Infection Control Key Skill/ Managerial Section E

ME

Domain: knowledge of Health and Safety

E. Knowledge of Cross Infection Control procedures

Recommended for assessment by the Deanery:

Copy of practice infection control procedures

Signed reflective commentary demonstrating understanding of the procedures.

Included for assessment:

Practice policies for infection control and reflective commentary. There is also an updated section that gives a synopsis of the new HTM 01-05 regulations.

Infection Control

Control of the spread of infection is a fundamental aspect of daily clinical dental practice. There is no clinical procedure or clinical dental professional that is exempt from its principles. This section aims to reflect on the practice’s compliance with current decontamination and sterilisation procedures.

Universal precautions and practice protocols

Within the practice there is a written policy¹ that should be followed to keep cross infection a priority within the practice.

The policy includes topics such as

• The use of personal protective equipment i.e. gloves, masks etc. Although it does state that a new pair of gloves should be worn for each patient it does not state when masks should be changed. Ideally, masks should be changed between patients also.
• Briefly covers the sterilisation procedures- though does not go into great detail, it provides the essentials of what must stages the instruments should go through before being used again.
• Disposal of contaminated waste and sharps and its storage before collection.
• Hepatitis B immunisation for team members and recording the seroconversion for practice records.

Reflection

The cross infection control policy does realistically reflect what I experienced at a clinical level. Although there will always be variance between individual levels compliance e.g. one of the dentists does not like to wear safety glasses. Overall however the policy is well adhered to. If anything it does not reflect the attention to detail and the adherence to the principles of cross infection within the surgery. E.g. the policy does not cover topics such as the use of:

• Disposable covers for any areas that may be contaminated such as keyboards, hand pieces and the operating light for the chair.
• Single use instruments such as endodontic files or matrix bands- that are difficult to effectively decontaminate, though many items used within the clinic are disposable.
• Water lines disinfection- most waterlines will contain a biofilm which could act as a source of infection. The practice used the Sterilox system to flush through the water lines to reduce the bacterial load. In addition all chairs use a bottled water source.
• Although the policy covers the basics of how an inoculation injury should be dealt with- it does not include the phone number or address of the occupational health. I gained this information and passed it on to the practice manager to add in to the policy and also to add the details to the practice address book. (XYZ). There is also a separate sheet that gives more details on the cross infection policy. ²
• Surgery clothing- all clinical members wear scrubs and are encouraged to wash them daily at a high temperature wash.
• The policy does not adequately cover aerosols though the practice uses high volume aspiration and the use of rubber dam in often utilised where practicable.
• The policy covers the segregation and storage until collection of clinical waste but does not cover detail the disposal of clinical waste. I was able to locate the practice waste transfer note³ that identifies the waste disposal company as Cannon Hygiene. Under the Environmental protection Act 1990/The waste and Contaminated Land (Northern Ireland) Order 1997 the waste must be disposed of appropriately and the transfer note should be kept for a minimum of two years. The purpose of this process is to give accountability for the disposal of contaminated waste.
• The policy does not detail the use of ACT (automated control tests) within the cycle for disinfection. E.g. read outs from vacuum autoclave etc. (see Evidence 7 for Example of print-out from vacuum autoclave)

Evidence 7 shows photographs of existing protocols at my previous practice along with reflective commentary.

Staff immunisation

The existing staff immunisation records were incomplete and so at a practice meeting asked if everyone would review their Hep B immunisation status and provide evidence. Some staff simply had to contact their GP for a copy of the report whereas some had to go for blood tests or boosters. The information is still being collected from the staff. ⁴

Staff training

Realistically the majority of staff training occurs through discussion and conversation informally at work. Formally however there is training in place

• Once per year an external training group attend the clinic and provide training on medical emergencies and cross infection. The whole team are required to attend. ⁵
• Any new team member must be trained in the cross infection protocols of the practice. A training record card is provided and must be countersigned by the trainer⁵

After joining a new practice there was a training session which involved reviewing the existing cross infection protocol and layout of the central sterilisation room. A plan was drawn up⁶ to give a pathway for the sterilisation of instruments. We also audited the verifying of the disinfecting and sterilisation process and put in place a instrument sterilisation check-list⁷ and a maintenance schedule.⁸ This training took part in two sessions and all staff were involved in the sessions.

KS 2.3 Managing critical incidents.

Present practice policy¹ is based on the BDA advice sheet A12⁹ and follows the protocols written.

RIDDOR 95 guidelines require any injuries to be recorded and any serious accident should be reported to the Health and Safety Executive (HSE). The practice has an accident book and included within the portfolio is a photocopy of a needle stick injury that occurred to me within the first few weeks of my starting the clinic. Unless an injury involves the transmission of a blood born virus, it is not necessary to report it to Health and safety executive

Analysis.

Cause: Although I was given some training is using the ‘wand’ local anaesthetic delivery system I was not familiar with ‘handling’ the wand

Incident: When I tried to re-sheath the needle using the safe re-sheathing device I made the mistake of holding the sheath with my left hand. My hand slipped and there was a small injury to my left hand involving the piecing of the skin.

Action: encouraging bleeding at the site, washing the wound and drying it thoroughly and placing a waterproof dressing. There was little concern about transmission as the needle was still sterile. An entry was made within the accident log book¹¹ and I learnt never to hold the sheath again! This incident was discussed at the next practice meeting to avoid any similar injuries to other members of staff.

KS2.4 Awareness of written protocols

Compliance with infection control is measured against existing protocols. These protocols are found within the practice manual¹⁰. The manual details the procedures for:

• Start of day procedures
• During procedure
• Between Patients
• End of Day procedures

For discussion on inoculation issues- please see KS4.1

The practice also has a protocol for sending lab-work and the infection control procedures that should be adhered to¹².

Infection Control

Update to Key skills Febuary 2010

In KS2.1 there was discussion about the insufficiency of the existing cross infection written protocol, though the in-surgery standard was relatively high. Previous policies were not specific or up to date with current guidelines. In light of the new Health Technical Memorandum 01-05 (DOH, April 2009), The regional clinical director has reviewed the existing cross infection policy and associated policies and updated as necessary.

The policy consists of a summary document along with several sub-sections including:

• Waste Disposal Policy
• Hand Hygiene Policy
• Personal Protective equipment policy
• Prevention and management of sharps injuries and body fluid contamination
• Instrument decontamination and storage policy
• New reusable Instrument Policy
• Disinfectant guidelines
• Impression Decontamination Protocol
• Protocol for manual cleaning of dental instruments.

These documents have yet to be implemented- but in-house training is planned for all staff in the near future. All the documents are provided as Evidence 13 at the end of the section.

Some Key points from HTM 01-05:

The document starts by outlining how the document fits in with/alongside existing guidelines including. The Health and Social Care Act 2008: Code of Practice.

Where new practices are commissioned or new premises contemplated, it is advised that the full best practice provisions of this guidance be utilised wherever reasonably practicable.

The document clearly differentiates between 'essential practice' and 'best practice'

Essential practice includes cleaning instruments- prior to sterilization instruments should be free of visible contaminants when inspected.

Instruments should be reprocessed using a validated decontamination cycle including: cleaning/washing

Reprocessed dental instruments should be stored in such a way as to ensure restraint of microbiological recolonisation.

Practices should audit their decontamination processes quarterly using an audit tool

Practices should have in place a detailed plan on how the provision of decontamination services will move towards best practice.

Best Practice includes:

A cleaning process that should be carried out using a validated automated washer-disinfector.

Evidence for Key Skill 2:

Infection Control in Dental Practice.

