NEEDLESTICK AND CONTAMINATION INJURY POLICY

Version: 5
Ratified by: Senior Management Team
Date ratified: January 2017
Title of originator/author: Consultant Occupational Health Physician, Taunton
and Somerset NHS Foundation Trust; Amended for
Somerset Partnership by Head of Infection
Prevention and Control/Decontamination Lead, and
Well@Work Lead
Title of responsible
Clinical Governance Group
committee/group:
Date issued: January 2017
Review date: January 2020
Relevant Staff Groups: All staff working in areas where clinical care is
delivered

This document is available in other formats, including easy read summary versions and other
languages upon request. Should you require this please contact the Trust’s Equality and
DOCUMENT CONTROL Diversity Lead on 01278 432000

Needlestick & Contamination Injury Policy

V5 -1- January 2017
DOCUMENT CONTROL
Reference Version Status Author
LS/Aug/10/N&CP 5 Final Head of Infection Prevention and Control/
Decontamination Lead, and Well@Work Lead
Amendments: Amended to reflect the acquisition of Somerset Community Health
and changes to the Trusts governance structure and to ensure compliance with the
Trusts revised policy for Development and Managing Organisation-wide Procedural
Documents. July 2015: Reviewed and amended to ensure continued compliance with
national guidance and to reflect Occupational Health Provider name change.
4.1 - updated to ensure relevance for all Sompar staff, including those based outside
of Somerset.
Document objectives: To ensure that any contamination injury (e.g needlestick,
sharps injury, bite, scratch or blood or bodily fluid splash) is managed appropriately
and safely
Intended recipients: All staff including permanent, temporary, full-time, part-time
staff and locums, bank staff, volunteers, trainees and students.
Committee/Group Consulted: Health, Safety and Security Management Group;
Clinical Governance Group, Infection Prevention and Control Assurance Group

Monitoring arrangements and indicators: As described within Section 14.

Training/resource implications: as indicated within the Trust’s Staff Training Matrix
(Training Needs Analysis) referred to in Section 11.
Clinical Governance
Approving body and date Date: November 2016
Group
Formal Impact Assessment Impact Part 1 Date: August 2016
Clinical Audit Standards No Date: N/A
Senior Management
Ratification Body and date Date: January 2017
Team
Date of issue January 2017
Review date January 2020
Head of Infection Prevention and
Contact for review
Control/Decontamination Lead
Lead Director Director of Governance and Corporate Development

CONTRIBUTION LIST Key individuals involved in developing the document

Name Designation or Group
Karen Anderson Head of Infection Prevention and Control/Decontamination Lead
Dawn Coleman Well@Work Lead

Optima Health Consultant Occupational Health Physician , Optima Health

Infection Prevention and Control Assurance Group
All members
Health, Safety and Security Management Group
Clinical Governance Group
Andrew Sinclair Equality & Diversity Lead
Michele Crumb Head of Risk
Jean Glanville Claims and Litigation Manager

Needlestick & Contamination Injury Policy

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CONTENTS
Section Summary of Section Page
Doc Document Control 2
Cont Contents 3
Action to be taken in the event of a contamination
Diagram 4
injury to NHS staff
1 Introduction 5
2 Purpose & Scope 5
3 Duties and Responsibilities 7
4 Explanation of Terms used 10
Procedure to follow in the event of a Contamination
5 11
Injury
6 Prophylaxis after exposure to Hepatitis B 13
7 Exposure to Hepatitis C 15
Guidelines on pre-test discussion before HIV testing
8 15
and testing for other Blood Borne Viruses
Post Exposure Prophylaxis following occupational
9 17
exposure to HIV
10 Management of Incidents and Risk Assessments 20
11 Training Requirements 21
12 Equality Impact Assessment 21
13 Counter Fraud 21
14 Monitoring Compliance and Effectiveness 21
Relevant Care Quality Commission (CQC)
15 23
Registration Standards
References, Acknowledgements and Associated
16 24
documents
17 Appendices 24
Appendix A Sample of Pathology Forms 25
Appendix B How Do I Counsel Source Patient For Consent To 27
Blood Test?
Appendix C Safe Handling and Disposal of Sharps 28

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 ACTION TO BE TAKEN IN THE EVENT OF A CONTAMINATION INJURY TO
MENTAL HEALTH AND COMMUNITY DIRECTORATE STAFF

Sharps injury, bite or Blood or body fluid splash Blood or body fluid splash
contaminated needlestick, in eyes or mouth on broken skin
scratch

+ First Aid + First Aid + First Aid

Encourage bleeding & wash under Irrigate under running water Wash under running
running water and cover water and cover

Report incident to Senior Staff on Duty

Refer to Needlestick and Contamination Injury Policy
Complete DATIX form

Immediately contact Occupational Health (OPTIMA)

0844 826 0308
If out of hours answer phone will provide guidance on actions to be taken

Is source patient known to be or high risk of being HIV positive? NO

YES
(Discuss with source patient’s doctor/medical team)
contact details
IMMEDIATE ACTION IS NEEDED: IDEALLY PEP Take 6ml clotted blood sample
TO BE GIVEN 24-48 HOURS POST INJURY from recipient for “save serum”
Contact the Medical Registrar on call at local to be sent to local virology
District General Hospital (DGH) laboratory, with report to
Optima Occupational Health

Medical Registrar should obtain the Post

Exposure Prophylaxis for HIV (PEP) information
pack located in A&E at local DGH NO Is source patient known and able to
give informed consent?

YES
Arrange transport of injured HCW to A&E at local
DGH if necessary Optima Occupational
Health will assess need for Source patient’s medical team
Hepatitis B booster (HIGG will explain issue and obtain
See Medical Registrar immediately for risk for non responders) and INFORMED CONSENT from
assessment. PEP if indicated should be offer serial testing donor
commenced as soon as possible (ideally within
one hour of the injury).
6ml clotted blood sample is collected from
source patient for Hep B surface antigen.
3-day pack of PEP drugs is located in A&E at Hep C antibodies and HIV antibodies. Send
local DGH to local virology laboratory, with copy to
Optima Occupational Health Service

Optima Occupational Health Service will follow up results,

advise of any other action required, and offer serial testing
for injuries from unknown donors or donors who are If source patient is Hepatitis B surface
infected with HIV, Hepatitis B and or Hepatitis C. antigen positive then recipient may require
a Hepatitis B booster (HIGG for non
responders) within 24 to 48 hours of injury
Manager to review the incident. How could it have been prevented? (may need to go to A & E out of hours).
Contamination injuries involving donor who are positive for Hepatitis B,
Hepatitis C or/and HIV should be reported under RIDDOR
Recipient = Injured health care worker
Source patient = patient involved in the
Needlestick & Contamination Injury Policy contamination injury. Source patients who
V5 -4- refuse testing should be treated2017
January as high risk.
1. INTRODUCTION

1.1 Somerset Partnership NHS Foundation Trust is committed to caring for the
health and safety of its employees. The Trust has a duty to its staff, patients,
visitors and contractors to ensure that the risk of receiving a contamination
injury is kept as low as is reasonably practicable.

