Code of Safe Practice

STATEMENT OF MANDATORY PRINCIPLES

YOUR WORKPLACE

1. You must only perform acupuncture in premises suitably equipped (see guidelines below).
2. You must ensure that both you and any premises in which you work are properly registered or licensed for the practice of acupuncture
3. You must have up to date indemnity insurance and public liability insurance suit your practice and to provide cover for all of your clinical acupuncture skills and any adjunctive therapies you use.
4. You must have suitable hand washing facilities (see guidelines below).
5. You must keep the treatment room clean and tidy
6. You must avoid possible cross-infection from treatment surfaces

YOUR EQUIPMENT

1. You must only use equipment which is CE-marked and conforms to current legislation.

YOUR DUTY OF CARE

1. You must ensure the health and safety of your patient and other users of your work environment.
2. You must ensure that your own health and personal hygiene do not put the patient other users of your work environment at risk.

YOUR RESPONSIBILITY TO PERFORM ACUPUNCTURE SAFELY

1. You must establish and maintain a clean field at all times.
2. You must maintain high levels of hand hygiene.
3. You must insert and remove needles hygienically and safely.
4. You must use well-fitting single-use disposable surgical gloves for blood or body fluid spills or handling infectious skin conditions.

YOUR SAFE DISPOSAL OF EQUIPMENT AND CLINICAL WASTE

1. You must dispose of used equipment and clinical waste legally, safely and in accordance with current legislation

YOUR COMMITMENT TO HEALTH AND SAFETY

1. You must comply with the requirements and provisions of current health and safety at work legislation, including clinical facilities hazardous waste and fire regulations.
2. For more information please visit https://www.hse.gov.uk/legislation/hswa.htm

 

London Local Authorities Special Treatment Licencing guidelines:

SAFE NEEDLE PUNCTURE

Only use pre-sterilised disposable needles. Always wipe the skin with non-allergenic wipes prior to and after needling.
Wear sterile vinyl or latex gloves if you have a skin disease, have sweaty fingers, cuts, abrasions, lesions or suffer from an infectious disease. Some needle types allow for aseptic puncture without the use of guide tubes by holding the needle handle, whilst others require the use guide tubes. Never allow your fingers or anything else which is not sterile to touch the inserted needle shank before insertion. For longer needles, we recommend the use of guidetube or wearing sterile gloves. Needles must be used directly from the sterile pack and not placed on non-sterile surfaces before use.

Where the point of an unused needle comes in contact with the skin, nail or any non-sterile surface it must not be used, and be discarded in a yellow sharps container.  All used needles must be placed in a yellow sharps container and disposed of correctly by incineration by an approved sharps service. Used cotton wool wipes and couch roll must be disposed of in an appropriate manner according to local authority regulations.

NEEDLE AND INSTRUMENT QUALITY CONTROL

All needles should be purchased from a reputable medical supplier. Do not use the needles if you have any doubt of their quality, such as bent or broken needles, torn sterile packaging etc. Ensure any needle used is within its use-by date. Since May 2014 there has been a recognised International Standard for needle quality which has been adopted as a British Standard by the British Standards Institute. The title for this is sterile acupuncture needles for single use and the Standard Number is BS ISO 17218:2014.

Electro-acupuncture
All electro-acupuncture equipment must be checked and serviced by a registered electrician following the Electricity at Work Regulations (1989). Documentation of its electrical safety test certificate should be retained.

Indwelling needles
The Acupuncture Society recommend against the use of indwelling semi-permanent needles and auricular acupuncture inserted devices because the use of semi-permanent needles carries a greater risk of infection than with regular acupuncture techniques (Ernst & White 1999).

Auricular Acupressure balls/magnets/seeds
The use of acupressure balls, magnets or seeds in the ear is a technique that carries less risk than semi-permanent needles. We advise that acupressure balls magnets or seeds should not be used until full training has been completed in auricular acupuncture.

