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OHD001 – SOP for Needle Stick Injuries and Other Exposure Incidents of 28

HSE WEST LIMERICK, CLARE & NORTH TIPPERARY

STANDARD OPERATING PROCEDURE FOR NEEDLE STICK INJURIES AND OTHER

EXPOSURE INCIDENTS Document reference number

OHD 001 Document drafted by

Dr. Collette MacDonagh-White Occupational Health Physician

Revision number

01 Document approved by

Dr. Anthony Dempsey, Consultant as Clinical Director MWRH Hospitals Dr Patrick O’Sullivan A/Director of Public Health

Approval date

March 2011 Responsibility for implementation

Occupational Health Department

Revision date March 2013 Responsibility for evaluation and audit

Occupational Health Department

Pages 28


Table of Contents:

1.0 Policy Statement 3 2.0 Purpose 3 3.0 Scope 3 4.0 Glossary of Terms and Definitions 4 5.0 Roles and Responsibilities 4 5.1 Healthcare Workers 4 5.2 Injured Healthcare Worker 4 5.3 Supervisor / Head of Department 5 5.4 Clinical Staff where Source Patient is located – Supervisor/ Department Head 5 5.5 Duty SHO / Registrar 5 5.6 Doctor Responsible for Source Patient 5 5.7 Management in Emergency Department 6 5.8 Roles/Responsibilities of the Laboratory 6 5.9 Action by Surgeons 6 5.10 Responsibilities of the Occupational Health Department 6

6.0 Procedure 7 7.0 Implementation Plan 7 8.0 Evaluation and Audit 8 9.0 References 8 10.0 Appendices 8 Appendix 1 - Prevention – Universal Hygiene Precautions for Persons whose work brings them into contact with Human Blood or Body Fluids 9 Appendix 2 – Needle Stick Injury and Other Exposure Incident Form 10 Appendix 3 – Resource Pack for Emergency Department 17 Appendix 4 – Resource Pack Information 27

Signature Sheet 28


1.0 Policy Statement The HSE is committed to managing risks to safety, health and welfare at work. The HSE West – Limerick, Clare & North Tipperary aims to ensure that all staff members are protected, so far as is reasonably possible, from the risks arising from contact with needles, sharps and body fluids by ensuring controls are in place to minimise the risks involved. This policy sets out the procedures to be followed if an injury occurs. 2.0 Purpose 2.1 The purpose of this policy is to set out the protocols and procedures to be followed

by healthcare workers in HSE West, Limerick, Clare & North Tipperary, to protect them from the transmission of bloodborne pathogens and outline the steps to be taken when workers are exposed to the risk of infection through a Needle Stick or other Exposure Incident.

2.2 Needle Stick Injuries cause considerable concern and uncertainty for the injured

healthcare worker. Because of the documented risks of bloodborne diseases caused by Hepatitis B, Hepatitis C, and HIV, it is necessary for all HSE West, Limerick, Clare & North Tipperary, staff to take precautions to protect themselves and others from blood contact and in particular to prevent Needle Stick Injuries and other similar injuries.

2.3 In the event of a Needle Stick Injury or other similar injury occurring, it is important for all staff to know:

2.3.1 What action to take 2.3.2 Who has responsibility for assessment 2.3.3 Where to go for treatment of the injury and follow-up. 2.3.4 How to report the incident so that systems can be reviewed and future injuries

reduced or avoided. 3.0 Scope 3.1 This policy applies to all employees working in HSE West, Limerick, Clare & North

Tipperary. 3.2 This includes: 3.2.1 All employees 3.2.2 Supervisors / Heads of Departments. 3.2.3 Clinical Staff dealing with source patients. 3.2.4 Clinical staff dealing with recipients of injuries in the Emergency Department 3.2.5 Clinical staff dealing with recipients of injuries in the Occupational Health

Department. 3.2.6 Service Management of HSE West, Limerick, Clare & North Tipperary.


Needle stick injuries and other exposure incidents occurring among other groups i.e. Gardai, public, should be referred to the appropriate resource, e.g. Emergency Departments, G.P., Gardai, Medical Services .etc It is the responsibility of these departments/practices to ensure that they have proper protocols in place to deal effectively with such injuries.

3.3 Senior managers and line managers have the ultimate responsibility to ensure that every employee is aware of the contents of this policy – a requirement of the Safety, Health and Welfare Act 2005.

3.4 A copy of this policy will be placed on the Intranet HSE West, Limerick, Clare & North Tipperary, for general viewing and down loading.

4.0 Glossary of Terms and Definitions 4.1 ED Emergency Department 4.2 BBV Bloodborne Viruses 4.3 HBV Hepatitis B Virus 4.4 HCV Hepatitis C Virus 4.5 HCW Healthcare Worker 4.6 HIV Human Immunodeficiency Virus 4.7 NCHD Non-Consultant Hospital Doctor 4.8 PEP Post-Exposure Prophylaxis 4.9 SHO Senior House Officer

4.10 Sharps Injury: Caused by needle, scalpel blade, bone or tooth fragments and

other sharp objects contaminated with body fluids. 4.11 Splashes: Splashes of blood, body fluids into the eye or mouth, open cuts or

lesions on the skin. 4.12 Bites/Scratches: Human bites or scratches 5.0 Roles and Responsibilities 5.1 Healthcare Workers must: 5.1.1 Know how to prevent Needle Stick Injuries / other exposure injuries

(Appendix 1). 5.1.2 Know what action must be taken (Appendix 2 – Needle Stick Injury and Other

Exposure Incident form, page 2) post Needle Stick injury or other exposure incidents.

