Standards and Guidance for the Prevention & Management of Body Fluid ... · PDF fileStandards and Guidance for the Prevention & Management of Body Fluid Exposure Incidents for...

Standards and Guidance for the

Prevention & Management of

Body Fluid Exposure Incidents for Healthcare Students on

Clinical Placements

Students enrolled onto healthcare courses at King’s College London

may undertake practical procedures on patients, including those with

potential for body fluid exposures (BFE); these carry a very small

but important risk of blood-borne virus infection. The key standards

and responsibilities outlined in this publication outline best practice,

and give practical guidance, for students to prevent and to manage

inoculation injuries or body fluid exposure incidents whilst on clinical

placement.

This booklet comprises one element of a comprehensive information

package that students on healthcare courses at King’s will be

introduced to, and will be revisited during their programme of study.

The exact content of the teaching package may differ according the

health discipline being studied however all share the same standards

and responsibilities for the University and Faculties, students, partner

organisations and occupational health.

King’s takes your safety very seriously. Please familiarise yourself with

the contents of this booklet so as to both reduce your likelihood of an

inoculation injury or body fluid exposure, and to enable you to respond

swiftly and effectively should this happen.

Introduction

Responsibilities of students in the prevention & management of body fluid exposures

Introduction

Students on clinical placements may be at risk of exposure to blood

borne viruses through accidental injury from medical sharps/ splashes

of blood or body fluids. Students should do all that they can to reduce

the risk of this occurring.

Students must:

1. Attend all required statutory, mandatory and timetabled teaching

related to the safe use of medical sharps (including completing

e-learning), and the prevention and management of body

fluid exposures, and practice in accordance with the teaching

received.

2. Only undertake procedures involving the use of medical sharps

when you have completed the required learning cited above.

3. Ensure that you are aware of and practice in accordance with

local organisational policy relating to safer use of medical sharps

and the prevention and management of body fluid exposures

when on clinical placement. This includes being aware of and

adhering to local policy regarding the use of personal protective

equipment when undertaking tasks that may result in body fluid

exposure

4. Always consider whether it is safe for you to participate in any

procedure involving contact with medical sharps or body fluids.

You should consider the needs of the patient, your competence,

the environment and suitability of supervision available (see (5)

below).

5. In clinical placement only undertake procedures involving

medical sharps under the supervision of a registered / qualified

practitioner. The level of supervision may vary according to your

level of training but ONLY undertake the procedure if you feel it

is safe to do so.

6. Students may onlytake bloods or cannulate patients known to

have blood borne virus when they have been deemed competent

to do so by their faculty. (DH 1998)

7. If at any time you are concerned that your own or anyone else’s

safety is being put at risk through unsafe practice relating to

medical sharps or body fluid exposure in clinical practice you

should inform your clinical supervisor and your university

representative immediately.

8. If you sustain an inoculation injury or body fluid exposure report

it immediately to your clinical supervisor and then follow the

local emergency procedure for management of a inoculation

injury or body fluid exposure (see also page 19 of this booklet).

9. You must also complete the placement organisation and the

university Airsweb incident reporting process (http://www.kcl.

ac.uk/ai-report). You must also inform Student Occupational

Health even if others have said that they will do this for you.

10. Arrange with Student Occupational Health for appropriate

follow up.

11. Attend a debrief discussion following an inoculation injury or

body fluid exposure with an identified member of university staff

to ensure that your wellbeing is promoted.

Responsibilities of partner healthcare organisations in the prevention & management of body fluid exposures

Introduction

Partner healthcare organisations such as Trusts, General Medical &

Dental Practice Clinics and private and voluntary healthcare providers

have responsibilities which relate to the prevention and management

of body fluid exposures. They must, as part of their contractual

commitments, have appropriate standards of practice and supervision

for the teaching of students in the clinical environment. The majority

of these standards will be met by existing organisational policy and

contractual agreements

Partner healthcare organisations must:

1. Through their educational administration teams and local

managers

• know which students are on their site

• provide an induction session for students new to the site within

48 hours of the students commencing on the site / placement.

This must include information in relation to BFE risks, and on the

emergency procedures to follow if involved in a BFE incident.

• have a risk assessment for all types of placement in relation to

training and procedures that may place students at risk, and a

strategy to minimise risk.

• identify any students who have insufficient background (e.g.

classroom- based) training for the tasks which they are likely to

undertake; and in such cases liaise with the relevant education

provider to review their training; and in certain cases provide

relevant training.

