RESPONSE TO NEEDLE STICK INJURY
AND SPLASHES POLICY
Document Version number: 1.0
Date Written: September 2007
Updated: Not Applicable
Author: Dee May / Helen Evans
Job Title: Infection Control Advisors
Email Address: firstname.lastname@example.org
Contact Number: 0208 812 7643
Date Approved by Infection Control Committee: September 2007
Next Review Date: September 2009
This policy can only be considered valid when viewed via the
Wandsworth PCT website. If this document is printed into hard
copy or saved to another location, you must check that the version
number on your copy matches that of the one online.
This Policy is valid on: 30 December 2011
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Response to Needle Stick Injury and Splashes Policy
1.1 Due to the need for prompt action with an exposure to blood or blood-
stained body fluids, staff should be made aware of the action to be
taken at induction before there is a risk of injury, and at regular
intervals thereafter to ensure that practice is up-to-date.
1.2 This policy deals with sharps / splash incidents which may result in
accidental exposure to Blood Borne Viruses (BBVs).
Health care workers who come into contact with patients’ blood or body
substances may be at risk of exposure to blood borne viral infections.
To prevent the likelihood of transmission this policy must be followed in
the event of a sharps/splash incident.
The policy is applicable to all healthcare workers who come into
contact with patients’ blood or body substances.
4 Roles and Responsibilities
The Director of Provider Services has over-arching responsibility for
all Infection Control issues at Wandsworth tPCT. The tPCT has an
Infection Control team who are available to advise on any issues on
0208 812 7643. The Infection Control Team also provide the
Infection Control Training.
5 Training Requirements
The management of needle stick and splash injuries is covered at
Infection Control Training. Infection Control Training is mandatory for
all staff as identified in the Training Needs Analysis. Non-clinical staff
are required to attend Infection Control training at Corporate Induction
at commencement of employment. Clinical Staff are required to attend
Infection Control Training at corporate induction at commencement of
employment and thereafter for updates annually.
6 Blood-borne Viruses (BBVs)
6.1 Blood-borne viruses include Hepatitis B and C and the Human
Immunodeficiency Virus (HIV).
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6.2 All individuals infected with blood borne viruses may be capable of
transmitting the virus to others irrespective of whether they are ill or
apparently fit and healthy. Infectivity depends on a number of
individual risk factors and will vary from individual to individual. Many
individuals are unaware that they are infected and thus health care
workers should always treat all blood and body substances as if they
are infected. Body substances that have been shown to transmit BBVs
human breast milk
saliva in association with dentistry
any other body substance containing visible blood, e.g. faeces,
unfixed tissues and organs
exudate or other tissue fluid from burns or large skin lesions.
7.1 The risk to the healthcare worker for each virus is proportional to the
prevalence of that infection in the population, the infectious status of
the individual source patient (which may or may not be known) and the
risk of a significant occupational exposure occurring during the
7.2 The risk of transmission to a healthcare worker from an infected patient
following a sharps injury has been shown to be:
Hepatitis B (e antigen positive) 1:3
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(if healthcare worker is non-immune)
Hepatitis C 1:30
(UK Health Departments, 1998)
Certain geographical areas of the world have a higher prevalence of
blood-borne viruses than others. Such information is useful in certain
situations e.g. when making epidemiological assessments of risk.
However, on a day-to-day basis, ethnicity is not used as a determinant
8 How Can BBVs be Transmitted?
By needle stick injury, contaminated sharp object, bite, scratch or
other skin puncture with contaminated blood or bloodstained body
Unprotected sexual intercourse with an infected person.
From infected mother to baby. Either via the placenta or at the time
of delivery, or through breast-feeding.
Via exposure prone procedures (when infected healthcare workers
can infect patients)
Via sharing contaminated sharps/”works” of injecting drug abusers.
Via contaminated blood or blood products (not usually a risk in the
UK but may occur if receiving blood in other countries).
9 Occupational Acquisition of BBVs
9.1 A number of factors are associated with an increased risk of
occupationally acquired BBV infection:
Visible blood on the device which caused the injury
Injury with a needle which had been placed in a source patient’s
artery or vein
High levels of circulating virus in the source patient – as in late
stage AIDS or during sero-conversion in the early stages of
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These factors will be taken into consideration when assessing the risk
of BBV transmission following a sharps injury. Such an assessment
will be undertaken by either the Occupational Health Department or
other departments, such as Accident and Emergency or Minor Injuries
Treatment Unit following national guidelines. Risk assessment should
never be undertaken by the individual who has received the sharps
9.2 The risk of HIV transmission after percutaneous exposures involving
larger volumes of blood, particularly if the source patient’s viral load is
likely to be high, may exceed the average risk. This may occur if injury
is sustained with a large hollow-bore needle when the needle contains
a large volume of blood from either an artery or vein.