Withdrawal of auricular needles and ball/seed/magnets
We recommend using medical tweezers to grab and withdraw pasters for auricular balls/seeds/magnets and needles, tweezers must be washed and wiped with alcohol gel as instructed below between patients.

Re-usable equipment
Re-usable equipment such as glass or plastic cups, probes and massage equipment should be washed between uses in hot water with detergent and stored in a clean dry place. If possible, washing of reusable equipment should be done in a dishwasher at a high temperature, follow the guidelines of your  practitioner insurance cover.

Alcohol swabs
Alcohol swabs should always be available should they be required though their use is not mandatory (Cummings & Reid 2004).
They should always be used within their use by date. Visibly soiled or dirty skin or skin which has recently had emollients applied can be cleaned with 70% isopropanol or 0.5% chlorhexidine or soap and water.

Cotton wool
Cotton wool balls are recommended to be used to control a small bleed following the removal of the acupuncture needle. Cotton wool balls must remain clean, but sterile cotton wool is not mandatory. They should be disposed of according to environmental health guidelines.

First aid kit
All practices should have a fully stocked first aid kit. The first aid kit should be regularly checked and restocked and there should be an appointed person to take charge of first aid arrangements. There is no mandatory list of items to put in a first aid box. The contents of any first-aid kit should reflect the outcome of your first-aid needs assessment. The Health and Safety Executive have a suggested list of contents, please see
http://www.hse.gov.uk/pubns/indg214.pdf for more information.

Sharps container
All sharps containers should be compliant with UN3291 and BS7320 standards. They should be kept locked away when not in use. Sharps containers should be kept at a safe height, in a stable place and adjacent to the treatment couch when in use.

Treatment couch
Each treatment area should have a treatment couch. All treatment couches should be height adjustable and in good working order. The non-porous upholstery should be free from tears. Treatment couches should be covered with disposable paper couch roll which should be renewed after each patient. Material couch covers should not be used.

Infection Prevention and Control

Storage of sharps
Under the Health and Safety at Work Act 1974 Section 3 we have a duty to protect those people who are not in our employment, i.e. members of the public, guests, patients, visitors, and contractors to the site; so the method to lock away potentially hazardous objects is seen as a measure of protection. Therefore the Acupuncture Society recommend best practice to store sharps of all types (including new boxes of needles, used sharps and sharps containers) in a lockable cupboard or equivalent.

Steps to remain “sharps safe”:
•    All sharps containers should be approved under BS7320: 1990/ UN 3291
•    Do discard any sharps directly into the sharps container immediately after use at the point of use. Close the aperture to the sharps container when carrying or if left unsupervised to prevent spillage or tampering
•    Do place the sharps container close to your working area so you do not have to travel with the sharps.
•    Do carry sharps containers by the handle and do not hold them close to the body
•    Do lock the container when it’s three-quarters full using the closing mechanism
•    Do label the sharps containers with premises/departmental address before disposal
•    Do place any damaged sharps containers inside a larger sharps container. Lock and label before disposal.  Do not place this or anything sharp inside a hazardous waste bag may cause injury
•    Do keep sharps containers in a locked room/cupboard when not in use
•    Do keep all sharps waste in a designated, secure area until it is collected
•    Do dispose of disposable razors in a sharps bin immediately after use. Razors should never be re-sheathed after use
•    Do not place anything other than sharps in the sharps container
•    Do not try to re-sheath any used needles, should they be supplied sheathed
•    Do not leave sharps lying around and do not try to retrieve items from a sharps container
•    Do not try to press sharps down in the container to make more room
•    Do not place sharps containers on the floor, window sills or above shoulder height. Use wall or trolley brackets, they should be stored above knee level and below shoulder level
•    Do not bend or break needles before discarding them
•    Do not re-use needles during or after any treatment session
•    Do not use makeshift containers such as drinks cans, bottles or cardboard boxes as sharps disposal. They are not adequate for the purpose and may find their way into domestic waste and present a hazard to refuse workers and members of the public
•    Full sharps containers must be collected and disposed of by a licenced waste management company

Clinical Waste Disposal HSE 

All waste that has become contaminated with blood or body fluids should be disposed of correctly by a licensed waste handler. Some local councils may provide support with clinical waste disposal.

