The Prevention and Management of Latex Exposure Policy Approved by: Issued by: Review date: Executive Management Team and Health and Safety Policy Action Group May 2005 Infection Control Team June 2005 June 2007 INDEX Page No. 1. 2. 3. 4. 5. 6. Introduction 1 1.1 Background 1 Objectives of the Policy 2 2.1 2.2 2 2 Objectives of the Policy Achievement of Objectives Roles and Responsibilities 4 3.1. 3.2. 3.3. 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 4 4 4 4 4 5 5 6 7 7 8 Trust Board Chief Executive The Executive Management Team Locality Management Teams Service Managers Line Managers Employees Agency Staff and External Contractors Logistics Department/Purchasing Manager Occupational Health Departments Human Resources Types of latex allergy 8 4.1 4.2 4.3 4.4 8 9 9 9 Background Skin irritation (irritant dermatitis) Delayed hypersensitivity (type IV) Immediate hypersensitivity (type I) Risk factors of latex allergy 10 5.1 5.2 10 10 People most likely to react to latex Risk factors in the use of powdered gloves Protocol for latex sensitive clients 11 6.1 6.2 6.3 6.4 6.5 11 11 11 12 12 The importance of questioning of clients Recording of the clients response Provision of alternatives to latex based products Maintenance of records Clients who develop symptoms of possible latex allergy 7. 8. 9. Protocol for latex sensitive healthcare workers 12 7.1 7.2 13 13 Information dissemination to staff Reporting possible latex allergy Glove quality and selection 13 8.1 14 Why only powder-free gloves must be worn References and further reading Appendix 1 : Sources of Latex Appendix 2 : Questions to ask clients/staff to identify sensitivity to Latex Appendix 3 : Information leaflet 14 15 16 1. INTRODUCTION 1.1 Background Over the past twenty years the health risks associated with the exposure to natural rubber latex (NRL) have been increasingly recognised. The development of allergy to NRL is associated with a range of reactions from skin rashes, hay fever-like symptoms and asthma, through to anaphylaxis, which has resulted in some fatalities. The incidence of latex allergies within both the hospital and community setting has become an increasingly significant problem for staff and clients. The risk of developing NRL allergy is associated with the extent of individual exposure to latex proteins. During the 1980s and 1990s the use of Standard Precautions in health care led to an increased use of NRL gloves. This increasing demand for NRL products led to changes in the manufacturing process resulting in materials which allowed a higher level of NRL proteins to be released during use (particularly when combined with powder in gloves). The repeated exposure of clients to certain treatments e.g. catheterisation also led to increased exposure and an increasing risk of developing allergy (a process referred to as sensitisation). It is important that all staff recognise latex allergy as a potential problem and know where and when to refer clients/staff for further investigation. The aim of the Medicines and Healthcare Products Regulatory Agency (formerly known as The Medical Devices Agency) is to ensure NHS organisations take all reasonable steps to protect the public, clients, carers and staff. A bulletin published in April 1996 (MDA DB 9601) highlighted evidence of latex sensitisation. In 1999 the Health and Safety Executive issued guidance to health care about the use of latex gloves (HSE 1999). This policy details the responsibilities of all staff in ensuring the effective management of NRL risks. A report by the National Patient Safety Agency (NPSA) in 2005 has examined the response of NHS organisation to latex allergies and whether they have taken adequate measures to protect workers and clients. (Beckford-Ball 2005) 1 2. OBJECTIVES OF THE POLICY 2.1 Objectives of the Policy The South West Yorkshire Mental Health Trust recognises its obligation to ensure as far as is reasonable practicable, the health, safety and welfare at work of all its employees (section 2(1) of the Health and Safety at Work Act 1974). Furthermore, it has a responsibility to protect the health of clients and visitors from the hazards of an unsafe environment and unsafe working practices. The Control of Substances Hazardous to Health Regulation (2000) requires risk assessments to be carried out in relation to specific substances used in the work place, so that control measures can be implemented in order to protect the health of staff and others. The SWYMHT is also required by the Disability Discrimination Act (1995) to make reasonable adjustments to enable employees diagnosed with a latex allergy to continue in their work. The South West Yorkshire Mental Health NHS Trust Health and Safety Policy defines the means by which the Trust will plan and execute the assessment and control of health and safety risks, and monitor and review the progress of this. The Latex policy specifically defines the specific organisational arrangements through which SWYMHT will reduce the risk of clients, staff employed by the Trust, those contracted to the Trust and those providing agency cover within the Trust from developing NRL allergy and ensure safe employment or treatment for those who become sensitised. 