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CHAPTER FOUR FINDINGS FROM THE EVALUATION

4.1 This chapter describes the findings from the evaluation; first the numbers of police and prison service staff who notified their OH department or their H&S department of an incident of occupational exposure over the study period, and then the data from the IRFs on the circumstances and the management of each incident. The chapter then reports on the results of the Incident Review. It concludes with the findings from the follow-up questionnaires completed by respondents who reported an incident of exposure.

I: Numbers of occupational exposure incidents reported over the study period

4.2 The evaluation was carried out over 55 weeks in police forces (although in one force data collection by OH was carried out over 40 weeks due to staff shortages) and over 47 weeks in the SPS.

4.3 Table 4.1 shows the number of cases of occupational exposure reported to police and prison service H&S and OH departments over the study period.

Table 4.1: Numbers of occupational exposure incidents reported over the study period

4.4 More instances of exposure were notified to H&S departments than were reported to OH. Most of these differences in numbers related to the SPS and 2 police forces. In the SPS, despite the procedure put in place for the study, only 5 of 19 staff who notified H&S of an incident of exposure (16 of whom were referred to A&E) attended the OH provider. No information was available about the difference in numbers.

4.5 In the SPS and the 2 police forces mentioned in 4.4, it was reportedly usual for staff exposed to blood or body fluids to seek initial medical attention from A&E. In the SPS and one of the forces there was also no automatic referral from H&S to OH. By contrast, in several other police forces the numbers reported to H&S and OH units were identical, and in 2 forces more incidents were reported to OH than to H&S.

4.6 Of the 146 cases of exposure reported to OH (Table 4.1), 38 were not included in the evaluation: 8 members of staff did not wish to participate, another 12 did not return a consent form, and 2 were not invited on the judgement of OH. No reason was recorded in the other 16 cases.

4.7 As table 4.1 shows, 108 completed IRFs were included in the evaluation; of these, 105 were from police OH units and 3 from OH providers to the SPS ( OHSAS and SALUS).

4.8 Since the majority of cases notified to police OH units were included in the evaluation (105 of 141), the cases investigated may be seen as representative of all cases reported to OH. However, the 3 SPS cases evaluated cannot be seen as representative of all cases of occupational exposure reported in the prison service.

II: Findings from the Incident Report Forms

Demographic characteristics

4.9 The exposed individuals were predominantly male (75/108, 69.4%). Their ages ranged from 19 to 55 years, with a mean age of 35.1 years and median 36 years. The average length of service was 4 years (median = 4, IQR (inter-quartile ratio) = 8), ranging from 0.25 to 30 years service. The majority of the exposed individuals were police constables (90/108, 83.3%) (Table 4.2).

Table 4.2: Job title of the exposed person

The occupational exposure incidents

4.10 The commonest types of incidents reported were spits (28/108, 25.9%), bites (27/108, 25.0%) and splashes (24/108, 22.2%). Eight NSIs were reported, which included the 3 cases from the prison service. Three NSIs involved a hollow needle and one a solid needle; in the other 4 cases the type of needle was not known. A further 6 individuals had sustained injuries from 'other sharp' instruments such as a blade or knife (Table 4.3).

Table 4.3: Nature of the incidents

Notes to table
a Sharps included knife (n=2), blade (n=2), paper cut (n=1). One response was missing.
b Included: Cut and splash (n=1), scratch and splash (n=2), spit and splash (n=1)

4.11 Just over half of all 108 incidents were deliberate acts perpetrated towards the exposed person (62/108, 57.4%). These deliberate acts included 26 of the 27 bites, 27 of the 28 spits and 3 of the 4 scratches, but did not include the NSIs or sharps injuries.

Types of exposure

4.12 In 26 of the 108 incidents, contamination occurred through clothing. In 2 of these cases, OH reported that there had been no contact between any blood or body fluids and the 'exposed' person's skin or mucous membranes.

4.13 Of the other 106 cases, 46 injuries (43.4%) were classified by OH on the IRF as percutaneous exposures (penetration of the skin). A further 60 (56.6%) cases were classified by OH as mucocutaneous exposures, defined as including a spit or splash into the eyes, nose or mouth, or to intact or non-intact skin. Twenty-nine (48.3%) of the exposures classified as 'mucocutaneous' involved contact with intact skin only. ² The other 31 (51.7%) involved exposure to mucous membranes or broken skin. (Four of the 46 cases classified as 'percutaneous' also involved exposure to mucous membranes or broken skin.)

4.14 Several incidents involved contact with more than one body fluid. Forty-six cases (42.6% of 108), including 19 of the 29 exposures to intact skin, involved blood. In a further 45 cases (41.7% of 108), the main fluid was non-blood-stained fluid, usually saliva.

4.15 The types of body fluid involved and the main site of contamination, for the 77 exposures involving mucous membranes or broken skin ( i.e. that were not to intact skin) are shown in Table 4.4. Where there was more than one site of contamination, or more than one body fluid, the most serious with respect to potential transmission has been used in the table.

Table 4.4: Exposures involving broken skin or mucous membranes showing the main body fluid involved (n=77)

Notes to table
a Moderate penetration = 'into dermis'.
b Deep penetration = 'subcutaneous tissue or deeper'.
c Includes one case where depth of penetration was not specified on IRF
d Total includes 2 cases where depth of penetration was not specified on IRF

4.16 As Table 4.4 shows, the fluid that contaminated the mucous membranes of the eyes, nose or mouth was typically non-blood-stained fluid. Exposure to blood was involved in all non-intact skin exposures. Of the 14 NSIs or sharps injuries (see Table 4.3 above), the instrument was known to be soiled with visible blood in 6 cases, and in one of these cases with fresh blood.

First aid

4.17 Thirty-seven incidents resulted in a wound that bled, and further bleeding was encouraged in 26 (70.3%) of these. In 86 (81.1%) ³ cases the exposed areas were washed.

