Patient Notification Exercises (PNEs), also commonly called lookback exercises, may be recommended when bloodborne virus infected healthcare workers have been performing exposure prone exposures that could potentially have resulted in exposure of the patient to the blood of the healthcare worker.

In 2017, NHS England (NHSE) Midlands and East supported by Public Health England (PHE) and NHS Improvement (NHSI), co-ordinated a PNE across 24 hospitals in 21 NHS Trusts in England on the recommendation of the United Kingdom Advisory Panel on Bloodborne Virus Infected Healthcare Workers (UKAP), following a report of a healthcare worker who had been diagnosed with Human Immunodeficiency Virus (HIV). The healthcare worker had worked in locum roles at several NHS Trusts in the specialities of Trauma and Orthopaedics and Accidents and Emergency.

A total of 397 patients were offered testing for HIV; 337 accepted the offer of a test and 336 tested negative with one patient testing positive. Phylogenetic analysis showed that this patient had a different strain from the healthcare worker.

The investigation into the healthcare worker and the co-ordination of the multi-site PNE presented several challenges and the multi-organisational debrief conducted at the end of the incident identified lessons for the organisations involved around the themes of leadership, information sharing, professional obligations, the lack of clarity in relation to the employer checks of locums employed through locum agencies and the requirement for PNEs.

Dr Vanessa MacGregor, Public Health England East Midlands