9.3 Risk of infection from cutaneous exposure from infected blood/or
contaminated body fluids will depend on the infectivity of the material
and the size of the exposed area e.g. people with large areas of
psoriasis or eczema could be at higher risk of acquiring these
infections if in contact with infectious material when splashed.
9.4 The highest risk of contamination from cutaneous exposure relates to
splashes involving mucous membranes such as conjunctivae and
mouth. Hence the requirement for staff to wear appropriate PPE when
undertaking splash-inducing procedures e.g. endoscopy, or aerosol
producing procedures e.g. many dental treatments
10 Sharps /Splash Incidents
10.1 There are three types of exposures in health care settings associated
with significant risk. These are:
percutaneous injury (from used needles, scalpel blades, lancets and
other pointed instruments or equipment; bone fragments, significant
bites which break the skin, etc)
exposure of broken skin (abrasions, cuts, eczema, etc) to blood
and/or blood stained body fluids
exposure of mucous membranes, including the eyes, nose and
mouth, to splashes of blood and/or blood stained body fluids
11 Responding to an Injury (Appendix 1)
It is essential that a risk assessment is undertaken at the earliest
possible opportunity as delay in receiving prophylaxis (if required)
could affect outcome. This needs to be undertaken at the time of the
injury NOT at the end of the shift. Current guidance states that HIV
prophylaxis should be commenced within one hour of the incident, but
can still be given after that time.
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11.1 First Aid
Encourage bleeding from the wound. Do not suck.
Wash the area thoroughly with warm running water and soap
Cover with water-proof dressing
Eyes or mouth - irrigate with copious amounts of saline or water
ALL sharps injuries and splash incidents must be reported to the
Senior Nurse or Manager on duty (dependent on place of work) as
soon as possible, but do not delay seeking guidance on the need for
prophylaxis if a manager cannot be contacted.
An incident report must be completed by the person affected by the
event as soon as possible. The completed incident report should be
sent to the Risk Manager.
11.3 Record Details
Try to identify the source patient.
Complete the Checklist Form - Following Sharps/Splash incident
(Appendix 1) to help with the risk assessment and take it to the nearest
Accident and Emergency Dept. (Kingston or St. George’s Hospitals)
The Checklist will help to establish if the member of staff has had a
significant exposure to a high risk body fluid and provides guidance on
the important questions that will be asked by the assessing clinician
when undertaking risk assessment.
Wandsworth PCT staff
During office hours:
QMH and community staff:
As soon as possible after injury, inform the Occupational Health (OH) service
where you have been seen before (for QMH contact Orchard Hill):
St. George’s Hospital OH (020) 8725 2633
Orchard Hill OH (020) 8770 8308
Attend the nearest Accident and Emergency Department (either Kingston or
St. George’s Hospital). Identify yourself as a healthcare worker who has
sustained a sharps injury requiring risk assessment
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GP Practice staff
During office hours:
As soon as possible after injury, inform Occupational Health Tel. No. (020)
Out of hours:
Staff should attend St. George’s Hospital Accident and Emergency
Department. Identify yourself as a healthcare worker who has sustained a
sharps injury requiring risk assessment
When attending for risk assessment, the staff member affected must
take the completed Checklist to ensure that appropriate information is
available to the clinician undertaking the risk assessment. The staff
member may be required to have a blood sample taken and stored for
further testing if necessary. You may also be required – dependent on
the risk assessment – to have medication or immunisation to reduce
the likelihood of sero-conversion. Any concerns due to exposure, drug
treatment or employment etc. can be discussed in confidence at this
If the source is identified the clinician undertaking the risk assessment
will arrange for testing of that patient’s blood via their GP / clinician.
If seen out of hours, the Occupational Health Department will arrange
co-ordination of results and follow-up and determine whether further
blood tests will be required at 3, 6 and 12 months. This will be
undertaken the following working day after injury.
Complete the WtPCT’s Accident and Incident Report (AIR) form. See
Trust web page:
If the exposure is from a Hepatitis B, C or HIV positive source,
RIDDOR form 2508 will be completed by the Occupational Health
Physician once confirmation of the test results are known.