2.2 Achievement of objectives The objectives of the organisational arrangements will be achieved by : ensuring that all reasonably practical measures are taken to maintain a safe environment for clients and staff to protect against latex sensitisation, advising healthcare personnel of any increase in reports of the incidence of latex allergy, 2 ensuring staff are aware of the possibility of latex sensitisation and how to avoid it, emphasising the importance of identification of latex sensitisation in staff and clients, ensuring staff question clients about reactions to latex products as part of their allergic medical history, encouraging staff to seek guidance if suspected or confirmed latex allergy presents, ensuring adequate occupational health facilities for staff, recognising the importance of recording adverse latex reactions in clients records and reporting any evidence of latex allergy using the South West Yorkshire Mental Health NHS Trusts incident reporting system, ensuring recorded incidents are reported to the Medicines and Healthcare Products Regulatory Agency (formerly known as the MDA) to allow accurate national data collection, ensuring that the correct types of products are purchased as advised by the Infection Control Team including alternatives to latex-based devices as necessary, providing latex-free environments for latex allergic clients. This policy should be used in conjunction with the: Incident Reporting Procedure, Serious Untoward Incident Reporting Procedure, Infection Control Policy, Medical Devices Management Policy, COSHH Guidance, Health and Safety Policy. 3 3. ROLES AND RESPONSIBILITIES 3.1 Trust Board The general responsibilities of the Trust Board are detailed in the SWYMHT Trust Health and Safety Policy 3.2 Chief Executive The Chief Executive has overall responsibility for ensuring compliance with this policy and that there are effective arrangements within the Trust. They are responsible for ensuring that all Executive Directors, Locality Management Teams and staff understand and accept their responsibilities with regard to this policy. 3.3 The Executive Management team The Executive Management Team is responsible for approving the contents of the policy and ensuring that risks associated with NRL allergy to clients and staff are managed in accordance with this Policy and the associated protocols and procedures. 3.4 Locality Management teams The Locality Management Teams will: 3.5 ensure that the policy is implemented within their areas, ensure that business plans capture any resource implications identified by risk assessment, ensure that adequate facilities are made to fulfil the policy including releasing staff for training, disseminate information and seek advice from the Infection Control Team where necessary. Service Managers Service Managers are responsible for: ensuring that all staff within their service have access to and have read this policy, 4 providing the appropriate resources and access to training. It is strongly advised that managers retain a checklist of signatories to confirm that all staff members have seen, read and understood the contents of this policy. 3.6 Line Managers Line managers are responsible for: 3.7 ensuring that staff are aware of and comply with this policy and carry out their responsibilities as outlined within this policy, ensuring that general NRL risk assessment is undertaken with regard to work and clinical activities within their areas of responsibility. Specific individual risk assessment will be required where clients or staff are identified as allergic to NRL. Identifying and implementing any action required following the NRL assessment i.e. ensuring that latex free gloves and equipment are available for individuals who have been assessed as having a latex sensitivity. Further advice may be sought from the infection Control Team or Occupational Health. Ensuring that staff are given the necessary information, instruction and training to enable them to manage NRL allergy and comply with this policy including the need for reporting. Reporting NRL allergic reactions experienced by clients via the untoward incident reporting system. Referring staff with symptoms suggestive of NRL allergy to the Occupational Health Department Employees Each employee is responsible for taking reasonable care of themselves, clients and any other people affected by their acts or omissions during infection prevention and control procedures in accordance with Health and Safety at Work Act 1974. The responsibilities of employees working in the Trust are to: comply with the information, instruction and training provided by their Line Manager by following the associated protocols, procedures safe systems of work for their area(s) of work and responsibility, 5 report any possible NRL allergy symptoms to Occupational Health. In order to reduce their risk of latex sensitisation employees must : wear only recommended gloves which are powder-free, low in extractable proteins and residual chemicals, only wear gloves when necessary, ie. when the hands will come into contact with body fluids or hazardous substances, ensure that the right glove is being used for the right job, always wash hands preceding and following the wearing of gloves, gloves must be removed and hands washed thoroughly after each task or contact with each client and discarded as clinical waste, gloves must not be worn for long periods of time, any soreness or skin rashes experienced after glove use must be reported to the line manager and referral made to the Occupational Health Department. A risk incident form should be completed. Oil-based hand creams should not be used as these are not compatible with latex. (Further information is available in the Infection Control Policy Section 5: Glove Usage.) 