Management of Human/Animal Bites Guidelines

of 21

Management of Human/Animal Bites Guidelines V1.1 August 2020

Management of Human/Animal Bites Guidelines

Version : 1.1

First Issues: 01/08/2020

Revision Date: 01/08/2021

of 21


DOCUMENTATION INFORMATION

Version Date

01/08/2020

Version Number:

1.1

Status:

Approved

Next Revision Date:

01/08/2021

Developed by:

Kay Bagridge, Samantha Day Clinical Lead Melanie Salter Nurse Practitioner

Key Contact:

Kay Bagridge

Approved by:

CLG

Date Approved:

01/08/2020

Version Control

Version No:

Description Version Date Author

1.1 New Document 01/08/2020 Kay Bagridge, Samantha Day Clinical Lead Melanie Salter Nurse Practitioner

of 21


This document is controlled and maintained on behalf of The Partnership of East London

Cooperatives:

Distribution List

All NELFT & PELC Clinical Staff

Related Documents

HI Guidelines/flowchart

CONTENTS:

Section Page Assurance Statement 4

1. Introduction 4 2. Aims and Objectives 4 3 Roles and Responsibilities 6-7 4 Process/Guidelines 7-8 4.1 Human bite 8-9 4.2 Animal bite 9-11 5 Consent 11 6 Implementation process 11 7 Monitoring process 11-12 8 Equality statement 12 9 External references 12-13

of 21


10 Training 13 Stakeholder form 14 Equality Impact Assessment form 15-16 Approval Checklist 17

Leadership team approval sheet 17-18

Assurance Statement The aim of this SOP is to ensure that all patients presenting with a Human / Animal bite receive thorough clinical assessment and appropriate treatment for their presenting condition.

1. Introduction This SOP details the clinical management of patients presenting to the Walk-in centre (WIC) with a Human / Animal bite This SOP incorporates the previously ratified clinical policies for the management of Human /Animal bites at the WIC into a single umbrella guideline. Patients presenting to the WIC are seen, assessed and treated by autonomous Nurse Practitioners or Emergency Care Practitioners who will make diagnostic decisions based upon their consultation, clinical examination and interpretation of diagnostic tests.

2. Aims and objectives The aim and objective of this SOP is to ensure that the management of Human /Animal bites are treated in a consistent and clinically appropriate manner based upon recent clinical evidence. To ensure that patients receive a comprehensive clinical assessment based upon their individual needs. Clinicians are responsible for obtaining a clinical history and making diagnostic decisions facilitated by a medical consultation model. This SOP aims to support a consistent approach in the diagnosis, management and treatment of Human /Animal bites The NHS Constitution safeguards the enduring principles and values of the NHS; it sets out the rights to which patients, public and staff are entitled, and pledges which the NHS is committed to achieve. NHS bodies and local authorities are required by law to take account of this Constitution in their decisions and actions; therefore all policy/procedural documents should consider and take into account the NHS Constitution pledges – NHS Constitution click here The Trust acknowledges the significance of National Health & Clinical Excellence (NICE) guidance. The Trust strives to provide high quality care that consistently improves by taking account of best practice. In order to achieve this, National Health & Clinical Excellence (NICE) Guidance must be disseminated, reviewed and where appropriate, implemented within the Trust. The Trust is

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/170656/NHS_Constitution.pdf

of 21


therefore committed to ensuring National Health & Clinical Excellence (NICE) Guidance is disseminated, reviewed and where appropriate implemented within the Trust.