1.2 Injuries of this kind not only cause obvious injury and distress to employees,
it also stops patients being treated and leads to increased sickness absence
and poor morale.

1.3 Through suitable and sufficient risk assessments, robust reporting systems,
training and safe systems of work, the Trust aims to reduce the risk of
contamination injuries to it’s employees so far as is reasonably practicable.

1.4 This policy should be read in conjunction with the Trust’s Risk Management
policy, Untoward Event Reporting Policy and the Healthcare (Clinical) Waste
Policy.

2. PURPOSE & SCOPE

2.1 To ensure that all contamination injuries including needlestick, sharps injury,
bites, scratches and blood or other bodily fluid splashes are managed
appropriately and safely.

2.2 To ensure that the Trust complies with appropriate Health and Safety
Legislation including:

The Health and Safety at Work Act 1974 places a legal duty on employers
to provide for the health and safety of their employees. NHS Trusts have
been subject to the full requirements of this legislation since 1991 and these
duties were extended under a number of Regulations including;

 The Management of Health and Safety at Work Regulations 1999, which

require employers to assess risks to the health and safety of their
employees and arrange for implementation of a comprehensive system
of safety management.

 The Control of Substances Hazardous to Health Regulations 2002 (as

amended) specifically include micro-organisms in the definition of
substances that are hazardous to health. The law requires employers to
make a suitable and sufficient assessment of the risks to the health of
workers exposed to such substances, with a view to preventing or
adequately controlling the risks. This includes the proper use of
protective equipment and regular monitoring of exposure.

 The Reporting of Injuries, Diseases and Dangerous Occurrences

Regulations 2013 (RIDDOR), requires exposures to Hepatitis B or C, or
HIV, to be reportable to the HSE as a dangerous occurrence (“accidental
release of a biological agent likely to cause severe human illness”)

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  The Safety Representatives and Safety Committees Regulations 1977
(as amended) and Health and Safety (Consultation with Employees)
Regulations 1996 (as amended)require employers to consult with
accredited trade union safety representatives on health and safety
issues including the introduction of new technology and information to
employees on the risks and dangers arising from their work, measures to
reduce or get rid of these risks and what employees should do if
exposed to these risks;

 Health and Safety (Sharps Instruments in Healthcare) Regulations 2013

These Regulations implement the EU Council Directive 2010/32/EU on
the prevention of sharps injuries in the hospital and healthcare sector.
Many of the requirements contained in the Directive already formed part
of health and safety law in Great Britain.

 In the context of needlestick injury, examples of where consultation is

required include the development of sharps polices and risk
assessments and the introduction of safety engineered devices.

Employers

Section 2 of the Health and Safety at Work Act (1974) states that, “it shall
be the duty of every employer to ensure, so far as reasonably practicable, to
ensure the health, safety and welfare at work of all his/her employees. The
employer is required to provide appropriate information and instruction,
normally in the form of a policy, together with appropriate safety equipment,
training and supervision to ensure their employees are protected at work. In
healthcare, all employers should provide a safe working environment in
which safe equipment is available and where staff are appropriately trained
in the hazards posed by handling sharps and body fluids.

Employees

Employees also have duties under sections 7 and 8 of the Health and
Safety at Work Act, 1974 and Reg. 14 of the Management of Health and
Safety at Work regulations 1999. They must comply with any safety policies
or procedures put in place to protect their health. Employees must also
protect their own health and safety by using any protective clothing issued
to them. Employees also have a duty to ensure that their actions do not
harm the health and safety of others, e.g. the careless disposal of a sharp in
a bag could injure a porter or cleaner transporting the waste. Therefore,
employees must use all work items (sharps) provided by the Trust
correctly, in accordance with their training and the instruction they
received to use. Further detail outlining the Safe Handling and
Disposal of Sharps can be found in Appendix C.

2.3 This policy applies to all staff whatever their grade, role or status.,
permanent, temporary, full-time, part-time staff including locums, bank staff,
agency staff, volunteers, trainees and students.

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2.4 For the purposes of this policy please note that the Occupational Health
Service for the Trust is provided via Optima Health.

3. DUTIES AND RESPONSIBLITIES

3.1 The Trust Board via the Chief Executive

Responsibility for ensuring compliance with the statutory requirements

within the policy lies with the Chief Executive.

3.2 Director of Governance and Corporate Development

The Director of Governance and Corporate Development is the Trust lead

for risk and as such will oversee the monitoring and implementation of this
policy through the Health, Safety and Security Management to ensure that it
is applied throughout the Trust.

3.3 Health, Safety and Security Management Group (HSSMG)

Will review reports of needlestick and contamination injuries for the relevant
quarter at each meeting, advise on lessons learned and ensure that
procedures for the implementation of the Needlestick and Contamination
Injury Policy are continually reviewed and improved within the Trust. The
HSSM Group Terms of Reference membership will include a safety
representative from Occupational Health/Work and Wellbeing Service.

3.4 The Regulation Governance Group will be responsible for overseeing and
monitoring the work of the Health, Safety and Security Management Group
and will escalate areas of concern to the Integrated Governance Committee.