1. Infection Control Policy. 

2. Needle-stick /sharps injury policy. 

3. Waste transfer note. 

4. Staff immunisation status. 

5. Training tick-sheet and training in cross infection certificate

6. Central Sterilisation plan

7. Protocols for decontamination /sterilisation of instruments. Including photographs and reflective commentary.

8. Equipment maintenance schedule.

9. BDA advice sheet A2. Infection control in Dental Practice. BDA, Wimpole St.

10. The practice manual. 

11. Accident logbook entry. 

12. Protocol for disinfection of lab-work. 
13. New infection control policy (yet to be fully implemented)
12. Waste Disposal Policy
13. Hand Hygiene Policy
14. Personal Protective equipment policy
15. Prevention and management of sharps injuries and body fluid contamination
16. Instrument decontamination and storage policy
17. New reusable Instrument Policy
18. Disinfectant guidelines
19. Impression Decontamination Protocol
20. Protocol for manual cleaning of dental instruments.

Protocol for the decontamination of impression materials and prosthetic and orthodontic appliances

	The responsibility for ensuring impressions and appliances have been cleaned and disinfected prior to dispatch to the laboratory lies solely with the dentist. It is good practice to agree the cleaning and disinfection process with the laboratory and label the impressions to indicate their disinfected status. This removes uncertainty and the possibility of the impression being repeatedly disinfected, which may detract from its quality
	1	Immediately on removal from the mouth, the impression or appliance should be rinsed under running water to remove saliva, blood and debris
	2	Continue the process until it is visibly clean. If an appliance is grossly contaminated, it should be cleaned in an ultrasonic bath containing detergent and then rinsed
	3	The impression or appliance should then be disinfected. Different impression materials require different methods of disinfection and the manufacturer's recommendations should be followed.
		Perform (Schulke & Mayer) is prepared using a sachet of powder added to 2 litres of warm water, using a contact time of 10 minutes
		Unoguard (UnoDent) is prepared using a scoop of powder added to 2 litres of warm water, using a contact time of 10 minutes
		These materials have a recognised health risk (COSHH Group 2 rating), with the potential to cause eye or skin irritation. PPE is needed (gloves and eye protection) during preparation and handling For more detailed information, see the COSHH Report
	4	There are two methods of disinfection: immersion and dipping
		Immersion in disinfectant (following the manufacturer’s recommendations for dilution and duration) can be effective but may be compromised by the limited working life of the disinfectant, which is affected by the frequency of use and the presence of biological debris. Solutions should be changed when visibly contaminated or at the end of a session
		Dipping avoids the prolonged immersion that can distort hydrocolloid and polyether impression materials. The recommended contact time is still necessary, during which the impression must not be allowed to dry out.
	5	Following disinfection, the impression (or appliance) must be thoroughly rinsed in water before packaging to send to the laboratory with a confirmation that it has been disinfected. Items received from a laboratory should also be disinfected.

Evidence 13

The Updated Guidelines.

These guidelines are considerably more comprehensive and more adherent to current best practice.

Infection Control Policy

	Infection control is of prime importance in this practice. It is essential to the safety of our patients, our families and us. Every member of staff will receive training in all aspects of infection control, including decontamination of dental instruments and equipment, and the following policy must be adhered to at all times. If there is any aspect that is not clear, please ask the Practice Manager or your RCD. Any of our patients might ask about the policy, so make sure you understand it.
		This policy will refer to, and should be read in conjunction with, the following documents:
		Waste Disposal Policy
		Hand Hygiene Policy
		Personal Protective Equipment (PPE) Policy
		Prevention and Management of Sharps Injuries and Body Fluid Contamination
		New Reusable Instrument Policy
		Instrument Decontamination and Storage Policy
		Disinfectant guidelines
		Impression Decontamination Protocol
		Protocol for Manual Cleaning of Dental Instruments
		All staff must be immunised against hepatitis B and a record of their hepatitis B seroconversion held by the Clinic. Medical advice and counselling should sought for those who do not seroconvert or cannot be immunised. In these cases it may be necessary to restrict their clinical activities
		The clinic provides protective clothing, gloves, eyewear and masks that must be worn by dentists and DCPs during all operative procedures. Protective clothing worn in the surgery must not be worn outside the practice premises. For detailed information, see PPE Policy
		Before donning gloves, hands must be decontaminated. Any glove that becomes damaged must be replaced and a new pair of gloves must be used for each patient. Between glove changes and if not contaminated, hands can be decontaminated using an alcohol hand rub. For more detailed information, see Hand Hygiene Protocols and Hand Cleaning Techniques
		Before sterilisation, re-usable instruments should be cleaned either by placing in a washer-disinfector or ultrasonic cleaner. Inspect instruments for residual debris, which if present should be removed by hand and the instrument re-cleaned using an automated process. Instruments that have been cleaned in an ultrasonic bath are then immersed and thoroughly rinsed and dried before being sterilised using an autoclave. Appropriate gloves and eye protection must be worn when handling and cleaning used instruments. All instruments that have been potentially contaminated must be cleaned and sterilised. Single-use items must be discarded, never decontaminated and reused. For more detailed information, see Instrument Decontamination and Storage Policy
		Sterilised instruments should be stored in covered trays / pouches. For more detailed information, see Instrument Decontamination and Storage Policy
		Working areas that have instruments placed on them during treatment will be kept to a minimum, clearly identified and, after each patient, cleaned using [product name].
		Needles must be re-sheathed by the operator using the re-sheathing device and in line with the training provided. Needles, scalpel blades, LA cartridges, burs, matrix bands etc must be disposed of in the yellow sharps container, which should be near the point of use and out of the reach of children. The container must never be more than two-thirds full. For more detailed information, see Prevention and Management of Sharps Injuries and Body Fluid Contamination
		All clinical waste must be segregated and placed in the appropriate sacks or bins provided in each surgery. The sack must be securely fastened when three quarters full, correctly labelled and stored in the designated area. For more information, see Waste Disposal Policy
		All dental impressions must be rinsed until visibly clean and disinfected using Perform (according to the manufacturer’s instructions) and labelled as 'disinfected' before being sent to the laboratory. Technical work being returned to or received from the laboratory should be disinfected and labeled in a similar manner. For more information, see Impression Decontamination Protocol
		In the event of an inoculation injury, the wound should be allowed to bleed, washed thoroughly under running water and covered with a waterproof dressing. The incident should be immediately discussed with your RCD, or a senior dentist, to assess whether further action is needed. Advice on post-exposure prophylaxis can be obtained from [contact name/local occupational health department]. The incident must be recorded in the accident book. For more detailed information, see Prevention and Management of Sharps Injuries and Body Fluid Contamination
		Any spillages involving blood or saliva or mercury will be reported to the Practice Manager or RCD
		Anyone developing a reaction to protective gloves or a chemical must inform the Practice Manager or RCD immediately

Instrument Decontamination Cycle

Protocol for the manual cleaning of dental instruments

		Immersion method
	All personnel involved in the decontamination of dental instruments should be trained in the content and application of this protocol and associated guidance. To minimise the risk to personnel undertaking manual cleaning, the splashing and creation of aerosols should be avoided at all times. Remember: Maintaining a dirty-to-clean workflow procedure will assist in the cleaning process.
	1	Wash hands.
	2	Wear personal protective clothing (PPE).
	3	Prepare sinks, equipment and setting-down areas.
	4	Dismantle and open the instruments, as applicable, ready for immersion.
	5	Fill the clean sink (NOT wash-hand basin) with the appropriate amount of water and detergent (specified for the purpose). Note: ensure correct temperature as recommended by the detergent manufacturer is maintained.
	6	Fully immerse the instruments in the solution and keep under water during the cleaning process to prevent aerosols.
	7	Agitate/scrub the instruments using long-handled brush with soft plastic bristles.
	8	Drain any excess cleaning solution prior to rinsing
	9	Rinse in a second sink with satisfactory potable, freshly distilled or RO water.
	10	After rinsing, drain and dry if instruments are to be wrapped.
	11	Visually inspect all items under an illuminated magnifier ensuring they are clean, functional and in good condition.
	12	Lubricate any relevant items prior to sterilization with a non-oil-based lubricant.
	13	Dispose of cleaning materials safely in accordance with local policy.
	14	Replace cleaning solution and the rinse-water after each use
	15	Complete any relevant documentation

