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CHAPTER TWO POST-INCIDENT MANAGEMENT: POLICIES AND PROCEDURES IN THE POLICE AND PRISON SERVICES

2.1 This chapter first outlines the elements of appropriate post-incident management of occupational exposure to blood or body fluids, from existing guidelines. It then describes the relevant policies and procedures for managing incidents of exposure in Scottish police forces and the Scottish Prison Service ( SPS), from information provided by the representatives of these organisations.

2.2 UK legislation requires employers to protect the health and safety of their employees, (Health and Safety at Work Act, 1974; Management of Health and Safety at Work Regulations, 1999). Under the Reporting of Diseases, Injuries and Dangerous Occurrences Regulations ( RIDDOR) (1995), dangerous occurrences that could result in severe infection, including occupational exposures to BBVs, should be reported to the Health and Safety Executive ( HSE, 2008).

2.3 Early meetings were held with key individuals and groups from the police and the SPS to gain an understanding of organisational structures and the policies governing the post-incident management of occupational exposure incidents, and to seek support for the evaluation. The OH staff consulted were also asked for their views about the strengths or weaknesses of the current system and whether they had any suggestions for improvements. Several staff commented that they were in a "transition period" regarding dealing with occupational exposure, so current procedures could change.

Post-incident management

2.4 Appropriate management after an incident of exposure to potentially contaminated blood or body fluids includes taking full details of the incident, assessing the risk of BBV transmission from the information available and offering information, advice, treatment and counselling as necessary.

2.5 A vaccine is available to reduce the risk of acquiring HBV, although a minority of the population do not respond to it, and routine vaccination may not always be appropriate (Murphy, 2000). After an exposure, the risk of HBV infection can be reduced by treatment with a booster or accelerated doses of vaccine. Guidance exists on appropriate post-exposure measures, which to be effective need to be administered within 7 days (DoH, 2006).

2.6 Although no vaccine is available, post-exposure prophylaxis ( PEP) can reduce the risk of acquiring HIV after an incident of exposure; the side-effects, however, can be unpleasant. To be effective, HIVPEP should be administered as quickly as possible, ideally within an hour of exposure and no later than 72 hours afterwards (DoH, 2008).

2.7 There is no vaccine and no effective PEP against HCV infection. However, the infection can clear spontaneously in about 20% of cases, and recently developed treatment protocols can be effective in sustaining viral clearance (DoH, 2004; Scottish Intercollegiate Guidelines Network ( SIGN), 2006; Health Protection Agency Centre for Infections ( HPA), 2008; Scottish Government, 2008).

2.8 Blood tests can detect the presence or absence of HBV, HCV and HIV if carried out at an appropriate time (up to 6 months after the incident). Guidance exists on appropriate testing protocols, depending on the assessed risk of transmission (DoH, 1998; 2004; 2006; 2008). The exposed person's infection status at the time of the incident can be established by taking a serum sample for storage as soon as possible after the incident. If follow-up blood tests show a BBV infection, a test on the stored blood can establish if the infection was present at the time of the incident or alternatively could have resulted from the exposure.

Policies and procedures in Scottish police forces

2.9 The 8 police forces in Scotland - Central Scotland Police, Dumfries and Galloway Constabulary, Fife Constabulary, Grampian Police, Lothian and Borders Police, Northern Constabulary, Strathclyde Police, and Tayside Police - vary in the size and type of the geographical area served and in the density of population. At the time of the study, each force was autonomous in its organisation and its policies. There were no national (Scottish) police policies regarding staff health care, the remit of OH departments, education and training on BBVs, or HBV immunisation. Each force had developed its own guidelines for dealing with occupational exposure to blood or body fluids. An internal police enquiry in 2005-2006 had collected each force's guidelines on HBV immunisation, BBVs and occupational exposure, any leaflets issued to staff and any training provided.