3. Roles and responsibilities 31 Chief executive The Chief executive has accountability for ensuring the provision of high quality, safe and effective services within the Trust. 3.2 Senior Leadership Team (SLT) Responsible for the approval of all trustwide procedures/guidelines/protocols. 3.3 Directors All directors are responsible for the implementation of this procedure into practice within their service areas and taking appropriate action should any breach of this procedure arise. 3.4 Assistant Directors All assistant directors have a delegated responsibility for ensuring that this procedure/guideline is known to all staff and that its requirements are followed by all staff within their area. 3.5 Operational leads Responsible for: • bringing to the attention of their staff the publication of this document • providing evidence that the document has been cascaded within their team or department • ensuring this document is effectively implemented • ensuring that staff have the knowledge and skills to implement the procedure and provide training where gaps are identified 3.6 Staff It is the duty and responsibility of all clinicians to be conversant and competent in the management of conditions detailed within this procedural guideline. Clinicians will also be responsible for undertaking and documenting a full clinical history ensuring that the clinical records comply with Trust and professional standards for record keeping. It is the responsibility of the Operational Lead to ensure that clinical staffs are adequately trained and competent to treat the conditions detailed within this procedural guideline. A written record of assessed clinical competencies will be kept. It is the responsibility of the organisation to provide financial support for training and development to support clinical staff to practice at an advanced level. 3.7 Authors Responsible for writing the procedure/guideline, sending out for consultation

of 21


and making all amendments prior to final sign off. 3.8 Quality and Patient Safety Responsible for: • Quality checking all documents to ensure both statutory and Trust Requirements are met (this is to be carried out via stakeholder consultation) • Publishing approved/ratified/amended documents on NELFT’s internet • communicating newly approved/ratified/amended documents to Communications for publication in the Trust weekly newsletter 3.9 Communications Publishing an article in the Trust weekly newsletter indicating all newly approved/ratified/amended documents

4. Process/Guidelines Human / Animal bites will be discussed separately. However, all patients will undergo the same initial process to establish their individual health care needs. Individual health needs will be identified by utilization of a medical model, which supports effective communication for both the patient and clinician. Communication is therefore more accurate and will improve health outcomes. Clinicians will undertake consultations based upon a medical framework model, which will support diagnostic decision-making. Clinical records will be written up reflecting the consultation model and include the following elements. • Initial concept of the problem • Information gathered to provide clinical assessment • Physical examination • Interpretation of examination findings / diagnostic tests • Explanation of findings • Education / treatment • Discharge advice / referral Clinicians will undertake a holistic approach when assessing individual health needs to ensure that all patients are discharged safely from the service. It will be the responsibility of the clinician to take into account any previous past medical history and social circumstances as an integral part of their clinical assessment. Specific examination of Human/animal bites will be detailed individually in the following clinical guideline. Management of individual conditions will be decided separately however all clients will undergo a similar initial process to establish their individual need and a working diagnosis. 4.1. Human Bites Definition: One person biting another usually causes human bites. Although they may result from a situation in which one person comes into contact with another person’s teeth. A person’s knuckle may come into contact with another person’s teeth, and if the impact breaks the skin, the injury would be considered a bite.

of 21


The primary function of the skin is to serve as a protective barrier against the external environment. Therefore the education in the structure and function of the skin is vital if excellence in wound prevention and treatment is to be achieved. There are three layers to the skin Epidermis layer Dermis Subcutaneous layers, The Skin: The epidermis, There are two layers of epidermis, the living basal layer, which is next to the dermis, and the external stratum corneum, or horny layer, which is composed of dead, keratin-filled cells that have migrated outward from the basal layer.Here you will find the formation of hair follicles and exocrine glands. It is this continuous line of epidermis that allows islands of epithelium to appear in healing. Dermis layers, consist of nerves, glands, fatty (adipose) tissue and muscular tissue. These structures are maintained by the fibrous and elastic connective tissue each structure playing a special role in maintaining homeostasis, to maintain temperature, perception of stimuli, protection and excretion. It has a fibrous component of collagen and elastin; collagen gives the dermis its structural stability and strength to healing wounds whilst elastin provides elasticity and resilience. The dermis also contains sensory nerve endings that respond to the sensations of touch, temperature, pressure and pain. Beneath the dermis layer is the subcutaneous layer of adipose tissue containing a plexus of blood vessels. This layer connects the dermis to the lower structures, provides protection between bony prominences and the skin surface, providing energy when required and maintaining warmth of the lower structures. 4.1.1 Human bite History Record history including: • Document how and when the bite occurred • Examine the bite, and document its location, appearance, and any damage to underlying structures. • For a bite affecting the hand document whether it is an injury inflicted by an actual bite or by a clenched fist injury. • Assess whether the wound is infected: Signs of infection redness, swelling, serosanguinous or purulent, discharge, pain, localised cellulitis lymphadenopathy/lymphangitis or fever. • Size and depth of wound • Assess Tetanus status, drug history, any known allergies and immunisation status (If tetanus prone wounds or childhood immunisations not completed refer to ED)