Policy on New Reusable Instruments

	Wherever reasonably practical, new instruments should be disposable, single use items. Before being put into use all new reusable dental instruments should be fully decontaminated
	1	When selecting a new instrument any alternative single-use device that would meet the requirements should be considered
	2	New instruments should be cleaned and sterilized before using for the first time, unless supplied as sterile.
	3	Reusable dental instruments should be separated into:
		Those that can withstand either processing in a washer-disinfector or ultrasonic cleaning; and
		Those that will require manual cleaning (although practices should aim to procure instruments that can withstand automated washer-disinfector processes).
	4	Some instruments consisting of more than one component will need to be dismantled for cleaning. The manufacturer’s instructions should always be followed. Difficult-to-clean serrated handles should be avoided when selecting new instruments, and it should also be ensured that hinges are easy to clean
	5	Items that cannot be immersed in water (for example, electrical and electronic equipment) should be cleaned in accordance with the manufacturer’s instructions.
	6	If recommendations include wiping with a detergent solution, then a clean non-linting cloth plus the recommended detergent solution (to wipe the instrument) should be used. This should be followed by wiping with a clean damp non-linting cloth to remove residues. The instrument should be dried thoroughly using a clean non-linting cloth.
	7	If disinfection with alcohol is advised, the advice given in paragraph 5 should be followed. While the procedure may be recommended, it should be understood that alcohol may have the property of fixing certain contamination

Personal Protective Equipment (PPE) Policy

	When used appropriately, and in conjunction with other infection control measures, PPE forms an effective barrier against transmission of infection.
		Gloves
	1	Gloves are needed:
		To protect hands from becoming contaminated with organic matter and microorganisms;
		To protect hands from certain chemicals that will adversely affect the condition of the skin. Particular care should be taken when handling caustic chemical agents, particularly those used in disinfection and for washer-disinfectors;
		To minimise the risks of cross-infection by preventing the transfer of organisms from staff to patients and vice-versa
	2	Used gloves should be replaced before performing any activity that requires aseptic precautions or when touching equipment that is difficult to clean.
	3	It is important that gloves fit properly if they are to produce the level of protection against anticipated contaminants. The use of latex gloves is subject to local risk assessment (see Practice Risk Assessment). This is partly attributable to reports of long-term allergy development in some users. Vinyl or nitrile gloves should be used wherever possible.
	4	All disposable clinical gloves used in the practice should be CE-marked and should be: • low in extractable proteins (<50 μg/g); • low in residual chemicals; • powder-free.
	5	Gloves other than domestic household types are single-use only. They should be discarded as clinical waste.
	6	Jewellery (for example watches, dress rings, bracelets etc), and long or false nails may damage the integrity of the glove and may pose an infection risk. The Hand Hygiene Policy gives details of the requirements in this area
	7	Glove integrity can be damaged if in contact with substances such as isopropanol or ethanol; therefore, alcohol rubs/gels should not be used to decontaminate gloves
	8	Gloves (except household gloves) should not be washed as liquids may be absorbed into the glove and compromise the efficacy of the barrier.
	9	Domestic household gloves, if used, should be washed with detergent and hot water and left to dry after each use to remove visible soil. Replace these gloves weekly or more frequently if worn or torn or if there is any difficulty in removing soil.

		Face and eye protection
	1	During clinical and decontamination procedures, there is a risk of contaminated fluids splashing onto the face and into the eyes. Therefore, the dental team should ensure protection of their mucosa from splashes and other contaminated fragments that may escape during these procedures.
	2	Facemasks are single-use items and should be disposed of as clinical waste.
	3	Spectacles do not provide sufficient eye protection unless specifically designed for the purpose. A visor or face shield should be worn over spectacles; this gives added protection for prescription glasses.
	4	Eye protection may be reusable but is often difficult to clean. It may be reused if cleaned according to manufacturers’ instructions. This should take place when it becomes visibly dirty and/or at the end of each session. Disposable visors are available and may be used.
	5	Footwear should be fully enclosed, in good order and comply with health and safety guidance. Particular care should be taken concerning the risk sharps injury or of chemical or hot water spillage onto feet.
		Disposable plastic aprons
	1	These should be worn during all decontamination processes.
	2	Aprons should be used as a single-use item and disposed of as clinical waste. Plastic aprons should be changed at the completion of each procedure.
		Clothing, uniforms and laundry
	1	The surgery clothing provided by The clinic is not only suitable for the procedures carried out, but is also used to reinforce our corporate image. Uniforms should be properly fitting, clean and neatly presented
	2	Clothing worn during clinical and decontamination procedures should not be worn outside the practice
	3	Short sleeves allow the forearms to be washed as part of the hand hygiene routine. All staff need to be familiar with the requirements of the Hand Hygiene Policy
	4	Clothing/uniforms can become contaminated with microorganisms during procedures. It is important that freshly laundered uniforms are worn everyday.
	5	Machine-washing clothing for ten minutes with a suitable detergent at a minimum temperature of 60oC will reduce any potential microbial contamination

		Removal of PPE
		Depending on the type of PPE worn, items of PPE should be removed in the following order:
	1	Gloves should be removed first (so that the gloves end up inside-out). Make sure hands do not get contaminated when removing gloves. Wash hands thoroughly, if visibly contaminated, before removing the rest of the PPE (see Hand Hygiene Policy)
	2	Plastic disposable apron: The plastic apron is removed by breaking the neck straps and carefully gathering the apron together by touching the inside of the apron only. Avoid touching the outer contaminated area.
	3	Face mask: Remove the mask by breaking the straps or lifting over the ears and dispose of into a clinical waste receptacle. Avoid touching the outer surface of the mask and do not crush the mask before disposal. Masks should never be left to hang around the neck and should be disposed of immediately after use.
	4	Face and eye protection: Take care not to touch the outer surfaces. Single-use eye protection should be disposed of into the clinical waste receptacle.
	5	Wash hands thoroughly again (see Hand Hygiene Policy)

Prevention and Management of Sharps Injuries and Body Fluid Contamination

		Purpose:
		To protect employees, self-employed providers, contractors, patients and visitors from exposure to blood borne viruses
		Objectives
		To ensure that all staff are aware of preventative measures and post exposure management procedures
		For use by
		All employees and self-employed providers
		Related Policies:
		COSHH Policy Health & Safety Policy RIDDOR Infection Control Policies
		Definitions (Acronyms & Abbreviations used in policy)
		BBV: Blood Borne Viruses
		BNF British National Formulary
		COSHH Control of Substances Hazardous to Health
		EPP Exposure Prone Procedure
		HBsAg Surface protein of Hepatitis B virus - used as a marker of infection
		HBeAg Risk of transmission is higher if this marker is +ve in HBV infected cases
		HBIG Specific human immunoglobulin used as HBV post-exposure prophylaxis
		HBV Hepatitis B virus
		HCV Hepatitis C virus
		HCW Healthcare Worker
		HIV Human Immunodeficiency Virus
		IP Injured Person
		IVS Identified Validated Samples
		OHD Occupational Health Department
		PEP HIV Post-exposure prophylaxis
		PPE Personal Protective Equipment
		Source Person whose blood or body fluids contaminate recipient
		Victim Person exposed to blood or body fluids of another person

		Contents	Page
	Section 1 – Prevention of Sharps Injuries
	1.1 1.2 1.3 1.4 1.5 1.6 1.7	Policy Statement Responsibilities in Relation to Prevention Background Prevention of Exposure to BBVs Safe Practice for the Prevention of Sharps Injuries Pre-Employment/Change of Employment Health Checks Post Employment Health Checks	3 3 3 4 4 4 5
	Section 2 - Management of Sharps Injuries – Patient to HCW Exposure
	2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10	Immediate Management Action to be requested from Occupational Health Action to be requested from A&E PEP considerations Advice for recipients of PEP PEP in pregnancy Choice of PEP drugs Follow up after receiving PEP drugs Source Management Action to be taken by Clinician contacted by OHD or A&E	6 6 7 7 7 8 8 9 9 9
	Section 3 – Management of Sharps Injuries - HCW to Patient Exposure
	3.1 3.2 3.3	Employee to Patient Exposure to Blood Immediate Action Use of PEP	10 10 10
	Section 4 – Training		11
	Section 5 – References		11
	Section 6 – Appendices
	Appendix 1. Routine Hepatitis C Testing Appendix 2. Guidance for obtaining blood test from source patient Appendix 3. Questions in relation to source risk assessment Appendix 4. Needle stick Risk Assessment Tool Appendix 5. Post-Exposure Prophylaxis Sample Policy Appendix 6. PEP Sample Information Sheet Appendix 7 PEP Example interactions and side-effects Appendix 8. Explanatory leaflet on Hep B, C & HIV for Injured Person		12 13 14 15 17 18 19 20