5.1.3 Read and understand the contents of this policy 5.1.4 If vaccinated against Hepatitis B, keep their record of it in an accessible place at

work. 5.2 Injured Healthcare Worker 5.2.1 Should you receive a Needle Stick Injury / other exposure injury apply prompt

first- aid (Appendix 2 – Needle Stick Injury and Other Exposure Incident form, page 2).


5.2.3 Report the injury to your Supervisor / Head of Department. 5.2.4 Make sure the incident is reported by your manager on the Incident Report form

(Starsweb). 5.2.5 Attend the Emergency Department immediately. 5.2.6 Attend the Occupational Health Department for confidential follow-up. Please

ring for an appointment - 061-482179. 5.3 Supervisor / Head of Department 5.3.1 Ensure first-aid is given. 5.3.2 Arrange for the staff member to attend the Emergency Department 5.3.3 Report Incident on the Incident Report Form. 5.3.4 Complete N.S.I. / Other Exposure Injury Management Form – (Appendix 2 –

Needle Stick Injury and Other Exposure Incident form, page 3) 5.3.5 Investigate the cause and take action to prevent a recurrence. 5.3.6 Ensure that all steps are taken and follow-up is completed. 5.4 Clinical Staff where Source Patient is located – Supervisor/ Departmental

Head 5.4.1 Locate source patient if possible – use resource pack for doctor responsible for

source patient (.Appendix 2 – Needle Stick Injury and Other Exposure Incident form, pages 5 – 9).

5.4.2 Arrange for duty SHO / Registrar to carry out a risk assessment and to seek source patient’s consent to have blood tested for HBV, HCV and HIV (Appendix 2 – Needle Stick Injury and Other Exposure Incident form, pages 7 and 9).

5.4.3 Arrange for immediate transport of the sample to the laboratory. If the sample is being sent outside core working hours notify the laboratory beforehand to arrange testing.

5.4.4 Ensure completion of N.S.I. / Other Exposure Injury Form and give it to the injured staff member to take to the Emergency Department (Appendix 2 – Needle Stick Injury and Other Exposure Incident form, page 7).

5.5 Duty SHO / Registrar 5.5.1 Consult guidelines on approaching source patient and establishing risk status

(Appendix 2 – Needle Stick Injury and Other Exposure Incident form, pages 5 and 6).

5.5.2 Risk assess source patient (Appendix 2 – Needle Stick Injury and Other Exposure Incident form, page 7).

5.5.3 Seek consent from the source patient (Appendix 2 – Needle Stick Injury and Other Exposure Incident form, page 9). Keep consent form on patient file. Do not send it to the Laboratory.

5.5.4 Take blood if patient consents and send to the Serology Department of the laboratory immediately, indicating that it is a source patient from a needle stick injury. – report to be directed to the Emergency Department.

5.5.5 Advise the patient’s consultant that the incident has occurred 5.6 Doctor Responsible for Source Patient. 5.6.1 Develop local arrangements allowing source patients to be approached for

consent to have blood tested – following procedures as outlined in the policy.


5.6.2 Inform the patient of the results. 5.6.3 Arrange for specialist counselling when a positive result is obtained. 5.6.4 Ensure the SHO / Registrar is aware of arrangements for preventing and dealing

with Needle Stick Injuries. 5.7 Management in Emergency Department 5.7.1 Triage in the Emergency Department – assess degree of urgency – use resource

pack for ED (Appendix 3 - Resource Pack for Emergency Department). 5.7.2 Take incident details 5.7.3 Confirm if injury is high risk (Appendix 2 – Needle Stick Injury and Other

Exposure Incident form, Page 7). 5.7.4 Assess significance of injury and treat accordingly (Appendix 3 - Resource Pack

for Emergency Department, Page 1). 5.7.5 Consider treatment with Hepatitis B vaccine and Hepatitis B immunoglobulin

(Appendix 3 - Resource Pack for Emergency Department, page 3). If high risk of HIV, consider treatment with PEP (Appendix 3 - Resource Pack for Emergency Department – pages 5 to 11). Ensure Declaration Form for post exposure prophylaxis is signed (Appendix 3 - Resource Pack for Emergency Department, page 13).

5.7.7 Arrange for longer term follow-up by the Occupational Health Department. Advise Healthcare Worker to contact the Occupational Health Department on 061-482179.

5.7.8 Ensure all documentation relating to the Needle Stick Injury is faxed immediately to the Occupational Health Department (Fax Number 061-482597).

5.8 Roles / Responsibilities of the Laboratory 5.8.1 Positive results from the Source Patient are phoned to the Consultant

Microbiologist. 5.8.2 The Consultant Microbiologist will contact the duty SHO / Registrar and the

Occupational Health Department. 5.8.3 Specimens from NSI and Other Exposure Incidents will be stored in the

Laboratory for two (2) years after the date of receipt. 5.9 Action by Surgeons 5.9.1 If a significant injury associated with a high risk patient occurs during surgery the

staff member should stand down from the operation as soon as possible and seek advice immediately from the Emergency Department and the Occupational Health Department.

5.9.2 When operating on a known HIV positive patient the surgeon and theatre staff should ensure that the appropriate drugs for prophylaxis are available prior to commencement of surgery. The drugs are available in the Emergency Department. The surgeon should contact the Emergency Department / Occupational Health Department to discuss the appropriate post exposure prophylaxis upon pre-operative assessment / at the earliest opportunity.

5.10 Responsibilities of the Occupational Health Department. 5.10.1 Follow-up on all documentation received by the department relating to both the

source patient and the injured staff member.