Hepatitis B immunisation

4.18 Of the 108 cases, 93 (86.1%) exposed individuals had been fully vaccinated against hepatitis B, a further 9 had incomplete vaccinations and 6, including 2 SPS staff, were unvaccinated.

4.19 Of the 102 individuals who had been vaccinated, whether fully or partially, 91 (90.1% of 101) had done so on the advice of their employers, 8 used their own initiative, whilst the remaining 2 had done so for travel reasons (one response was missing). OH were the main providers of these vaccinations (71/101, 70.3%) whilst a further 26 (25.7%) had been given by a GP (one response was missing).

4.20 Of the 93 fully vaccinated individuals, 80 (86.0%) were known responders, 5 were non-responders and a further 8 had unknown response status. The 8 individuals whose response was unknown were all police service staff; 5 had received their vaccination from their GP, 2 from OH and one from a travel clinic.

The source person

4.21 The source person was considered identifiable in 102 (94.4%) of the 108 cases. Information about risk factors was known or suspected in 65 cases (63.7% of 102) (Table 4.5). Intravenous drug use was implicated in 32 of these 65 cases (36.3% of 102).

Table 4.5: Source person risk factors

4.22 Table 4.6 demonstrates that the exposed officer or OH had very little knowledge about the BBV infectivity status of identifiable source individuals.

Table 4.6: Knowledge about infectivity status of identifiable source (n=102)

Notes to table
Due to missing data the totals may not equal 102

4.23 The source person had been approached for a voluntary blood sample in 24 (23.5%) of the 102 incidents with an identifiable source, 14 of which were deliberate assaults and 10 accidental injuries. In 5 of these 24 cases, the exposure involved intact skin only.

4.24 In half the incidents (12/24) the source person had been approached by a police officer, but not the exposed person. However, in 2 incidents the source had been approached by the injured member of staff themselves (Table 4.7).

Table 4.7: Who approached source person for blood sample

4.25 Fourteen (58.3%) of the 24 people approached provided a blood sample. Nine did not and one response was missing. From the 10 requests made by medical staff (A&E staff, a consultant, or police doctors), 8 individuals reportedly provided a blood sample, and in one further case the response was unknown.

Exposed persons' contact with medical services including OH

4.26 A&E was the first point of medical contact for 58 (53.7%) of the 108 individuals, whilst 36 (33.3%) attended OH first (Table 4.8 below). In only 3 of the 72 cases where the exposed person had attended another medical service prior to their OH consultation had information been forwarded from that service to OH. The medical service involved in these 3 cases was A&E.

Table 4.8: First point of medical contact after the incident

4.27 The 72 individuals who had attended another medical service prior to attending OH were significantly more likely to have experienced a 'legitimate' exposure (60/72, 83.3%), i.e. either contamination to the eyes/nose/mouth, broken skin or a percutaneous exposure, than were the 36 who attended only OH (17/36, 47.2%) (? ² (1) = 15.29, p<0.001).

4.28 The majority of the 27 individuals who were bitten attended A&E as their first point of medical contact (20/27, 74.1%). All 8 individuals who sustained a NSI attended A&E, though 2 of the 3 SPS staff first attended their prison health centre (Table 4.8). Those who were splashed were somewhat more likely to attend only OH (14/24, 58.3%).

Time taken to attend A&E

4.29 Information about how soon after the incident the exposed person attended A&E was available for 38 of the 58 cases. Of these 38 cases, presentation to A&E typically took one hour or less (33/38, 86.8%).

Time taken for contact with OH

4.30 Table 4.9 below shows the length of time between the incident and initial contact with OH, for those exposed individuals who attended another medical service prior to contacting OH, and for those who attended only OH. For both groups the time taken to contact OH was varied, with very few making immediate contact and some taking a week or longer. Of the 15 who took over a week to report to OH, those who had first sought medical attention from another medical service had sustained various types of exposure, but those who reported only to OH had almost all sustained spits or splashes.

Table 4.9: Length of time between the incident and initial contact with OH by first point of medical contact

Notes to table
Data missing for one case, so sample size for 'Other medical contact' is 71.

4.31 For both groups, the time taken to contact OH may in part be explained by the timing of the incident, as 91 (84.3%) of the 108 incidents occurred outwith OH working hours; that is, they occurred either after 5 pm but before 9 am on a weekday, or during the weekend.

4.32 Once initial contact had been made with OH, the majority of the OH consultations happened either that day or the next working day, as shown in Table 4.10. Approximately half of the 108 consultations (53/108, 49.1%) were conducted by telephone only, 51 (47.2%) were face to face only and a further 4 consultations were conducted over both the telephone and in person.

Table 4.10: Length of time between initial contact with OH and consultation

Notes to table
Data missing for 3 cases.

Risk assessment and management

4.33 The majority of cases (78/108, 72.2%) were considered by OH to be low risk (Table 4.11 below).

Table 4.11: Risk assessment assigned by OH

4.34 The clinical management of cases, by OH risk assessments, is shown in Table 4.12 below. Many cases were quite complex but some statements can be made. In no case was PEP given for HIV, although it was recommended in 3 cases (one low risk, one medium risk and one indeterminable risk). Immunisation measures for HBV were recommended in 23 cases; in 17 cases these comprised prophylaxis, and in 5 routine vaccination to complete the course (one response was missing). Booster doses were given in 8 cases where the exposed person was reportedly already fully vaccinated.

4.35 In all cases assessed as medium, high or indeterminable risk (n=12), and in the majority of cases assessed as low risk, blood was taken for storage. Follow up testing for HBV, HCV and HIV was recommended for the one high risk and one indeterminable case, and for HCV in the cases assessed as medium risk. The data indicated that there could be differences between units, and sometimes within units, in the recommended HCV follow-up testing, suggesting the use of different protocols. There were also 5 cases (not shown on the table) where follow-up testing was recommended although no blood had reportedly been taken for storage.

