Dr Blanaid Hayes

8/7/2019 Dr Blanaid Hayes

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1

National Guidelines on

Blood-Borne Pathogens

Dr Blnaid Hayes, FRCPI, FFOM,

Occupational Health Department,

Beaumont Hospital,

Dublin.


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22/04/2006 National Needlestick Injury Conference 2

DOHC Guidelines: 2005

Launched DOHC

website March 29th

2006

HSE implementation

group (multidisciplinary)

to meet in early May


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Background to DOHC guidelines

1995: Advisory Group

on Transmission of ID

in Health-care Setting

established to adviseMinister for Health

1997: first report

published

Standing AdvisoryCommittee established

1999: The Prevention

of Transmission..


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Key Questions

Who?

What?

When?

Where?

How?..........

All healthcare workers

Guideline, code ofpractice, policy,

recommendations,protocols

Now

Any organisation in whichhealthcare is practised e.g.hospital, institution, clinic,medical or dental practice


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Key Players

Internal

Individual HCWs

Clinical managers

Employer / CEO ICNs / Consultant

Microbiology

OHAs and Specialist

Physicians

ID consultant

Risk manager

Laboratory

External

Minister for Health

DPH

Local Expert Group Standing Advisory

Committee

Training Bodies

Schools of medicine,nursing and dentistry

Specialist faculties


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Key Solutions

International guidelines

Legislation

Policies

Standard operating procedures Good management

Individual responsibility

Up to date training / incorporating new

developments/ immunisation Data collection / incident management / surveillance

/audit


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DOHC Guidelines: contents

Assume detailed knowledge of / familiarity with StandardPrecautions (1996)

Risk management approach underpins guidelines

Defines the risk

Key recommendations Implications for employers

Implications for OHS services

Implications for employees

Testing procedures

Training

Work restrictions

Conclusion


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Recommendations: ARisk Management and Infection Control

Develop and adopt riskmanagement and infectioncontrol policies that aremonitored for effectiveness

Access for all to specialistadvice in OH, microbiology, IDand IC

Education of all potentially atrisk HCWs in application ofSPs, on initial employment andannually thereafter (bycompetent individuals)

IC education to beincorporated into training of allmedical, nursing and dentalstudents


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Recommendations: ARisk Management and Infection Control

Institutions to appraise new technology and invest inappropriate / relevant devices

Apply protocols also to potential risk oftransmission between equipment and patients

STANDARD PRECAUTIONS HCW responsibility to keep themselves informed on

developments and risks

Haemodialysis units

EPP workers to complete risk assessment Contact and SPs for patients positive for BBV with

uncontrolled bleeding


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Recommendations: BPrevention of Transmission of Hepatitis B

All at risk HCWs (andstudents) to be immunisedor provide evidence ofimmunity (natural or vaccineinduced)

EPP workers (and those whomay in future perform EPPs)to be tested for antiHBc andHBsAg (professionalinterpretation)

No offer of employmentwithout compliance with

appropriate pre-employmentoccupational healthassessment programme


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Recommendations: BPrevention of Transmission of Hepatitis B

Confidential maintenance of immunisation records

Issue such records to individual HCWs

EPP workers positive for HBsAg to be tested for HBeAg.Exclude those positive from EPPs

HBsAg+ and HBeAg- HCWs to have viral load determined Where risk of patient exposure has occurred, institutions

must have look back policy for implementation of look backexercise if recommended by Local Expert Group. StandingAdvisory Committee to be informed


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Recommendations: CPrevention of Transmission of HIV and Hepatitis C

Incremental screening ofHCWs who perform EPPs tobe initiated and evaluated.

Anti-HCV+ HCWs to havePCR for HCV RNA. Excludethose PCR+ from doing EPPs.(No HIV screening pro tem)

HCWs to be aware of ethicalobligation to seek diagnostictesting if exposed to BBVthrough work or other riskbehaviours

Exclude HIV+ HCWs fromEPPs

Look-back policy: as per HBV


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Recommendations: DDialysis and Renal Transplant Settings

Implementation of SPsand appropriatesegregation of infectedpatients and theirequipment.

Pre-treatmentscreening andvaccination of dialysis

patients andsurveillance while ontreatment


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Recommendations: EIdentification of Infected Health-care Workers

Employers to facilitate voluntary disclosure ofinfection status. On commencing employment, allemployees should be made aware of risk factors foracquiring BBD and of their ethical duty to disclosesuch infection .

Once notified, physician to inform DPHanonymously who will dictate response dependingon previous or ongoing risk to patients. May require

LEG to be convened. Inform infected HCW andCEO of any need for work restrictions


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Recommendations: FRedeployment, retraining and/ or support

Every effort should be made to retrain or re-deploy infectedHCWs where appropriate

Training bodies to be aware of challenges and to take these intoaccount

Provide appropriate support arrangements for infectedpermanent employees unable to work

Faculties should set up mentoring system to provide support andinformation on financial, medical and career consequences ofinfection

Medical, dental and nursing schools should take account ofnational guidance in developing policies


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EPP: A procedure where there is a risk that injury to the health-care worker may

result in exposure of the patients open tissues to the blood of the worker

Include Surgical entry into tissues, cavities

or organs or repair of major traumatic

injuries, vaginal or Caesareandeliveries or other obstetric

procedures during which sharpinstruments are used

The manipulation, cutting or removal

of any oral or perioral tissues

including tooth structure, during

which bleeding may occur

Where workers hands may be in

contact with sharp instruments,needle tips or sharp tissues (spiculesof bone or teeth) inside patients

open body cavity, wound or confined

anatomical space.