of 21


Guidance available at https://www.who.int/ith/vaccines/tetanus/en/ https://www.nhs.uk/conditions/tetanus/ https://cks.nice.org.uk/bites-human-and-animal#!scenario • Assess whether there is a risk of acquiring a blood-borne viral infection (e.g. Hepatitis B (If suspected refer to GP for follow up or ED if acute symptoms) Guidance can be found https://www.nhs.uk/conditions/hepatitis-b/ • HIV (refer to GP/Sexual Health clinic for follow up)

• Associated medical conditions (for example diabetes mellitus, asplenia, immunocompromised status, chronic liver disease, prosthetic heart valve or joint).

• Although rare, consider the possibility of child neglect if there is a report or appearance of a human bite on a child who has been inadequately supervised. Refer for further assessment in line with local policy and follow safeguarding referral pathway.

Facial bites: Refer to Queens ED for Max Fax review Examination • Assess the location of the wound; • Assess the size of the injury • Assess the type of the wound e.g. penetrating or crush injury. • Assess the degree of injury, devitalized tissue, nerve or tendon damage, and involvement of bones, joints or blood vessels. • Assess the range of movement of adjacent joints • Assess any lymphadenopathy/lymphangitis • Assess any presence of any foreign bodies e.g. teeth • Assess any signs of infection

• Assess for systemic signs of infection BP Pulse Respiration SP02 and Temperature if infection present or suspected (NEWS 2/PEWS score)

Investigations • Soft tissue X-ray to rule out foreign bodies e.g. teeth or broken bone if indicated • Exploration of wound under local anaesthetic (if indicated) as per PGD Lidocaine 1% & 2% Non-Medical prescribers as per PGD/NICE guidance • Any bites at high risk of blood borne infection Hepatitis/HIV will require blood tests refer to ED/GP as appropriate (See guidance above) Management If the wound has just happened encourage it to bleed, unless already bleeding freely • Irrigate with warm running water thoroughly • Wound closure is rarely advised in primary care (seek advice from Broomfield/ED if concerned or risk to underlying structure involvement) • Advise pain control to reduce symptoms (OTC paracetamol Ibuprofen) • Prescribe prophylactic antibiotics for all human bites under 72 hours old as per Antibiotic PGD Non-Medical Prescribers as per PGD/NICE Guidance even if there is no sign of infection (note below) • Consider if tetanus prophylaxis is required (as above)

https://www.who.int/ith/vaccines/tetanus/en/

https://www.nhs.uk/conditions/tetanus/

https://cks.nice.org.uk/bites-human-and-animal#!scenario

https://www.nhs.uk/conditions/hepatitis-b/

of 21


• Any patients at high risk from HIV/Hepatitis discuss with Sexual Health Clinic/GP • Patient may require a wound swab in these circumstances so GP review is

recommended. Treat with antibiotics as per PGD Non-Medical prescribers as per PGD/NICE guidance any patients that are excluded under guidance patients should be referred to ED. Discharge

• Advice should be given on wound care and follow up • Analgesia • Red Flags and to seek review if develops

4.1.2 Animal bites Definition An animal bite can result in a break in the skin, a bruise or a puncture wound. History Record history including: • Document how and when the bite occurred • Assess Tetanus status, drug history, any known allergies and immunisation status (If tetanus prone wounds or childhood immunisations not completed refer to ED) Guidance available at https://www.who.int/ith/vaccines/tetanus/en/ https://www.nhs.uk/conditions/tetanus/ https://cks.nice.org.uk/bites-human-and-animal#!scenario • Assess the risk of acquiring rabies refer to ED if any risk that the animal had rabies or bite contracted in high risk countries Guidance available at https://www.nhs.uk/conditions/rabies/vaccination/ • Assess what country and when the bite occurred • What sort of animal was it domestic/wild? • Was it provoked? • Any risk of infection


• Associated medical conditions (for example diabetes mellitus, asplenia, immunocompromised status, chronic liver disease, prosthetic heart valve or joint).