3.8 Agency Staff and External Contractors The Trust has an obligation to safeguard the health and safety and welfare of any person working for it. This responsibility applies to those working in the Trust who do not necessarily hold Trust contracts of employment. Latex-free gloves must be made available to all individuals stating that they have an allergy to latex. Managers have an important role in ensuring that individuals who enter Trust premises whilst undertaking work or visiting clients are protected wherever possible from risk. Agency staff and External Contractors are expected to comply with reasonable instructions given by staff who are seeking to protect them from risk of allergic reaction. 6 3.9 Logistics Department/Purchasing Manager The logistics department/purchasing manager will: provide information for purchasers about products containing latex and suitable alternatives, purchase powder-free gloves on behalf of the Trust in accordance with Glove Usage : Section 5 of the Infection Control Policy. Powdered gloves must not be used or available for use within the Trust. Powder free latex gloves with low extractable levels of protein must be used. 3.10 Occupational Health Facilities The Occupational Health Service will: screen potential employees at their pre-employment health assessment and arrange diagnostic testing for those whose history may suggest latex sensitivity, ensure staff or prospective staff with NRL allergy and their managers are advised of any necessary adjustments or restrictions to their work activities using a risk assessment approach, support diagnostic testing for Trust staff referred to the Department having presented with signs of reaction, provide guidance to staff and managers on suitable and safe working environments for NRL sensitised employees, liaise with Service Managers to ensure safe working practices and the availability of alternative gloves and /or other equipment, inform the GP that the member of staff is experiencing problems, advise the individual to inform all health care workers i.e. podiatrists, dentists, who are involved in their care about the condition. This advice must be documented. Liaise with Managers to ensure that latex-free powder-free gloves and equipment are available to staff who have been assessed as having a 7 latex sensitivity and that suitable arrangements are made to allow the symptoms to subside. 3.11 Report any staff reaction to a latex product to the MHPRA. Liaise with managers for relocation of staff to environments where there is no/reduced risk of allergic reaction if symptoms cannot be controlled. Human Resources The Human Resources Department will : 4. support health care workers who may develop a latex allergy by arranging temporary relocations, work with managers and Occupational Health to facilitate permanent relocations of these individuals with confirmed allergies to alternative safe working environments. TYPES OF LATEX ALLERGY 4.1 Background NRL comes from the milky sap of the rubber tree known as Hevea brasiliensis. The sap contains proteins, preservatives and other chemicals added during the manufacturing process. The NRL proteins enter the body in different ways such as via the skin, mucous membranes and lungs. They set up an allergic response which worsens on repeat exposure. NRL is durable, flexible and affords a high degree of protection from many organisms. It is found in a wide variety of medical devices (gloves, adhesive tape, elastic stockings, bandages, blood pressure cuffs) as well as in general usage (balloons, elastic bands, hot water bottles). Please see Appendix 1. Many countries, including the UK have experienced an increase in latex sensitisation due to general exposure to latex within the clinical and social environments. In recent years concerns among health care workers and the general public regarding hazards of infection have lead to the increased use of barriers against infection with gloves forming a primary method of protection. 