• Provide all students with a named clinical supervisor

2. Ensure that relevant professionally-qualified staff in receiving

wards, departments and clinics, and other staff or contractors

involved with training particular students, are suitable to train

others, and are aware of their responsibilities with regards

to student supervision and practice in relation to BFE risks.

Students who visit a wide range of clinical areas and perform

clinical examinations and procedures should also be informed

during induction (as above) of their own responsibility to

appreciate the importance of their background training needs,

competency and awareness of BFE risks.

3. Be aware that students may only take bloods or cannulate

patients known to have blood borne virus when they have been

deemed competent to do so by their faculty (DH, 1998).

4. Ensure appropriate and adequate levels of supervision of students

during their training until they are deemed to be at the relevant

level of competency.

5. Risk assess the activities and training processes students

undertake to ensure appropriate controls and record the results

and any remedial actions identified.

6. Where contractually required to provide them, ensure that

clinical skills training facilities are adequate for classroom-based

teaching of their students.

7. Ensure that adequate personal protective equipment and

approved safer sharps devices are available, demonstrated and

provided to students when required in the clinical environment.

8. Demonstrate a commitment to safer sharps management in

accordance with the Health and Safety (Sharps Instruments in

Healthcare) Regulations 2013, by ensuring that organisational

policy outlines the requirement to:

• avoid the unnecessary use of sharps

• use safer sharps devices where possible

• prevent the recapping of needles

• place secure containers and instructions for safe disposal of

medical sharps close to the work area

9. Ensure that there is an adequate procedure for dealing with a

BFE of a student, which is aligned to the same procedures for all

staff

10. Refer to Local Security Management Specialist (LSMS)

if the incident occurred in the context of violence/ assault.

Consideration should be given to the need for counselling/

psychological support, and incident recording and reporting.

11. Ensure that in the case of students on placement, any incident is

re-ported to the university’s Health & Safety Services using the

electronic web-based system (http://www.kcl.ac.uk/ai-report).

This is done either directly by the student and/or a supervisor, or

via the local Occupational Health & Safety Department, or via

the Student Occupational Health Service.

12. Work in partnership with the university Health & Safety

Services in the investigation of any BFE incident when requested

to do so, and ensure that lessons learned are applied across the

organisation and not just in the location where the incident

occurred.

Responsibilities of Occupational Health (OH)in the prevention & management of body fluid exposures

Introduction

The immediate management of a student who sustains a BFE

rests with the Occupational Health Service (OHS) or Emergency

department of the healthcare organisation where the student is on

placement. Student OHS has responsibility to prepare King’s students

regarding the risks of BFE prior to placement, and to follow up any

student who sustains a BFE during the healthcare programme.

Local OHS

1. Ensure that, on notification of a student having sustained a

BFE, the student is given explicit instruction on the immediate

action to be taken (first aid, obtaining source details, attending

OH/A&E).

2. Ensure that a full risk assessment is undertaken, including access

to a doctor for HIV PEP if appropriate, within one hour of the

incident, in adherence to the OHS Protocol for the Management

of BFE.

3. Ensure that the medical team looking after the source patient is

contacted as soon as possible with regard to risk assessment and

consent of the source for blood testing, and that the student is

informed of results.

Student OHS

1. Ensure that students are made aware of the risks of BFE prior

to their first clinical placement. Ensure that, during their

New Starter Check appointment students are provided with

information on the use of safe sharps, appropriate PPE, correct

disposal of sharps, immediate first aid to be performed and the

reporting procedures to be followed.

2. Ensure that clear arrangements are made with the student for

follow-up where necessary (in cases where source unidentifiable,

not tested, positive for BBV, or student on PEP).

3. Ensure that, where a student has sustained a BFE, contact

with OH in these organisations is made to arrange appropriate

assessment and follow-up.

4. Ensure that reporting to the Health and Safety Executive

(HSE) in accordance with Reporting of Injuries, Diseases and

Dangerous Occurrances Regulations 2013 (RIDDOR) and

Public Health England (PHE)

following high risk exposures (source positive for BBV) is

undertaken.

5. Provide the schools with figures of BFEs sustained by students

within the quarterly OH reports to King’s.

Responsibilities of the University / Faculty in the prevention & management of body fluid exposures

1. It is important to note that the university’s legal, moral and

ethical obligations relevant to items such as Duty of Care,

health and safety, insurance, risk management and equality and

diversity legislation also apply to students on placement.

2. There must be clear written information and guidelines on the

placement in the form of a written agreement and this must be

disseminated to providers and students.