Dont include

Injections / taking blood/

line set up

Minor surface suturing

Incision of abscesses

Routine vaginal or rectal

examination

Uncomplicated endoscopies


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Implications for Employers:

Statutory duty to employees under H&S Act2005: information, training, safe place ofwork, safe systems of work, PPE, saferdevices etc.

Resources forinfection control

ICNs, microbiologists Surveillance

Policies

Education (SPs, contact precautions whereappropriate)

Resources foroccupational health

OHAs, specialist physicians

Prevention, management and follow-up of OBEs PEHA assessment / vaccination

Management of infected HCW

Statutory duty to notify all cases of viralhepatitis


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Implications for Employers : 2 Prepare / update appropriate organisational policies on

prevention of exposure, management of infected HCW anddealing with look-backs

Arrange appropriate health assessment at recruitment

Assess risk of work practices and modify those identified ashazardous

Observe specific arrangements for haemodialysis patients(and staff)

Educate staff on use of new devices, use of PPE, disposal ofsharps and health-care risk waste

Promote a safety culture

Record and audit incidents

Maintain confidentiality

Provide appropriate support arrangements for infectedpermanent employees unable to work

RISK MANAGEMENT


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Implications for training bodies

Medical, nursing, midwifery and dental

students must be immunised / and or tested

for evidence of hepatitis B infection

Training bodies to be aware of

responsibilities in providing support for

infected HCWs / facilitating retraining/

mentoring system etc.


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Implications for OH Services

At PEHA, do BBV risk assessment on all EPP workers (includinglocums, temporary staff or supernumeraries).

Ensure liaison with recruitment staff to ensure no offer ofemployment until candidates comply with PEHA requirements

Immunise those at risk against hepatitis B

Test EPP workers for infection (HBV,HCV) in accordance withaccepted procedure

Test renal unit staff for HBV . Restrict those with viral load >104

from undertaking clinical procedures in the unit. Annual HBsAgtesting of those non-immune.

Manage infected HCWs in supportive and professional manner

Hepatitis B is prescribed disease: occupational injury benefitavailable

Remember statutory obligation to notify


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Implications for Employees

Be aware of ethical obligations (primum non nocere)

Be aware of legal responsibilities vis a vis H&S at work : Participate in training

Take SPs at all times and in particular, use sharps safely(planning, avoidance etc.)

Report all incidents

Avoid putting oneself at risk (personally and occupationally)

Standard Precautions

Infected HCW who is involved in clinical cases should remainunder medical / OH supervision

Infected HCWs must abide by any restrictions imposed by LEG


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Testing

General procedure:

Ensure sample is verifiable: takenin OHD, or confirm taken in OHDelsewhere

Repeat test if doubt integrity ofresult

HCWs must not provide their ownspecimens

Testing for EPP clearance

Show proof of identity

Take sample in OHD

Transport sample to lab in normalway and not by HCW

OHD must confirm, on receipt of

results from lab, that sample wastaken in OHD

OH professional should takereasonable steps to ensure HCW isnot taking antivirals

Approved laboratory is VRL Belfield

Specifics:

HBV viral load on 3 sequentialsamples using same testing kitover 6 week period

Annual testing for those withviral load 5,000copies/ml or significantincrease in load.

Hepatitis C antibody and if positivedo PCR.

Test annually for PCR in thosewho are antiHCV+

Epidemiology if infectivity isuncertain and decisions onrestrictions should be made oncase by case basis, particularlyfor those on anti-virals (P 25)


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Training Programme Content:(to be provided upon initial employment and at appropriate intervals thereafter)

Epidemiology and mode oftransmission

Use and location of PPE

Understand SPs

Be aware of role of OH

Be aware of procedure forblood exposures (1st aid andPEP)

Have access to relevantpolicies to protect HCWs andpatients from BBVs

Have access to policies forinfected HCWs

Training should be interactive

Training records must bemaintained (date, content,names)


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WORK RESTRICTIONS

All EPP workers to be screened formarkers of HBV. If +, need viral loadtesting and exclude those with DNA >104

copies per ml

All EPP workers to be screened for HCV(incremental i.e. starting with trainees)

No routine testing for HIV but those whobelieve they may have risk factors must betested. No HIV+ HCW should do EPPs

All renal unit staff to be tested for HB

markers and restricted from clinicalprocedures if DNA > 104

Annual testing of renal unit workers whoare non-immune for HBsAg

2005


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Conclusion

Old guidelines have been enhanced but basics areunchanged (infection control, risk management etc.)

Additions summarised:

Renal unit guidance Hepatitis C screening / work restrictions

New threshold for HB screening

Greater detail on testing procedures

Sample OH form for EPPs (Appendix)

Algorithm for managing infected HCWs (P 52) Retraining, redeployment and / or support: apply to those

who acquire infection in Irish public health sector

Reference to risks from contaminated equipment

Documents

Dr Blanaid Hayes