8 As the frequency and duration of the use of latex products has increased, the emergence of latex sensitisation has been identified as a problem for some individuals. This may lead to a variety of allergic reactions. Reactions may vary in severity. There are three recognised types of reactions (Medical Devices Agency 1996): 4.2 Skin irritation (irritant dermatitis) This is a non-allergic condition, the affects of which are usually reversible although some individuals may have a predisposition to progress onto allergy problems. When latex gloves are used redness or a rash may occur on the back of the hands, which is characteristically dry and itchy. These symptoms usually resolve themselves once contact with the latex product is discontinued. It is important to note that such skin irritation may be caused by a wide range of substances, for example; glove powder, skin cleansing or disinfecting agents, which may be confused with latex sensitisation. 4.3 Delayed hypersensitivity (type IV) This type of reaction is predominantly caused by an allergy to agents used in the manufacturing process of gloves. It is the most common reaction to latex sensitivity. The reaction is delayed, occurring several hours after contact, reaching a maximum after 24-48 hours and then it subsides. Repeated exposure may cause the skin condition to extend beyond the actual contact area of latex. It may also lead to sensitisation with other latex products. This type of reaction is often characterised by: 4.4 a red rash on the back of the hands and between the fingers, skin may become leathery and develop papules or blisters. Immediate hypersensitivity (type I) This is the most serious reaction caused by an immune response to protein allergens. It may occur within 5-30 minutes of latex exposure causing: local or generalised urticaria (nettle rash), itching, redness and swelling (oedema) of the skin, rhinitis (runny nose) if the mucous membranes are affected, conjunctivitis (red, itchy eyes), 9 5. sneezing and wheezing with breathlessness. Anaphylactic shock may occur in extreme cases. Such a reaction is almost immediate in effect but respiratory difficulties usually diminish rapidly once contact with the latex material has ceased. RISK FACTORS OF LATEX ALLERGY 5.1 5.2 People most likely to react to latex: individuals who are predisposed to allergies in general e.g. hayfever, eczema, dermatitis and asthma, clients/staff with spina bifida or congenital urological abnormalities who have undergone a large number of surgical procedures, occupational workers who, in the course of their work, are likely to have been exposed to frequent prolonged latex contact, individuals who are sensitive to avocado, melon, kiwi fruit, passion or star fruit, banana, potatoes, tomatoes and/or chestnut. This is due to shared antigenic similarities between the fruit and the latex. There is also a higher instance among the female population. The users of powdered gloves. The powder in the gloves is added to make it easier to put the gloves on. However this powder absorbs the latex antigens and disseminates them into the air when the gloves are handled, making it widely available to non-sensitised and sensitised people alike. Risk factors in the use of powdered gloves It is also recognised that powdered gloves increase latex exposure because the protein residue present in latex is carried by an aerosol action into the environment when gloves are removed. Where powdered gloves are used in procedures or during contact with mucosal surfaces, sensitisation and ensuing allergic reactions may occur. Powdered gloves must not be used or available for use within the Trust. Powder free latex gloves with low extractable levels of protein must be used. 10 6. PROTOCOL FOR LATEX SENSITIVE CLIENTS 6.1 The importance of questioning of clients In order to prevent allergic reactions and the rare occurrence of anaphylaxis staff must familiarise themselves with the following: it must be ascertained during the admission process whether there is a possibility of latex sensitivity. The person should be asked whether they have had any of the following symptoms: 6.2 skin, nose or breathing problems after handling rubber items such as balloons, sneezing, wheezing, shortness of breath, or swelling, itching or wheals on the skin after being examined by a health care worker wearing latex gloves, itching, swelling or redness of the skin appearing within minutes or hours after wearing latex or rubber gloves, allergies to banana, melon, avocado, kiwi fruit, passion or star fruit, chestnuts, potato or tomatoes, multiple surgical procedures i.e. replacement of urinary catheters, spina bifida or neurological problems. Recording of the client’s response The client’s response must be recorded and incorporated into the plan of care if relevant. If latex sensitivity is identified a sticker indicating this must be affixed to the front of the client’s note to ensure that all staff are aware of this information. Appendix 2 is a flow chart giving examples of questions to ask clients to ascertain whether there is a possibility of latex sensitivity. 