	Section 1 – Prevention of Sharps Injuries
	1.1	Policy Statement
	The Dental Clinic values the health and safety of all employees, self-employed providers, patients and visitors. This policy is to protect them, as far as reasonably practicable, from contracting a blood borne virus (BBV) through accidental exposure to blood or body fluids within the practice
	1.2	Employees Responsibilities
	a	Following safe systems of work
	b	Using and maintaining PPE as appropriate
	c	Informing their manager of any problems with their PPE
	d	Attending their GP or OHD for information on immunisations
	e	Protecting the health and safety of patients and fellow employees
	f	Informing their OHD if they are, or could be, carrying a BBV
	g	Reporting any BBV exposure to their manager and attending their OHD or GP for follow-up investigation and treatment as required
	h	Completing an incident/accident form following any BBV exposure
	i	Attending training on commencement of employment and at regular intervals thereafter
	j	Providing an IVS or result to their GP or OHD prior to clearance for EPP
	k	Attending OHD annually for an IVS to check hepatitis B surface antigen if non-immune and carrying out EPP
	l	To be aware of their HBsAb status and date tested
	1.3	Background
		There are more than twenty dangerous blood-borne pathogens, including Hepatitis B, C and HIV that can be contracted through a sharps injury or body fluid contamination. These, in the healthcare setting, can be transmitted from patient to healthcare worker (HCW), patient to patient, or HCW to patient. Further information on HIV, Hepatitis B and C is contained on the explanatory leaflet in Appendix 8. The greatest risk of transmission of BBVs is through exposure to blood and certain body fluids and tissues. Listed below are the body fluids that should be treated with the same precautions as blood. Cerebrospinal fluid Peritoneal fluid Pleural fluid Pericardial fluid Synovial fluid Amniotic fluid Semen Vaginal secretions Breast milk Any other fluid containing visible blood, including saliva in association with dentistry. Unfixed organs or tissues

	1.4		Prevention of Exposure to BBVs
			The Control of Substances Hazardous to Health Regulations (2002) place a duty on employers to identify hazardous substances, carry out risk assessments and put into place methods of preventing and managing exposures. Employees have a duty to adhere to safe systems put in place by employers to protect their health. These include the correct usage and disposal of equipment. Risk assessment should be carried out on all procedures to identify and manage any hazards by identifying training needs and safe practice as well as devices to minimise the risk. Should personal protective equipment (PPE) be required this must be used. Some examples of PPE are gloves, visors, goggles and aprons.
	1.5		Safe Practice for the Prevention of Sharps Injuries
	1		Dispose of used sharps into a sharps container at point of use
	2		The user of a sharp is responsible for its safe disposal
	3		Do not recap or re-sheath used needles by hand.
	4		Do not pass used sharps from person to person by hand.
	5		Do not put used sharps into a disposable receiver – put directly into a sharps bin.
	6		Have a sharps bin with you when you are using sharps
	7		Do not manually dismantle disposable needles.
	8		The person assembling a sharps container must sign and date it – thereby accepting responsibility for ensuring it is assembled correctly
	9		The person who seals a sharps container must sign and date it thereby accepting responsibility for ensuring it is closed properly
	10		Sharps container must be sealed when two thirds full.
	11		Sharps bins must be stored safely out of easy reach of children (e.g. do not put on the floor).
	12		All clinical waste must be disposed of as in accordance with the waste disposal policy.
	1.6		Pre-employment Health Checks
			Pre-employment and change of employment health checks should be carried out by a GP or OHD to protect patients from BBVs. For employees who carry out Exposure Prone Procedures (EPP) proof of non-carrier status of Hepatitis B is required.

	1.7		Post-employment Health Checks
			Staff who carry out EPP and are not immune to Hepatitis B should attend their OHD annually for a Hepatitis B surface antigen test to ensure they have not contracted the virus. Failure to do so will result in suspension from EPP duties. Occupational Health Departments may recall for relevant staff, but this should be confirmed locally. Staff who contract Hepatitis B will require future testing to determine viral load and advice will be sought from the UK Advisory Panel for HCW Infected with BBVs to determine if they can resume EPP duties. All EPP blood tests must be Identified Validated Samples (IVS). To qualify as an IVS the HCW should show a proof of identity with a photograph when the sample is taken (passport or drivers license). The sample of blood must be taken in the Occupational Health Department. A member of the OHD team should deliver the sample to the laboratory.

Definition of Exposure Prone Procedure (EPP) EPP is defined as 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 procedures include those where the worker’s gloved hands may be in contact with sharp instruments, needle tips or sharp tissues (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.

	Section 2 – Management of Sharps Injuries and Body Fluid Contamination: PATIENT TO HEATHCARE WORKER
	2.1	Immediate Management (First Aid)
	1	Immediately after exposure wash the affected area liberally with soap and water.
	2	Do not scrub the skin as this may damage it.
	3	If a mucous membrane has been exposed e.g. a blood splash into an eye, irrigate the affected site with copious amounts of water. If you wear contact lenses irrigate eyes before AND after their removal.
	4	If a puncture wound has been sustained e.g. from a used sharp object, then encourage free bleeding but the wound should not be sucked.
	5	After taking the first line action detailed above you must inform your duty manager of the incident.
	6	You must attend an Occupational Health Service (normal working hours) or A&E outside of these hours. It is unacceptable to carry on working and not report an exposure incident.
	7	A risk assessment should be carried out by your OHD or A&E to determine if you should be offered PEP, Hepatitis B vaccination or immunoglobulin. For high risk injuries PEP should ideally be commenced within an hour of contamination
	8	Ensure that you complete an accident/incident report as soon as possible but not at the expense of a delay in seeking help. The form can be completed after all appropriate actions have been taken.
	2.2	Action to be Requested from Occupational Health
	a	An employee who reports to their Occupational Health Department after an exposure incident should be seen urgently.
	b	A risk assessment of the nature of the injury and source of body fluid exposure should be undertaken. The risk assessment tool (Appendix 4) will help to determine if Hepatitis B vaccine, immunoglobulin and/or post exposure prophylaxis (PEP) is required.
	c	If PEP is required it should ideally be commenced within one hour of injury however, it is not known how the efficacy will be affected if delayed. PEP can therefore be commenced up to two weeks post injury.
	d	The Hepatitis B status of the injured person should be determined.
	e	Take blood from the IP for save serum and if previous Hepatitis B antibody testing was more than two years ago request a further test.
	f	If the source patient is known a risk assessment should be carried out. Guidance for the assessing clinician can be found in Appendix 2.

