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EXECUTIVE SUMMARY
1 Police and prison service staff are at risk of occupational exposure to blood or body fluids, with a consequent risk of acquiring a blood borne virus ( BBV) infection such as HIV, hepatitis B ( HBV) and hepatitis C ( HCV). Following a Scottish Police Federation petition to allow mandatory blood testing of source individuals, the working group that considered the proposal recommended that an evaluation of the management of occupational exposure in the police and prison services be carried out.
2 The aim of this evaluation, carried out between March 2007 and December 2008, was to describe and evaluate post-incident management services for preventing psychological and physical harm in police and prison staff potentially exposed to BBVs in the work context.
3 Information was sought on the policies and procedures for managing exposure incidents in police forces and the Scottish Prison Service ( SPS). All staff were advised to report incidents to Health and Safety (H&S). Police service staff could seek medical help from Accident and Emergency (A&E) services and/or Occupational Health ( OH), but there were differences between forces in the use of medical services. Prison service staff could seek medical help from an identified A&E department, which also organised follow-up care.
4 Publicity was circulated to encourage staff to report exposure incidents. In the SPS a procedure was put in place so that staff reporting an incident were asked to attend OH for the purpose of the evaluation. Data were collected for 55 weeks in police forces and 47 weeks in the SPS. OH and H&S recorded the numbers of exposure incidents notified to them. For each case reported to OH, staff recorded details of the circumstances and management on a standardised form. From this information a panel of experts assessed the risk of BBV infection in each case and evaluated the appropriateness of the clinical management. Exposed individuals were asked to complete a postal questionnaire about their experience of services and their anxiety following the incident.
5 108 incidents were included in the evaluation, 105 from police forces and 3 from the SPS. 288 incidents were reported to all H&S units, and 146 to OH, over the study period.
6 The 108 exposed staff were men (69%) and women aged 19-55 years, with between 3 months and 30 years service; 83% were police constables. Most incidents (74%) were spits, bites and splashes, but there were 14 needle-stick or sharps injuries. Just over half the incidents were deliberate. 77 (71%) involved contamination of broken skin or mucous membranes and 27 of these involved blood. 91 (84%) occurred outside OH working hours. A&E was the first point of medical contact in 58 (54%) cases, and these were more likely than those reported first to OH to have incurred a risk of BBV infection. In 102 cases the source person was identifiable, and 14 of the 24 sources who were asked provided a blood sample.
7 105 cases were evaluated by the expert panel. In 81 cases (77%) panel members felt that OH had assessed the overall risk of BBV infection correctly. In the large majority of cases they judged the management by OH to have been adequate and appropriate. Some concerns were expressed, however, about inconsistency in HCV follow-up testing. Reviewers were unable to evaluate medical services other than OH since no first-hand information was available, but they noted some evidence of variation in care. They were also critical of missed opportunities for source testing, a reported lack of communication between A&E and OH, and instances of poor staff first aid and delays in reporting to OH.
8 73 exposed individuals (68%) returned the postal questionnaires. These respondents were representative of the main sample, though slightly older, and the proportions attending each first point of medical contact were similar. Generally, individuals' reported anxiety lessened after contact with medical services, although those whose first point of medical contact was OH were less anxious overall than those who first attended other services. Most respondents were satisfied with the care they had received, particularly from OH. Their main reasons for dissatisfaction concerned a lack of information, and several felt they had received little advice from A&E. About half of the 73 respondents remembered receiving training about BBVs.
9 The evaluation had limitations. The lack of information about the actions of medical services other than OH, and the fact that OH did not normally provide post-incident care to SPS staff, meant that statements about clinical management could only be made about police OH units. In addition, OH staff were aware that their actions were being evaluated.
10 The findings provided no grounds for recommending mandatory source blood testing. However, when there is an assessed risk of BBV infection, source blood should be requested where it is feasible to do so.
11 No conclusions could be drawn about the management of incidents of occupational exposure in the SPS because of the small number of cases, which could not be seen as representative. Nevertheless 2 of 3 employees were unvaccinated against HBV, and concerns were expressed by panel members and exposed individuals about a lack of advice and apparent confusion about procedures in the medical services initially contacted.
12 Since clinical management should be consistent, regardless of the service provider, there should be a clear protocol, to be used by all medical services. Guidelines for the management of exposure incidents should be developed for police and prison services, based on current NHS guidance but including issues specific to these services, and the circumstances in which a request for source blood would be appropriate. Training may be needed for A&E staff, police and prison medical staff, and OH.
13 Arrangements should be in place to enable OH staff to receive joint training and share information on best practice. OH staff should follow best practice in providing support, written information and follow-up to exposed members of staff.
14 The practical or local arrangements for providing post-incident management may be a matter for each organisation, but these arrangements should be discussed at a senior level so that all services are aware of their responsibilities. There should be discussion about ways in which information can be passed directly between services, particularly A&E and OH, but also between H&S departments and OH providers.
15 Police forces and the SPS should publicise clear guidelines for staff on the procedures to be followed after an exposure of broken skin or mucous membranes (eyes, nose, mouth) to blood or body fluids. They should also publicise their policies of free HBV immunisation, and try to ensure that all staff at risk are vaccinated, and records kept. More training on BBV infection may be needed for police and prison service staff.
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