3.5 Ward Managers, Matrons, Service Managers and Heads of Service are
responsible for:

 the completion of appropriate risk assessments and ensuring a safe

working environment within their own areas;

 compiling the local risk register and keeping the document up to date;

 ensuring that staff receive the relevant training / awareness (see the
Trust’s Mandatory Staff Training Matrix for more information accessible
on the Trust Intranet);

 ensure that incident reporting is carried out in line with the Trust
Untoward Event Reporting Policy and Procedure, and incidents are
investigated appropriately. The DATIX form should record the source
patient’s hospital number. If a decision is made not to test the source
patient, reasons for this decision should be recorded on the DATIX form;

 the completion of a modified root cause analysis (RCA) assessment for

any staff member who is subject to a needle stick incident. Ensure that all
contamination injuries are investigated in line with the Trust Untoward
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 Event Reporting Policy and Procedure and that action plans are in place
and monitored;

 where required, RIDDOR forms are completed and forwarded to the

Head of Corporate Services for action;

 ensure that information regarding action to take in the event of a

contamination injury are displayed in staff areas;

 Ensure that all staff who are exposed to a contamination injury contact
the Occupational Health Service immediately or as soon as possible the
next working day. Managers will give support to all staff who have a
contamination injury.

3.6 All Staff

 All staff are responsible for reporting incidents and raising any concerns.
The incident reporting process is in place to support this (See Untoward
Event Reporting Policy and Procedure). All contamination incidents must
be reported via DATIX but this will be secondary to ensuring that correct
and timely action is taken following any contamination injury. Staff will
cooperate with the Trust, follow the correct procedures and follow the
devised safe systems of work to ensure the safety of themselves and
their colleagues. Staff will attend all relevant training. Staff should follow
procedures set out in this policy following any contamination incident.
(See section 5.0 onwards).

 Any member of staff who is exposed to blood and / or body fluids will
contact the Occupational Health/Health and Wellbeing department
immediately or as soon as practicable during office hours via 0844 826
0308.

 Booking themselves onto initial and update mandatory training and for
attending mandatory training, regardless of their grade, role or status,
including permanent, temporary, full-time, part-time staff and locums,
bank staff, volunteers, trainees and students.

3.7 Occupational Health and Well@Work

3.7.1 For the purposes of this policy the Occupational Health Service is provided
by Optima Health, and the Well@Work Service is Trust managed.

The services will;

 the Occupational Health and the Well@Work Service will work

collaboratively to actively monitor and review needlestick incidents and
subsequent follow up appointments for immunisations which may result
from these incidents;

 the Occupational Health Provider/Well@Work service will take a

proactive approach to identify non-compliance in relation to
Needlestick & Contamination Injury Policy
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 immunisations for new starters and will inform managers if an Exposure
Prone Procedure worker does not complete serial testing.

3.7.2 The Occupational Health Service are key to ensuring that staff receive
timely advice and support following any contamination injury. The Services
will:

 Maintain and ensure the needle stick hotline (0844 826 0308) is effective
and all calls are acted upon promptly during office hours.

 Provide advice and support to all staff on contamination injuries and

instigate appropriate follow up

 Promote, via the Well@Work Service, the correct management of

contamination injuries by providing an up to date poster which can be
displayed in all clinical areas (on request) and an intranet site which has
guidance for staff in the event of a contamination injury

 Provide advice, support and guidance to the Trust in relation to

contamination injuries

 Report incidents of known contaminated source incidents to the Head of

Corporate Services and via the RIDDOR pathway (this can be done
anonymously)

 Provide information and instruction via Well@Work Service

representation at the Health, Safety and Security Management Group
that meets Quarterly

 Provide a pre-employment screen for blood borne viruses or hepatitis B

vaccination, depending on role and risk assessment and an ongoing
immunisation programme to ensure staff have optimum protection
against transmissible disease.

3.8 Head of Risk

The Head of Risk is responsible for the day to day management of the
Truswide DATIX Untoward Events Reporting and Risk Reporting system.

The Head of Risk produces a quarterly report of needlestick injuries for the
Health, Safety and Security Management Group.

3.9 Head of Corporate Services

The Head of Corporate Services will also ensure that the Health and Safety
Executive are informed of any incidents that are defined as a dangerous
occurrence under the requirements of the Reporting of Injuries, Diseases
and Dangerous Occurrences Regulations (RIDDOR).

3.10 Medical Teams (injuries with a known patient source)

Will assist the person in charge at the time of the incident / on call manager
to obtain further information on which to base an assessment of the risk of
Needlestick & Contamination Injury Policy
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 exposure to blood borne viruses, particularly the risk of HIV, associated with
the injury. See section 5 in this policy on general procedures to follow in the
event of a contamination injury. This includes the need to gain consent from
a known source patient.

3.11 Microbiology Laboratory

Will receive laboratory requests from medical teams following contamination

with a known source.

All responsibilities in relation to assessing the need for PEP (Post Exposure
Prophylaxis) and the full procedure are listed in section 8.2.

3.12 Learning and Development Department

Will record attendance at Training and will advise Operational Managers of

non-attendance.

4. EXPLANATION OF TERMS USED

4.1 Sharps are needles, sharp-edged instruments, broken glassware or any

other item which may be contaminated in use by blood, body fluids or
tissues and which may cause laceration or puncture wounds.

4.2 Sharps injury is a percutaneous injury caused by a sharp penetrating the

skin, this includes cuts, pinches, scratches, nicks and gashes and bites
which break the skin.

4.3 Needlestick - Accidents with needles are most common so injuries from
sharps are often called needlestick injuries

4.4 Sharps injury procedure – is the procedure following occupational

exposure to body fluids by sharps injury or exposure to mucous membranes
or non intact skin

4.5 A contamination incident - is an exposure to blood or body fluids via a

sharp implement or human bite that causes bleeding or punctures the skin;
or exposure of mucous membranes or non intact skin to blood or other body
fluids

4.6 The source patient- The source patient is the person from whom the body
fluid originated

4.7 The Recipient- Refers to the person who has received the injury

4.8 RIDDOR- Reporting of Diseases and Dangerous Occurrences Regulations

4.9 DGH- District General Hospital, this will be the nearest hospital with an A&E
department

4.10 EPP – Exposure Prone Procedures are those 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
Needlestick & Contamination Injury Policy
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 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.

4.11 A&E- Accident and Emergency Department

4.12 PEP- Post exposure prophylaxis, prophylactic treatment that may be given
after exposure to Hepatitis B or HIV.

4.13 BBV – Blood Borne Virus

4.14 HCW – Health Care Worker

4.15 DATIX - the Trust’s electronic risk management database used for
recording the following data: PALS; Complaints; Untoward Events;
Corporate and Local Risks; Medical Devices Register and CAS Alerts.