• Although rare, consider the possibility of child neglect if there is a report or appearance of an animal bite on a child who has been inadequately supervised. Refer for further assessment and follow safeguarding referral pathway.

Facial bites: Refer to Queens ED for Max Fax review Examination • Assess the location of the wound; • Assess the size of the injury • Assess the type of the wound e.g. penetrating or crush injury.




https://www.nhs.uk/conditions/rabies/vaccination/

of 21


• Assess the degree of injury, devitalized tissue, nerve or tendon damage, and involvement of bones, joints or blood vessels. • Assess the range of movement of adjacent joints • Assess any lymphadenopathy • Assess any presents of any foreign bodies e.g. teeth • Assess any signs of infection


• Investigations • Soft tissue X-ray to rule out foreign bodies e.g. teeth or broken bone if indicated • Exploration of wound under local anaesthetic (if indicated) as per PGD Lidocaine 1% & 2% Non-Medical prescribers as per PGD/NICE guidance • Any bites at high risk of blood borne infection I.E Rabies will require blood tests refer to ED (See guidance above) Management • If the wound has just happened encourage it to bleed, unless already bleeding freely Irrigate with warm running water thoroughly • Wound closure is rarely advised in primary care (seek advice from Broomfield/ED if concerned or risk to underlying structure/ involvement) • Advise pain control to reduce symptoms (OTC paracetamol Ibuprofen) • Prescribe prophylactic antibiotics for all human bites under 72 hours old as per Antibiotic PGD Non-Medical Prescribers as per PGD/NICE Guidance even if there is no sign of infection (see note below) • Consider if tetanus prophylaxis is required (as above) • Any patients at high risk of Rabies exposure ref to ED (guidance as above) Treat with antibiotics as per PGD Non-Medical prescribers as per PGD/NICE guidance. Any patients excluded under the guidance should be referred to ED. Discharge

• Advice should be given on wound care and follow up • Analgesia • Red Flags and to seek review if develops

5. Consent 5.1 Valid consent to treatment is central in all forms of healthcare.

“Consent” is a patient’s agreement for a health professional to provide care. Patients may indicate consent non-verbally, orally or in writing. For the consent to be valid, the patient must:-

be competent to take the particular decision have received sufficient information to take it not be acting under duress

of 21


5.2 Please refer to the Consent to examination and treatment policy 2016. 5.3 If there is any indication that the patient may lack mental capacity to consent a mental capacity assessment must be carried out. Please refer to your specific business unit mental capacity act policies. 5.4 Consent and access to treatment for children and young people: please refer to the Consent to examination and treatment policy 2016.

6. Implementation process

a. Staff will be made aware of any new approved policies/procedures/guidelines via the Trust weekly newsletter. Quality and patient safety team will be responsible for ensuring newly approved documents are sent to the communications team in order for them to insert into the Trust weekly newsletter.

b. All senior managers/heads of service/team leaders need to ensure new policies

and procedures are placed on team meeting agendas for discussion. There is an expectation that the team leader will develop local systems to ensure their staff are instructed to read all relevant policies and to identify any outstanding training deficits.

7. Monitoring process

Compliance to this procedural guideline will be monitored via audit of clinical records.

Element to be monitored

Lead Tool Frequency Reporting arrangements

Recommen-dations

Learning lessons

Guidelines to be updated as per National Guidance and best practice.