Table 4.12: Clinical management provided for the exposed individual by OH risk assessment

Notes to table
a 'Indeterminable': OH stated that they were unable to determine the risk of BBV infection from the information provided by the exposed person.
b Measures for HBV included both prophylaxis and routine vaccination

4.36 In 79/108 cases (73.1%) OH made further appointments with the exposed individual, usually for follow-up blood tests. In 11 cases the exposed person was either referred to, or advised to attend, another medical service.

III: Findings from the Incident Review

4.37 105 of the 108 cases were evaluated by the expert panel. Two cases were received after the deadline for delivery to the panel, and one could not be evaluated due to lack of information.

4.38 Panel members evaluated the service provision for each case by first assessing the risk of each BBV and stating whether they agreed with the OH assessment of risk, and then by evaluating whether, in their view, the post-incident management was adequate and appropriate guidelines were followed (see Incident Review Form, Annex 3). They also provided case-specific and general comments and explanations, as well as suggestions for improvements in services.

Blood borne virus risk assessment

4.39 Panel members were asked to assess the risk of each BBV for each case by using the scale: 0) None, 1) Low, 2) Medium, 3) High. They could also answer, 'Cannot determine as information is inadequate'. These were the terms that OH nurse advisers said that they used to assess BBV risk, and that were used, therefore, on the IRF.

4.40 Panel members were rarely in complete agreement about the risk of each BBV but differences were small. A median score for each case was calculated, omitting any answers of 'cannot determine'. Figure 4.1 and Table 4.13 below highlight that the experts considered the majority of cases to be of 'no risk' (a score of 0) or 'low risk' (a score of 1).

Figure 4.1: Experts' assessment of the risk of each BBV infection

Table 4.13: Numbers and percentages of cases by median risk assessment for each BBV

4.41 Whereas panel members assessed the risk of each BBV separately, OH staff (nurse advisers in police forces, clinicians for SPS cases) assessed the general risk of BBV infection, or the significance of the exposure. Reviewers were asked to state whether or not they agreed with the OH risk assessment, using the scale: 1) Disagree: OH assessment is too low, 2) Agree, or 3) Disagree: OH assessment is too high. A median score for each sub-panel (again omitting any other answers such as 'cannot determine') was calculated for each case (Figure 4.2). Because medians have been used, and there are intermediate values, the chart uses numbers as well as named categories.

Figure 4.2: Experts' level of agreement with OH risk assessment

4.42 As Figure 4.2 shows, in most cases, in the opinion of panel members, OH staff were assessing the general risk of BBV infection correctly. The panel reviewed 81 of 105 cases (77.1%) as being correctly assessed by OH.

4.43 In some cases, although not necessarily agreeing exactly with the OH assessment of risk, reviewers said that they could understand or accept it. Several noted the difficulties of distinguishing between 'categories' of risk, commenting, for example "I can see why they said 'low' (although I have said 'none')". Some panel members noted particularly the difficulty of distinguishing (and treating) cases of 'negligible' risk.

4.44 However, from Figure 4.2 it can also be seen that, in 2 cases, the OH assessment of BBV infection was considered by a majority of panel members to be too low, and in a further 4 cases, half of the panel members who had given an assessment held this view. The former 2 cases were NSIs, both of which had been assessed by OH as 'low risk'. Other cases where half the panel saw the OH risk as 'too low' included one further NSI (rated 'low risk'). One reviewer commented on this low-rated incident: "I'd call this high risk … can't think of a much higher risk actually". Other cases were a mouth-to-mouth contact involving fresh blood (assessed as 'low risk' by OH), a spit to the eye of a partially-vaccinated member of staff (assessed by OH as 'no risk'), and a splash of blood to non-intact skin where little information was available (assessed by OH as 'medium').

4.45 There were also 10 cases (see Figure 4.2 above) where a majority of reviewers felt that the OH assessment of risk was 'too high' and a further 8 where half the panel held this view. Most of these 18 cases had been rated 'low risk' by OH, though they included 3 which had been rated 'medium risk' (2 bites and a mouth-to-mouth exposure). Almost all of these cases rated by OH as 'low risk' involved splashes of blood or body fluid on to intact skin. All panel members emphasised that such incidents incurred no risk of BBV infection. A few felt that OH staff were sometimes loath to say 'no risk'. Most reviewers saw a need for a protocol for medical services, which would include clear guidelines about risk: "The procedure must say there is no known risk from splash of blood on to intact skin."

4.46 Panel members expressed the view that OH nurse advisers should be able to assess the risk of BBV infection from the circumstances of an occupational exposure incident, with advice from supervisors or BBV experts if needed. They stated that OH services should be able to assess risk independently of A&E and without the exposed person being asked to contact another medical service.

First aid

4.47 Although in most cases first aid precautions had reportedly been carried out, where there was evidence that an exposure to blood or body fluids had not been washed, or bleeding encouraged from a wound, panel members were critical of inadequate first aid. Some suggested that improved staff training might be needed. A few reviewers recommended that improved safety precautions might be needed in some situations, e.g. stronger gloves for searching arrested individuals' bags.

Reporting to medical services

4.48 Although only 3 cases were reported from the SPS, all panel members commented that there was evidence of some confusion and uncertainty about reporting procedures. They also felt that earlier reporting to SPSOH providers would be beneficial.

4.49 A few reviewers questioned why some incidents in the police were reported first to A&E and others first to OH: "Not clear why officer went to A&E for a low-risk incident; what are the criteria?" or, "What is the protocol?"

4.50 Panel members were critical of any apparent delay on the part of police service staff reporting incidents to their OH units. Some felt that more information or staff training might be needed: "Delay on the part of officer suggests that more awareness education needed". Some questioned why an incident might not be reported to OH for some days or even weeks.