5. PROCEDURE TO FOLLOW IN THE EVENT OF A CONTAMINATION

INJURY

5.1 First Aid Action

Recipients should:

 encourage bleeding of the wound site under running water;

 do NOT suck the wound;

 flush mucous membranes or skin with copious amounts of

running water – before and after removing any contact lenses;

 apply waterproof dressing (plaster) to wound site;

 inform source patient’s medical team.

In cases where the source patient is known the following action must be
taken:

 inform the most senior member of staff on duty or the on call manager
and the donor where known, this should take place within 24 hours of
the injury occurring;

 contact the Needle stick Hotline via 0844 826 0308.

 immediate action should be taken by the senior member of staff with

the assistance of the source patient’s medical team to obtain further
information on which to base an assessment of the risk of exposure to
blood borne viruses, particularly the risk of HIV, associated with the
injury.

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5.2 Assessing the exposure risk / need for HIV post exposure prophylaxis
The patient’s medical team should assess the source for personal risk
factors associated with BBV such as:

 high risk sexual activities;

 present or past history of intravenous drug use;

 from country of origin known to have a high prevalence of HIV

infection;

 multiple blood transfusions prior to September 1991;

 If the source patient is known to be positive or HIV is strongly

suspected, the HIV post exposure prophylaxis (PEP) procedure in
section 8 should be followed immediately.

Following compliance with the PEP procedure, or in circumstances where

no HIV risk is identified or when PEP is not indicated, the remaining
elements of the reporting and follow up procedure must be completed.

5.3 Testing the source patient for blood borne viruses

 Testing of the source patient for hepatitis B surface antigen, Hepatitis

C antibodies and HIV antibodies can only take place with informed
consent

 Pre-test discussion with the patient is the responsibility of the medical

team caring for the patient and should take place in all cases. The
injured member of staff should not approach the source patient

 A Trust consent form can be used or verbal consent can be recorded

in the patient’s medical notes

 Write “source patient in needle stick injury to (staff members name) on

(date)” on the request form in addition to the specific tests required

 In some cases it is not appropriate or possible to obtain consent (e.g.

when the source patient is a child or is not fit to consent). Decisions on
prophylaxis and follow up will then be made on a risk assessment of
available information.

 The medical team taking the test are responsible for informing the
patient of the result of the tests and if required arranging further advice
or treatment for the source patient.

5.4 Blood sample from recipient staff member

 A clotted sample of blood is taken from the injured staff member.

Request “save serum” under tests (see sample form appendix A)

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  Write “recipient of needle stick injury on (date) and source patient
(patients name and date of birth)”

 The staff member’s sample will not be tested at this stage. The sample
will be stored for at least two years and may be tested at a later date
with consent, should the employee test positive for hepatitis B,
Hepatitis C of HIV viruses in follow up assessment.

5.5 Blood samples will be stored at the laboratory, local to the incident and to
where, geographically, they are obtained:

o Somerset based staff – Somerset Pathology Service, Taunton or

Royal United Hospital, Bath

o Dorset Based staff – Poole Hospital or Dorchester Hospital

o Isle of Wight Staff – St Mary’s Hospital

o If Occupational Health provide a blood pack for stored bloods this

blood will be sent by the employee to the laboratory designated by
Occupational Health in the appropriate envelope provided by
Occupational Health

5.6 If testing is required, the Occupational Health Provider will liaise with the
relevant laboratory and consultant microbiologist to ensure this is
undertaken.

5.7 Where to get advice on the need for prophylactic treatment for hepatitis B
exposure: -

 Needlestick Helpline: 0844 826 0308. Out of hours leave contact

details and a brief message(for incidents at night, advice can be
sought the next morning, but note this does not apply where there is a
risk from HIV, See section 8) Out of hours staff should attend their
nearest A&E department for advice, blood storage and any treatment
that may be required;

 if needed, prophylactic treatment for Hepatitis B should ideally be

given 24-48 hours post injury and can be given in A&E if out of hours;

 prophylaxis for HIV is described in the HIV post exposure procedure in

sections 5, 8 and 9

6. PROPHYLAXIS AFTER EXPOSURE TO HEPATITIS B

Table 1 below describes treatment after exposure to hepatitis B

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 HBV Significant Exposure Non-significant Exposure
Status of
person
exposed

HBsAg Unknown HBsAg Continued No further

positive source negative risk risk
source source

< 1 dose Accelerated Accelerated Initiate Initiate No HBV

HB vaccine course of HB course of HB course of course of prophylaxis
pre vaccine* vaccine* HB HB vaccine Reassure
exposure HBIG x1 vaccine

< 2 doses One dose of One dose of Finish Finish No HBV

HB vaccine HB vaccine HB vaccine course of course of prophylaxis
pre followed by 2nd HB HB vaccine Reassure
exposure dose one vaccine
month later

Known Consider Consider Consider Consider No HBV

responder booster dose booster dose booster booster prophylaxis
to HB of HB vaccine of HB dose of dose of HB Reassure
vaccine vaccine HB vaccine
AntiHBs vaccine
>10miu/ml
Known HBIG Give HBIG No HBIG No HBIG No
NON X1consider consider consider consider prophylaxis
responder dose of HB dose of HB booster booster Reassure
to HB vaccine vaccine. dose if HB dose of HB
vaccine A second dose A second vaccine vaccine
AntiHBs of HBIG should dose of
<10miu/ml be given at 1 HBIG should
month be given at 1
month

*An accelerated course of vaccine consists of doses spaced at zero, one

and two months.

A booster dose maybe given at 12 months to those at continuing risk of

exposure to HBV

Information accessed via:

[Link]
e/263311/Green_Book_Chapter_18_v2_0.pdf

HBV = Hepatitis B virus

HB = Hepatitis B

HBIG = Hepatitis B Immunoglobulin

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7. EXPOSURE TO HEPATITIS C

 Hepatitis C can be transmitted occupationally. Currently there is no

prophylaxis available.

 The Occupational Health Department will advise the injured person

and arrange further testing and specialist advice after exposure to
Hepatitis C.

 Specialist testing of the source patient may help to establish the level
of infectivity. In the very rare event that the recipient becomes infected
early treatment for Hepatitis C infection is effective in the majority of
cases.

 Pending follow up and in the absence of seroconversion, the

employee need not be subject to any restrictions in their working
practices.