2.10 This enquiry, and discussions with police representatives, showed that, broadly, all police service staff exposed to blood or body fluids while on duty were advised to carry out first aid, report the incident to their line manager or supervisor and to H&S, where an Accident Form had to be completed for notifiable incidents. Staff were also advised to seek medical attention, either from their OH unit or from an Accident and Emergency (A&E) department, and to report the incident to OH. Incidents of occupational exposure experienced by police service staff were most likely to occur at night, particularly over the weekend.

Occupational Health services

2.11 Each force had an OH unit, located in or near headquarters, which all service staff, including support and forensic staff, could attend. OH units were available from Monday to Friday, 9am - 5pm. OH teams included nurse advisers (or in some forces nursing advisers, hereafter referred to as nurse advisers), who would normally have OH experience as well as nurse training, and each unit had the services of a physician.

2.12 The organisation and the provider of OH services varied from force to force. Services could be provided either internally ( i.e. staff were force employees) or externally by a contracted OH ( NHS or independent) provider. External contracts were held for 3-4 years and the provider could be changed at renewal. The OH providers for each police force at the time of the study are shown in Table 2.1 below.

Table 2.1: Police force OH providers

2.13 The resources of OH units and the remit of staff varied between forces. One unit, for example, had a 24-hour telephone helpline, while others did not. Further, while all units had facilities for face-to-face consultations and performing blood tests and vaccinations, 2 units mainly provided a telephone advisory service.

Information, education and training

2.14 Police service staff could access information about BBVs and occupational exposure in the force staff handbook (or manual) and on the force intranet site. Much of this factual information was common to all forces, especially regarding the types of incidents that carried a risk of BBV infection: "injuries with needles or sharp objects that have been in contact with blood or other body fluids, or for splashes of blood or body fluids on broken skin, eyes, nose or mouth and where a human bite breaks the skin". Staff manuals also provided advice about appropriate first aid measures following an exposure to blood or body fluids: "Encourage bleeding of puncture wounds, wash the affected area and irrigate mucosal surfaces".

2.15 Additional information and advice about procedures was also often provided to staff in each force via the manual or intranet site, or on posters ( e.g. in police stations), leaflets or 'aides-memoire'. This advice might vary from force to force.

2.16 OH advisers stated that education and training on BBVs and occupational exposure was provided to staff in their force. This could encompass: safe working practices, the prevalence of BBV infection, risks of transmission, and first aid and reporting procedures. A presentation would normally be given to new staff at induction. In some forces, OH staff said that refresher education was also provided, especially for staff most at risk, and there could be general 'promotions'. Training on BBVs could be provided by HR or H&S staff, and in some forces OH nurse advisers were involved in supplying materials or delivering sessions.

2.17 Several OH staff expressed the view that police service staff often did not retain the information that they were given about occupational exposure to blood and/or body fluids, saying that, "it's not until it happens to them that they really think about it". Some felt that knowledge should be tested, saying, "The information - say about first aid - is out there, but it doesn't go in", or "Most know the risks of needle-stick injuries, but not otherwise".

Hepatitis B immunisation

2.18 At the time of the study, free HBV immunisation was being introduced to each police force in Scotland, and was reportedly recommended to all new service staff. Immunisation was voluntary, but OH nurse advisers said that staff were aware of the reasons why it was offered and few declined. Immunisation programmes had started with employees most at risk. Some staff in a few forces were unsure if all support staff, such as drivers or reception staff, had been offered vaccination, but most OH staff stated that immunisation had been offered to all new staff in their force, with existing staff being reminded of its importance by publicity. Some OH units had produced an explanatory leaflet about HBV.

2.19 Until recently HBV vaccination had reportedly been carried out by the staff member's GP, but OH staff in most forces said that normally they ( OH) would now provide vaccinations and follow-up blood tests. All OH units kept records of staff HBV vaccinations and titre levels. OH nurse advisers noted the difficulties of keeping up with staff changes, but most thought that almost all their force had been vaccinated. Some said they were pro-active in checking their HBV immunisation records and ensuring that staff vaccinations were up to date.