		g	Request that the clinician meets with the source patient to discuss the injury and risk assessment. The can be carried out as part of a pretest discussion/counseling, required prior to taking and testing the source patient blood.
		h	Request blood for testing to determine Hepatitis B, C and HIV status of source patient.
		i	If the source patient is not present their GP should be contacted for a risk assessment and to request testing as above.
		j	Ensure that any accidental exposure resulting in the contraction of a blood borne virus is reported as required by RIDDOR.
		k	Report any exposure to HIV, Hepatitis B or C to the Health Protection Agency
		l	Ensure all actions taken are fully documented.
		m	Provide ongoing support to employees who have sustained a sharps injury or body fluid contamination
		n	Provide post exposure testing for the employee following known or suspected occupational exposure to a BBV
		o	Refer an employee to an appropriate specialist if a BBV is contracted following an occupational exposure.
		2.3	Action to be Requested from Accident & Emergency when OHD closed
		a	An employee who reports to an A & E Department after an exposure incident should be seen urgently
		b	A risk assessment of the nature of the injury and source of body fluid exposure should be undertaken. The risk assessment tool (Appendix 4) will help to determine if Hepatitis B vaccine, immunoglobulin and/or post exposure prophylaxis (PEP) is required. Immunoglobulin may be available through the on-call Consultant Microbiologist.
		c	The Hepatitis B status of the injured person should be determined.
		d	Take blood from the IP for save serum and if previous Hepatitis B antibody testing was more than two years ago request a further test.
		e	Contact the clinician caring for the source patient and request a risk assessment. Guidance for the clinician can be found in Appendix 2
		f	Request that the clinician meets with the source patient to discuss the injury and risk assessment. This can be carried out as part of the pretest discussion/counselling required prior to taking and testing the source patient blood.
		g	Request blood for testing to determine Hepatitis B, C and HIV status of source patient
		h	Commence IP on PEP if deemed appropriate through risk assessment and following counselling. An information sheet on PEP can be found in Appendix 6.
		i	Advise IP to contact their OHD for further counselling whether or not they have been prescribed PEP. The OHD may provide further support and guidance as well as refer the IP the Occupational Health Consultant or the GUM Consultant if appropriate.

	PEP should be recommended to HCWs when the risk is considered to be significant/high following assessment e.g. significant injury from a HIV positive source or a high risk patient.
	2.4		What Needs to be Considered Before a HCW Commences PEP
	a		Ideally PEP should be commenced as soon as possible after the injury, preferably within an hour. However as knowledge on the efficacy of the drugs is limited it can be considered for up to two weeks post injury.
	b		PEP should normally be taken for four weeks.
	c		As nausea and diarrhoea are common side effects prescribing a prophylactic anti-emetic and anti-motility may help facilitate adherence to completing the course PEP course. Guidance on typical medication can be found in Appendix 7
	d		The information sheet in Appendix 6 gives the IP details on PEP and its side effects.
	e		If PEP is to be commenced then medications the healthcare worker is taking may interact with PEP drugs. Further guidance can be found in Appendix 7.
	f		The possibility that a female healthcare worker is pregnant should be considered. Urgent pregnancy testing should be carried out on any who are uncertain.
	g		Bloods for baseline liver function/blood biochemistry/amylase and full blood count should be taken before asking a healthcare worker to start taking PEP.
	2.5		Advice for Recipients of PEP
	a		Use a barrier method of contraception until HIV infection is excluded, as during incubation period recipient could be highly infectious to sexual partners.
	b		Avoid conception whilst taking medication
	c		A course of PEP normally lasts 4 weeks. Advise the healthcare worker to report any side-effects. Nausea is a common problem and you can be prescribed an anti-emetic to help prevent this
	d		An appropriately experienced physician should follow up all HCW commenced on PEP and this should be organized by OHD. A weekly assessment by Occupational Health may also be of benefit
	e		All staff must be offered follow-up counselling (Occupational Health & GUM) whether or not they have received PEP or declined the offer of PEP
		2.6	PEP in Pregnancy
			Pregnancy does not preclude the use of HIV PEP and expert advice should be sought where PEP is considered necessary. Urgent pregnancy testing should be arranged for any worker who cannot rule out the possibility of pregnancy, as part of the evaluation prior to them reaching a personal informed decision about starting PEP.

	2.7		Choice of PEP Drugs
			Details on typical PEP drugs can be found in the PEP Procedures; Appendix 5
	2.8		Follow-up of HCW who Receives HIV PEP Drugs
	a		The Occupational Health Department should arrange follow up of the HCW together with the Consultant G.U.M. Physician.
	b		Periodic testing for HIV antibodies should be offered. The G.U.M. Consultant should also advise and monitor the HCW on drug therapy, which is normally continued for a period of up to 4 weeks.
	c		A healthcare worker occupationally exposed to HIV who has declined the offer of PEP should be seen by a Senior Occupational Health Nurse or Physician and have follow-up counselling, and be offered post-exposure testing and medical evaluation
	2.9		Source Management
			The injured person ideally should not carry out source patient risk assessment and pre-test counselling in relation to a sharps injury or body fluid contamination. The OHD or A&E should contact another clinician involved with the source patient care and request the relevant risk assessments.
		2.10	Action to be Taken by Clinician Contacted by OHD or A&E
		a	Check the source patient’s notes for risk factors.
		b	Approach the source patient to gain consent for testing (see Appendix 2)
		c	It is unusual for a source patient to refuse testing if an explanation for the test is given. The explanation should include informing the source that a member of staff received an injury and that testing would reassure them or ensure appropriate treatment is started.
		d	Asking all patients for consent to carry out HIV, Hepatitis B and C testing post injury avoids the appearance of discrimination against people perceived as belonging to groups associated with higher than average HIV prevalence. Appendix 3 suggests areas that might be covered by the clinician who has to obtain consent from a patient. It is not expected that the clinician should need to have an extensive knowledge of Hepatitis B, C or HIV. If the circumstances of the incident are tactfully explained then many patients will not withhold consent
		e	Where a source patient is known to be or suspected of being 'high risk' Occupational Health must be informed immediately (out of hours A&E) - for optimal management of the recipient.
		f	If the source patient withholds consent they should be deemed a high risk.
		g	Parental consent should be sought for the testing of children
		h	A child under six months should not be tested following a sharps injury. The child’s mother should be approached and tested instead (with informed consent)
		i	Any source who is newly diagnosed HIV positive as a result of this process will need immediate post-test counselling and assurance of confidentiality.

	Section 3 – Management of Sharps Injuries and Body Fluid Contamination: HCW TO PATIENT EXPOSURE
	3.1	Employee to Patient Exposure to Blood (Bleed back)
	To minimise the risk associated with bleed back HCWs who are HIV positive or carriers of Hepatitis B or C are restricted from performing EPP. HCWs who know or suspect they have a BBV should inform their Occupational Health Service. Failure to do so may breach their duty of care to patients.
	Circumstances that could allow the transmission of blood-borne viruses from health care worker to patient include:-
	a	Visible laceration occurring to a HCW’s hand in circumstances where the patient’s open tissues or mucous membranes could be contaminated with the HCW’s blood
	b	Visible bleeding of a HCW from any other site (e.g. nosebleed) leading to significant bleed-back into a patient’s open tissues or mucous membranes.
	c	An instrument or needle contaminated with the blood of the HCW is inadvertently introduced into the patient’s tissues.
	3.2	Immediate Action Following Bleed Back Incident
	a	Stop the procedure as soon as reasonably practicable, wash and dress the wound and finish the procedure as soon as is practicable.
	b	Ensure that GP or Occupational Health is informed without delay so that a risk assessment can be conducted.
	c	Out of hours report the incident to an appropriate Senior Manager to conduct a risk assessment.
	d	If the risk assessment is deemed not to be significant the incident should be reported and treated as a sharps injury. It should be recorded in the HCWs occupational health records and the patient does not need to be informed
	e	If the risk assessment is deemed significant the HCW should inform their Line Manager and attend their Occupational Health Service or GP when next open.
	f	The Occupational Health service should test for HIV, Hepatitis B and C. Informed consent should be obtained prior to testing. The pre test discussion should cover both occupational and personal implications of a positive test result. Details of this should be noted in the OH record. All testing is confidential and anonymised.
	g	If the test results are negative the patient should not be informed
	h	If a HCW refuses to be tested following a bleed back injury they will be suspended from EPP.
	3.3	Use of PEP Following Bleed Back Incident
		Where a patient has been accidentally exposed to the blood of a health care worker who is known or found to be HIV infected, PEP is recommended. Advice should be sought from a HIV specialist consultant (GUM Consultant) on the risk/benefit ratio for sick patients