Source blood testing

4.51 All the reviewers commented that post-incident management might have been more straightforward, and the exposed person's anxiety, lifestyle restrictions and need for testing lessened if the results of source blood tests had been available. They noted that there were a number of cases where there had been a significant exposure and there appeared to have been an opportunity to request a sample of blood from the source person - the person was identifiable and in custody - but no request had been made: "Lack of source approach, when presumably individual available at time". Some argued that this was illogical and unfair:

"If we believe the risk to the officer is such that we should recommend post-incident blood testing, then the same logic would dictate that we would consider source blood testing at that time."

4.52 While some reviewers felt that such cases had been poorly managed, and a few were critical of (police) OH staff for not having promoted source testing, responsibility for requesting source blood did not lie with OH. Some panel members noted the difficulties for police employees of asking a person being arrested for a blood sample. They suggested that those who would be making such a request, e.g. custody officers or police doctors, might need more help or support. All reviewers recommended that more efforts should be made to obtain source blood samples, they suggested that police force and SPS guidelines should state that in all cases of exposure to blood or body fluids with 'significant injury' ⁴ there should be consideration of requesting source blood.

Post-incident management

4.53 The focus of the panel's evaluation was on the post-incident management reportedly provided by OH and other medical services. The clinical management could have been appropriate, even if the risk had been assessed differently by OH than by panel members, and even if no source blood had been requested.

Management by Occupational Health

4.54 Each expert was asked to evaluate the management of care provided by OH for each BBV using the scale: 1) Excessive, 2) Somewhat excessive, 3) Appropriate, 4) Somewhat inadequate, or 5) Inadequate. They could also answer, 'Difficult to determine as information inadequate'. Panel members' individual ratings varied. A median 'evaluation of care' score was calculated, for each BBV, from the individual ratings of panel members for each case.

4.55 Figure 4.3 and Table 4.14 below show that in the majority of cases, OH management was viewed as 'appropriate', that is, a median score of 3. (Because medians have been used, and there are intermediate values, numbers have been used on the chart and table as well as named categories.) The quantitative findings were supported by panel members' comments that overall they had "found no major problems". Some stated that OH departments appeared to be "doing an excellent job", or "providing the closest approximation to best practice".

Figure 4.3: Number of cases by median 'evaluation of care' score for each BBV

Table 4.14: Numbers and percentages of cases by median 'evaluation of care' score for each BBV

4.56 As shown in Table 4.14, of the 105 cases reviewed, panel members considered that 100 (95.2%), 77 (73.3%) and 99 (94.3%) of the cases had received appropriate HBV, HCV and HIV care respectively. It was noteworthy, however, that with respect to HCV, fewer cases were considered by the experts to have received 'appropriate' care in comparison with the other BBVs (see below).

4.57 Hepatitis B- In most of the cases reviewed, the member of staff had been immunised against HBV, and OH had a record of their response status. Where this was not the case, OH staff had normally noted that vaccination and/or testing had since been arranged. Several panel members commented favourably on the proportions of police service staff immunised against HBV, but all expressed concern that in 2 of 3 cases from the SPS, the member of staff had not been immunised.

4.58 Panel members felt strongly that police and prison service staff, including custody officers and support staff, should be fully vaccinated before being exposed to any possible risk of BBV infection. Many viewed (police) OH staff as responsible for ensuring that force employees were fully immunised, and deemed their management of HBV 'inadequate' if this was not the case: " OH should ensure that full course is received and response level checked". They also stated that staff should be given a written record of their response status to carry with them. Perhaps recognising that HBV immunisation was voluntary, some reviewers advised that, "More education is required for staff about HBV testing and vaccination".

4.59 Hepatitis C- Most criticisms of OH management related to follow-up HCV testing. There were some differences in opinions, however, between experts.

4.60 In some cases the proposed HCV testing was viewed as 'excessive', usually because the reviewer judged that the case was low risk and no tests were necessary. In a small number of cases, panel members said that "too many tests" had been proposed, suggesting some OH confusion about an appropriate testing protocol.

4.61 A more common criticism was that HCV testing was 'inadequate'. Usually, this was because panel members felt that a 6-week PCR test should have been considered. For example, PCR testing at 6 weeks had not been recommended after one NSI, or after one spit to the eye with blood-stained fluid, and most reviewers felt that this test was required. Panel members commented generally that PCR testing seemed to be "not widely practised". Another reason for HCV management being judged 'inadequate' was that an additional antibody test was felt to be needed: "If you are going to test for HCV, it should be at 3 and 6 months to account for the window period". One OH unit normally recommended antibody testing only at 6 months, and most panel members saw this as incorrect: "Not sure why, if worried about hepatitis C, 3-month bloods (are) not done".

4.62 By the end of the evaluation all panel members had drawn attention to a "continuing inconsistent approach to testing for HCV," or, "continuing uncertainty about when to test for HCV". They felt that there was considerable confusion about appropriate testing, and a need for a consistent protocol. This was strongly recommended: "We need an HCV testing policy".

4.63 HIV - There were a few cases where reviewers felt that there was inconsistency or uncertainty about HIV follow-up testing.

4.64 In general, most panel members viewed the measures provided or offered by OH as 'adequate and appropriate' unless excessive follow-up testing had been recommended. In some cases, however, experts said that the recommended testing appeared to be inconsistent or illogical. Panel members were critical of recommendations for follow-up testing, and/or advice about precautions, in cases that they judged to have incurred no or negligible risk: "Why instigate testing for a low risk event? Some people should simply be reassured". Where OH themselves had assessed the risk as 'none', many reviewers were emphatic: "If no risk, no testing".

4.65 At the same time, panel member noted that follow-up care could be influenced by the degree of anxiety felt by the exposed person. Most welcomed evidence of OH willingness to carry out blood tests if requested, to allay the exposed person's anxiety, saying that it was "good to see staff wishes taken into account", or that OH had a responsibility to address staff needs. In a few cases, though, some reviewers felt that OH could have been more prescriptive in recommending follow-up testing: "I have some sympathy with OH trying to down-play stress if low-risk injury, but think follow up testing should be encouraged - interesting here they seem to be discouraging it".