5.10.2 Arrange follow-up with the Occupational Health Nurse / Occupational Health Physician.

5.10.3 A referral for counselling will be offered if appropriate. 5.10.4 Appropriate follow-up treatment will be carried out by the Occupational Health

Nurse. 5.10.5 Complete the file and sign off. Note: Potentially Infected Fluid / Tissues

Semen, vaginal secretions, C.S.F., synovial, peritoneal, pericardial and amniotic fluids, human breast milk and saliva in association with dentistry

6.0 Procedure 6.1 Procedures are outlined in the Appendices 1, 2, 3. 6.1.1 Management of Needle Stick Injuries and Other Exposure Incidents 6.1.2 Reporting and Follow-up 6.1.3 Patient Risk Assessment Form 6.1.4 Dealing with the Source Patient 6.1.5 Consent Form for Source Patient 6.1.6 Management of Exposure by the Emergency Department 6.2 Training will be given to all healthcare workers regarding this policy by the

Occupational Health team. 6.3 Training will be the joint responsibilities of the Occupational Health Department and

the Infection Control team, if given adequate resources. 6.4 Training will be given to all Emergency Department Doctors in July and January

each year. 6.5 All staff will be requested to read the policy and sign that they have received and

understood its contents. This should form part of a robust Health & Safety Strategy for the HSE West, Limerick, Clare & North Tipperary,. Every ward and department manager will be responsible for ensuring that this is carried out in their relevant work area.

6.6 A copy of this policy will be placed on the Intranet HSE West, Limerick, Clare &

North Tipperary, for general viewing and down loading. 6.7 To ensure effective dissemination of the policy, it will be posted on the Intranet HSE

West, Limerick, Clare & North Tipperary, to be printed for each ward and department.

6.8 Significant time will be utilised by both the Occupational Health Department team,

the Infection Control team in educating managers and staff on the revised policy. Sufficient resources in terms of time and personnel will be required for this task.


7.0 Implementation Plan 7.1 The policy will be reviewed 2 years after it has been disseminated and

implemented. 8.0 Evaluation and Audit 8.1 Given adequate resources this policy will be audited 6 months after its

implementation in line with good health & safety practice. 9.0 References 9.1 Serious Communicable Diseases & Injuries to Health Care Workers – General

Medical Council (UK) 1997 9.2 UK Health Department. HIV post exposure prophylaxis: Guidance from the UK Chief

Medical Officers’ Expert Advisory Group on AIDS. Revised September 2008 9.3 Department of Health UK. Update to HIV post-exposure prophylaxis (PEP)

Guidance from the expert advisory group on AIDS (EAGA) following the recent recall of Viracept (Gateway reference 8562) (2008)

10.0 Appendices Appendix 1 – Prevention – Universal Hygiene Precautions for Persons whose work brings them into contact with Human Blood or Body Fluids Appendix 2 – Needle Stick Injury and Other Exposure Incident Form Appendix 3 – Resource Pack for Emergency Department Appendix 4 – Resource Pack Information


APPENDIX 1

Prevention

UNIVERSAL HYGIENE PRECAUTIONS FOR PERSONS WHOSE WORK BRINGS THEM INTO CONTACT WITH HUMAN BLOOD OR BODY FLUIDS

The following procedures should be followed: The worker should cover any abrasions/eczema/raw area or cut on their skin with a waterproof

dressing. Latex disposable gloves should always be worn whenever there is known or anticipated

contact with blood, saliva or other body fluids. Hand washing after contact with a persons blood or body secretions is always recommended. Care should be exercised when opening ampoules and when preparing chemicals so as to

avoid minor cuts. Never re-sheath needles. All needles, syringes and sharps must be disposed of into appropriate containers i.e. sharps

containers and never into refuse sacks. Sharps disposal bins must not be overfilled above the level indicated. They must be carefully

sealed prior to disposal so that those handling them will not be injured. Clothing contaminated with blood should be placed in a water-soluble bag, sealed and then

placed in a red bag for transport to the laundry. A hot cycle of a domestic washing machine is sufficient to de-contaminate any blood-soiled clothing.

“Presept” disinfectant should be used to clean any blood-contaminated surfaces. Blood spattered surfaces: Presept disinfectant tablets – 1 tablet in 1 litre water = 1% solution. Use disposable disinfectant saturated cloth. Spillage:

Don disposable gloves and apron. Sprinkle Presept granules liberally to cover the spillage. Leave for at least two minutes. Remove with a disposable paper towel and place in yellow plastic bag. Wipe surface thoroughly with a damp cloth and place in yellow plastic bag. Arrange appropriate waste disposal.

Smoking and eating should be prohibited in areas where work is carried out on cadavers.


APPENDIX 2 Needle Stick Injury and Other Exposure Incident Form

HSE WEST

Limerick, Clare & North Tipperary

OCCUPATIONAL HEALTH DEPARTMENT

Supervisor/Head of Department, HSE West, Limerick, Clare and North Tipperary

October 2010 Dear Supervisor/Head of Department, The new “Standard Operating Procedure for Needle Stick Injuries and Other Exposures” was signed off on 11/06/2008 (reviewed September 2010). This pack includes a Needle Stick Injury and Other Exposure Management Form - Part I and Part II. Part I of this form should be completed by the Supervisor/Head of Department

together with the injured worker. Part II of this form should be completed by the source patient’s doctor. The

Supervisor/Head of Department should ensure that this is given to the doctor who will be carrying out the risk assessment and taking the required bloods from the source patient.

When Part I and Part II are completed, the forms should be given to the injured

employee to take to the Emergency Department where an assessment will be carried out.