12 Hepatitis B – Vaccination / Prophylaxis
All health care workers at risk of exposure to blood/body fluids as part
of their work should be offered vaccination against Hepatitis B.
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12.1 Primary Course
This consists of 3 injections at 0, 1 and 6 month intervals followed by a
blood test to determine antibody levels.
Some people may not develop antibodies even after further doses of
In addition to primary immunisation, Hepatitis B specific
immunoglobulin may be required within 24 hours in the event of
accidental exposure from a high risk Hepatitis B source.
12.2 Accelerated Course
Accelerated Hepatitis B immunisation consists of injections at 0, 1 and
2 month intervals which may be administered to a non-immunised
person in the event of accidental exposure from medium to low risk
Hepatitis B source.
12.3 Routine Follow-up
It is recommended that all health care staff who receive Hepatitis B
vaccine should be screened by Occupational Health department every
five years to ensure antibody levels remain sufficiently high to provide
protection in the event of an injury. A booster dose may be given if
13 HIV – Vaccination / Prophylaxis
13.1 Although there is no protective vaccine for exposure to HIV there are
certain drugs which, if taken soon after exposure, offer some protection
to the exposed individual. Ideally, this should be received within 1 – 2
hours of injury but can still be administered for up to 72 hours post-
14 Hepatitis C - Vaccination / Prophylaxis
14.1 There is currently no vaccine available for prevention of Hepatitis C
15 Staff Support
15.1 Needle stick and splash injuries, especially those resulting in
Prophylaxis can cause a great deal of worry for members of staff
directly affected by the incident and it is important for managers to
recognise this and support the member of staff through this period.
15.2 Occupational Health services are also available to advise and support
staff following such incidents and are contactable on 0208 725 2633.
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16 Blood-borne Virus-infected Healthcare Workers
16.1 Healthcare workers who are known to have a BBV are restricted from
certain aspects of patient care. These restrictions are in place in order
to reduce the risk of transmission of BBVs to patients from infected
healthcare workers whilst carrying out certain procedures known as
Exposure Prone Procedures (EPP’s)
16.2 EPP’s are those invasive procedures where there is a risk that injury to
the worker may result in the exposure of the patient’s open tissues to
the blood of the worker (bleed-back). These include procedures where
the worker’s gloved hand may be in contact with sharp instruments,
needle tips or sharp tissues (e.g. shards of bone or teeth) inside a
patient’s open body cavity, wound or confined anatomical space.
However, other situations, such as pre-hospital trauma care and care
of patients where the risk of biting is predictable (e.g. such as with a
disturbed and violent patient) should be avoided by healthcare workers
restricted from performing EPP’s.
17 Review and Monitoring
17.1 All NHS trusts must ensure that policies are in place to identify and
manage employees with blood borne viruses.
17.2 All staff are under legal and ethical duties to protect the health and
safety of their patients. They also have a right to expect that their
confidentiality will be respected and protected.
17.3 All risk assessments must be sent to Occupational Health.
17.4 Needlestick and splash injury incidents are analysed by the Trust’s
Risk Manager and Infection Control department and are monitored by
the Infection Control Committee and Provider Safety Committee.
Figures will be presented and any trends will be highlighted, this will
enable the Trust to consider how recurrences might be prevented.
The Infection Control Team Tool is undertaken on an annual basis.
17.5 The Provider Infection Control Committee will meet bi-monthly to
review the effectiveness of this policy and ensure best practice.
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RISK ASSESSMENT FOLLOWING SHARPS/SPLASH INJURY
To be completed by staff member who has sustained the sharps/splash injury
and then taken to Accident & Emergency Department and / or Occupational
Name: Date of Birth:
Post: Place of Work:
Telephone Number: Manager:
Date: Time of Accident/Incident:
DETAILS OF THE INJURY
Brief description of the incident with blood/blood stained body fluids
(please tick box if applicable)
Needle/scalpel blade or other sharp instrument
EXPOSURE TO MUCOUS MEMBRANE
Which high risk body substance?
Blood stained body fluid
Saliva (if visibly blood stained e.g. in association with dentistry)
Other please specify ……………………………………………………………
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C Source Patient History (if known, to be completed by doctor/nurse
managing the staff member NOT the injured person)
Name…………………….. Tel No: ……………………………………
GP / Clinician details: ……………………………………………………..
Source patient infected with
Source patient on medication for one (or more) of above illnesses
IV drug user (present or previous)
Does client have high-risk behaviour? (ask only if appropriate and in the
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