4.66 Several panel members stated that an important aspect of the OH role should be to provide ongoing reassurance to the exposed person, especially since source test results might not be available. They welcomed any evidence of OH offering counselling or invitations to return for further discussion. Some recommended that exposed individuals should be seen by OH services face-to-face wherever possible, given written advice, and followed up at least once by telephone.

Management by medical services (first points of contact) other than Occupational Health

4.67 In 56 of the 105 cases considered by the panel, post-incident management had been provided by more than one medical service. Usually the individual had first attended A&E and then OH, but some had first consulted a GP, police doctor or prison health centre. In several of these cases, panel members said that they were unable to evaluate the post-incident management provided by these services since the data was not first hand and it was not clear what had been done or advised. For example, PEP for HIV had reportedly been offered, although not started, in 3 of 105 cases, but this information was second-hand. Because of the high number of 'cannot determine' answers, a quantitative analysis of management by medical services other than OH was not carried out.

4.68 In cases of low or negligible risk of infection, some reviewers wondered whether the first point of contact ( e.g. A&E) should do anything, apart from suggesting that the exposed person contact their OH unit. However, care by services other than OH was deemed inadequate when no information or advice was apparently given to the member of staff, and significant reported delays (at A&E) were 'unacceptable'.

4.69 There were a few cases where panel members felt that the treatment given for HBV by these other services was 'probably excessive' ( e.g. in 2 cases when immunoglobulin had been given at A&E). Several reviewers noted, however, that A&E staff might not have known the exposed person's HBV immunisation status. They recommended that police and prison service staff should carry information about their HBV status: "Officers should carry HBV levels. A booster within 7 days would have prevented HBV if levels were inadequate".

4.70 Panel members were more critical of what appeared to be 'inadequate' management of cases by these other services. In a few cases, they felt there were "major causes for concern", as, for example, when no action was apparently taken at A&E in cases of bites or blood-to-blood contact involving suspected IV drug users. In 2 of these cases source blood had reportedly been taken but panel members assumed that the results were not available to A&E.

4.71 Reviewers were also critical of a failure, usually at A&E, to offer appropriate prophylaxis for HBV after a significant injury, or to an unvaccinated individual. In one case no treatment had been instigated by A&E following a NSI to an employee who was unprotected against HBV ("There was a case for immediate immunoglobulin"). In another NSI case, also initially managed by A&E, where the source person was thought to be HBV positive, one reviewer noted: "The accepted recommendation is that a booster dose for HBV vaccine should be given with a known positive source".

4.72 At the end of the study, several reviewers stated generally that there was evidence of "variable", "unreliable" or "inconsistent" management by A&E, or that A&E management could be "unsatisfactory regarding delay, assessment or action".

4.73 In commenting on specific cases, reviewers were also critical of incorrect advice reportedly given by one police doctor. Some felt that there was evidence of an inadequate post-incident management procedure in the SPS. It was suggested that the evidence indicated a possible need for more training on BBVs for police doctors and prison health centre staff.

Management by more than one service

4.74 Experts did not suggest any standardised approach for managing incidents of exposure by more than one medical service.

4.75 However, they questioned why an individual who reported an incident of exposure initially to their OH unit should need to be referred to another medical service for BBV risk assessment or to have blood taken for storage. They felt that OH units should be able to provide this service, and they expressed concern about possible delays if a person had to be sent elsewhere. Several were also critical of any reliance by OH on A&E risk assessment and management, since they felt this could be unreliable: one reviewer felt that, "less involvement with A&E is required".

4.76 In some cases where an individual had initially attended A&E, panel members concluded that OH had then assessed the risk of BBV infection independently of, and differently from A&E. In many cases, this re-assessment by OH was felt to have been helpful in ensuring that correct treatment was offered. At the same time, they noted the importance of consistent information and advice.

4.77 All panel members recommended that communication systems between A&E (or any other first point of contact) and OH should be improved. They suggested that thought should be given to possible methods of passing information to OH: "You would not expect immediate contact between A&E and OH, but some arrangements which mean that written reports might follow". One suggestion was that A&E departments might be asked to send the relevant OH unit a copy of the information that would automatically be sent to a patient's GP.

Conclusions (post-incident management)

4.78 Several of the panel members' comments and suggestions about post-incident management applied to any medical service. There were a few cases which were deemed to have been poorly managed overall if, for example, source blood had not been requested, or little attention seemed to have been paid to an exposed person's apparent anxiety.

4.79 In some cases panel members were critical of the measures taken at the first point of medical contact, e.g. if the BBV risk seemed to have been wrongly assessed, if blood had not been taken for storage, or if PEP for HIV could have been considered. Some panel members felt that there were additional cases where HIVPEP should have been considered, since the exposed person had presented in time.

4.80 Panel members stated that where there was any possibility of BBV infection, a sample of the exposed person's blood should be taken for storage to protect that person's interests. At the same time, since taking blood for storage could imply a risk of infection, with consequent anxiety and the implication of follow-up testing, some reviewers argued that this should not be done in 'no risk' cases. Several experts felt that there was evidence of some confusion about when blood should be taken for storage and for testing.

4.81 While there were differences in views between panel members, and in the issues that most concerned them, all felt that there was a need for a clear post-incident management protocol for medical services: "Develop a standard shared protocol". Some advised that, "procedures in the police and prison services should as far as possible be modelled on those in the Health Service". They advised that the protocol should cover risk assessment, blood for storage, HIVPEP, HBV prophylaxis and follow-up testing, particularly for HCV.

4.82 Noting that 'best practice' implied a 24-hour service, one reviewer suggested that a National 24-hour helpline, as "one place to come" could be helpful. ⁵

IV: Findings from Staff Evaluation Questionnaires

4.83 An SEQ was sent to each of the 108 individuals whose cases were included in the evaluation. 73 (67.6%) completed SEQs were returned, 70 (66.7% of 105) from the police and 3 (100%) from the SPS.

