CHAPTER FIVE DISCUSSION AND CONCLUSIONS
Discussion
5.1 This study aimed to describe and evaluate services for preventing psychological and physical harm in police and prison staff exposed to blood and/or body fluids, and therefore potentially exposed to BBVs, in the work context.
5.2 Although the evaluation took place in Scotland, the findings may be relevant to the UK as a whole, as there has been little UK research in this area.
5.3 The evaluation investigated 108 incidents of exposure, 105 from police forces and 3 from the SPS. In two thirds of cases (72/108) the exposed person first sought medical help from another medical service before attending OH, usually A&E.
5.4 The procedures for reporting incidents of exposure and organising post-incident management in the SPS differed from those in police forces. There were also differences between police forces.
5.5 Higher numbers of incidents of exposure were notified to police and prison H&S units over the study period than were reported to OH units or providers, despite publicity, confirming the views expressed by some police and prison representatives that incidents were more likely to be reported to the former. The numbers of incidents reported to H&S - 269 in the police and 19 in the SPS - were of the same order as those reported in earlier years.
5.6 Since the majority of cases reported to OH were included in the evaluation, the 108 cases evaluated may be seen as reasonably representative of all cases reported to OH, although nothing was known about the cases not sent to the researchers. The 108 cases, however, cannot be seen as representative of all cases of occupational exposure to blood or body fluids reported to H&S. The 3 SPS cases cannot be seen as representative of all exposure incidents reported in the SPS over the study period.
5.7 Just over half of the exposures were caused by bites and spits, and a number involved splashes of blood. Eight incidents involved NSIs, and a further 6 other sharp instruments. The types of incident reported by police service staff reflected the findings from other research (Sonder et al, 2005b). Seventy-seven of the 108 cases involved exposure to mucous membranes or broken skin.
5.8 105 incidents were reviewed by a panel of 12 experts (in 2 sub-panels). They assessed the risk of BBV infections in most of the incidents to be 'low' or 'none'. In most cases, the majority of panel members judged that OH had assessed the risk of BBV infection correctly. There were, however, some concerns that not all 'no risk' cases had been identified as such, and in a few cases, that the risks from more significant exposures, such as NSIs, had been underestimated. Experts emphasised that police and prison OH staff should be able to assess BBV risk.
5.9 Panel members were rarely in complete agreement about the risk of each BBV, in line with other studies (van Wijk et al, 2008), though differences were small. These differences between experts may have illustrated the difficulty of assessing risk of infection with limited information; a recognised problem for medical service dealing with incidents of exposure to blood and body fluids occurring in the community (Sonder et al, 2005a). They may also have reflected different perceptions of 'objective' risk, or alternatively different use of language; that is, different individuals ( OH nurses as well as BBV experts) might ascribe different meanings to the terms 'none', 'low' and 'high'. These findings have indicated a possible need for more clarity about the terms used to assess risk. To this end, the recently published HSE consultation document has suggested the use of the terms 'very low risk', 'low risk' and 'high risk', and the types of exposure covered by each ( HSE, 2008).
5.10 In most of the cases evaluated in this study, a majority of each panel judged the post-incident management by OH of each BBV to have been 'adequate and appropriate'. Several reviewers expressed the view that, overall, police OH units were "functioning correctly". In a similar way, most police and prison service staff who completed a questionnaire were satisfied with the care provided by OH.
5.11 Some concerns were expressed by panel members, however, about evidence of inconsistency in the HCV follow-up testing proposed by OH staff. A recent report by the Health Protection Agency ( HPA, 2008), based on a surveillance of incidents of occupational exposure to healthcare workers, found similar inconsistencies in HCV testing. All the reviewers in this study considered that there was a need for a consistent shared post-incident management protocol, which would cover risk assessment, blood for storage, post-incident treatment for HBV and HIV and appropriate follow-up testing, particularly for HCV.