It is important that this process is carried out as quickly as possible i.e. preferably within 2 hours of the injury – where post-exposure prophylaxis has been demonstrated to be most effective. I would appreciate if you could photocopy these forms (Part I and Part II) so that you always have copies on your ward or department. Yours sincerely, Collette MacDonagh-White ___________________ Dr. C. MacDonagh White, M.C.R.N. 06279 Consultant Occupational Physician MB.; MSC.; F.F.OM.; M.A.C.O.E.M.; c.M.I.O.S.H.


HSE WEST

Limerick, Clare & North Tipperary Occupational Health Department

Management of Occupational Blood Exposures to Staff

Action to be taken by Staff Following

PLEASE NOTE Emergency Department closed in Ennis / Nenagh from 8pm to 8am. Injured employee to attend ED in Limerick during these hours unless alternative arrangements are in place.

Wash and make wound bleed under running water Splashes to the eyes / mouth should be washed with copious amounts of water.

Inform immediately: Head of Department, ward manager or supervisor as appropriate, who should advise on policy. Ensure that the Incident Report form and Needle Stick Injury and Other Exposure Management Form is complete

Occupational Blood Exposures: Sharps injury Body fluid splash Human bite / scratch

Seek IMMEDIATE medical advice at: Emergency Department - Mid-Western Regional Hospital, Limerick Emergency Department - Mid-Western Regional Hospital, Ennis Emergency Department - Mid-Western Regional Hospital, Nenagh

After attending the Emergency Department contact the Occupational Health Department for follow-up

of your injury. Tel No: 061-482179


NEEDLE STICK INJURY AND OTHER OCCUPATIONAL BLOOD EXPOSURE MANAGEMENT FORM PART 1

TO BE COMPLETED BY SUPERVISOR / HEAD OF DEPARTMENT MUST BE COMPLETED IMMEDIATELY AFTER THE INCIDENT

This Form should be completed in BLOCK CAPITALS USING A BLACK BALLPOINT PEN

This form will be brought by the recipient (staff member) of the injury to the Emergency Department where a decision will be made regarding further management

SECTION ONE PERSONAL DETAILS OF STAFF MEMBER / RECIPIENT OF INJURY

Surname:__________________________________ First Name: ________________________________________________________ Date of Birth: _____________________ Address: _______________________________________________________________________________________________________________________________________ Phone No.: WORK: ____________________________ MOBILE: ____________________________________________________ HOME: _______________________________ Job Title/Grade/Position: _________________________Work Address: ____________________________________________________________________________________ Male: Female Hospital No:____________________________________ Staff Personnel No: _________________________________________________

SECTION TWO REPORT DETAILS

Incident Date ______________________________ Time: ________________________ PREVIOUS INCIDENT: YES NO Date Incident Reported to Supervisor: ______________ Time: _____________ Name of Supervisor /: Departmental Head __________________________________________

SECTION THREE TYPE OF INCIDIENT

PLEASE X TICK APPROPRIATE BOX Stab with sharp or pointed instrument Needlestick with BMstix Body fluid splash onto skin where integrity is compromised Needlestick while re-sheathing Needlestick involving sharps box Body fluid splash to mouth Needle from I/V procedure Needlestick from rubbish bag Scratched by patient Needlestick with butterfly Body fluid splash into eye Human bite Blood gas syringe Specify Other

SECTION FOUR STAFF MEMBER / RECIPIENT OF INJURY JOB TITLE / POSITION

PLEASE X TICK APPROPRIATE BOX Administrative Staff CSSD worker Health Care Assistant Nursing Student Nurse Agency Dental Surgery Assistant House Keeping Pharmacy Staff Sub Contractor Allied Health Prof. Dentist Maintenance Phlebotomist Therapist Ambulance Personnel Doctor Medical Medical Student Porter/Ward Attendant Volunteer Catering Staff Doctor Surgical Midwifery Radiologist/Radiographer Com. Welfare Officer Environmental Health Officer Mortuary Attendant Security Specify Other

SECTION FIVE STAFF MEMBER / RECIPIENT OF INJURY HEPATITIS B IMMUNISATION STATUS

PLEASE X TICK APPROPRIATE BOX Unvaccinated 1 vaccination only 2 vaccinations only Full course: Hepatitis B antibody unknown Full course: Hepatitis B antibody known Anti Hepatitis BsAg mIU/ml

SECTION SIX SOURCE DETAILS

Source Patient Unknown: Source Patient Known: SOURCE PATIENT NAME: ______________________ CHART NUMBER: __________

PART 2: To be completed if Source Patient known

Signature: Job Title/Grade/Position: …………………………………. Date:

Please Fax PART 1 & PART 2 (if applicable) of this form to the Occupational Health Department on completion of treatment in the Emergency Department


Information for Doctor / Appropriately trained Competent Healthcare Worker

DEALING WITH THE SOURCE PATIENT

BEFORE OBTAINING A BLOOD SAMPLE FOR TESTING * Source of inoculation injury i.e. Hospital patient / Patient in community services 1. Explain fully and in simple language to the source patient exactly what has

happened. 2. Request permission from the consultant / G.P. responsible for the care of the

source patient for a blood sample to be taken for testing for Hepatitis B, Hepatitis C and HIV if the status of the patient is not known.

3. Explain to the source patient why the blood sample is required for testing indicating

that it is needed to allay the fears and apprehensions of the member of staff following the exposure incident. One must indicate to the source patient what tests will be carried out on the blood and the implications for him/her if the test should prove positive. The fact that these infections may be passed to others and how that may happen must also be fully explained. The consequences of a positive result must also be indicated as must the fact that he/she is free to decide that they do not wish the test to be undertaken.