Demographic characteristics

4.84 Forty-seven (64.4%) of the 73 respondents were male and 26 (35.6%) female. Their ages ranged from 21 to 55 years, with a mean age of 36.8 years and median 37.5 years. Their length of service ranged from 0.4 to 29 years, with an average (median) of 6 years (median = 6.0, IQR = 13.0). Fifty-six (76.7%, and 80% of police respondents) were police constables.

4.85 In order to assess whether these 73 respondents were representative of the whole sample, comparisons were made between those who returned the SEQ and those who did not. Those who returned the SEQ were significantly older by 8 years (median = 37.5, IQR = 11) than the non-responders (median = 29, IQR = 13), (U = 787, p = 0.002), but there were no differences in years of experience or gender. All job titles were represented. All staff who sustained a NSI completed a questionnaire. No type of incident was under-represented.

Reporting to medical services

4.86 As with the whole sample, the most common first point of contact for the respondents who completed the SEQ was A&E; 40 of the 73 (54.8%) first attended A&E (Table 4.15 below). Six first saw a police doctor or surgeon, 3 their GP and 2 a prison health centre. For 22 respondents, OH was the first and only medical service contacted. The proportions attending each medical service were very similar to those of the whole sample.

Table 4.15: First points of medical contact for respondents who returned a SEQ

4.87 Table 4.16 shows the reasons given by respondents for reporting the incident to OH. The main reasons were that they were worried about their risk of acquiring a BBV (44/73, 60.3%), they were instructed by their line manager or another colleague to do so (38/73, 52.1%), or that this was service policy (29/73, 39.7%). The answers of SPS staff were no different from those given by police, except that 2 said that they had been instructed to do so by Human Resources; in the SPS, referral to the OH provider was via HR.

Table 4.16: Reasons for reporting the incident to Occupational Health

Notes to table
Respondents could select more than one answer. Numbers and percentages will not add up to 100%
a These answers were coherent with respondents' reported anxiety after the incident

4.88 Most of these 73 respondents (52/73, 71.2%), including the 3 SPS staff, said that they had reported the incident to their OH unit or provider within 2 days. Eighteen (24.7%) respondents said that there had been reasons why they had not reported to OH immediately. The main reasons given were: being off duty or on leave immediately after the incident, being unaware of protocol for reporting to OH, the incident occurring during the weekend, work responsibilities, and working night shift.

Experiencing and reporting previous exposures to blood or body fluids

4.89 More than half of these respondents (41/73, 56.2%) stated that they came into contact with blood or body fluids 'every day', as shown in Table 4.17 below.

Table 4.17: Reported frequency of contact with blood or body fluids

4.90 Asked if they had ever been exposed to others' blood or body fluids via needle-stick injuries, other broken skin, or mucous membranes, apart from the recent incident, 32 (43.8%) said 'yes', 31 (42.5%) said 'no', and 10 (13.7%) were unsure.

4.91 The frequency of earlier occupational exposures incidents ranged from 'once a year or less often' to 'more often than once a month'. Some gave a number but others were less precise ("probably 10-20") or indicated uncertainty: "don't know - exposed to various fluids throughout job". Some inconsistencies in answering these questions similarly suggested that staff could be unsure about whether or not an incident was an 'exposure'.

4.92 Most of these previous incidents had not been reported to OH. Of the 34 respondents who answered a question about previous reporting, most (25/34, 73.5%) said that they had reported none of these exposures to OH. Two had reported some and 7 (20.6%) had reported all earlier incidents to OH.

4.93 Twenty-six of the 27 respondents who said they had reported none or some of their previous exposures to OH answered a question about their reasons for not reporting. The main reasons selected were 'reluctance to make a fuss about what could be nothing', and 'unfamiliarity with policy or procedure' (Table 4.18).

Table 4.18: Reasons given for not reporting earlier incidents to OH

Notes to table
More than one answer could be selected. Numbers and percentages will not add up to 100%
Other reasons included 'Lack of OH support' (n=2), 'Concerns about insurance' (n=1), 'Reported elsewhere and saw no need' (n=1), 'No witnesses' (n=1) and 'Skin not broken' (n=1).

4.94 These findings suggest that incidents of exposure to blood or body fluids may have been reported to OH more often at the time of the study than they had been earlier. The evaluation might or might not have raised awareness. One respondent stated that their OH unit had been "more active with respect to this type of exposure as a result of this survey, which has raised their profile and activity".

Information and training about blood borne viruses

4.95 Seventy-one of the 73 respondents answered a question about information and training on BBVs. Just over half of these (37/71, 52.1%) said that they had received information or training about BBVs. Nineteen (26.8%) said they had not, and another 15 (21.1%) were unsure.

4.96 Not all the 37 participants who said they had received training answered questions about the topics and the year of their most recent training. Between 24 and 30 respondents said they had received training on each topic: BBVs, risk of transmission following exposure to blood or body fluids, protecting against exposure, first aid procedures, or reporting an occupational exposure incident. Of those who gave a year (about 20 respondents depending on the topic), most said that they had received training since 2005.

Consequences of the recent incident of exposure

4.97 After the recent occupational exposure to blood or body fluids, 8 respondents had taken sick leave. The number of days ranged from 2 to 180 (n=7, one response was missing). Five individuals had been absent for between 2 and 7 days, one for 28 days and one for 180 days. The injuries for the latter 2 cases were a NSI and a blood-to-blood exposure.

Anxiety

4.98 Respondents were asked to mark on a line from 0 (not at all anxious) to 10 (extremely anxious) their anxiety at 4 different times, namely:

• immediately following the incident
• after the visit to their first point of medical contact if not OH
• after their consultation with OH
• the day they completed the questionnaire.

4.99 Respondents' reported anxiety after the incident could vary widely. Table 4.19 illustrates the spread of anxiety levels immediately after the incident, and shows that a number of respondents experienced quite high levels of anxiety.