Kay Bagridge Samantha Day Clinical Lead

NICE guidelines

3 yearly – guidance from Walk-in centre Operational Lead

Operational Lead Clinical Lead

Barking & Dagenham Leadership Team

Staff will follow the clinical guideline when carrying out the procedure to ensure best practice is followed

of 21


8. Equality statement This procedure/guideline reflects the organisation’s determination to ensure that all parts of our community have equality of access to services and that everyone receives a high standard of service as a service user, a carer or employee. This procedure/guideline anticipates and encompasses the Trust’s commitment to prevent discrimination on any illegal or inappropriate basis and recognise and respond to the needs of individuals based on good communication and best practice. We recognise that some groups of the population are more at risk of discrimination or less able to access to services than others and that services can often unintentionally put barriers in place that can limit or prevent access. The organisation is continually working to prevent this from happening. 9. External references Bickley 2012 Bates’ Guide to Physical Examination 12th edition Wolters Kluwer USA Purcell, D. (2016), Minor injuries a clinical guide 3rd Edition. Churchill Livingstone https://cks.nice.org.uk/bites-human-and-animal#!scenario accessed June 2019 https://www.nhs.uk/conditions/rabies/vaccination/ accessed June 2019 https://www.nhs.uk/conditions/hepatitis-b/ accessed June 2019 https://www.who.int/countries/gbr/en/ accessed June 2019 https://www.nhs.uk/conditions/tetanus/ accessed June 2019 https://www.who.int/ith/vaccines/tetanus/en/ accessed June 2019 https://www.nhs.uk/conditions/tetanus/ accessed June 2019 Patient Group Directions for supply and administration of Antibiotics 10-2018-04 2019


https://www.nhs.uk/conditions/rabies/vaccination/

https://www.nhs.uk/conditions/hepatitis-b/

https://www.who.int/countries/gbr/en/




of 21


Patient Group Directions for supply and administration of Lidocaine 10-2016-58 v 3 2019 10. Training

All staff undertaking autonomous clinical consultations will have skills in advanced assessment.

Competency is assessed and maintained through completion of a specific clinical competency framework supported by additional training where identified, in line with local PGD.

Training will be accessed via the STEPS and external training providers where needed.

of 21


Stakeholder form

Stakeholder title

Date sent to Stakeholders C

om

me

nts

rec

eiv

ed

Re

turn

ed

,

no

co

mm

en

ts

No

t re

turn

ed

Equality and Diversity Manager

Leadership Team – Basildon and Brentwood Locality

Leadership Team – Barking and Dagenham Locality

Leadership Team – Havering Locality

Leadership Team – Redbridge Locality

Leadership Team – Thurrock Locality

Leadership Team - Waltham Forest Locality

Leadership Team - MHIPAD

Compliance Team (QPS) [email protected]

Consultant in Old Age Liaison Psychiatry and Associate Medical Director Stephen.O'[email protected]

Associate Director of Human Resources [email protected]

Director of Nursing (Clinical Effectiveness – [email protected]

Director of Nursing (Patient Safety, BTUH Health Economy) – [email protected]]

Director of Nursing (Patient Experience) [email protected]

Associate Director of Nursing Quality & Patient Safety [email protected]

Finance [email protected]

Performance [email protected]

Estates [email protected] [email protected]

Communication team [email protected]

Add extra rows for any further stakeholders you may wish to send your document to

mailto:[email protected]











of 21


Add extra rows for any committees or groups that your document may need to be approved by indicating the name of the committee and the date of approval

of 21


NORTH EAST LONDON FOUNDATION TRUST INITIAL SCREENING EQUALITY IMPACT ASSESSMENT FORM

Directorate/Department

Barking & Dagenham Integrated Care Directorate / Walk in Centre

Name of Procedure/Guideline/Service/Function

Procedural guidelines for the Management of Human/Animal Bites

New or Existing Procedure/Service/Function?

New Umbrella Procedural (replacing previously ratified clinical policies)

Name and role of Person completing the EQIA

Samantha Day

Date of Assessment

June 2019

Yes/No What/Where is the Evidence to suggest this?