2.20 OH units in most forces provided staff with a written record, or certificate, of their HBV immunisation, often as a card that could be carried in a pocket or pouch to be presented when required. In at least one force, HBV non-responders' written records stressed that they should take particular care to follow safe working practices, and that, if they were exposed to blood or body fluids, they should inform medical staff of their non-response status.

Reporting occupational exposure incidents

2.21 The advice given to staff about reporting incidents of exposure to blood or body fluids could vary from force to force. For example, staff in one force were instructed that if they were injured ( e.g. with a syringe or needle), they should if possible retain the weapon that caused the injury. Also, if they were injured by a prisoner who was known or suspected to have a BBV infection, they should contact the duty medical officer, since the prisoner might agree to have a blood test to confirm his/her infectivity.

2.22 Information from OH staff also indicated that the advice about the type of incident that should be reported, to which service, how quickly, and for what reasons - could vary between forces. In some, staff exposed to blood or body fluids while on duty, even within OH working hours, were advised to attend an A&E department in the first instance. If a member of staff in these forces reported an incident of exposure to OH, they would normally be advised to attend A&E for an initial risk assessment and to have blood taken for storage. Some OH nurses said that police service staff would often be 'fast-tracked' in A&E.

2.23 In one such force, information given to staff advised that they should attend OH for "confidential follow-up to obtain appropriate counselling and action", and that, "needle-stick injuries must be followed up within 48 hours of the injury". Staff in another force, however, were asked to report all incidents of occupational exposure to OH and H&S within 24 hours. In a third, a poster advised that all incidents involving contact with blood or body fluids, including splashes to intact skin, should be reported to the line manager and to OH, and an incident report form completed.

2.24 Most OH nurse advisers said that they would normally first hear of an occupational exposure to blood or body fluids from the exposed person or their line manager. In a few forces, OH staff said that they would occasionally first hear of an incident from H&S. However, there seemed to be differences between forces in the links between H&S and OH. In some, the H&S adviser reportedly alerted OH to any incident of exposure on an Accident Form. In others, OH staff said that they usually received copies of Accident Forms. In others again, OH staff said that this was not the procedure in their force but H&S would normally advise the member of staff to report any incident to OH. In one force, however, OH staff estimated that they only heard about a minority ("four in ten") of incidents reported to H&S.

Occupational Health procedures and responsibilities

2.25 Each OH unit had written guidelines covering the procedures to be followed for incidents of occupational exposure to blood or body fluids.

2.26 OH nurse advisers said that, on hearing of an exposure incident, they would contact the person and would usually ask them to come into the unit if possible. Whether the OH consultation was by telephone or face-to-face might depend on the facilities of the unit, where the member of staff was based, the significance of the exposure, the exposed person's anxiety, and whether they had already attended another medical service. The OH nurse would take the details of the incident, with any information known about the source person, and check the exposed person's HBV record. If immunisation was required, they would recommend this, and in most forces they would offer to carry out the necessary vaccination(s).

2.27 Most OH nurse advisers stated that, at that time, they were not required to record the number of occupational exposure incidents reported. They described various ways of keeping records (electronic or hard copies) of incidents and consultations, such as adding details to the individual's OH record, or keeping a diary. In some forces OH staff said they would "make a few notes", whereas in others details were recorded on a standard form.

2.28 Police representatives said that the identity of the source person was often known to the exposed member of staff, and that the police might be aware of some risk factors, such as injecting drug use. In some cases there might be information about the person's BBV infectivity status; either anecdotal (often a claim by the individual) or occasionally information (that might or might not be validated) from a police database. OH staff were not involved in recommending source blood testing. Some OH nurse advisers reportedly received the results of any source blood tests, but most said that they were not informed of source blood test results.

2.29 Most OH nurse advisers said that they would assess the risk of BBV infection. In a few units, however, the role of some OH nurse advisers did not include risk assessment ( e.g. if this was normally carried out at A&E), and these nurses said they would be uncomfortable with this responsibility. Those who did assess risk noted that they could call on a supervisor ( e.g. Force Medical Adviser) and/or staff at specialist Infectious Diseases ( ID) or Genito-Urinary Medicine ( GUM) clinics for advice on risk assessment if required.