6.3 Provision of alternatives to latex based products Immediate hypersensitivity (type I) client at risk should: be provided with a latex-free environment to include latex-free mattress covers and pillows, 11 have available treatments for anaphylactic shock. Pharmacy should also be made aware to ensure latex-free procedures when preparing medication. Catering staff should be made aware not to prepare food for the individual concerned using latex-gloves. Delayed hypersensitivity (type IV) client at risk should: 6.4 be treated by staff wearing latex free gloves with low levels of extractable proteins, have available treatments for anaphylactic shock. Maintenance of records 6.5 Observation, assessment and management of an allergic reaction must be fully documented and the allergy be clearly apparent in the client’s records. The response must be recorded and incorporated into a plan of care if relevant. All staff must be made aware of this information. Clients should be advised to inform all health care workers of their allergy. This advice must be documented. An information leaflet should be given to the client and the content discussed as appropriate. Please see Appendix 3. An incident report form must also be completed and sent to the Health and Safety Manager who will communicate with the MHPRA if necessary. The client’s GP/Consultant must also be informed, especially if surgical or mucous membrane contact is indicated. Clients who develop symptoms of possible latex allergy 7. Clients who develop symptoms of possible latex allergy should be assessed by a doctor as soon as possible and, if appropriate, referred to a Dermatologist. PROTOCOL FOR LATEX SENSITIVE HEALTHCARE WORKERS To comply with current legislation it is important that staff follow the procedures below, to safeguard their own health and that of their colleagues and clients. 12 7.1 Information dissemination to staff. Staff will be informed of the potential problems caused by latex sensitisation by the following: 7.2 Occupational Health pre–employment assessment, distribution of the guidelines for dealing with latex sensitivity by Locality Management teams. Managers should ensure members of their team are aware of the Trust’s Latex Policy and ensure compliance within their area. As part of both the Trust and locality induction programme. As part of the mandatory infection control training programme. Availability of information leaflets. As part of mandatory infection control training. Reporting possible latex allergy Staff should be aware of the symptoms of latex sensitisation and be assured that if affected the Trust will be supportive. 8. Whenever latex sensitisation is suspected diagnostic testing should be encouraged to ensure positive identification of the allergen. Healthcare workers who regularly use gloves and show any characteristic symptoms of allergy should seek advice from Occupational Health Services. Service Managers should be aware of any symptomatic member of staff. They must advise against continued latex contact, and refer the member of staff to the Occupational Health Service. This must also be recorded in the relevant staff personal file. The occurrence must be reported via the incident reporting procedure. GLOVE QUALITY AND SELECTION 8.1. Why only powder-free gloves must be worn The risk of latex allergy appears to be exacerbated by the use of powdered gloves not only to the user but also to sensitised individuals in the area. 13 Most powdered gloves have higher extractable protein levels than powderfree gloves. Where powdered gloves are used in procedures powder may be introduced into the patients body or come into contact with mucosal surfaces. This may cause sensitisation and subsequent allergic reactions. SWYT has shown a commitment to reduce this problem whilst ensuring the protection of staff by ensuring that all staff wear powder free gloves which have low levels of extractable protein. Further information can be found in Glove Usage : Section 5 of the Infection Control Policy 9. REFERENCES AND FURTHER READING NPSA (2005a) Report of the survey of the responses of NHS organisations to the risks of patient and staff sensitivity to natural rubber latex. www.npsa.nhs.uk/site/media/ NPSA (2005b) Patient Safety Information. www.npsa.nhs.uk Becford-Ball, J. (2005) Tackling latex allergies in patients and nursing staff. Nursing Times; 101:24, 26-27 MDA Devices Bulletin (1996) Latex Sensitisation in the Healthcare Setting MDA DB9601 MDA Bulletin (198) Latex Medical Gloves (Surgeons and Examination) Powdered Latex Medical Gloves (Surgeons and Examination) MDA SN9825 Health and Safety Commission (1999) Control of Substances Hazardous to Health Regulations Health and Safety Commission (1995) Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) Health and Safety Executive (1992) Personal Protective Equipment at Work Regulations Infection Control Nurses’ Association (2003) Royal College of Nursing (1999) Latex Allergy in Healthcare Settings www.hse.gov.uk/latex - information leaflets regarding latex available www.upsa.nhs.uk/advice www.pasa.nhs.uk www.lasg.co.uk 14 APPENDIX 1 Common medical and household sources of latex Medical items: adhesive tape blood pressure cuffs disposable syringes catheters enema tips gloves stethoscope tubing wheelchair wheels bandages elastic stockings Household items: balloons swimming costumes cycling shorts condoms elastic bandages hot water bottles rubber bands rubber plants rubber toys swim caps underwear this is not an exhaustive list 15 APPENDIX 2 Questions to ask clients/staff