3. Records of adequate legal, financial and health and safety

compliance must be documented and records kept of any

applicable cover.

4. There must be an identified point of contact at King’s for

students on placement (link lecturer/ personal tutor or other)

and an identified point of contact for the placement organisation

(Key account manager or other) to facilitate effective risk

assessment, management and incident investigation.

5. The process of placement quality assurance must include a

specific focus upon sharps safety ensuring relevant and up to

date policies are in place and that a process exists to audit their

implementation. It must also include a review of relevant sharps

safety incidents and evidence of actions taken to reduce the risk

of reoccurrence.

6. The university will provide training for staff involved in

placement learning so that staff are competent in their

understanding of student needs and are able to fulfill the relevant

requirements of their role. This should include ensuring that staff

who have contact with students regarding practice learning/

experience are aware of the correct process to follow when a

student identifies a risk related to sharps safety or experiences an

inoculation injury.

7. Each faculty/ school is responsible for providing training to

identified relevant staff (personal tutor/ link lecturer/ key

account manager) regarding the safe use of medical sharps and

the correct process students should follow in the event of an

inoculation injury.

8. Each faculty/ school must have an agreed process of reporting,

investigation and dissemination of findings following inoculation

injuries. This must include dissemination to the student, practice

partner, school/ faculty and across health schools.

Exposure Prone Procedures

What is an Exposure Prone Procedure?

EPPs are those invasive procedures where there is a risk that injury to

the worker may result in exposure of the patient’s open tissues to the

blood of the worker. These include procedures where the worker’s

gloved hands may be in contact with sharp instruments, needle tips

or sharp tissues (eg spicules of bone or teeth) inside a patient’s open

body cavity, wound or confined anatomical space where the hands or

fingertips may not be completely visible at all times. Such procedures

occur mainly in surgery, obstetrics and gynaecology, dentistry and

some aspects of midwifery. Most nursing duties do not involve EPPs;

exceptions include accident and emergency and theatre nursing.

Health care staff and students who perform EPP as part of their role

are required to be tested for HIV, Hepatitis B and C. Students who test

positive for any of the above may be able to perform EPP’s if they meet

specific criteria regarding regular monitoring, treatment and viral load.

Detailed advice and support will be provided by occupational health.

Only students who have been tested for blood borne viruses as part of

an EPP screening process may take part in exposure prone procedures.

Safety with Insulin Pen Devices

Needle stick injuries from insulin pen needles are one of the most

common BFE incidents. Insulin pens are designed for patient use.

They best suit the self-management needs of the patient rather than

staff safety, therefore special consideration needs to be taken when

using these devices (HSE Sharps Instruments in Healthcare, 2013).

These needles do not possess the safety features common with

standard hypodermic needles which make them particularly high risk

for inoculation injury. As a student of King’s College London you

should not use these patient use needles. If you are required to use an

insulin pen device you should use it with a specially designed safer

sharp for insulin pen needle (figure 1). If these are not available you

should use an approved insulin syringe with safer sharp needle attached

(figure 2).

Figure 1

Patient single use insulin pen needles (figure 3) should only be handled

by the patient and the needle disposed of directly into a sharps box by

the patient. In any circumstances where a healthcare practitioner is

required to assist with administering insulin using a pen needle without

a safer sharp then this must be disposed of safely and never re-sheathed

in any way. When self-management is being taught and encouraged

then a sharps box must be provided to ensure immediate disposal

of sharps. King’s College London healthcare students MAY NOT

administer insulin from insulin pens unless there is a safer needle in use.

Figure 2 Figure 3

How to reduce the risk of body fluid exposure.

The risk of sustaining a BFE can be reduced through careful

consideration prior to the procedure. So each time you are offered the

opportunity to undertake a procedure that may result in a BFE make

sure you:

STOP:

Does the procedure you are about to undertake involve the risk of

exposure to body fluids? This includes the use of sharp instruments

and potential splash injuries.

THINK:

Is this procedure necessary?

Do you need to use a sharp instrument or is there an alternative?

RISK ASSESS:

All procedures that involve the risk of body fluid exposure should be

risk assessed.

Some risk assessments will be formal written assessments but as

healthcare students you and your supervisor should assess the risk of

procedures that involve potential body fluid exposure each time you

perform them.

The ongoing assessment of risk that occurs in the clinical environment

is called a dynamic risk assessment. The purpose is to identify hazards

and take action to eliminate or reduce the risk.

What to risk assess

A range of factors should be considered which may vary depending on

the situation but as a minimum you should consider risks involving:

Supervision - What level of supervision do you need to safely

undertake the procedure?