2.30 The remit of most OH units also included offering, advising on and carrying out follow-up testing to detect the presence or absence of BBVs. They would also take blood for storage if they felt this was necessary. Some of these units had produced explanatory leaflets. Many OH staff said that decisions about follow-up testing were often a matter for the exposed individual; some people whose risk of BBV infection was negligible might request testing for their 'peace of mind', whereas others sustaining a more significant exposure might decline follow-up blood tests. The policy in at least one unit was to explain the testing available rather than using the language of 'recommending' it.

2.31 In a few units, however, OH staff would normally recommend that the exposed person attend another medical service ( e.g. a local ID or GUM clinic) for follow-up care (and for the risk of BBVs to be checked if felt necessary). Staff would be given contact details and advised to make an appointment.

2.32 Most OH nurse advisers said that, on the basis of their risk assessment and/or any information from the exposed person about advice given elsewhere, they would advise the exposed member of staff about any actions they should be taking to avoid passing on a possible BBV infection, such as safe sex precautions. They would also offer reassurance and counselling, emphasising that the member of staff could return to OH if they or family members had any further worries or concerns. Most noted that other counselling services were available if required, such as an Employee Assistance Programme.

2.33 Some OH staff said that they would normally follow up each case of occupational exposure by contacting the person after a given time ( e.g. 6 months). Others said that they would normally actively follow up cases that they perceived as 'high risk'.

2.34 In summary, incidents of exposure to blood or body fluids could be notified to OH for various reasons: i) to ensure that there was a record of incidents at work which had implications for the employee's health and welfare, ii) so that counselling and follow-up care could be offered, and iii) in some cases so that an initial assessment of BBV infection could be carried out and treatment initiated if deemed necessary. There could be differences between forces in the remits of OH units and in responsibilities of staff, and in local arrangements for providing post-incident management.

Management by more than one medical service

2.35 The post-incident management of incidents of occupational exposure to blood or body fluids sustained by police service staff could be provided by more than one medical service. The first medical service contacted might be OH, A&E, a police doctor or surgeon, or a GP, depending on when and where the incident occurred, the severity of the exposure and force guidelines.

2.36 Follow-up care (counselling and follow-up testing) would usually be provided by OH but could also be given by a GP, and/or an ID or GUM clinician, and/or a psychologist, as necessary. This system of management by more than one service could raise issues about where decisions are taken and responsibility lies, if and how information passes between the medical services involved, and whether the follow-up measures are independent of actions or advice provided at the first point of contact.

2.37 In some forces the follow-up measures offered by OH were based on the actions or decisions taken at the first point of contact. For example, in one force where risk assessment was carried out at A&E, only if A&E had taken blood for storage would follow-up testing be offered by OH. OH staff in some other units indicated that they would assess the risk and any treatment to be offered, independently. In at least one force, however, OH provided a counselling service only.

2.38 Several OH nurse advisers expressed concerns about the quality and consistency of the advice and treatment that was provided at A&E. Some felt that measures offered could be "variable" and that not all staff were conversant with current guidelines on occupational exposure:

"It depends who a patient sees in A&E. There can be a high turnover of doctors and nurses, and some of them, especially newly qualified, don't seem to know as much as they should about occupational exposure."

2.39 Most OH nurse advisers said that police service staff who attended A&E would normally be advised by A&E to contact their OH department for follow-up care. Staff in one force were asked to inform A&E that they were police employees so that full details would automatically be sent to OH. Another unit reportedly received information on HBV status if A&E had checked this. A third said that A&E would sometimes contact them directly with recommendations for follow-up blood tests. The majority of OH nurse advisers, however, stated that they did not normally receive any information or recommendations from A&E. Some said that, if they felt it necessary, they would request information from A&E, with the exposed person's consent, and they would expect to get it.

