Blood Borne Viruses

The overall aim of the policy is to control the risk to patients and staff from health care workers (HCW) infected with blood borne viruses (BBV), to control the risk to HCWs from BBV infected patients and to reinforce good practice. The policy outlines how NHS Lothian will ensure compliance with the Scottish Government’s guidance on health clearance for HCW for BBV (Hepatitis B, Hepatitis C and Human Immunodeficiency Virus (HIV)).

Key points include:

− Clarification of roles and responsibilities for delivery of this policy. All HCW involved in clinical roles have a professional duty to protect patients and should be aware of the procedures outlined in this policy. Individuals who believe they may have been exposed to a BBV must seek medical advice. The establishment of BBV fitness criteria and associated testing regimes for staff employed in, or applying for, posts involving Exposure Prone Procedures (EPP – defined as those invasive procedures where there is a risk that injury to the worker may result in the exposure of the patient’s open tissues to the blood of the worker).

− This involves the establishment and operation of:
o Detailed lists of posts assessed as involving EPP and staff employed within these posts.
o Effective recruitment and pre-employment procedures ensuring no staff commence EPP work prior to confirmation that the BBV status is compatible with the policy.
o Effective ongoing monitoring, surveillance, self-reporting and staff support systems to ensure BBV status of staff in EPP posts continues to be in accordance with the policy.

− The establishment of policy for the ongoing management and support of BBV-infected HCW, according to the NHS Lothian Redeployment policy.

− The establishment of policy for reporting procedures and risk assessment where a BBV-infected HCW is found to have performed EPP.

− Details of the current NHS Lothian Needlestick Injury Management Procedure, including rapid access for reporting, effective access to post-exposure prophylaxis and follow-up according to agreed guidelines.