to identify sensitivity to latex products Eczema Asthma Hay fever Dermatitis Allergy to: Avocado Bananas Chestnuts Tropical fruit YES YES Tingling, Swelling, Wheezing or Rashes associated with: Hot water bottles Rubber gloves Elastic bands Following a visit to the dentist Any other products containing latex (see appendix 1) YES consider the potential for latex sensitisation Was the reaction immediate Was the reaction delayed Consider Type 1 Sensitivity Consider Type 4 Sensitivity Measures to reduce the risk: Measures to reduce the risk: All staff aware Provide latex free environment Treatment available for anaphylactic shock Treat using powder free non latex gloves with low extractable proteins 16 What happens if the client is sensitive? The Trust Policy gives guidance on what to do about the whole subject of latex sensitivity, including trying to identify at-risk clients on assessment. In summary, it says that the client: Will be assessed for risk prior to any procedure, then, if necessary, the client: o o o o will be provided with a latex-free environment, be scheduled first in a session, will have treatment for anaphylactic shock available at all times, have details of the sensitivity recorded in their case notes. INFORMATION What is the Trust doing about Latex generally? The Trust has produced a latex policy and all staff must read it and follow the guidance it contains. The policy states that: powder-free gloves which are low in protein and chemical content must be provided for use, staff will be trained to care for their hands and to use gloves correctly, clients with a latex problem will be identified, any problems staff have must be reported and Occupational Health will be notified for investigation, in high-risk work situations, latex-free alternatives will be provided, affected staff will be helped to carry on with their current jobs whilst avoiding contact with latex. To make this policy work effectively, the Trust, its staff and Occupational Health need to work in close co-operation. FOR PEOPLE WITH LATEX SENSITIVITY This information leaflet is supplementary to the Trust’s Policy and Guidance relating to Latex sensitivity. How will I recognise it? If you: What is Latex sensitivity? There are three types of reaction to Latex: Irritation – this is a non-allergic condition and the effects are usually reversible. It generally develops as a dry, itchy rash. Delayed hypersensitivity – appears several hours after contact, as dermatitis or eczema of varying severity. Predominantly caused by an allergy to residues of chemicals used in the manufacturing process. Immediate Hypersensitivity – appears within 5 – 30 minutes of exposure. Symptoms may include local or generalised nettle rash (urticaria) an associated swelling (oedema), hay fever-like reactions (rhinitis), irritated red eyes (conjunctivitis) or wheezing. Respiratory difficulties and severe potentially life-threatening allergic reaction (anaphylactic shock) may occur in extreme cases. It is usually a response to the natural protein residue found in latex rubber. What should I do about it? If you think either you or one of your clients has latex allergy you should report it to your Line manager as soon as possible. As a member of staff you should attend the Occupational Health Service for further investigation. The client’s GP must be informed of the concern. In the meantime, you should: Who is at risk? use alternative latex free gloves i.e. nitrile. avoid contact with any product containing latex. What will happen if I am sensitive? Anyone can be sensitive but particular groups of people have a higher than average risk: get a rash on your hands after wearing gloves, suffer from runny eyes/nose, wheezing or develop breathing difficulties after any exposure to latex products, then you may have a latex sensitivity. If latex sensitivity is confirmed, the Trust will do everything it can to help you carry out your job whilst avoiding contact with latex products. People who are prone to allergies, Those who have undergone a large number of surgical procedures (especially children), Individuals who are sensitive to avocados, bananas or chestnuts, Healthcare workers who are likely to have been exposed to frequent prolonged latex contact. This will include: How will I come into contact with latex? The most common method of contact for healthcare workers is by wearing latex gloves. This practice has increased enormously in recent years in response to the demand for protection against disease. Latex is also present in a large number of other items used in our working and domestic lives, masks, catheters, elastic bandages, stockings, waterproof bed covers, are just a few of the items you may come into contact with at work. At home there are items such as rubber gloves, family planning devices, balloons, elastic bands, hot water bottles. 1 Providing you with alternative latex free gloves Providing information on what products you may work with which contain latex and have alternatives available if at all possible, Monitoring the situation to offer you support and to make sure you are not still exhibiting symptoms.