4. The confidential nature of the test must also be emphasised indicating that the

result will be sent to the consultant in charge of their case, the Occupational Health Department or to a named family GP if they so indicate. They should be informed that the injured party will also be made aware of the test result and that professional confidentiality will be maintained.

5. The fact that the patient has given informed written and witnessed consent after

being counselled by a fully registered medical practitioner or appropriately trained/ competent healthcare worker should be recorded in his/her hospital notes and signed by the Doctor/or appropriately trained/competent healthcare worker who has undertaken the counselling. Similarly, if consent is not given, this should also be recorded and signed by the Doctor/or appropriately trained/competent healthcare worker who has undertaken the counselling. The signed and witnessed Consent Form should be retained in the patient’s hospital records.


6. If the patient is unconscious when the injury occurs, consent should be sought once the patient has regained full consciousness. If the incident is considered high risk the injured person can take prophylactic treatment until consent has been obtained and the blood result known.

7. If the patient refuses testing, is unable to give / withholds consent because of

mental illness or disability, or does not regain consciousness within 48 hours, you should reconsider the severity of the risk to yourself, or another injured healthcare worker or to others. You should not arrange testing against patient’s wishes, or without consent other than in exceptional circumstances, for example, where you have good reason to think that the patient may have a condition such as HIV, for which prophylactic treatment is available.

In such cases, you may test an existing sample, taken for other purposes but you

should consult an experienced colleague first. It is possible that the decision to test an existing blood sample without consent could be challenged in the courts, or be the subject of a complaint to your employer or the Medical Council. You must be prepared to justify your decision.

8. If you decide to test without consent, you must inform the patient of the decision at

the earliest convenience. In this exceptional circumstance neither the fact that the test has been taken, nor the result should be entered in the patient’s personal medical record without the patient’s consent.

9. If the patient is deceased, you may test for a serious communicable disease if you

have good reason to think that the patient may have been infected and a healthcare worker has been exposed to the patient’s blood or other body fluid. In the event of a sharps injury involving an inoculation from a contaminated instrument/bone or tooth fragment/needle, it is important that a donor sample be taken from the deceased person for testing. Consent for this should be sought from the next of kin, or if this is not possible, from the coroner. Failing this the clinician in charge (for example hospital clinician or GP) can give consent. Verbal consent is deemed to be sufficient.

10.1 Positive results from the Source Patient are phoned to the Consultant

Microbiologist. 10.2 The Consultant Microbiologist will contact the duty SHO / Registrar and the

Occupational Health Department. 10.3 It is the responsibility of the Consultant or his/her team to inform the Source

Patient of the result.


NEEDLE STICK INJURY AND OTHER OCCUPATIONAL BLOOD EXPOSURE MANAGEMENT FORM PART 2

TO BE COMPLETED BY SOURCE PATIENT’S DOCTOR MUST BE COMPLETED IMMEDIATELY AFTER THE INCIDENT

This Form should be completed in BLOCK CAPITALS USING A BLACK BALLPOINT PEN

This form will be brought by the recipient (staff member) of the injury to the Emergency Department where a decision will be made regarding further management.

SECTION ONE SOURCE DETAILS

SOURCE PATIENT NAME

CHART NUMBER

REASON FOR ADMISSION

SECTION TWO RISK ASSESSMENT FOR BLOODBORNE DISEASES

TO BE COMPLETED BY A REGISTERED MEDICAL PRACTITIONER OR APPROPRIATELY TRAINED AND COMPETENT HEALTHCARE WORKER CARING FOR THE SOURCE PATIENT

PLEASE X TICK APPROPRIATE BOX

YES NO NOT KNOWN Is this person known to be a carrier of Hepatitis B, Hepatitis C or HIV?

Use of IV drugs and shared needles?

History of blood transfusions before 1985 in any country?

Ever had HIV, Hepatitis B, Hepatitis C antibody test?

If Yes, what was the result? POSITIVE NEGATIVE UNKNOWN

Men having sex with men?

Partner with known HIV infection?

Taken any anti-retroviral medication at any time?

Sexual contact with a partner who has lived in an area of high endemicity for HIV infection e.g.

Africa, Caribbean, Eastern Europe, Far East?

If the answer is “YES” to any of the above questions, please give details:

SECTION THREE ACTION TAKEN

Blood taken Yes No Tested for: Hep B Hep C HIV

SECTION FOUR REASONS FOR NOT TESTING SOURCE PATIENT

PLEASE X TICK APPROPRIATE BOX

Clinical team refused to do testing Source patient had died

Source patient had gone home Source patient refused consent

Staff member didn’t want patient tested Other

Further Details

Signature Job Title/Grade/Position: Date: Please Fax PART 1 & PART 2 (if applicable) of this form to the Occupational Health Department on completion of treatment in the Emergency Department OHD Fax Number 061-482597

NB If sample is being sent outside core working hours please notify the M.W.R.H. Laboratory before hand to arrange testing


CONSENT FORM FOR SOURCE BLOODS

Name: ___________________________________________________

Address: ___________________________________________________

___________________________________________________ ___________________________________________________ I have been fully informed of the tests to be carried out on my blood sample and I am agreeable to these tests being carried out. I understand the confidential nature of the tests and that the result will be sent only to Dr/Mr/Ms _______________________________, the Consultant in charge of my case. I am also agreeable to the person who sustained the injury being informed of the result of the test and he/she will maintain professional confidentiality. I am/am not also agreeable to the result being sent to my family Doctor and the Occupational Health Department. Signature of Patient: ____________________________________________ Witnessed by Doctor: ____________________________________________ Date: ____________________________________________ Name of Family Doctor: ____________________________________________ Address: ____________________________________________ ____________________________________________ ____________________________________________

