In response to the specific questions posed on page 32 of the consultation document:

1 Scope

The Safer Needles Network welcomes the Department of Health’s broad approach to tackling health care associated infections, and in particular the inclusion of staff as well as patients being at risk. Infection prevention and control needs a co-ordinated and multifaceted approach. Although MRSA is perhaps the best known cause of health care associated infection different perspectives of applying general principles of infection control and prevention need to be considered.

Although the draft Code of Practice mentions staff several times, there should be more references to staff in the introductory sections to reflect the broad scope of the approach. For example, on page 6 paragraphs 13 and 14 “whom do health care associated infections chiefly affect” there is mention of MRSA and “patients with severe or chronic diseases” but no mention of blood-borne viruses or staff.

2 Detail and Clarity

Clarity is vitally important in any guidance document.

Many of the measures listed under “Patient Care” (section 2.3, p18ff) are in fact measures to protect healthcare workers (e.g. bullet points 5, safe handling & disposal of sharps…, bullet point 6, prevention of occupational exposure to BBVs…., bullet point 7 management of occupational exposure to BBVs…and bullet point 23 Care of the Cadaver page 22, can hardly be said to be measures to protect patients.). Other measures also impact on staff health e.g. clinical waste management.

Some of the measures listed under “Healthcare Workers (section 2.5, p24ff) 2.52-2.57 are measures to protect patients although they involve staff.

In fact many of the proposed measures will protect patients, staff and visitors to hospitals, to varying degrees

Specifically, in the section on Patient Care, section 2.3 p.18ff):
Page 19 · Isolation of patients comment is made that “isolation policies should be evidence based”. However, current evidence about the relative merits of isolation is conflicting. It would be useful to include expert opinion on how a balance of such evidence is viewed. (e.g. Cooper et al Isolation measures in the hospital management of MRSA systematic review of the literature. BMJ 2004; 329:533-9 and Biant LC, Teare EL, Williams WW, Tuite JD. Eradication of methicillin resistant Staphylococcus aureus by “ring fencing” of elective othopaedic beds. BMJ 2004; 329:149-51.)

Page 19 section 2.3 Clinical Care Protocols · “Safe handling and disposal of sharps …” We suggest that the words “where indicated” should be deleted as they are superfluous in this context. The first bullet point mentions training in the management of needle stick injuries. The first step should be in the training of the prevention of needle stick injuries through safer systems of work, leading from “risk assessment and risk management”. The management of a needle stick injuries is a specialist function carried out by Occupational Health or Sexual Health Services, or Infection Control or Infectious Diseases specialists. The point is that there should be access to qualified support in the management of needle stick injuries.

Page 19 section 2.3 Clinical Care Protocols

“Prevention of occupational exposure to BBVs…”

· the first bullet point mentions immunisation against hepatitis B. This is important but is doesn’t prevent exposure, it minimises the risk of transmission in the event of exposure and therefore it should be in a separate section on “Prevention of transmission of BBVs” or “Prevention of Infection”.

· The second bullet point refers to “…measures to reduce risks during surgical procedures” This should be made more specific and aligned to chapter 19 of the Blue Book e.g. “the provision of medical devises incorporating sharp protection mechanisms to reduce the risks during surgical procedures”.

Page 19 section 2.3 Clinical Care Protocols

“Management of occupational exposure to BBVs and post exposure prophylaxis”

Reference to designated doctors. Many such exposures can be managed competently by properly trained occupational health nurse advisors. Doctors are needed for the prescription of anti-retroviral drugs (post-exposure prophylaxis) in the event of exposure to HIV.

There should also be the mention of the possibility of two-way exposures i.e. patients being exposed to blood from health care workers for example when sharps injury occurs in the context of exposure prone procedures. In this scenario there needs to be robust procedures to ensure that such incidents are reported (often they are not) and the designation of a doctor with suitable qualifications and experience (e.g. Occupational Medicine, Virology, Microbiology, Sexual Health, Infectious Diseases) to asses the risks and give appropriate advice in these cases.

Page 22 · Care of the cadaver, The reference to “health surveillance” and “immunisation” needs clarification. The term “health surveillance” has specific meaning and in this case it is not clear which particular exposure requires health surveillance and which immunisations, over and above those normally recommended for health care workers, need to be considered in this context.

Page 23 section 2.3.2 · “Systems to protect both patients and staff from the transmission of infection…” This is a principle that needs to be emphasised more throughout the document to reflect its broad scope (see above).

Page 23 section 2.3.5 The first sentence in this paragraph does not make sense. Suggest “for all appropriate clinical settings there should be written evidence of local surveillance and use of comparative data where available”.

Page 24 section 2.5.1 The recommendation that Occupational Health Services should include “health screening for communicable diseases” and “relevant immunisations” needs to link with specific guidance from other sources such as the “imminent” definitive guide on screening new health care workers for serious communicable diseases, and the Department of Health’s Green book guidance on Immunisation Against Infectious Diseases.

Page 24 section 2.5.2 The wording of this section is confusing. Suggest “Occupational health policies for the provision of advice and support for health care workers infected with or who may have been exposed to (occupationally or otherwise) blood-borne virus infections, to minimise the risk of transmission to patients”. Again the bullet points in this section could usefully link to other sources of specific DH guidance (HIV infected HCWs).

3 Pressure for change

The Safer Needles Network welcomes the Department of Health’s rejection of the option to introduce new criminal sanctions in the case of breaches of the Code of Practice. Positive change is far more likely to result from specific guidance and support for individual health care workers (in the form of guidance) and health care organisations (in the form of appropriate resourcing) than the threat of legal action. There will be a financial investment associated with the implementation of many of the measures indicated. Although most would recognise that the investment in safer working practices and technology to protect patients and healthcare workers will ultimately be offset by a significant range of savings that will be enjoyed by the health system and society at large, it does not alter the short-term budgetary challenges. Perhaps the Department of Health should plan to make funding available for the initial introduction of measures indicated in the Code of Practice, such as has been provided by the Spanish government to facilitate the pilot introductions of medical technologies and safer working practices to prevent needlestick injuries.

4 Current measures

Current areas of confusion which could benefit from clarification include

a) Robust reporting procedures for staff and patient blood/body fluid exposures. Clear communication of the benefits of reporting and managing blood and body fluid exposures (as in ch19 of the Blue Book)

b) The relative benefits and costs of measures such as isolation of patients

c) Communication of appropriate and practical guidance on best practice in areas such as hand hygiene.

Dr Paul Grime 19th September 2005.

NEWS ARCHIVE

16 Nov 2005 Safer Needles Network Minutes - 13 Sep 2005

10 Oct 2005 Response to "Action on Health Care Associated Infections in England"

10 Oct 2005 CPME Position Paper on Neeldestick Injuries

15 Jun 2005 National Risk Conference 2005

31 May 2005 Nursing Safety Survey 2005

31 May 2005 2nd Needlestick Awareness Week

24 May 2005 Safer Needle Network minutes

26 January 2005 Needlestick Management Guidance

26 January 2005 Healthcare workers still at risk from HIV and Hepatitis C

25 January 2005 Needlestick injuries in healthcare workers still occurring

12 August 2004 Sharp Thinking: An All Wales strategy for sharps injury prevention'

11 March 2004 ‘Safer Needles Now!’ roadshow hits London, Bristol, Birmingham, Newcastle and Glasgow

20 February 2004 Unions demand ‘Safer Needles Now!’

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