8. GUIDELINES ON PRE-TEST DISCUSSION BEFORE HIV TESTING AND

TESTING FOR OTHER BLOOD BORNE VIRUSES

8.1 See Appendix B for suggested simple pre-test discussion suitable for use
with most source patients.

 If the patient is given a careful explanation of the reason for the test
there is rarely a problem obtaining consent form a source patient to
test for blood borne viruses after an employee has been injured.

 HIV testing is undertaken in a number of different situations for

different reasons. The pre test discussion will vary depending on the
reason for the test and clinical situation of the patient. Discussion
about HIV and HIV testing should now be part of main stream clinical
care.

 In cases when the source patient is asked to consent to a test as a

routine measure after needle stick injury, the discussion can usually be
quite simple. This would be the case where there is considered to be
no clinical need for an HIV test.

 In cases where the patient’s history suggests a clinical need for a test,
or the patient has had a previous test for clinical reasons, or the
patient is concerned that they may be in a high risk group, a fuller
discussion is normally indicated. A specialist Genito-urinary Medicine
counsellor (via local DGH switchboard) may be required if the patients
circumstances are complex and time consuming and more detailed
discussion is needed.

 The discussion should take into account the patients own situation.
Not all points below will be appropriate in all cases. Select the points
relevant to the given situation:
Needlestick & Contamination Injury Policy
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 - explain that testing for blood borne viruses after a sharps injury is
a routine procedure recommended in nationally agreed guidance;

- explain that testing prevents needless anxiety for the injured

employee;

- ensure the patient understands the nature of HIV infection and

how it is transmitted;

- if the patient wishes, be prepared to discuss the patients personal

risk factors for HIV including IV drug use, sexual practice,
overseas travel, tattooing and exposure to blood products;

- provide a brief summary of the advantages and disadvantages of

testing including:

Advantages
 Allows for appropriate medical care
 Allows decisions about the future to be made
 Allows sexual partners to be protected
 Reduces needless anxiety about infection
 A negative test would not affect life insurance.

Disadvantages

 Psychological complications

 Possible impact on relationships including family, work,

partners

 Possible issues if result is positive such as new implications

for mortgage and life insurances

- if appropriate discuss how a patient would cope with a positive

result;

- explain the test procedure and how the result will be given;

- explain the significant of positive and negative results;

- obtain informed consent. A Trust consent form can be used or

write in the medical notes that consent has been given;

- the source patient’s clinical team is responsible for notifying the

patient of the result in an appropriate manner.

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8.2 Hepatitis B and C

 Usually only a very simple explanation and discussion is required.

Explain that testing for blood-borne viruses after a needle stick injury is
a routine procedure recommended in nationally agreed guidance.
Explain the advantages to the health care worker - removes needless
anxiety, in very rare cases enables prophylaxis to be given. In some
cases a brief discussion following a similar pattern to the HIV
discussion, may be required.

 The source patient’s clinical team is responsible for notifying the

patient of the result in an appropriate manner.

9. POST EXPOSURE PROPHYLAXIS FOLLOWING OCCUPATIONAL

EXPOSURE TO HIV

9.1 Post exposure prophylaxis (PEP) is most likely to be effective when initiated
as soon as possible (within hours) and ideally should be started within an
hour of exposure. When a significant risk of exposure to HIV is identified,
the procedure below should be followed in addition to the action required in
section 5.0 of this policy.

9.2 Action required by manager or recipient employee

 Manager / injured employee to contact the occupational health

consultant immediately. If he is not available contact the medical
registrar on call as prophylaxis treatment is required within 1 hour of a
contaminated injury

 Make arrangements for the member of staff to be seen as soon as

possible at the nearest District General Hospital and if necessary
arrange transport to A&E. This could include arriving by taxi.

 Advise the registrar to obtain the PEP emergency pack from A&E

 If an incident occurs outside of office hours, leave a message on the

Needlestick helpline via 0844 826 0308 to ensure follow up. Do not let
this delay obtaining PEP. A colleague or friend can fill out incident
forms on your behalf until such a time you can complete a summary of
events. The on-line DATIX Untoward Events Report form is
accessible to all staff on the Trust Intranet.

9.3 Action by the Consultant Occupational Health Physician or Medical

Registrar on call in receiving District General Hospital

 Obtain PEP emergency pack from A&E. Read the guidance for
doctors. A&E also holds a copy of the procedure.

 Complete the PEP record sheet in the pack documentation. Obtain

sufficient information about the incident and the source patient to
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 enable an assessment to be made of the likely risk of transmission of
HIV as a result of the incident. This is likely to require contact with the
clinical team responsible for the care of the source patient. This
process should start immediately even before seeing the recipient if
there is likely to be a delay before they arrive

 Assess the risk to the employee and decide if it is appropriate to offer

PEP. The guidance in the pack will assist with this. If necessary,
contact the occupational health physician, consultant in GU medicine,
consultant microbiologist or the medical consultant on call for further
advice

 If PEP is not appropriate: discuss the assessment with the employee

and follow the procedures in section 5.

 If it is appropriate to offer PEP, assess if there are any

contraindications to treatment or if the employee is pregnant. PEP may
still be appropriate if the employee is pregnant, but further advice may
be required.

 Advise the employee of the decision. Discuss the level of risk and the
implications of treatment. PEP should normally only be offered if the
source patient is known to be or strongly suspected of being HIV
positive and a penetrating exposure or exposure to mucous
membrane or broken skin has occurred with a potentially infectious
body fluid

 The employee should be asked if they wish to take PEP. The final
decision to take the medication rests with the employee. If they do not
wish to take PEP, follow the procedure in section 5.

 Ask the employee to read the information sheet and sign the consent
form. The documentation is located in the emergency information
pack. All the points discussed should be confirmed on the checklist
included in the PEP record sheet

 Complete and sign the prescription and advice of possible side effects.
The employee should be given copies of the drug information
guidance sheets and the employee information sheets.