	Section 4 – Training
	1		Induction training for clinical staff should include information on the prevention and management of sharps injuries.
	2		Sharps injury prevention and treatment to be included in an annual infection control update training for clinical staff.
	3		Individual and/or group training should be included when new sharps are being introduced to the practice
	Section 5 – Key References
			Blood-borne viruses in the workplace HSE (2001) Control of Substances Hazardous to Health (2002) Health and Safety at Work etc Act 1974 Hepatitis C Essential Information for Professionals NHS (2004) HIV Infected Health Care Workers, Department of Health (2005) The management of health, safety and welfare for NHS staff, NHS Employers (2005) HIV Infected Health Care Worker: Guidance on Management and Patient Notification (July 2005) HIV Post-exposure prophylaxis, Guidance from the UK Chief Medical Officers’ Expert Advisory Group in AIDS (Revised 2004) Immunisation Against Infectious Disease (2006) Department of Health www.dh.gov.uk The Health Act 2006: Code of Practice for the Prevention and Control of Health Care Associated Infections (Department of Health) Prevention and Management of Sharps Injuries and Body Fluid Contaminations. Bedford Hospitals NHS Trust 2009
			In situations where local advice cannot be obtained, seek advice from the following sources: ENGLAND: Health Protection Agency Centre for Infections, 61 Colindale Avenue, London NW9 5EQ  020 8200 4400 SCOTLAND: Health Protection Scotland, Clifton House, Clifton Place, Glasgow G3 7LN  0141 300 1100  hpsenquiries@hps.scot.nhs.uk WALES: PHL Cardiff, The University Hospital of Wales, Heath Park, Cardiff CF14 4XW  0290 742718

			APPENDIX 1
			Routine Hepatitis C Testing
			The following groups are routinely test for Hepatitis C carrier status prior to clearance being issued by NHS Occupational Health Departments New entrant to the NHS who carry out EPP Employees returning to the NHS who carry out EPP Pre training for certain occupations e.g. Midwifes, podiatrists, operating department practitioners, dentists, paramedics Junior doctors prior to first EPP post Staff who carry out EPP and have been working overseas. This list is subject to change if further guidance is issued by the Department of Health

		APPENDIX 2
		Guidance on Obtaining Consent for a Blood Test from the Source Patient
	This is a straightforward procedure but one that can cause anxiety for the clinician who has to approach the source patient after a needle stick incident has occurred. The following notes are designed to help in dealing with this situation but they cannot be comprehensive in their coverage because the approach made to each patient must be tailored to that individual's level of knowledge; current illness; cultural beliefs etc. It must be remembered that obtaining consent for a blood test for a blood borne virus is not very different from obtaining consent for any other medical procedure. Patients must be told all relevant details but clinicians are not expected to be experts in the field. The pre-test discussion does not need to take very long but sufficient time must be allowed to check the patient has understood what they have been told and for them to ask questions. Firstly, carefully explain what has happened e.g. a member of staff has sustained a sharps injury or body fluid contamination. Tell the patient that very occasionally certain illnesses like hepatitis can be spread from one person to another by contact with blood. Tell them a little bit about viral hepatitis if they do not already know. Move onto telling them that HIV, the virus that causes AIDS can also be spread by contact with blood. Tell them a little bit about HIV/AIDS. This does not need to be an in-depth discussion. Ask the patient if they consider that they may be at risk of having HIV. This may entail giving guidance on how this could be contracted.		Advise the patient that the result will be beneficial to the healthcare worker and determine what if any treatment and/or they should have. The patient should be advised that in the event they were positive for one or more of these diseases then knowing this would allow some early treatment of the healthcare worker to try and prevent them developing the disease as well. Tell them that their blood would be tested for hepatitis B, C and HIV. The test will be confidential but they would be told the result and the occupational health service will be informed so that the affected staff member can be re-assured or commence treatment. Inform the patient that if they consent for testing particularly for HIV then in the event the result is positive this might lead to them experiencing difficulty in obtaining such things as life insurance cover. Having the test itself with a negative result should not cause such problems. It is important that they are told that if any of the results are positive then they may need further counselling and there maybe implications for their partner as well e.g. whether or not the partner should be tested/informed of result etc. They need to be aware that whilst there are treatments available for HIV and Hepatitis C there is still no cure. However, early detection of HIV and hepatitis C might be beneficial in improving the efficacy of treatments currently available. The patients consent should also be sought to document the pre-test discussion, reason for testing and results in their notes. It should be clearly stated in their notes that the risk assessment, discussion and testing was following a sharps injury or body fluid contamination sustained by a member of staff. If they object to this, discuss their reasons, but if they still refuse then the information can, with their consent be stored in Occupational Health. You may need to talk to the OH consultant in these circumstances.

			APPENDIX 3
			Questions to be Asked by Clinician Carrying Out a Risk Assessment on a Source Patient Following a Sharps Injury or Body Fluid Contamination
			Has the patient ever been told that he/she has ever had Hepatitis B? Has the patient ever been told that he/she has ever had Hepatitis C? Has the patient ever been told that he/she has HIV? Has the patient ever injected drugs or shared needles? Has the patient ever worked as a sex worker? Is the patient homosexual or bisexual (males only)? Has the patient had a partner that any of the above questions apply to? Does the patient originally come from outside the UK? Where? Has the patient ever lived and/or worked outside the UK? Where? Has the patient ever received blood or blood products?

			APPENDIX 4
	Needlestick Risk Assessment / Action Chart
	1. Assess the nature of the injury and type of exposure e.g. a hollow bore needle with blood present. Look down the list in Section A and select the description that best fits the Sharps injury or body fluid contamination. Select only one description’s score. 2. Repeat this process for sections B and C. In section D you must ask the injured healthcare worker if they either know their hepatitis B status or if not, the number of vaccinations they have had. 3. You should now have four different scores - one from each section. 4. To determine whether or not HIV post exposure prophylaxis (PEP) might be required add together the scores for sections A and B and look at the table overleaf. 5. To determine whether or not a hepatitis B vaccination etc might be required add together the scores from sections A, C and D and consult the table overleaf.
	Section A - Description of Contamination				Score
		Contact with skin		Blood or other high-risk body fluid in contact with healthy intact skin	No action
				Blood or other high-risk body fluid in prolonged contact with broken/abraded skin e.g. an area of eczema	1
				Broken skin contact with sputum contaminated with visible blood e.g. patient spits at healthcare worker	1
				Broken skin contact with sputum with no visible blood e.g. patient spits at healthcare worker	0
		Mucocutaneous		Mucocutaneous exposure e.g. eye/mouth splash with a high-risk body fluid e.g. blood.	1
				Mucocutaneous contact with sputum, saliva etc contaminated with visible blood e.g. patient spits at healthcare worker.	1
				Mucocutaneous contact with sputum, saliva etc with no visible blood e.g. patient spits at healthcare worker	0
		Hollow bore needle		Superficial injury with hollow bore needle and visible blood	3
				Superficial injury with hollow bore needle and no visible blood	2
				Significant injury with hollow bore needle with visible blood	5
				Significant injury from hollow bore needle with no visible blood	4
		Solid bore needle or other sharp		Superficial injury with solid bore needle/instrument with visible blood	3
				Superficial injury with solid bore needle/instrument with no visible blood	2
				Significant injury from solid needle/instrument with visible blood	4
				Significant injury from solid needle/instrument with no visible blood	3
		Bite		Bite from a patient causing abrasion or penetrating injury of skin. Patient has bleeding gums	4
				Bite from a patient causing abrasion or penetrating injury of skin. Patient not known to have bleeding gums	3

	Section B – Patient risk assessment - HIV						Score
			Patient with AIDS or seroconversion illness				5
			Patient HIV positive but asymptomatic				3
			High risk patient e.g. lifestyle risks or has hepatitis B or C				2
			No high risk history and not known to have hepatitis B or C				0
			Source patient unknown (unless from high risk area)				-2