Table 4.19: Level of reported anxiety immediately after the incident (n=73)

4.100 Analysis showed that, of these 73 respondents, those who had taken sick leave were more anxious at the time of the incident (median = 8.5, IQR = 6) than those who had not (median = 5, IQR = 5) (U = 121, p = 0.045).

4.101 Those respondents who had received information or training on BBVs were less anxious (median = 5, IQR = 4.4) than those who did not, or who were unsure if they had received information or training (median = 7, IQR = 5) (U = 425.5, p = 0.044).

4.102 Comparisons were made between the anxiety levels of those who had first attended a medical service other than OH and those who had attended OH. Respondents' reported anxiety levels were also compared over time. Two of the 73 cases were excluded from this analysis, as the questionnaires were completed a considerable time after the recommended return date.

4.103 In 21 of the 71 cases analysed, the respondent attended only OH. In the other 50 cases, he/she attended another medical service prior to OH. Table 4.20 shows that the latter group were significantly more anxious immediately after the incident (median = 6.0, IQR = 4.0) than those who attended OH as their first point of contact (median = 3.0, IQR = 6.3), (U = 307.00, p = 0.005). This difference may be explained by the nature of the exposure, as those individuals who had attended another medical service were more likely to have experienced a 'legitimate' exposure ( i.e. body fluid onto eyes/nose/mouth or broken skin, or a percutaneous exposure) than those who attended only OH (? ² (1) = 13.24, p<0.001). Forty-four (88%) of the 50 individuals who attended another medical service prior to OH had experienced a 'legitimate' exposure compared to 10 (48%) of the 21 who attended only OH.

Table 4.20: Average anxiety levels over time by first point of medical contact (n=71)

4.104 Table 4.20 also shows that the median level of reported anxiety for each group dropped over time, lower average levels of anxiety being associated with contact with a medical service. Conducting a Friedman's ANOVA followed by pair-wise comparisons using Wilcoxon tests (Field, 2005) showed that all the falls in anxiety were significant. For those who attended a first point of medical contact other than OH, self-rated anxiety fell significantly between the time of the incident and after attending the first point of medical contact (times 1-2), between times 2-3 and 3-4, and by definition between each time point (? ²(3) = 62.07, p<0.001). ⁶ For those who attended only OH, self-rated anxiety fell significantly between the time of the incident and after attending OH (times 1-3) and between times 3-4, and by definition between each time point (? ²(2) = 22.33, p<0.001). ⁷ Although a causal relationship cannot be assumed, the evidence suggests that contact with OH had an important effect on reducing anxiety.

4.105 There were, however, individual variations in self-rated anxiety. Some staff were reportedly not anxious at any stage: "I wasn't concerned". Others, by contrast, continued to be anxious, saying, for example, "There will always be anxiety until I have the follow up blood tests". A few respondents indicated that their anxiety had increased after a visit to a medical service. Participants' views about the services offered some explanations.

Views about the services received

4.106 Respondents were asked for their views about the service they had received from OH and from any other service that had provided their first point of medical contact. They were asked to evaluate the quality of the service, whether it had helped them cope better with any anxiety, and how satisfied they were with the service overall, ⁸ and to add any comments or explanations. They were also asked about the extent to which they agreed or disagreed with 4 statements about their experience of each service.

4.107 All 3 SPS respondents were dissatisfied with the service they received from their first point of medical contact. In 2 cases the first point of medical contact was the prison health centre, and in the other case A&E. The respondents said that there was a lack of information and advice, and they felt that their first point of contact had not helped with any anxiety.

Views about A&E

4.108 Of the 51 respondents who had attended another recognised medical service before OH (see Table 4.15, above), 40 had first attended A&E. These 40 respondents' views of the service they received at A&E are shown in Table 4.21.

Table 4.21: Views about A&E services (n=40)

4.109 More than half rated the service they received from A&E as 'good' or 'excellent', but a quarter rated it 'poor'. Just over half the respondents (22/40, 55%) felt that A&E had helped them to cope 'somewhat' or 'a great deal' with any anxiety. However, 15 felt that the service had had 'no effect' and 3 felt that their anxiety had been made worse. The majority (75%, 30/40) of respondents were 'satisfied' or 'very satisfied' with the service from A&E, but 25% were 'dissatisfied' or 'very dissatisfied'.

4.110 These findings could suggest that perceptions differ, and/or that A&E services could be variable. Respondents' explanations for their views are reported later in this section.

4.111 As illustrated in Table 4.22 below, more than half of these respondents (25/40, 62.5%) agreed to some extent that they would have liked more information from A&E. Most (34/40, 85.0%) agreed, however, that they had the opportunity to ask questions. There was a range of views about whether things could have been explained more clearly. Three quarters (n=30) agreed to some extent that the advice they had been given by A&E was reassuring.

Table 4.22: Level of agreement or disagreement with four statements regarding A&E (n=40)

Views about Occupational Health

4.112 Most respondents who answered the question rated the OH service as 'good' or 'excellent' (58/68, 85.3%), with only 4 rating it 'poor' (Table 4.23). Just over half (40/72, 55.5%) felt that OH had helped them to cope 'somewhat' or 'a great deal' with any anxiety, although 27 (37.5%, the same proportion as for A&E) felt that OH had had 'no effect' on anxiety, and 5 felt that it had been made worse. However, the large majority of respondents (64/72, 88.9%) were 'satisfied' or 'very satisfied' with the OH service, with only 8 'dissatisfied' or 'very dissatisfied'.

Table 4.23: Views about Occupational Health services (n=73)

Notes to table
a Based on 68 responses; 5 were missing
b Based on 72 responses; 1 was missing

4.113 Table 4.24 (below) shows that a minority of respondents who answered the question felt that they would have liked more information from OH (18/69, 26.0%). The large majority (64/69, 92.7%) agreed that they had the opportunity to ask questions. Most (52/68, 76.5%) disagreed with a view that things could have been explained more clearly. Most also agreed that the information and advice from OH had been reassuring (58/70, 82.9%).