 After the employee’s agreement to commence PEP medication, the

consultant on call for medicine should be informed before the
prescription is issued. The first dose should be taken as soon as
possible

 Give the emergency pack of drugs to the employee, ensuring sufficient

quantities of the medication have been provided to last until they can
contact the occupational health department (taking account of
weekends / bank holidays). Arrange for an additional supply of drugs
from pharmacy if required

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  Ensure the remainder of the general procedure following occupational
exposure to body fluids is completed (section 5)

 Inform the employee to contact the occupational health department as

soon as possible to arrange follow up. This would normally be during
office hours or the next day if out of hours

 Complete the PEP record sheet and send to occupational health

immediately. This should be done whether the employee has accepted
PEP or not. The occupational health/ department should be informed
on 0844 826 0308 on the next occasion that it is open

 The pharmacy department should be contacted immediately during

office hours or the next time the department is staffed. If out of hours
send the notification letter from emergency pack information, to notify
that the emergency pack of PEP drugs in A&E have been used and a
replacement pack will need to be issued.

9.4 Action by Occupational Health Service

 Follow up counselling, further testing, and monitoring of medication will

be arranged, with the involvement of Genito-Urinary medicine if
required.

 The pharmacy department will be contacted to ensure replacement of

the emergency pack of PEP drugs has been arranged

 The Occupational Health Service will report the incident to the Health
Protection Agency reporting scheme for documentation

 The Occupational Health Service will communicate with the relevant

laboratory to ensure testing of blood samples is undertaken as
required

 The Consultant Occupational Health Physician will inform the

employee’s GP if PEP has been prescribed.

9.5 Follow up by Occupational Health/Well@Work Service for

contamination injuries when consent cannot be obtained or source
patient is unknown

 The following table describes the schedule of serial blood tests that
will be offered to the recipient of a contamination injury through
Occupational Health, when the source patient is unable or unwilling to
provide consent or when the source patient is unknown:

6 weeks post exposure 12 weeks post exposure 24 weeks post

exposure
HB surface antigen HB surface antigen HB surface antigen
HCV antibodies HCV antibodies
HCV PCR HCV PCR
Hiv antibodies HIV antibodies

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  Serial testing can be done under a coded system if requested to
ensure the employee’s anonymity

 Pending follow up and in the absence of seroconversion, the

employee need not be subject to any restrictions in their working
practices

 Stored blood taken at the time of the incident will be tested with
consent should the results of serial testing indicate seroconversion.

10. MANAGEMENT OF INCIDENTS AND RISK ASSESSMENTS

10.1 Trust arrangements to ensure effective management of contamination

injuries including proactive steps to reduce incidents are given below

10.2 Incident reporting, investigation and action plans

 As listed in the responsibilities section of this policy, all staff are

responsible for reporting any incident or near miss.

 Service and Team Managers/Matrons are responsible for ensuring

that a suitable investigation is carried out according to the
consequence of the incident and action plans are created and carried
out in a suitable time frame. A modified Root Cause Analysis
investigation will be undertaken and forwarded to the Risk Team at the
time of the DATIX report submission.

 Service and Team Managers/Matrons are responsible for ensuring

that incidents of consequence 3 or more are investigated promptly,
within the timescales given in the Trust Untoward Event Reporting
Policy. The Ward/Team will ensure that action plans to address any
issues raised in the investigation are monitored.
 Needlestick/Sharps injuries recorded on the Trust’s DATIX Untoward
Events Report forms will be provided quarterly by the Head of Risk to
the Health, Safety and Security Management Group for analysis and
discussion of lessons learned

10.3 Risk Register

 Any Ward or Team that has identified a risk with contamination injuries
will carry out a risk assessment in line with the DATIX Local Risk
Register Guidance and the Risk Management Policy and Procedure.
The local risk register will be monitored by the Service/Team Manager
and will be discussed in local Team meetings to raise staff awareness
and recorded in the minutes/notes for staff unable to attend the
meeting.

 Any risk, which involves a single staff member or patient, will not be
added to the DATIX risk register if information would identify the
person at risk. This information will be kept in the employee personal
file or, in the case of a patient, documented within their clinical health
record.
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  All risk assessments will be updated at least quarterly to ensure the
risk registers remain current and effective.

10.4 Staff training

 Managers should review the Mandatory staff training matrix to identify

the training requirements for staff in relation to contamination injuries.

11. TRAINING REQUIREMENTS

11.1 The Trust will work towards all staff being appropriately trained in line with
the organisation’s Mandatory Training Matrix (training needs analysis). All
training documents referred to in this policy are accessible to staff within the
Learning and Development Section of the Trust Intranet.

 Staff Induction – Standard Infection Prevention and Control

Precautions

 Infection Prevention and Control Training

 Untoward Event Reporting

12. EQUALITY IMPACT ASSESSMENT

12.1 All relevant persons are required to comply with this document and must
demonstrate sensitivity and competence in relation to the nine protected
characteristics as defined by the Equality Act 2010. In addition, the Trust
has identified Learning Disabilities as an additional tenth protected
characteristic. If you, or any other groups, believe you are disadvantaged by
anything contained in this document please contact the Equality and
Diversity Lead who will then actively respond to the enquiry.

13. COUNTER FRAUD

13.1 The Trust is committed to the NHS Protect Counter Fraud Policy – to reduce
fraud in the NHS to a minimum, keep it at that level and put funds stolen by
fraud back into patient care. Therefore, consideration has been given to the
inclusion of guidance with regard to the potential for fraud and corruption to
occur and what action should be taken in such circumstances during the
development of this procedural document.

14. MONITORING COMPLIANCE AND EFFECTIVENESS

14.1 Monitoring arrangements for compliance and effectiveness

Overall monitoring will be by the Regulation Governance Group who will
receive a quarterly progress report from the Health, Safety and Security
Management Group, via the Head of Risk.

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14.2 Responsibilities for conducting the monitoring

 The Regulation Governance Group will refer clinical issues to the

Clinical Governance Group who will monitor procedural document
compliance and effectiveness where they relate to clinical areas.

 The Wellbeing Service will monitor incident reporting and provide a

report relating to Needlestick and Contamination Injuries to the Health,
Safety and Security Management Group, quarterly.

14.3 Methodology to be used for monitoring

 internal audits

 incident reporting and monitoring

 clinical effectiveness monitoring

14.4 Frequency of monitoring

 Quarterly reports from the Head of Risk produced for the Health Safety
and Security Management Group

 Quarterly trend analysis reports from the Work and Wellbeing Team
produced for the Health, Safety and Security Management Group

14.5 Process for reviewing results and ensuring improvements in

performance occur.

 Any audit results will be presented to the Health, Safety and Security
Management Group, for consideration, identifying good practice, any
shortfalls, action points and lessons learnt. This Group will receive
assurance that improvements, where necessary, have been
implemented.