	Section C – Patient risk assessment – Hepatitis B							Score
			Patient known to be a hepatitis B carrier e.g. hepatitis B surface antigen positive					5
			High risk patient e.g. lifestyle risks or has HIV or hepatitis C					2
			Low risk patient e.g. no identifiable lifestyle risks and does not have either HIV or hepatitis C					0
			Source patient unknown (unless from high risk area)					0
	Section D – Healthcare Worker’s hepatitis B status							Score
			Health care worker immune to hepatitis B					1
			Healthcare worker not sure of hepatitis B immunity but has had at least 2 or more previous vaccinations					3
			Healthcare worker has either only had one vaccination to date or none at all.					9
			Healthcare worker knows they are a non-responder to hepatitis B vaccination					10
			Healthcare worker genuinely cannot remember if they have had vaccinations or not					6

	Actions
			Is PEP required?
			Add together scores from section A and section B.
			• 6 - 10 PEP is recommended • 4 - 5 Make HCW aware of PEP, offer PEP if requested • 3 or less PEP not required
			Is hepatitis B vaccination etc required?
			Add together scores from sections A, C and D.
			• 13 or more Hepatitis B booster required plus immunoglobulin • 4 - 12 Hepatitis B booster required • 0 - 3 No hepatitis B booster required.

		APPENDIX 5
		Combivir (Post-Exposure Prophylaxis) Example Policy
		Introduction The Department of Health (DOH) HIV PEP guidelines provide support and information for any person significantly exposed to the risk of HIV infection in a healthcare setting. There are 3 types of exposure associated with significant risk: 1. Percutaneous injury (from needles, instruments, bone fragments, bites that break skin etc.) 2. Exposure of broken skin (abrasions, cuts, eczema etc.) 3. Exposure of mucous membranes including the eye. History taking may highlight the need for other prophylactic interventions such as Hep B immunisation. The overall risk for HIV transmission after percutaneous exposure to HIV infected blood in the healthcare setting is 3 in 1000 injuries. After mucocutaneous exposure the risk is less than 1 in 1000 injuries. There are currently three classes of antiretroviral drugs licensed for the treatment of HIV infection. No antiretroviral has been licensed for post-exposure prophylaxis and zidovudine is the only drug for which there is evidence supporting its use in achieving a reduction of risk of HIV transmission following occupational exposure.		This policy recommends 1 month’s treatment with: Combivir (containing zidovudine 300mg & lamivudine 150mg) one tablet twice a day and Kaletra (containing Lopinavir 200mg & Ritonavir 50mg tablets) two tablets twice a day Where the occupational exposure is not considered significant, the healthcare worker should be advised that the potential side effects and toxicity of taking PEP outweigh the negligible risk of transmission posed by the type of exposure. Results from animal studies suggest that HIV PEP is most effective if taken within the hour. However, longer periods after exposure are not considered an absolute contraindication to PEP. Immediate Action The exposure site should be washed liberally with soap and water, but without scrubbing. Antiseptics and skin washes should not be used. Free bleeding of puncture wounds should be gently encouraged but not sucked. Exposed mucous membranes (including conjunctivae) should be irrigated copiously with water. During normal working hours, the healthcare worker should report to their Occupational Health service who will liaise will the GUM Clinic Outside normal working hours, the Accident & Emergency Department should be the first point of call
		.

		APPENDIX 6
	Combivir (Post-Exposure Prophylaxis) Example Information Sheet
	What does the PEP pack contain?
	This pack contains 1. A 6 day supply of Combivir (zidovudine 300mg plus lamivudine 150mg) Dose: ONE tablet TWICE a day (12 tablets). 2. And one month’s supply of Kaltera tablets (Lopinavir 200mg plus Ritonavir 50mg) Dose: TWO tablets TWICE a day (120 tablets). It is important that you do not run out of medication. Please make an appointment with Occupational Health as soon as possible.
	How long do I take treatment for?
	A four-week course of treatment with both drugs is recommended. Important: Please do not start taking these tablets until you have read all the enclosed information. If you decide not to take these tablets then do not open the container but return it to the hospital pharmacy department. If you do decide to proceed and take these medicines, then take any remaining supply to your follow-up appointment. The doctor should give you a prescription to obtain a further supply of the Combivir tablets only to complete the four weeks course, (as you should have the appropriate amount of Kaletra tablets remaining)
	How should I take the tablets?
	Combivir There are no food restrictions. Combivir can be taken with food or on an empty stomach. Kaletra Take with or without food, swallowed whole do not crush or chew. It is recommended that treatment should be started as soon as possible. Take the tablets regularly every twelve hours. It is important that you do not miss any doses.
	What are the possible side effects?
	Combivir Common: nausea, vomiting, headache, diarrhoea, cough, abdominal pain/cramps, muscle pain, tiredness, flu-like symptoms, difficulty in sleeping Uncommon: pancreatitis (inflammation of the pancreas) anaemia (a low red blood cell count), neutropenia (a low white blood cell count), peripheral neuropathy (numbness in the hands or feet), liver abnormalities Kaletra Common: diarrhoea, increased cholesterol, and abnormal liver function tests, insomnia, headaches, nausea, vomiting, abdominal pain, gastrointestinal disorder, rash. Uncommon: Infections, anaemia, endocrine disorders, palpitations, hyperglycaemia, dehydration, cardiac disorders

			APPENDIX 7
	PEP -Drug Interactions and Side Effects
			For Nelfinavir these include: • Analgesics: methadone • Antiarrhythmics including amiodorone, quinidine • Antibacterials including rifabutin, rifampicin • Antidepressants St John’s Wort • Antiepileptics: levels possibly reduced by carbamazepine, primidone, reduces phenytoin levels • Antimalarials: artemether/ lumefantrine • Antimuscarinics; solifenacin, tolterodine • Antipsychotics: aripiprazole, pimozine, sertindole • Antivirals: indinavir, ritonavir, saquinavir, lopinavir • Anxiolytics and hypnotics: midazolam • Barbiturates • Ciclosporin • Cilostazol • Cytotoxics: paclitaxel • Diuretics: eplerenone • Ergot alkaloids: ergotamine, methysergide • 5HT Agonists: eletriptan • Ivabradine • Lipid-regulating drugs: atorvastatin, simvastatin • Oestrogens • Progestogens • Sildenafil • Tacrolimus
			Interactions with Zidovudine include • Increased toxicity with nephrotoxic and myelosuppressive drugs • Analgesics; NSAIDs, methadone • Antibacterials: clarithromycin, rifampicin • Antiepileptics: phenytoin, valproate • Antifungals: fluconazole • Antimalarials: pyrimethamine • Antivirals: gancyclovir, ribovarin, stavudine, tipranovir • Atovaquone • Probenecid
			Interactions with Lamivudine include • Antibacterials: Trimethoprim • Antivirals: emtricitabine, foscarnet, ganciclovir, zalcitabine
	Side Effects with these agents are numerous (Refer to BNF). Most commonly patients require treatment for nausea, vomiting and diarrhoea.