2.40 The normal procedure was for OH staff to ask the exposed person about any treatment or advice that they had received at their first point of contact. Several felt, however, that many staff could be "quite unsure exactly what has been done in the hospital; for example what treatment they have received, or whether or not they have been referred".

2.41 Although a few OH nurse advisers felt that communication between A&E and OH was adequate, or said that they had no need of information other than that provided by the member of staff, the majority felt that the information flow between A&E (or occasionally other NHS services) and OH could be improved: "The information that we get is not sufficient and it doesn't come through". While most OH staff talked about their need for information from A&E, some made the point that OH also had information which could be useful to A&E, such as information about HBV immunisation which could avoid unnecessary injections. However, potential difficulties with improving communication were highlighted, such as the fact that the OH unit might be closed when the patient was at A&E.

Occupational Health staff views of best practice

2.42 All OH nurse advisers highlighted certain procedures in their force which they felt were of a high standard or 'best practice'. These included:

• a system for passing information directly from H&S to OH
• a system for passing information directly from A&E to OH
• a pro-active OH approach to HBV immunisation, explanatory leaflets
• information on HBV immunisation status provided for staff to carry with them
• OH staff involved in staff training
• advice on what to do in the event of an occupational exposure (posters, aide-memoire)
• 24-hour emergency OH contact helpline
• leaflets on risks of BBV and follow-up testing
• good links with local NHS services for advice and follow-up.

However, these procedures were not available in all forces, nor were they all available in any one force.

2.43 Several OH staff felt that there was scope for improvement in the post-incident management provided for police service staff. Some felt that "a more joined-up approach" was needed. One suggestion was that there should be "joint training across Scotland" for police OH staff.

Policies and procedures in the Scottish Prison Service

2.44 The SPS supplied policy documents covering the post-incident management of occupational exposure to blood and body fluids and HBV immunisation, and other relevant topics. SPS policies were developed at national level in partnership with the relevant trade unions. They were introduced by the SPS Human Resources ( HR) Directorate, and were available to staff on the HR Directorate intranet site or from the HR Department. SPS staff could also be made aware of policies by 'Notices to Staff'.

Occupational Health services

2.45 The remit of SPSOH staff included issues of health and safety, well-being, competence and absence. At the time of the study, OH services in the SPS were centralised, rather than being provided on site at individual prison establishments. There was an SPS Occupational Health and Welfare ( OH&W) Team which had an administrative function.

2.46 OH services were contracted out. At the time of the study, the SPS contract was held by SALUS Occupational Health and Safety. SALUS supplied services in the south and west of Scotland from its headquarters in Coatbridge. Services in the east and north of Scotland were subcontracted to OHSAS (Occupational Health and Safety Advisory Services), whose headquarters were in Rosyth, with offices in Perth, Aberdeen, Inverness, Dundee, Kirkcaldy, and Edinburgh. Services in Aberdeen, Peterhead and Inverness were also sub-contracted and were provided by Abermed or NHS Highland.

2.47 Prison service staff would be referred to the OH adviser if they were absent from work because of an accident, injury, assault or disease contracted in the workplace, or because of stress or anxiety. Line managers notified of absences which required referral to OH would liaise with the HR manager. Prison service staff could themselves seek support and advice from OH, as well as from other internal sources of support, even if they were not absent from work, and liaison with OH would again be via HR.

2.48 Support for SPS staff and members of their immediate family was also available from the Employee Wellbeing Programme ( EWP), an independent free confidential telephone counselling and advisory service available 24 hours a day, 365 days a year. Another service available to SPS staff from 2004 was Critical Incident Response and Support ( CIRS), whose purpose was to provide support by trained lay staff following an event ( e.g. an assault) whose impact threatened the person's sense of safety or well-being. A support meeting would take place as soon as possible after the incident, with further meetings arranged if required. If referral was deemed necessary, this would be to the OH provider and/or the EWP.

