting a blood gas syringe, remove the needle using a removal device and attach a blind hub prior to transport.

Refer to the ‘Safe Practice Guide’ for further information which can be found at Appendix B.

In the event of a sharps injury occurring, immediate action must be taken as shown at Appendix A. For additional information see the Management of Sharps and Contamination Incidents policy.

Use of Sharps Containers Sharps containers must be utilised appropriately, in accordance with the following principles:

Sharps must only be disposed of in designated sharps containers that meet the requirements of the British Standard: BS 7320 (1990).

Always assemble a sharps container correctly ensuring that the:

o Lid is on properly.

o Label is completed. o Container is placed in a suitable, safe location.

Ensure sharps containers are of an appropriate size for the clinical activity; do not select excessively large sharps containers, or those that are too small for the size of needle/syringes you use.

Sharps containers should be available at the point of use of the sharp; they should be taken to the bedside, placed on drug and cardiac arrest trolleys, and be carried by all staff who use sharps as part of their work in the community.

After drug rounds, used sharps containers should be placed in treatment rooms away from patient areas and not left on the drug trolleys in bays or corridor areas.

Wall and trolley brackets should be used as appropriate to avoid spillages.

Sharps containers must be located at approximately waist height, and never placed on the floor, on top of high surfaces, or where children or confused adults can tamper with them.

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Larger sharps containers that have to be placed at floor level, for example those used for disposal of IV lines, must be on a stand or in a frame to enable effective cleaning beneath them.

Between uses, the temporary closure device should be utilised to prevent accidental spillage of sharps if the container is knocked over.

Always carry a sharps container by the handle, or use the carry tray provided for smaller containers. Never place it against your body.

Never overfill a sharps container. Replace it when the container has been filled to the indicated line.

Ensure sharps containers are closed and locked before disposal, and complete the closure label on the container.

Do not place sharps containers in waste bags for disposal.

Used sharps containers must be stored in a locked segregated cupboard, sluice or a clinical waste bin provided for the purpose and these must be located away from patients and the public.

Sharps bins containing sharps that have been, or may have been, contaminated with radioactive material must be labelled as such by using 'radioactive' warning tape and disposed of in accordance with the requirements for radioactive waste.

Staff using Sharps in the Community Staff employed by the Trust who use sharps in the community should undertake a risk assessment to ensure the appropriate sharps devices are being utilised and safe working procedures are in place. The size of the sharps container carried should be appropriate for the safe disposal of sharps used, yet it should be as small as is practicable. While the sharps container is being transported in a car, it must have the temporary closure mechanism in place and should be secured so spillage would be minimised in the event of an accident. The sharps container may be placed inside a clear plastic bag during transport in a vehicle in order to prevent leakage. Sharps containers should be kept out of sight and the vehicle in which it is stored must be locked. The vehicle should be checked after every shift to ensure there has been no spillage of sharps. If sharps have been spilled, the affected area should not be used until the vehicle has been safely decontaminated. The incident should be reported appropriately. Patients discharged on medication requiring needles and syringes. Occasionally patients are discharged home taking medications which require needles and syringes, e.g. enoxaparin. Staff must complete the form located on Staffnet which must be faxed or emailed to the relevant local authority. Link Below: http://staffnet/TrustDocsMedia/DocsForAllStaff/InfectionControl/Patientsdischargedonenoxaparinhealthcarewast/Healthcarewastecollectionreferralform.doc Once received they will register the patient for sharps bin collection. The patient must be informed to telephone their local authority when they are ready to have their three quarters full sharps bin collected. Contact numbers are found on Staffnet along with the form.

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The patient must also be taught how to safely use the sharps container prior to discharge. This information must include where to safely store the sharps bin whilst in use, how to use the temporary closure and how to lock the bin closed ready for collection.

8 Implementation It is imperative for the safety of staff and to ensure compliance with legislation that this policy is implemented within the Trust:

Communication and Dissemination Plan

This policy will be placed on the Infection Prevention section of the Intranet Policy pages, and on the extranet and public websites in order that the information contained within it is available to primary and community care providers, patients and the public.