5.12 Panel members were unable to evaluate the post-incident management provided by medical services other than OH because of the lack of first-hand information. However, on the basis of reported information, several felt that, overall, there was evidence of variation or unreliability in post-incident management by medical services other than OH, and a possible need for staff training. They expressed some concerns about an apparent lack of action by A&E in some cases, incorrect advice given by a police doctor and uncertainty in prison health centres about risks and procedures. In a similar way, some, although a minority of, police and prison service staff who returned questionnaires felt that the care they had been given by a first point of contact other than OH, especially A&E, could have been improved.
5.13 These findings mirror those of a study which compared the out-of-hours management of occupational body fluid exposures in a London hospital with that provided by OH. OH were found to be more consistent in assessing and managing exposures and gave more appropriate advice on prophylaxis (Patel et al, 2002). An earlier UK study investigated the extent to which recently-introduced guidelines for the management of occupational exposure had been implemented in London hospitals, and health workers' knowledge of procedures, and concluded that the implementation of policies and the briefing of staff should improve (Sidwell et al, 1999).
5.14 In this study, panel members recommended that communication between the first point of contact and OH should be improved to ensure consistency and aid management, and that thought should be given to how this could be achieved. It should be noted that in one police OH unit, arrangements had been made with local hospitals so that if staff informed A&E that they were police employees, information would be forwarded automatically to OH. Similarly, a recent UK study which investigated communication between OH and other hospital services in incidents of occupational exposure found that that there could be communication problems because of the complexity of cases, but that areas for improvement could be identified and problems reduced by improved documentation (Clough and Collins, 2007).
5.15 The SPF request to the Scottish Government for legislation to allow mandatory source blood testing formed the background to this evaluation. A request for mandatory testing implies that source individuals are unlikely to provide a blood sample voluntarily. In this study, 14 of the 24 source individuals who had been asked to provide a blood sample did so. Requests by medical professionals, whether A&E staff or police doctors, were most likely to be agreed to. These findings support those from recent research in Amsterdam, which investigated the rate and outcome of all occupational exposure incidents that occurred in the police and that were reported to the Municipal Health Service over a 4-year period. The findings showed that a high proportion of source individuals who had been arrested agreed to be tested, and that blood samples were volunteered most often when requested by an independent person such as a doctor or nurse (Sonder et al, 2005a; b).
5.16 Panel members in this study noted that there were a number of other cases where source testing would have been helpful and was apparently feasible, i.e. the person was in custody, but no request had been made. They recommended that there should always be a consideration of source blood in cases of significant injury, by which they meant contamination of mucous membranes or broken or punctured skin with blood or body fluids, and that any guidelines should include this recommendation. The fact that a few requests for source blood testing were made following 'exposures' to intact skin highlights the need for clarity on the circumstances that should initiate a request for source blood.
5.17 The exposed individuals who completed a follow-up questionnaire expected medical staff to know what to do, to provide clear and accurate information, to provide as much reassurance as possible and to act speedily. They wanted their exposure to blood or body fluids to be taken seriously by medical services and by their colleagues and supervisors. These findings support the results of a small qualitative study in America which looked at the impact of occupational exposure on health care workers. This study found that participants were satisfied with the care they had received, but they felt that managers should be more involved when staff were exposed to a potential risk of BBVs (Gershon et al, 2000).
5.18 Little is known about the impact of occupational exposure incidents on affected staff. The findings from this evaluation have shown that there can be wide variations in anxiety, with higher anxiety associated with incidents incurring a higher potential risk of BBV infection, and that contact with a medical service may help to lower anxiety.
5.19 Only about half the respondents who returned a questionnaire stated that they had received training on BBVs, though others were unsure. It was possible that training sessions - e.g. at induction - might have been forgotten. Several participants recommended that more information be provided to staff, both about procedures to be followed after an exposure and the risks of infection. There was some evidence from these questionnaires, however, of possible raised awareness about occupational exposure to blood or body fluids and increased reporting to OH. Any increased awareness might or might not have been due to the evaluation.