Education and training on blood borne viruses

2.49 No information was received about any education and training on BBVs in the SPS.

Hepatitis B immunisation

2.50 At the time of the study, the SPS recommended that all staff seek Hepatitis B immunisation ( SPS, 2001a). The Notice to Staff explained that immunisation would normally be carried out by the member of staff's GP, with the costs borne by the SPS, and advised that staff who wished to have this preventative measure should consult their GP regarding vaccination, the requirement for blood tests post-vaccination and the possibility of requiring a booster injection in the future.

Reporting occupational exposure incidents

2.51 The researchers were informed that most occupational exposure incidents reported by prison service staff were needle-stick injuries ( NSIs), and many injuries were accidental. As well as different types of incident, there were differences in procedures when compared to those implemented by the police.

2.52 The action to be taken by SPS employees following a NSI or other possible mechanism of exposure to BBVs was outlined in a Notice to Staff ( SPS, 2001b). Staff were advised to take first aid measures (wash the area and encourage bleeding from a wound), report the incident to their line manager, and then to attend an identified local A&E department, dependent on the location of the prison, with minimal delay. It was explained that treatment relating to the prevention of HIV was best affected if commenced within 2 hours of the exposure.

2.53 Prison service staff were also instructed to ensure that an Accident Form was completed. H&S staff would ensure that an accident investigation was carried out as required. If staff initially contacted their establishment Health Centre, which was for prisoners' health care, they would be given first aid, asked to complete the Accident Book, and referred to A&E if this was deemed necessary.

2.54 The Notice to Staff advised that it would be helpful if the person could tell A&E if they had been immunised against HBV and, if so, their antibody level if this was known. They were also advised to make arrangements, if possible, to take the instrument that caused the injury to A&E for analysis, and to ascertain whether the source individual, if known, was affected with HBV, HCV or HIV. This would be done by SPS health care staff asking the source person and/or obtaining their health care records.

2.55 A&E staff would assess the risk of BBV infection, and offer advice and treatment as required. SPS staff would be expected to follow any advice given at A&E about post-incident management, and it would be explained that follow-up by an ID Consultant might be required.

2.56 At the time of the study it was not routine for SPS staff to attend the OH provider after exposure to blood or body fluids. Any treatment and advice would have been given by A&E. However, OH could provide counselling after an occupational exposure incident if this was felt to be needed, and could offer advice, e.g. about insurance claims.

2.57 If HR were informed of an incident of exposure to blood or body fluids, the exposed member of staff would be referred to the OH provider. They might be seen by the OH provider about a week after a high-risk incident, but more usually 2 to 3 weeks afterwards. The consultation would normally be face-to-face rather than by telephone. The OH clinician or nurse would normally ask about absence, the circumstances of the incident, what measures had been given or offered ( e.g. by A&E) and what precautions the person was taking. OH staff did not assess the risk of BBV infection, because this would have been done at A&E.

2.58 At the time of the study, SPS staff sustaining an exposure were, in practice, often referred to the OH provider. New guidance covering blood /body fluid infections in the workplace was being drafted to formalise many of the procedures and practices reportedly then in place.

2.59 SPS guidelines published in March 2008 advised staff to attend the identified A&E department within an hour of the incident where practicable. The line manager should by then have informed A&E of the incident and the expected time of attendance ( SPS, 2008). The exposed person - with their line manager - would complete a form with details of the incident and their HBV immunisation status, and take this with them to A&E. The line manager would liaise with HR regarding referral to the OH provider. All staff involved in an incident where potential contamination by blood or body fluids may have occurred would also automatically be invited to attend a CIRS meeting.

Summary

2.60 Policies and procedures in the Scottish police forces and the SPS regarding the post-incident management of occupational exposure were different. Guidelines and operational procedures and the responsibilities of OH advisers could also vary between police forces. A system which might be practical for one service or organisation might be less appropriate for another. However, similarities and differences in policies and practices may or may not have any bearing on the appropriateness and adequacy of the measures provided for the post-incident management of occupational exposure.

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