 A briefing of audits undertaken, highlighting key learning will be

provided to staff to raise awareness through the Trust SPICE
newsletter.

 Line Managers will complete a modified root cause analysis (RCA)

assessment with any staff member who is subject to a needlestick
incident. A modified RCA tool is embedded within the DATIX report.
Key learning points will be disseminated locally by the Line Manager
and via the appropriate Best Practice Group.

 Well@Work will support the Head of Infection Prevention and

Control/Decontamination Lead to review all DATIX reported incidents
cross referencing data received from Occupational Health to monitor
compliance in relation to immunisation.

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  Key learning points will be evaluated at the Health, Safety and Security
Management Group and disseminated Trust-wide.

15. RELEVANT CARE QUALITY COMMISSION (CQC) REGISTRATION

STANDARDS

15.1 Under the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2014 (Part 3), the fundamental standards which inform this
procedural document, are set out in the following regulations:
Regulation 9: Person-centred care
Regulation 10: Dignity and respect
Regulation 11: Need for consent
Regulation 12: Safe care and treatment
Regulation 13: Safeguarding service users from abuse and improper treatment
Regulation 15: Premises and equipment
Regulation 16: Receiving and acting on complaints
Regulation 17: Good governance
Regulation 18: Staffing
Regulation 19: Fit and proper persons employed
Regulation 20: Duty of candour
Regulation 20A: Requirement as to display of performance assessments.

15.2 Under the CQC (Registration) Regulations 2009 (Part 4) the requirements
which inform this procedural document are set out in the following
regulations:

Regulation 12: Statement of purpose

Regulation 16: Notification of death of service user
Regulation 17: Notification of death or unauthorised absence of a service user who
is detained or liable to be detained under the Mental Health Act
1983
Regulation 18: Notification of other incidents
Regulation 22A: Form of notifications to the Commission (although this is in Part 5, it
relates to regulations in Part 4).

15.3 Detailed guidance on meeting the requirements can be found at

[Link]
providers%20on%20meeting%20the%20regulations%20FINAL%20FOR%2
[Link]

Relevant National Requirements

The Health and Safety at Work Act 1974
Immunisation against infectious disease, December 2013 via:
[Link]
e/263311/Green_Book_Chapter_18_v2_0.pdf
Directive 2010/32/EU – Prevention from Sharp Injuries in the Hospital and
Healthcare Sector
Health and Safety (Sharps Instruments in Healthcare) Regulations 2013
Safety Representatives and Safety Committees Regulations 1977 (as
amended) and Health and Safety (Consultation with Employees)
Regulations 1996 (as amended)
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 Department of Health (2009) The Health and Social Care Act 2008
(Updated 2015) Code of Practice for health and social care on the
prevention and control of infections and related guidance.
Department of Health, HIV post exposure prophylaxis, 2004 (Revised 2008)
Department of Health, the Management of Health, Safety and Welfare
Issues for NHS staff, 2005

16. REFERENCES, ACKNOWLEDGEMENTS AND ASSOCIATED

DOCUMENTS

16.1 References

NHSLA Risk Management Standards 2012-2013 for Trusts providing Acute,

Community, or Mental Health & Learning Disability Services and Non-NHS
Providers of NHS Care

16.2 Cross reference to other procedural documents

Corporate and Local Induction Policy
DATIX Risk Register Guidance
DATIX Untoward Event Reporting Guidance
Hand Hygiene Policy
Health and Safety Policy
Healthcare (Clinical) Waste Policy
Infection Prevention and Control Policy
Standard infection control precautions policy (incorporating blood and body
fluid spillage)
Risk management Policy and Procedure
Risk Management Strategy
Staff Training Matrix (Training Needs Analysis)
Untoward Event Reporting Policy
Waste Management Policy
All current policies and procedures are accessible in the policy section of the
public website (on the home page, click on ‘Policies and Procedures’). Trust
Guidance is accessible to staff on the Trust Intranet.

17. APPENDICES
17.1 For the avoidance of any doubt the appendices in this policy are to
constitute part of the body of this policy and shall be treated as such.
Appendix A – Sample of Pathology Forms
Appendix B - How Do I Counsel Source Patient For Consent To Blood Test?
Appendix C - Safe Handling and Disposal of Sharps

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 APPENDIX A
SAMPLE OF PATHOLOGY FORMS

Form for Recipient Staff Member:

Somerset Pathology Service MICROBIOLOGY CPA Accredited

Hospital GP/NHS Test required: Lab No:

No: No. Save Serum ……………………………….
……………………………….

Surname Bloggs (Staff) M/F

M

Forename Joe DOB Date received:

06.06.1966
Patient’s Address Post Code Specimens will not be examined
Insert home address and post code unless full name, date of birth,
registration number and source of
request are provided and the
specimen container labelled with full
name and date of birth
Hospital, Ward/GP Surgery NHS √ Please tick relevant boxes
Somerset Occupational Health Private □ Antenatal infection screen □
Cat 2 □ ……………………………
Consultant/GP

Address for report and/or copies

Occupational Health
Date of Time of Specimen type For laboratory use
collection collection VB
13.06.05 1430
Relevant clinical details
Contamination injury to staff Joe Bloggs on 03.05.04
Source Patient is John Smith 11.11.59
Date of onset of illness Antibiotics

MO’s signature Bleep No.

Note – specimen request forms may differ depending on the receiving laboratory, please ensure all
relevant information as detailed above is entered as per local guidance

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Form for Source Patient:

Somerset Pathology Service MICROBIOLOGY CPA Accredited

Hospital GP/NHS Test required: Lab No:

No: No. HBsAg
HCV antibodies
HIV antibodies

Surname Smith M/F

M
Forename DOB Date received:
John 11.11.59
Patient’s Address Post Specimens will not be examined unless full name,
Insert home address and post Code date of birth, registration number and source of
request are provided and the specimen container
code labelled with full name and date of birth
Hospital, Ward/GP Surgery NHS √ Please tick relevant boxes
Insert name of ward or team Private Antenatal infection screen □
□ ……………………………
Cat 2 □
Consultant/GP
Insert name of consultant

Address for report and/or copies

Copy to Somerset Occupational Health

Date of Time of Specimen For laboratory use

collection collection type
13.06.05 1530 VB
Relevant clinical details
Source patient of contamination injury to Joe Bloggs on 13.06.05
Date of onset of illness Antibiotics

MO’s signature Bleep No.