1 Does the Procedure/Service/Function effect one group less or more favourably than another on the basis of:

Race, Ethnic origins (including, gypsies and travellers) and Nationality

No

Gender (males and females) No

Age No

Religion, Belief or Culture No

Disability – mental, physical disability and Learning difficulties

No

Sexual orientation including lesbian, gay and bisexual people

No

Married/or in civil partnership

No

Pregnant/maternity leave No

Transgender reassignment

No

2 Is there any evidence that some groups are affected differently? Is the impact of the procedure/guideline likely to be negative?

No

3 Is there a need for additional consultation e.g. with external organisations, service Users and carers, or other voluntary sector groups?

N/A

of 21


4 If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

N/A

5 Can we reduce the impact by taking different actions?

N/A

Assessor’s Name: Samantha Day Date: June 2019 Name of Director: Melody Williams

This section to be agreed and signed by the Equality and Diversity Manager in agreement with the Equality and Diversity Team Recommendation Full Equality Impact Assessment required: NO □ YES □

Assessment authorised by: Name: Date:

of 21


Approval Checklist – for the Review and Approval of Policy and Operating

Procedures or Guidelines

To be used as a guide to quality check that Policy and Procedure/Guideline practice has been implemented before submitting for approval. If you have answered “No” to any of the questions, your document will NOT be accepted for ratification

Checklist

Yes/No Comments

1 Does your document follow the current template for Policies/Procedures/Guidelines available on the Trust website?

Yes

2 Is the title clear – has best wording been used in order that staff can

locate policy easily? Is this in the correct style and format (Arial font

size 11, left justified throughout)?

Yes

3 Are all paragraphs and sub-paragraphs numbered? Have bullet points

been used appropriately, i.e. only for short lists and not in place of

paragraphs?

Yes

4 Is the front sheet fully completed? Yes

5 Does it have the correct version number? Yes

6 If this is a clinical adult guideline check to see if listed in Royal Marsden

on-line manual. If so can Royal Marsden guideline be used? On-line

manual accessed via Trust Intranet

Yes

7 CQC – Does your policy/procedure/guideline reflect

the criteria within the CQC’s 5 Key questions - that services deliver

Safe, Caring Responsive, Effective and Well led care?

Yes

8 Is the monitoring process clearly described and monitoring table within

template complete? Yes

9 Any training aspects of policy/procedure identified? Follow-up

procedures listed. Yes

10 Does this document link to any NELFT policies? Are they listed on document control sheet?

N/A

11 Are the references listed up-to-date and appropriate? Yes

12 Have you carried out a robust stakeholder process, ensuring those listed in the template as stakeholders are consulted and is the stakeholder form comment box complete?

Yes

13 Is the Equality Impact Assessment tool fully completed, individualised to this document and approved - have you received a signed authorised copy back from Equality and Diversity team?

Yes

14 If you have attached appendices are they appropriate, referred to

within the document and listed on contents page? N/A

15 Regarding HR policies – have they been signed off by the Joint

Negotiating Consultative Committee (JNCC) prior to submission to the

ratification process?

N/A

http://nelftintranet/policies-and-guidelines/

of 21


16 16

Finally have you carried out a final proof-read, checked all spellings and

ensured your document is accurate and ready for publication? Yes

of 21


LEADERSHIP TEAM APPROVAL SHEET

Procedure/Guideline title:

Management of Human/Animal Bites (Guidelines for)

Author: Kay Bagridge, Operational Lead Samantha Day Clinical Lead Melanie Salter Nurse Practitioner

Assistant/Associate Director approval

Once the form has been agreed/not agreed for ratification by Leadership team it should be sent to [email protected] as confirmation of approval

Meeting Date of meeting

Chair name and title Signature of LT Chair

Ap

pro

ved

?

Y /

N

Reason for non-approval

Leadership Team

Addendum

Date Section Change Agreed by

Management of Human/Animal Bites Guidelines

Documents

Transcript of Management of Human/Animal Bites Guidelines