Operator (You) - Is it appropriate for you to be doing this procedure,

with this patient at this time?

Procedure – What are the particular risks involved in the procedure?

Patient - Are there any specific patient related risks?

Environment – Is the environment as safe as it could be to work in?

Equipment – What equipment are you using or what equipment do

you need to work safely?

Think SOPPEE when risk assessing the potential for BFE.

More information on this is available on your sharps safety e-learning.

Immediate First Aid

What should I do if I experience a sharps injury?

• Encourage the wound to gently bleed, ideally holding it under

running water

• Wash the wound using running water and plenty of soap

• Don’t scrub the wound whilst you are washing it

• Don’t suck the wound

• Dry the wound and cover it with a waterproof plaster or dressing

• Report the injury to your supervisor.

• Seek urgent medical advice (see next page for where you should go)

• Complete relevant incident reports (placement provider and

university)

What should I do if I experience a body fluid exposure splash incident?

• Rinse the wound using running water

• Report the injury to your supervisor.

• Seek urgent medical advice (see next page for where you should go)

• Complete relevant incident reports (placement provider and

university)

WHAT TO DO IF YOU SUSTAIN A BODY FLUID EXPOSURE

Gently encourage bleeding, wash

area with soap and water

Sharps injuries, cuts,

abrasions and bites

Splash to eyes/mouth,

wound or non- intact skin

INFORM YOUR SUPERVISOR

Attend your placement Occupational Health Dept.

(Mon-Fri office hours)

or A&E (out of hours) IMMEDIATELY*

*If HIV PEP is needed, this should start within one hour.

Inform the triage nurse in OH or A&E

that you have sustained a body fluid exposure.

A risk assessment** will be undertaken and treatment provided***

Complete both a ‘local incident report’ and a university accident Report.

You must contact

Student Occupational Health Service (GSTFT OH)

the next working day following the incident to arrange follow up

Immediately irrigate eyes (before

and after removing contact lenses)

or mouth with water or normal

saline for at least 30 seconds

Emergency Next Steps

**Source (patient you sustained

injury from) patient’s details which

will assist with the risk assessment (if

known):

Information you can provide about the

source patient:

• Name, date of birth

• Current location

• Consultant in charge of source

patient’s care

• Ethnic origin & country of birth

Information provided by the source

patient’s clinician as per local policy.

The information listed below should

NEVER be sought by the injured

healthcare student / worker.

• Sexual history (i.e. men having sex

with men, past or present high risk

sexual behaviour, commercial sex

worker)

• Past or present IV drug use

• History of blood/plasma transfusion

• Sexual partner at risk of BBV

• Consent for BBV testing

***Information that will help

Student OH to follow you up:

• Ask placement OH/A&E to take a

“serum save” blood sample from you.

• If HIV PEP is to be started, ensure

a blood sample is taken from you for:

FBC, U&Es, LFTs, amylase, bone

profile (calcium and phosphate),

blood glucose, lipids and Gamma GT.

Urinalysis also needs to be done.

• Ask OH/A&E to give you a Hepatitis

B vaccination (if you have not had one

in the last year).

• If the source person has consented for

blood borne virus (HIV, Hep C and

Hep B) testing please ensure consent

includes the release of the results to

Student OH to assist management of

your case.

REMEMBER: Consent for BBV testing

of the source patiend should NEVER

be sought by the injured healthcare

student / worker.

Please ask for a copy of the risk

assessment and treatment received

Giving a succinct history of the incident:

To my clinical supervisor

1. What procedure or task you were doing, where and when.

2. Identify the patient you were working on (your supervisor may

check the patient’s notes to identify any risk factors).

3. Say who was supervising if it wasn’t your clinical supervisor.

To A&E or Occupational Health

To the receptionist and triage nurse:

1. State your name and say are a student medic/dentist/nurse/

midwife and where you are working.

2. State that you have received an inoculation (needlestick) injury

or body fluid exposure.

3. State if the source was from a known high-risk patient.

4. Say the time the injury or exposure occurred (to ensure you start

treatment within the “Golden Hour”).

To the attending physician

1. State you have received an inoculation (needlestick) injury or

body fluid exposure and how it was received.

2. State if the source was from a known high-risk patient.

3. Say the time the injury or exposure occurred (to ensure you

assessed and start treatment within the “Golden Hour”).

4. You MUST inform the physician if you have any underlying

health conditions or are on any medications.