5.20 The conclusions from the recent Amsterdam study, which also evaluated the use of a new protocol, were that treatment and follow-up after exposure needed to be improved, and that training, a health service on call 24 hours a day and a rigorous protocol were essential in minimising risk (Sonder et al, 2005a). The findings from this study are somewhat more positive, but they imply similar conclusions about the measures needed to provide a good service. The following conclusions and recommendations have been drawn.
Conclusions and recommendations
5.21 The findings of this evaluation provide no grounds for recommending mandatory source blood testing. Many cases reported were low risk. More than half of the source individuals who were asked to provide a blood sample did so, and there may be scope to improve on this proportion if requests are made by medical staff (see also 5.33 below).
5.22 Not enough information was available to draw conclusions about the management of incidents of occupational exposure to blood or body fluids in the SPS. Despite the small number of cases, however, some concerns were expressed about a lack of HBV immunisation, and about perceived uncertainties concerning procedures. New SPS guidelines for post-incident management, which included provision for the exposed person to be referred to the OH provider, were published during the course of the study ( SPS, 2008).
5.23 In the police, the large majority of cases were felt to have been appropriately managed by OH and the risk of BBV infection correctly assessed. Contact with OH seemed useful in ensuring that practical issues were not overlooked by other medical services and that time could be spent with the employee. Conclusions could not be drawn about the adequacy of management by medical services other than OH. However, there was some evidence of a lack of information and advice in some cases, apparent variation in standards of care, and across all medical services some inconsistencies in clinical management.
5.24 There were differences in procedures between the prison service and the police, and between police force OH units, especially in relation to the arrangements for the management of exposure incidents by more than one service. It may not be appropriate to recommend that all organisations, or even all police forces, have the same arrangements for managing incidents using different services. There are no grounds for making such a recommendation. In addition, arrangements between service providers may be a matter for each organisation to decide.
5.25 Whatever the arrangements or procedures for dealing with incidents of exposure, the same clinical management should be offered, and to the same standard, regardless of the service provider(s). It is recommended that a clear protocol be developed, to be used consistently by all medical services managing incidents of exposure. The protocol should draw on up-to-date NHS and HPA guidelines, and cover risk assessment, taking blood for storage, PEP for HIV, post-exposure prophylaxis for HBV and recommended follow-up testing, particularly for HCV. The development of such a protocol was recommended by the Working Group (Scottish Executive, 2007).
5.26 In addition, guidelines for the management of exposure incidents should be developed for police and prison services, based on current NHS and HSE guidance, but noting the issues specific to police forces and prisons (or public safety workers), such as the most common types of exposure, the likelihood of BBV infection in the source person and the difficulties of source testing. They should include guidance on the circumstances in which a request for source blood would be appropriate.
5.27 The guidelines should cover the provision of information, advice and counselling. Medical professionals should be aware of, and should be able to recognise, exposed individuals' anxiety after an incident of exposure, even if they themselves assess the risk of infection as low or non-existent.
5.28 The recent draft HSE guidelines have noted the specific requirements of emergency services, including the police, and of custodial services, including prisons and detention centres, for dealing with incidents of exposure to blood or body fluids ( HSE, 2008, Appendix 3). The Expert Advisory Group on AIDS ( EAGA) has suggested that those responsible for OH provision to staff where there is a risk of exposure to BBVs outside health care settings ( e.g. police, prison and fire service), may wish to use the existing guidelines as a basis for developing guidance relevant to their own occupational setting (DoH, 2008:4). To draw up the guidelines, it may be appropriate to identify a group which includes all the relevant individuals, and to involve EAGA and the Advisory Group on Hepatitis.
5.29 Training may be needed to ensure that all medical services are familiar with the most recent guidelines or protocol, and act in accordance with them in assessing the risk of BBV infection and offering appropriate advice and care.
5.30 Many incidents of occupational exposure in the police and prison services will be dealt with initially by A&E departments. Arrangements for providing post-incident management by more than one medical service should be discussed at a senior level, so that all services are aware of their responsibilities, and so that care offered or advised by all services (public or private) involved is appropriate and consistent.