Note – specimen request forms may differ depending on the receiving laboratory, please ensure all
relevant information as detailed above is entered as per local guidance

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 APPENDIX B

HOW DO I COUNSEL SOURCE PATIENT FOR CONSENT TO BLOOD TESTS?

Many staff are uncertain how to approach this. A suggested form of words would be:
“Unfortunately one of the members of staff has had an accidental injury where your
blood (or specify relevant body fluid) has been “involved”. I am here to ask if you
would let me take a blood sample for testing for the viral infections that can be
transmitted to staff in this way. This is something that we ask for routinely whenever
a patient’s blood (or specify relevant body fluid) is involved in such an accident. We
need your agreement to do this and would appreciate your help.
The purpose of the testing is to reassure staff where the results are negative. This
may allow them to stop taking precautionary medication that often causes
unpleasant side effects. In the unlikely event that a test is positive you will receive
specialist advice and management including treatment if required. The staff member
may also be offered additional treatment.
The tests are for hepatitis B, hepatitis C and HIV. The test results are usually
available within a few days but may take several weeks if extra investigations are
required for clarification. The results will normally be given to you by a member of
the medical staff caring for you. The results are confidential, but they will appear in
your medical records and the affected staff member will also be informed
Do you have any concerns? A common concern is whether having these tests done
will affect any existing life insurance policies or future life insurance applications.
The Association of British Insurers has issued guidance stating; “Existing life
insurance policies will not be affected in any way by taking an HIV test, even if the
result is positive.” For new life insurance applications, companies should only
enquire about positive test results, not whether a test has been performed. A
positive test result may affect the outcome of a life insurance policy application.
Do I have your permission to take a blood sample for hepatitis B, C and HIV testing?
I should remind you that you can refuse to have some or all of these tests performed
and that if you do choose not to be tested it will not affect your future care.”
A record of the discussion and patient’s consent (or non-consent) to testing
for HBV, HCV and HIV should be made in the medical records of the source.

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 APPENDIX C
SAFE HANDLING AND DISPOSAL OF SHARPS

1. SAFE HANDLING OF SHARPS

1.1 The European Union Directive was introduced in 2010 to prevent injuries
and blood-borne infections to hospital and healthcare workers from sharp
instruments such as needles. As a result of this legislation the Trust has
implemented needleless and safer needle systems whenever possible.
1.2 Where a safe sharps system cannot be implemented due to a risk assessed
clinical need, staff are advised of the following;
1.2.1 Keep handling of sharps to a minimum and avoid passing from person to
person.
1.2.2 Gloves should always be worn when handling sharps.
1.2.3 Sharps must not be carried to the patient by hand; ideally they should be
carried on a purpose made sharps tray and integral sharps bin.
1.2.4 Needles must not be manually re-capped / re-sheathed. Sharp safe
vacutainers should be used for phlebotomy wherever possible.
1.2.5 Disposable needles and syringes must be discarded of as a single unit and
not bent, broken or disassembled.
1.2.6 Care should be taken when removing dressings from subcutaneous
infusions. Dressings can stick to the gloves causing an increased risk of a
sharps injury occurring.

2. SAFE DISPOSAL OF SHARPS

2.1 Sharps must be disposed of into a sharps container at point of use.

2.2 The user should ensure that the size of the sharps bin is appropriate for the
clinical activity and size of the equipment.
2.3 Sharps boxes must not be filled above the maximum fill line.
2.4 It is the responsibility of the user to dispose of their own sharps and the
clinical waste generated as a result of the procedure.
2.5 Between uses, the temporary closure device must be used to prevent
accidental spillage from the sharps bin.
2.6 An empty sharps bin should be available and stored safely with
resuscitation equipment.

3. SAFE USE OF SHARPS BINS

3.1 Only yellow sharps bins that conform to UN 3291 and BS 7320 standards
may be used.
3.2 The applicable Waste Protocol should be adhered to regarding colour
coding of waste packaging. These are available on the intranet together
with the Waste flow charts.

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  Yellow lidded receptacles – yellow lidded sharps receptacles should
contain waste that requires disposal by incineration only, such as
sharps containing a quantity of medicinal product (for example
undischarged sharps or partially discharged sharps);

 Purple lidded receptacles – purple-lidded sharps receptacles should

be used for waste that is contaminated with cytotoxic and cytostatic
medicinal products.
3.3 Sharps bins must be assembled and labelled correctly; follow the
manufacturers’ instructions and ensure that the lid is securely fitted. The
appropriate information must be entered onto the label by the person
assembling the bin.
3.4 Faulty sharps boxes must not be used and any faults should be reported to
the ward / department manager. A Datix untoward event report form should
be completed.
3.5 Sharps bins must be located in a position that is out of reach of children.
Sharps bins should not be stored on the floor or above shoulder height; they
should be wall or trolley mounted using the correct bracket, or placed on a
secure, stable surface at approximately waist height.
3.6 When not in use the temporary closure mechanism must be used to keep
the contents of the sharps bin safely contained

3.7 Under no circumstances must the contents of one sharps container be

decanted into another container.

4. SAFE DISPOSAL OF SHARPS BINS

4.1 When maximum fill line is reached, sharps bin must be closed locked and
the label filled in by the person doing this. After sealing, sharps containers
must be stored in designated secured clinical waste store. Tags must be
attached to the handle of the sharps bin. Label the bin with ward/department
and date of closure
4.2 Domestic/Housekeeping staff will transport sharps containers to the central
storage facility. Sharps boxes are stored separately here awaiting collection
by the waste contractor.

4.3 Sealed sharps bins delivered back to the Community Hospitals for disposal
must be received by a member of the Community Hospital staff prior to
being placed in the designated secure clinical waste storage area.

5. ADDITIONAL GUIDANCE FOR STAFF HANDLING SHARPS IN THE

COMMUNITY
5.1 Staff employed by the Trust who use sharps in the community should keep
the size of sharps been carried to a minimum. While being transported in a
car the sharps bin must have the temporary closure mechanism in place
and should be secured in an additional transport box so spillage would be
minimised in the event of an accident. They should be kept out of sight and
the vehicle in which it is stored must be locked.

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IN THE EVENT OF A SHARPS INJURY: Please refer to Policy Flow Chart on
Page 4

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