Please file Consent Form in patient’s file NB Do NOT sent a copy of Consent Form to the Laboratory or Occupational Health Department


APPENDIX 3

RESOURCE PACK FOR EMERGENCY DEPARTMENT

MANAGEMENT OF EXPOSURE INCIDENTS IN THE EMERGENCY DEPARTMENT FORM

TO BE COMPETED BY EMERGENCY DEPARTMENT This Form should be completed in BLOCK CAPITALS USING A BLACK BALLPOINT PEN

MANAGEMENT OF EXPOSURE INCIDENTS FORM

Date: Time:

Name / DOB – ED Label Please make wide enough for labels (14 per page)

Attending Doctor:

Clinical details – History and Examination

IS THE EXPOSURE SIGNIFICANT If YES to any of the following, the exposure is significant. Circle the answer. Body fluid splash into eye or mouth YES NO Bites with breach of skin YES NO Body fluid splash onto non-intact skin YES NO (e.g. wound <24 hours old, eczema etc) Needlestick/sharps injury that drew blood where YES NO there was body fluid on the sharp

EXPOSURE SIGNIFICANT

Circle the answer. YES NO

INSIGNIFICANT EXPOSURE : No action or follow up required

SIGNIFICANT EXPOSURE : Complete NEXT PAGES - STEP 1 to STEP 5 Signed: ______________________________________ Date: _______________________

Note: Urine, vomit, saliva or faeces are low risk body fluids. Unless blood stained, they do not constitute significant exposure.


Management of Significant Exposure Incidents

Step 1: Blood Testing

Take a serum sample from the recipient of the injury (Brown top bottle – fill to 5 ml mark)

Fill out serology form attached to this pack Inform Healthcare Worker that you are checking their Hepatitis B titre.

(If they are previously vaccinated and titre is not known) If Hep B titre known no other testing required on Healthcare Worker but a sample should be sent to

Laboratory marked “Store blood for two years”.

Step 2: Is the source of the needlestick/exposure known?

Source known Emergency Department doctor to request HIV Risk Assessment on Source Patient from appropriate Ward or

Department if not brought by Healthcare Worker. Emergency Department doctor to determine if Source Patient bloods have been taken (Source Patient is tested

for HIV, Hepatitis B and Hepatitis C) If HIV Risk Assessment does not identify any risks PEP is not indicated.

Source unknown A decision may be made based on the likelihood of a HIV Source Patient being in the area i.e. perform risk

assessment of known patients in the area. In the vast majority of such exposures, it would be difficult to justify the use of PEP.

Step 3: Is anti-retroviral post exposure prophylaxis required?

If the answer to any of the following is YES consider starting PEP. Source Patient History Known to be a carrier of HIV IV drug user Men having sex with men Ever on any anti-retroviral medication Sexual contact with a person from an area of high prevalence for HIV infection AND High Risk Needlestick Injury Deep Injury Device visibly contaminated with blood Needle directly in blood vessel Terminal HIV disease in Source Patient High viral load in Source Patient

Post exposure HIV prophylaxis required Yes No Signed: ____________________________

NB If PEP is indicated the following baseline tests are required: FBC Renal function (U&E) Liver function test (LFTs) Serum amalyse Triglycerides Urinalysis

If PEP is required: 1 ED prescribing doctor should read Appendix 1 2. The employee / recipient should read Appendix 2 and sign the Consent Form in Appendix 3


Step 4: Is Hepatitis B immunisation required? Is Hepatitis B titre known to the Healthcare Worker / available on APEX system?

If not, make sure that you have requested Hepatitis B titre on the serum sample you sent to the Laboratory in Step 1 above

If results not available before injured Healthcare Worker leave the ED, treat using the information grid below.

If HBIG (Hepatect) is required admit Healthcare Worker to SSU (ED, Mid-Western Regional Hospital, Limerick) or relevant Emergency Department.

If Hepatitis B vaccine is initiated arrange for follow-up by the Occupational Health Department for HSE employees.

If the injured party is not employed by the HSE please refer to their General Practitioner

Step 5: What follow-up is required? Insignificant exposures do not require follow-up. Reassure health care worker and discharge. HSE staff members should be referred to the Occupational Health Department after initial treatment in

the ED (Fax this form and ED notes to 061-482597). Non-HSE employees should be referred to the Infectious Diseases Clinic ( Dr B Mooka - Tel 061-

482382) if they have been treated with Hepatect or PEP, after initial treatment in the ED (phone clinic for urgent appointment)

Non-HSE employees to be given small card with all contact details Non-HSE employees that require ONLY Hepatitis B vaccination can be referred to their General

Practitioner.

Source

Recipient

HbsAg Positive

HbsAg

Negative

Hep B Status

unknown

Unvaccinated A

B

C

Previously vaccinated

Antibody level <10 IU/ml or unknown

A

E

C

Antibody level 10-100 IU/ml

E

E

E

Antibody level >100 IU/ml

F

F

F

A. Give HBIG. Initiate Hep B

vaccination B. Initiate Hep B vaccination C. Initiate Hep B vaccination; Give

HBIG if high risk exposure D. No treatment; Needs

revaccination in near future E. Hepatitis B booster F. No treatment

HBIG is Hepatitis B immune globulin (Hepatect) Hepatitis B booster – Engerix B, HBVAXPRO

Healthcare workers requiring vaccination in the near future should be referred to Occupational Health if HSE West, Limerick, Clare & North Tipperary, employee; other patients should be advised to have follow-up with their

GP


HIV Post-Exposure Prophylaxis Information for Prescribing Doctors Post-Exposure Prophylaxis Pack The additional information provided below is for the doctor: 1. Five (5) day starter packs will be available in the Emergency Department – with backup supplies available from

Pharmacy Departments. 2. Both pregnant and non-pregnant healthcare workers should receive the same PEP (as advised by the Consultant

in Infectious Diseases). 2. The doctor should know whether any of the following apply before prescribing this course of treatment.