			APPENDIX 8
	Explanatory Leaflet on Hepatitis B, C, & HIV for Injured Person
	You have suffered a needle stick or sharps injury or have been exposed via mucous membrane/conjunctiva to blood or body fluids. Blood and body fluids may contain viruses, including Hepatitis B virus (HBV), Human Immunodeficiency virus (HIV) and Hepatitis C virus (HCV). Because we do not necessarily know who is carrying any of these viruses all blood and high-risk body fluids are treated as potentially infectious. You have reported exposure to blood or body fluids and the exposure has now been referred to the local Occupational Health Department (OHD). You have done the correct thing by reporting the incident as: • It may help to talk about it • You may need extra protection against Hepatitis B or HIV • You may need follow up Here are some facts about the risks associated with each of these viruses: HBV The chance of an unvaccinated healthcare worker becoming infected with HBV after a needle stick injury involving a carrier of HBV may be as high as 1 in 3. Clinical healthcare workers are offered vaccination against this virus and the Occupational Health Department will be able to tell you whether you are protected or whether you need a booster dose of vaccine to ensure continuing protection. On rare occasions, you may be one of the few unvaccinated workers and you will then start a course of vaccination. In all cases, if the patient is not a carrier of HBV then there is no risk to you and the Occupational Health Department will use the incident as an opportunity to review your protection against this virus. If you have not previously been vaccinated, it makes good sense to accept the offer so as to protect yourself in the future from a preventable infection. HIV The risk of becoming infected with HIV due to a needle stick injury involving a known HIV positive patient is about 1 in 300. The risk of acquiring the virus through mucous exposure is less than 1 in 1,000. If you have been exposed to blood or high risk body fluids from a known, suspected, HIV positive patient, you will be offered post exposure prophylaxis for 4 weeks starting as soon as possible and preferably within one hour of the incident. In such a case, this will already have been discussed with you. If the sharps injury you have sustained was from an unknown donor (e.g. a carelessly discarded needle) the risk of acquiring HIV is so remote that post exposure prophylaxis is not recommended. This is for two reasons:		a) The number of HIV positive people in the population is low b) Discarded needles usually contain only insignificant amounts of blood, if any. You may well be anxious over the risk of acquiring HIV whether or not the status of the patient is known, and therefore it is important that the Occupational Health Department discusses your concerns with you HCV (Hep C) HCV is also carried in the blood by some people but the number carrying this virus in the population is unknown. HCV causes infection of the liver, and this infection may go on to become chronic. The most common method of spread was previously via blood transfusion, but now all blood is screened for this virus and not used if the donor is a carrier. The risk of acquiring this virus from a significant needle stick injury involving a carrier of HCV is uncertain but is estimated to be approximately 1 in 30. To test for this virus we will need to have a sample of your blood 6 months after the injury and this will be bested for evidence of HCV infection. At present, neither a vaccine nor a drug, which will prevent infection, is available. However, treatment for established infection is available. If the source patient is HCV positive you will be offered testing at 6 weeks, 12 weeks and 6 months. This is to determine at an early stage if you have contracted the virus so treatment can commence. What happens next? If you know the source patient, this patient will be asked to provide a sample of blood, which, if they consent to, will be tested for Hep B, Hep C and HIV The sample of blood collected from you may be tested for antibodies to HBV depending on your vaccination status. It will then be saved for up to 2 years in case any further tests are indicated at a later stage. If follow up appointments are arranged, please make every effort to keep them. If you develop any illness in the interim or plan to move to a different workplace, please tell the person who is providing your post-exposure care.

Surface and Equipment Decontamination Policy

	General Decontamination Principles
	The dental practice should have a local protocol clearly outlining surface- and room-cleaning schedules. The cleaning process will be most effective if the more contaminated areas are cleaned first. Materials and equipment used to clean clinical areas and other higher-risk areas should be stored separately from those used for general and nonclinical areas. Simple records should be maintained in accordance with the HCAI Code of Practice.
	Commercial bactericidal cleaning agents and wipes are helpful in maintaining cleanliness and may also reduce viral contamination of surfaces. Care should be taken in the use of alcohol wipes, which – though effective against viruses on clean surfaces – may fix protein and biofilm. However, the careful use of water with suitable detergents, including those CE-marked for clinical use, is satisfactory provided the surface is dried after such cleaning.
	Cleaning equipment should be stored outside patient care areas.
	If instruments become contaminated (through, for example, being dropped or being placed in a dirty area), they should be sent for further reprocessing.
	Cleaning centres on simple techniques using disposable cloths wetted with clean water and a detergent.
	Dry cleaning should be avoided wherever possible as this may result in dust suspension
	Care should be taken to keep water well away from electrical devices, even though many of those provided in dentistry will have water-resistant housings.
	Soft toys are often difficult to clean and should accordingly not be provided within practices
	Decontamination of Treatment Areas
	The patient treatment area should be cleaned after every session using disposable cloths or paper towels – even if the area appears uncontaminated.
	Areas and items of equipment local to the dental chair that need to be cleaned between each patient include: local work surfaces; dental chairs; curing lamps; inspection lights and handles; hand controls including replacement of covers; trolleys/delivery units; spittoons; aspirators; X-ray units.
	Areas and items of equipment that need to be cleaned after each session include: taps; drainage points; splashbacks; sinks.
	Spittoons and aspirating units on Castellini equipment should be washed through at the end of a session using Ster 3. Ster 3 should be prepared by adding 3 measuring caps of product (3 x 21ml) to 1 litre of hot water NOTE: This material has a recognised health risk (COSHH Group 2 rating), with the potential to cause eye or skin irritation. PPE is needed (gloves and eye protection) during preparation and handling For more detailed information, see the COSHH Report
	Aspirators on Castellini equipment should have 2 VF Control anti-foaming tablets placed into the aspirator filter at the start of each day NOTE: This material has a low health risk (COSHH group 3 rating). PPE is recommended (gloves) during handling For more detailed information, see the COSHH Report Data Sheets on the Intranet
	In addition, cupboard doors, other exposed surfaces (such as dental inspection light fittings) and floor surfaces, including those distant from the dental chair, should be cleaned daily.
	Items that need to be cleaned at weekly intervals include: window blinds (if present); accessible ventilation fittings; other accessible surfaces such as shelving, wall display units, wall poster holders, X-ray viewing boxes and shelves in cupboards.
	Disposa-Shield single-use covers should be used to cover inspection light handles, headrests and tubings. These should not be taken as a substitute for regular cleaning. Covers should be removed and surfaces should be cleaned after each patient contact.
	Covers on keyboards should be changed or washed at frequent intervals. This should be regarded as a useful priority.
	After some clinical procedures, it is necessary to start cleaning as soon as care of the individual patient is complete. In these cases, staff should not wait until the end of the session to start cleaning the area.
	Intra-oral radiology film holders are potential sources of cross infection. This will require the use of steam sterilization following washing and disinfection
	For blood spillages, care should be taken to observe a protocol that ensures protection against infection. A solution with a yield of at least 1000 ppm free chlorine should be used. Contact times should be reasonably prolonged (not less than five minutes). A higher free chlorine yield of up to 10,000 ppm is useful, particularly for splash contamination. The process should be initiated quickly and care should be taken to avoid corrosive damage to metal fittings etc. Alcohol should not be used within the same decontamination process. Norsan Effervescent Chlorine Tablets should be used to produce a fresh solution: 1 Tablet in 1 litre of water gives available chlorine at 1000ppm 1 tablet in 100ml of water gives available chlorine at 10,000ppm NOTE: These materials have a recognised health risk (COSHH Group 1 rating): Chlorine gas has an Occupation Exposure Limit with the potential to cause lung, eye or skin irritation. PPE is needed (gloves, disposable gown and eye protection) during preparation and handling. Ensure adequate ventilation For more detailed information, see the COSHH Report
	Dental Unit Water Lines (DUWL)
	Self-contained water bottles (bottled water system) should be removed, flushed with distilled or RO water and left open to the air for drying overnight. They should be stored inverted.
	Where visual contamination is present, flushing with a suitable disinfectant followed by thorough washing is necessary. Perasafe should be used for Castellini equipment Perasafe should be prepared by adding 1 measure of powder (16.2g) to 1 litre of warm water NOTE: This material has a recognised health risk (COSHH Group 2 rating), with the potential to cause eye or skin irritation. PPE is needed (gloves and eye protection) during preparation and handling, and breathing the dust should be avoided For more detailed information, see the COSHH Report
	DUWLs should be flushed using the automated cycle on Castellini units at the beginning and end of the day and after any significant period when they have not been used (for example, after lunch breaks). In addition, they should also be flushed for at least 20–30 seconds between patients. Whilst these actions have been shown to have only a small effect on biofilm buildup within the DUWL system, they do usefully reduce microbiological counts in the water delivery tube during the period when patients are likely to be exposed..
	For dental surgical procedures, surgical flaps or other access into body cavities involving irrigation, the use of sterile water or sterile isotonic saline provided from a separate single use source is recommended