This revised policy will be launched with communication via the Intranet news pages and as an email alert. The Infection Prevention Team will also issue a briefing paper, highlighting the main changes in the revised policy, and this will be circulated to all Care Groups.

Education and Support Plan

Education sessions will be provided by the Infection Prevention Team as part of Mandatory Training, and these will be available for all Trust staff as outlined in the Trust Training Needs Analysis. Infection Prevention Link Staff will be provided with education sessions about the policy at their meetings.

9 Process for Monitoring Compliance/Effectiveness What aspects of compliance with the document will be monitored?

What will be reviewed to evidence this?

How and how often will this be done?

Who will co-ordinate and report findings?

Which group or report will receive findings?

Environmental sharps aspects of compliance

Audit carried out

Audit carried out annually as per infection prevention annual audit programme.

Clinical area Infection Prevention Committee

Sharps safety aspects of compliance

Audit carried out

Audit carried out annually

Daniels Healthcare to complete audit

Infection Prevention Committee, Divisional Governance Committees

Sharps safety Infection Prevention Spotlights carried out on wards

Carried out at least once a year on all wards across the Trust

Infection Prevention Team

Care group/Ward

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10 Arrangements for Review of the Policy The Infection Prevention Team will review this document every 3 years or earlier if changes in guidance or practice occur. 11 References and Additional Reading Reference A: Health and Safety at Work etc Act 1974. Reference B: Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. Reference C: Control of Substances Hazardous to Health (COSHH) Regulations 2002. Loveday, H., et al (2014) EPIC 3: National evidence-based guidelines for preventing healthcare associated infections in NHS hospitals in England. Journal of Hospital Infection 86 supp 1. Scottish Executive (2001) Needlestick injuries: Sharpen your awareness: Report on the short life working group on needlestick injuries in the NHS Scotland. Scottish Executive.

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Appendix A – Flow Chart – If a sharps injury does occur If a sharps injury does occur, the following action must be taken IMMEDIATELY

Bleed It:

Encourage bleeding – but do not massage the site (DO NOT squeeze to make it bleed)

Wash it: Wash injury with soap and hot running

water

Cover it: Apply a waterproof dressing

Report it:

Inform your manager and Contact the Needlestick Hotline 6353

(out of hours leave a message)

And attend the Occupational Health Department UHS

Service 08.00 – 16.00 Mon – Fri

or

Out-of-hours Needlestick Hotline 6353 And then the Emergency Department,

SGH, 023 8120 4994

More detailed guidance can be found in the following policy: Management of Sharps and Contamination Incidents.

Complete an electronic Incident form

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Appendix B – Safe Practice Guide

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Sharps Safety Policy Version: 5

Document Monitoring Information

Approval Committee: Infection Prevention Committee

Date of Approval: 31 March 2017

Ratification Committee: Policy Ratification Group (PRG)

Date of Ratification: 24 May 2017

Signature of ratifying Committee Group/Chair:

Chair of PRG

Lead Name and Job Title of originator/author or responsible committee/individual:

Infection Prevention Committee/ Infection Prevention Team

Target audience: All Trust Staff

Key words: Infection control, Sharp, needle, needlestick, Injury

Main areas affected: All UHS Wards/Clinical areas

Summary of most recent changes if applicable:

Page 3 – Scope Policy includes: Safe management of sharps point 1 extended Page 5 – Principles to follow – Safety Devices section updated. Page 5 – Safe Handling intro statement updated Page 7 – Staff using Sharps in the Community Section added. Page 7 - Patients discharged on medication requiring needles and syringes section added.

Consultation: Infection Prevention Committee

Equality Impact Assessment completion date:

1 March 2017

Number of pages: 12

Type of document: Level 1

Does this document replace or revise an existing document

No

Should this document be made available on the public website?

No

Is this document to be published in any other format?

No

The Trust strives to ensure equality of opportunity for all, both as a major employer and as a provider of health care. This document has therefore been equality impact assessed to ensure fairness and consistency for all those covered by it, regardless of their individual differences, and the results are available on request.