Has the patient had?

Liver disease Kidney disease Blood disorders, e.g. anaemia Allergic reaction to any other medication Hyperlipidemia Diabetes mellitus Haemophilia

Is the patient taking any other medication?

The doctor should be aware of all medication being taken by the patient including medication they have bought themselves, vitamin supplements, herbal remedies or homeopathic medicines. There is very little information about interactions between vitamins / herbal and homeopathic medicines so it is better to advise that where possible these are discontinued until you can check with the Irish Medicines Board.

The doctor should check these against a list of interacting medicines.

Please contact the MWRH Pharmacy (Limerick 2337) with any enquires regarding drug interactions.

3. Drug Interactions Truvada = Emtricitabine 200 mgs plus Tenofovir 245 mgs Tenofovir Interactions Zalcitabine, ganciclovir, foscarnet, trimethoprim, sulphamethoxczole Emtricitabine Interactions Zalcitabine

Kaletra Interactions Lovastatin, simvastatin, cyclosporine, sirolimus Rapamycin, tacrolimus, dexamethasone, fluticasone propionate, ethinyl oestradiol, other protease inhibitors, felodipine, nifedipine, nicardipine, bepridil, systemic lidocaine, quinidine, ketoconazole, itrconazole, methadone, carbamazepine, phenytoin, Phenobarbital, warfarin, rifabutin, clarithromycin, trazodone, midazolam administered by injection, sildenafil, tadalafil, digoxin, emcitrabine. Kaletra may reduce the effectiveness of oral and patch contraceptives.


KALETRA INTERACTIONS

Drugs that could potentially interact with Kaletra

Alternatives (have no significant interactions)

Analgesics

Opioids e.g. methadone Dose adjust methadone

Antiarrthymics

Lignocaine, bepridil, quinvidine

Antibiotics

Rifabutin, clarithromycin

Anticoagulants

Warfarin

Anticonvulsants Carbamazepine, phenytoin, phenobarbitone

Antifungals

Ketoconazole, itraconazole

Antidepressants Trazodone Fluoxetine, paroxetine, amitriptyline

Antihistamines

Loratadine Cetirizine

Antineoplastics Cyclophosphamide, paclitaxel, vinblastine, vincristine

Anti-psychotics

Chlorpromazine, pimozide

Anxiolytics/hypnotics Aprazolam, diazepam, flurazepam, zolpidem, midazolan

Temazepam

Calcium channel blockers

Amlodipine, nifedipine, verapamil, felodipine

Erectile dysfunction agent

Sildenafil (Viagra), tadalafil

Immunosuppressants

Cyclosporin, tacrolimus, sirolimus

Lipid-lowering drugs

Lovastatin, simvastatin, Atorvastatin, Rosuvastatin

Suspend statin for period of treatment

Anti-diabetic medications

Glipizide, tolbutamide

Steroids Dexamethasone, prednisolone, ethinyl oestradiol

Oral contraceptive pill Effectiveness is reduced so additional precautions should be used.

NB: Not all drug interactions are listed above. Not all drug interactions for Kaletra are

known. If you are in doubt contact the Pharmacy at the MWRH Limerick on 2337. For full prescribing information refer to the summary product characteristic sheet for the above medication - www.medicines.ie


SIDE EFFECTS

Most commonly reported side effects:

Tenofovir Emtricitabine Kaletra Headaches Insomnia Cough / nasal symptoms Nausea / vomiting Abdominal pain, cramps Diarrhoea Anaemia, neutropenia Transient elevation of liver enzymes Hepatitis Pancreatitis

Headaches / dizziness Insomnia, abnormal dreams Nausea and vomiting Abdominal pain Diarrhoea Asthenia Rash Dyspepsia Increased glucose Increased amylase Increased AST/ALT Abnormal liver function tests

Insomnia Headache Paresthesia Nausea and vomiting Abdominal pain Abnormal stools Dyspepsia Flatulence Gastrointestinal disorder Rash Lipodystrophy Acne Asthenia Pain Increased glucose Increased amylase Increased SCOT/AST Increased SGPT/ALT Liver function test abnormal

NB: It must be noted that information on side effects involving Truvada and Kaletra is limited and

the above is not a complete list. For full prescribing information refer to the Summary Product Characteristics Sheet for the above medications – www.medicines.ie


HIV Post-Exposure Prophylaxis Information for Injured Employee Post-Exposure Prophylaxis Pack Please read this carefully before starting treatment. If you have any doubts or worries, or if you are

simply confused about something, ask your doctor. You may have been exposed to the HIV virus via an occupational blood exposure. You are being

offered this medication because it is felt that it may decrease your chances of HIV seroconversion if you have been exposed to the virus.

There are a number of things you should know before you start taking this medication.

You may or may not have been exposed to the HIV virus. Knowledge about the efficacy and toxicity of the medication is limited.

The final decision to accept the treatment is yours.