The attending physician will assess the risks of exposure to a blood-

borne virus from the history given and may decide that post exposure

prophylaxis (PEP) is necessary. You will be told of what this consists of

and any contraindications.

To Student Occupational Health

1. State your name, that you have had a BFE, when and where.

2. Whether you have already attended OH or A&E and, if so,

provide details or any written information or advice given to you

as a result of your BFE consultation.

What happens next?

What should people be doing when I report this incident?

1. Placement organisation:

• The patient may have blood taken to assess their infection status.

The bloods must not be undertaken by the person who has

sustained the BFE.

Supervising staff will explain to the patient the need to check for any

risk factors for Hepatitis B, C or HIV and will request the patient has a

simple blood test to check for their presence

• If the patient has already left the healthcare organisation ( e.g.

they are attending as an outpatient) they will be contacted so that

the process outlined in emergency next steps can be followed.

• The student may be interviewed as part of the accident

investigation.

• There may be a follow-up review of processes at the local level of

the organisation.

• Depending on the nature of the incident and exposure, the

Health and Safety Executive may need to be informed

• The placement organisation will contact the Faculty (and

Student OH).

2. The student must attend Student OH for follow-up.

3. The university will be informed by Student OH and may need to

report the incident to the Health and Safety Executive through

the Health and Safety Services if it has not been reported by the

placement organisation.

How should I be followed up?

1. Student OH follow-up:

bloods, etc.

2. The Faculty (and

university, where

necessary) follows up with

the placement organisation

and provides pastoral care.

Sources of support

• Academic supervisor

• University representative at

placement provider

• GSTFT Occupational

Health

• Student Counselling

Centre

Guidance for International Electives

Many students have the opportunity to undertake an International

elective in the developing world. The risks of doing this in terms

of personal safety must be considered prior to undertaking this

experience. The student must familiarize themselves with the

emergency management of a BFE.

All students undertaking an international elective should be assessed

prior to departure by Student OH. OH may advise you to purchase

a PEP pack. If so, please do this and ensure you carry it with you at

all times during your elective. You will also be advised to take out

King’s travel insurance as well as comprehensive travel insurance. This

enables additional treatment medication to be flown out to you should

you sustain a BFE.

References & Relevant Reading

Department of Health (1998) Guidance for clinical health care

workers: protection against infection with blood-borne viruses.

Available at: http://webarchive.nationalarchives.gov.uk/+/

www.dh.gov.uk/en/publicationsandstatistics/publications/

publicationspolicyandguidance/dh_4002766

Department of Health. (2005) HIV Infected Health Care Workers:

guidance on management and patient notification. London:

Department of Health available at:

http://webarchive.nationalarchives.gov.uk/20130107105354/

http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@

dh/@en/documents/digitalasset/dh_4116416.pdf

Health and safety at work act (1974) available at:

http://www.hse.gov.uk/legislation/hswa.htm

HSE (2001) Blood-borne viruses in the workplace: Guidance for

employers and employees London: HSE available at:

http://www.hse.gov.uk/pUbns/indg342.pdf

Health and Safety (Sharp Instruments in Healthcare) Regulations

2013 Guidance for Employers and Employees: HSE available at:

http://www.hse.gov.uk/pubns/hsis7.pdf

King’s College London (2011) Statement of General policy,

responsibilities and arrangements in respect of health and safety

protection available at:

http://www.kcl.ac.uk/college/policyzone/assets/files/governance_

and_legal/Policy_health_statement.pdf Last accessed April 2015.

Public Health England (2014) The Management of HIV infected

Healthcare Workers who perform exposure prone procedures: updated

guidance, London: Department of Health available at:

https://www.gov.uk/government/uploads/system/uploads/

attachment_data/file/333018/Management_of_HIV_infected_

Healthcare_Workers_guidance_January_2014.pdf

RCN (2013) Sharps safety RCN Guidance to support the

implementation of The Health and Safety (Sharp Instruments in

Healthcare Regulations) Available at:

https://www.rcn.org.uk/__data/assets/pdf_file/0008/418490/004135.

pdf

UK Quality Code for Higher Education. Part B: Assuring and

enhancing academic quality.

UCEA Health and Safety Guidance for the placement of Higher

Education students.

This course, its content and all materials and methods used to deliver it or supplied in association with it in whatever

medium shall be the intellectual property of King’s College London. This extends to the rights in any visual or other recording of the course being delivered. This course, its

contents, methods and materials and any representations thereof may not be re-used, repackaged, adapted, broadcast

or transmitted to third parties for use without the express prior written permission of King’s College London.