5.31 Discussion is needed about ways in which communication can be improved between medical services providing post-incident management for exposures to blood or body fluids in the police and prison services, particularly between A&E and OH, with due regard for confidentiality.
5.32 Police forces and prison services should produce and publicise clear guidelines for staff at risk of exposure on the types of exposure to blood and body fluids that carry a risk of BBV infection, the measures that can reduce risk, and the first aid and reporting procedures to be followed after an incident. These guidelines should be consistent in terms of the type of incident to be reported and how quickly.
5.33 Police force and SPS staff guidelines should include the instruction that in all cases of exposure to blood or body fluids where there is contamination of mucous membranes or broken or punctured skin, there should be consideration of source blood. A risk assessment should be carried out as quickly as possible, and if there is an assessed risk of BBV infection, source blood testing should be requested, where it is feasible to do so. Any request to the source person should not be made by the exposed member of staff, and it may be most appropriate for medical staff, e.g. police doctors or prison medical staff, to make the request. Staff responsible for requesting source blood may need training and support. There should be discussion about ways in which source blood test results can be made available to services providing post-incident management, including OH, if the source person gives permission.
5.34 Police forces and the SPS should publicise their policies of free HBV immunisation and try to ensure that all staff at risk, including support staff, are vaccinated. Records of vaccination status should be kept, e.g. by OH. All police and prison service staff, including support staff such as custody officers, should be fully immunised against HBV, and response levels checked, before being exposed to any risk of BBV infection. Staff should carry written details of their response status with them.
5.35 Measures should be in place to try to ensure that all incidents of exposure are reported to OH. Police and prison OH units should be informed automatically of all such incidents notified to H&S.
5.36 One way to try to ensure the provision of appropriate and consistent post-incident management might be to produce a pack of materials for the use of police and prison service staff. This could include an aide-memoire, first aid procedures and details of who to report to for medical assistance, and also forms to be completed by medical services about any treatment or advice given or offered. The pack could be made directly available to staff either in a police car, at a police station or at the appropriate location within a prison. The member of staff could then follow the instructions provided, and take the pack with them when attending medical services. At the first point of contact, a form in the pack would be completed by the medical personnel, and this could be retained by the exposed person for future reference, or for use by the second or third points of contact. This approach would allow the individual to have more control over the information available to them. It would also improve communication of the details of medical care between various points of contact.
5.37 Another useful initiative might be a 24-hour helpline, to enable those sustaining a potential exposure to BBVs to receive clinical advice outside working hours. Such services as exist within the NHS seem to work well. The possibility of a helpline should be discussed at national level.
5.38 More training on BBVs and procedures may be needed by police service staff at all levels, and in the SPS, on risks, safe working practices, HBV immunisation, first aid and reporting procedures after an incident of occupational exposure to blood or body fluids ( e.g. the type of incidents that should be reported, to which medical service(s), within what time scale and for what reasons). Provision of improved information for police and prison service staff on BBVs and occupational exposure has already been recommended by the Working Group (Scottish Executive, 2007). There may be also a case for testing knowledge. OH staff should be involved in staff training on BBVs if possible.
5.39 Police and prison OH staff should follow the 'best practice' procedures highlighted by individual OH units. They should try to ensure for example, that HBV records are up-to-date, all staff are fully immunised against HBV (whether or not vaccinations and blood tests are carried out by OH) and have a written record of their response status (with advice to non-responders) in a form that can be carried while on duty. They should also try to ensure that exposed individuals are seen face-to-face, given written information, and followed up at least once by telephone.
5.40 Arrangements should be in place to allow OH providers to the police and prison services to share information about best practice, including innovations e.g. emergency helpline) and recent developments. Joint training of OH providers to public safety services may be worthwhile. There should also be channels to allow OH staff to report any problems they experience in managing incidents of exposure.
5.41 Finally, this evaluation has been unable to evaluate the appropriateness of post-incident management by NHS services. Although some research has been carried out in this area, there may be a need for further research to investigate the NHS management of cases in the police and prison services.