The medication is not licensed for prevention after an occupational blood exposure in this country

although both drugs are licensed for treatment of HIV. This pack contains the following medication:

Drug Dose Truvada tablets Tenofivir 245 mgs Emtricitabine 200 mgs

Take ONE tablet ONCE A DAY

Kaletra 250 mg tablets Lopinavir 200 mg plus Ritonavir 50 mg

Take TWO tablets TWICE A DAY (every 12 hours) (Tablets to be used – NOT capsules)

Metoclopramide 10mg tablets OR Domperidone 10 mg tablets

Take ONE tablet THREE TIMES A DAY when required for nausea and vomiting Take ONE tablet THREE TIMES A DAY when required for nausea and vomiting

Loperamide 2mg tablets

Take TWO tablets as a single dose following diarrhoea and then ONE tablet three time a day (maximum of five tablets per day)

You should start this medication as soon as possible after the exposure. You will need to take this medication for a total of four (4) weeks. During this time your bloods will be

monitored by the Occupational Health Department. You have been provided with a five (5) day supply of this therapy. Please obtain a prescription from the

Occupational Health Department for a further 23 days. It is important to take the Kaletra medication every twelve (12) hours if it is labelled as twice a day to

ensure there is a constant level of drug in your bloodstream. It is also important that you take your Truvada every 24 hours. Try not to miss any doses.

This treatment can be taken with or without food. Your PEP pack can be stored at room temperature and should be kept out of the reach of children.


Do you have or have you had? Liver or kidney problems Blood disorders, e.g. anaemia Allergic reaction to any medication If the answer is yes to any of these questions – tell the prescribing doctor. Are you or could you be Pregnant? If the answer to this question is yes, you will need to discuss this further with your doctor to see if the benefit of treatment outweighs the risks of adverse effects to your baby. Are you Breastfeeding? HIV can be transmitted via breast milk. You should discontinue breastfeeding whilst you are taking Truvada and Kaletra®. Please discuss this with your doctor or you may wish to discuss this with the HSE West – Limerick, Clare & North Tipperary Infectious Disease Consultant. Are you taking any other medication? The post-exposure prophylaxis drugs could interact with other medication you are taking. Tell your doctor if you are taking any other medication, including that you have bought yourself vitamin

supplements, herbal remedies, homeopathic medicines and recreational drugs. Check with your doctor first before taking any other medication once you have started taking the post-

exposure prophylaxis medication. Kaletra may reduce the efficacy of the oral contraceptive pill or contraceptive patch. You should use an

additional method of contraception whilst you are taking Kaletra. Please discuss this with your doctor. What side effects might this medication cause? Most common

Truvada Kaletra Nausea and vomiting Diarrhoea Headache Dizziness Fatigue Insomnia Abnormal dreams Rash

Insomnia Headache Nausea and vomiting Abdominal pain Rash


Less common side effects (report them immediately to a doctor) Liver problems (nausea, stomach pain, low fever, loss of appetite, dark urine, pale colonised stools and

jaundice (yellowing of the skin and eyes). Blood disorders (unusual bleeding, bruising, pale gums and/or nails, sore throat that does not get

better). Peripheral neuropathy (tingling or numbness in the fingers and toes). Increased thirst and urination, loss of appetite, weakness, constipation. Fever, cough, sore throat or other signs of infection. Pancreatitis (severe abdominal pain, with nausea and vomiting). Swelling of the eyelids, face or lips (Truvada). Alterations in blood sugar (severe thirst, frequent urination especially at night). Lactic acidosis (the signs of which may be a general feeling of tiredness, lack of appetite, nausea, liver

may be swollen and tender).

This is not a complete list of side effects. Please tell the Occupational Health Physician about any side effects you experience. Do not stop taking the medication without discussing this with your doctor first. This information should be read in conjunction with the patient information leaflet provided with the medication.


Declaration to be completed by ALL Staff recommended or offered ANTI-RETROVIRAL PROPHYLAXIS after OCCUPATIONAL EXPOSURE TO HIV

In some situations a combined anti-retroviral regime is recommended or offered for prophylaxis following exposure to HIV. The long-term toxicity in this situation is unknown. As the drugs are not licensed for this indication, it is necessary to gain written consent to receive the treatment. I confirm I have been advised on prophylaxis and have had the risks and possible benefits explained to me.

I have read Appendix 3: Information sheet on prophylaxis with Truvada and Kaletra or a combination of anti-retroviral drugs after occupational exposure to HIV (updated June 2009).

I wish / do not wish to receive prophylaxis with: ………………………………………….. against seroconversion to HIV. I understand that its long-term toxicity is unknown.

Signature and name of healthcare worker:

Signature: _______________________________________________ NAME (block capitals): _______________________________________________ Date: ______________________

Signature of Emergency Department who has performed the counselling and prescribed

medication: Signature: _______________________________________________ NAME (block capitals): _______________________________________________ Date: _______________________

THIS FORM MUST BE RETAINED IN THE FILE WHERE TREATMENT WAS STARTED

PLEASE FAX A COPY TO THE OCCUPATIONAL HEALTH DEPARTMENT Fax 061-482597


APPENDIX 4

RESOURCE PACKS The two (2) Resource Packs come in packs of five (5) forms per pack and must be ordered from Central Stores using an order number. 1. Appendix 2 – Needlestick Injury and Other Exposure Incident Form 2. Appendix 3 – Resource Pack for Emergency Department


Signature Sheet: I have read, understand and agree to adhere to the attached Policy, Procedure, Protocol or Guideline:

Print Name Signature Area of Work Date

standard operating procedure for needle stick … · ohd001 – sop for needle stick injuries and...

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