Table 4.24: Level of agreement or disagreement with four statements regarding OH (n=73)

Notes to table
a 4 respondents did not answer this question
b 5 respondents did not answer this question
c 3 respondents did not answer this question

4.114 These findings suggest that neither A&E nor OH was perceived as helping significantly with anxiety, although the information and advice given was usually seen as reassuring.

4.115 In general, more respondents were satisfied with the service provided by OH or saw it as high quality, compared with the numbers expressing these positive views about A&E. Whilst all services were perceived to have provided opportunities for questions, OH services were reported much more often to have given adequate information.

4.116 Forty-five of the 51 participants who had attended more than one service answered a question about which service they had found the most helpful. Of these, 25 (55.6%) stated that OH had been most helpful and 13 (28.9%) said A&E. Of the other answers, 3 respondents said more than one service had been helpful, and one cited the Employee Assistance Programme.

Respondents' comments on the services received

4.117 Not all respondents gave reasons for their views about the services. However, an analysis of participants' comments and the descriptions of their experiences clearly indicated their main concerns and their views about best practice.

4.118 Respondents praised individuals and services who "couldn't have done more to assist" after their exposure to blood or body fluids, and were critical of those who seemed "uninterested in my welfare". A few police and prison service staff reported that some of their work supervisors had offered no advice or support: "My line manager did not advise me or seem to take the issue seriously", or "My inspector and sergeant gave me no support or information; I only got help after speaking to my line manager, who then got OH involved".

4.119 Several staff who had sustained significant injuries (in 2 cases NSIs) stated that they had received "no help whatsoever" from A&E: "The doctor asked me why I was at A&E and said there was no reason for me to be there". One respondent reported that, "A&E told me they were too busy". A small number of respondents said they would have welcomed somewhat more support from OH. One felt that an appointment "to discuss my concerns" would have been helpful. Others said that they would have liked more follow-up: "I was left a bit in limbo after the blood tests". More positively, invitations to "come back to OH at any time" were welcomed.

4.120 Respondents were critical of medical staff who appeared not to know how to deal with an incident of occupational exposure: "The nurse was as ignorant as I was!" A number stated that A&E staff "did not know what to do", "were unaware of full procedures", or were "confused" or "incompetent". One commented: "Hospital A&E departments should know how to treat an exposure like this".

4.121 Most respondents' comments, positive and negative, related to the provision of information. Some said that they had welcomed practical advice about what they should do ("wash the injury and visit OH") as well as being told that something could be done: "The fact that there is a course of action is helpful". Participants wanted clear and accurate information. They praised staff who "explained the injury thoroughly", as in this example:

"Being informed of all risks, the full picture, was helpful as I was then aware of what the possibilities were. Although this was daunting, it was better than being left in the dark."

4.122 Participants were particularly appreciative of medical staff, often but not always OH nurse advisers, who "took time to explain", or of whom, "you could ask anything and get an answer". A number spoke highly of OH nurses and their knowledge: "very informative". Leaflets and handouts, and statistics, were welcomed: "Everyone has been very helpful, especially the OH nurse who gave me the statistics about chances of contamination". By contrast, several respondents complained about a lack of information or advice from A&E, and a few said that they had been given information that was incorrect.

4.123 Some respondents said they had received "conflicting advice" from different services. One said there were, "too many different opinions given by medical staff. Some say saliva can transfer disease. Others tell you that you're wasting their time going to A&E". Another said: "I feel I have suffered more with anxiety due to conflicting treatment and advice". By contrast, consistent information could offer reassurance: "Advice given was same as at start of service", as could contact between services: "A&E contacted my GP about boosters".

4.124 The variation in individual anxiety has been noted above. Some respondents explained why their contact with a medical service had helped with anxiety: "The doctor at A&E put it into perspective", or "They understood how I felt". Several had been reassured by their consultation with OH: " OH gave me further reassurance", or "The OH nurse was very supportive, easy to talk to and I felt relaxed".

4.125 Notably, however, a few respondents felt that information given by OH had added to their anxiety, or they thought that OH could have offered more reassurance: " OH were helpful and informative, although worrying". One stated, "I think, because it is routine for them, OH are not proactive enough in looking after the anxiety side of the incident".

4.126 All staff appreciated prompt attention: "I was seen quickly in a busy A&E department", or "The duty doctor at A&E was exceptional. Blood samples were taken and I got the results next day". Similarly, respondents who saw OH as 'excellent' noted their "very quick response", whereas others who saw the OH service as 'fair' or 'poor' noted delays: "Slow to respond". A few said that they had experienced some difficulties with making appointments: "I had to chase up blood test results that were already in. If my contact was off, no-one else could help". One respondent commented generally on the importance of speed in reducing anxiety:

"For this type of incident, the time to process the blood test and get information about the result is of extreme importance. If the possibility of contamination is low the worry factor is less, but this may not always be the case."

4.127 To summarise, participants wanted their exposure to blood of body fluids to be taken seriously by supervisors and by medical services, and to receive attention and support. They wanted medical professionals to be knowledgeable, to provide clear, accurate and consistent information and advice, and reassurance, and to act quickly.

4.128 Asked if they had any suggestions for improvements in services, 2 respondents noted that not all staff in their organisation had been immunised against hepatitis B. Most recommendations, however, were for more information. Some respondents wanted better information for people who had been exposed to blood or body fluids: "More information on procedures such as why blood is taken for storage", or "Statistics as to the likelihood of contamination". Some requested written information, such as "a leaflet which you could take away for you and your partner", or "a pamphlet with facts and figures and links to an easy-to-understand web-site".

4.129 Most, however, called for more information on "how to deal with a situation where you come into contact with body fluids", saying that, "Staff need to be made aware of procedures", or about the measures that were available and the reasons for reporting:

"Police officers and other persons should be informed that there is treatment that can be administered within a few hours of contact, with such incidents."

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