Local Council Waste Collection Services

https://www.gov.uk/request-clinical-waste-collection

Cleaning
All clinic areas must be cleaned regularly and it is advised that a cleaning log is maintained to demonstrate regular cleaning. A policy should be in place to dictate when certain clinic areas and equipment should be
cleaned and how this cleaning should take place.

Blood borne virus
BBV’s are viruses that some people carry in their blood and which may cause severe disease in certain people and few or no symptoms in others. The virus can spread to another person, whether the carrier of the virus is ill or not.

The main BBV’s of concern are:
•    Hepatitis B Virus (HBV), hepatitis C virus (HCV) and hepatitis D virus, which all cause hepatitis, a disease of the liver
•    Human immunodeficiency virus (HIV) which causes acquired immune deficiency syndrome (AIDS), affecting the immune system
of the body
These viruses can also be found in body fluids other than blood, for example, semen, vaginal excretions and breast milk. Other body fluids or
materials such as urine, faeces, saliva, sputum, sweat, tears and vomit carry a minimal risk of BBV infection unless they are contaminated with blood. Care should still be taken as the presence of blood is not always obvious.
(HSE 2011)

Below is a link to our Covid 19 Safe Practice Guidance for Acupuncture Society Members (these Covid 19 Safety protocols must be strictly adhered to during the current emergency and Government regulations which have arisen due to this pandemic, so please read them carefully and put them into practice before commencing practice)

https://docs.google.com/document/d/1gvA4LV5QnUDMcjLxnKgfCWl9mNv7ocE6_wQx8jc40Yc/edit?usp=sharing

 

Immunisations
Immunisation (vaccination) is available against Hepatitis B Virus (HBV), but no other blood borne viruses. The need for a worker to be immunised should be determined by the risk assessment where appropriate. It should only be seen as a supplement to reinforce other control measures. Employers should make vaccines available free of charge to their employees if they are needed. It is recommended that a vaccination record is kept and a reminder of when it is next due.
The Acupuncture Society recommends practitioners to be vaccinated against HBV.

See Health Authority Guidelines

https://www.gov.uk/government/publications/blood-borne-viruses-protection-of-health-care-workers

Decontamination procedures
Under ideal laboratory conditions HIV can remain infectious in dried blood and liquid blood for several weeks and HBV stays active for even longer. If materials become contaminated with blood or other body fluids, there are several methods available for decontamination. These procedures are designed to inactivate BBVs, mainly by using heat or chemical disinfection. You should have a local code of practice for dealing with spillages and other forms of contamination and all staff should be familiar with it.
HSE (2011)

•    Methods of decontamination are:
•    Physical cleaning
•    Ultrasonication
•    Heat
•    Autoclaving
•    Thermal washer disinfection
•    Dry heat
•    Chemical disinfection

Sharps injury
This section is taken from HSE (2013a) Health and Safety

Sharps training
Employers are required to train their employees on the use of sharps, the
training provided to employees must cover:
•    The correct use of safer sharps (if appropriate)
•    Safe use and disposal of medical sharps
•    What to do in the event of a sharps injury
•    The employer’s arrangements for health surveillance and other
procedures
All Acupuncture Society members must ensure that they have received proper training in the safe use and management of sharps before Joining

Sharps injury: notifying the manager
An employee who receives a sharps injury at work must notify their employers soon as is practicable. The employer will need to ensure they have sufficiently robust arrangements to allow employees to notify them promptly, including where the employee works out-of-office or away from the employer’s premises.

Recording and investigating a sharps injury
Employers must make a record of the sharps injury when they are notified of it, whoever provides that notification. They must investigate the circumstances and causes of the incident and take any action required.
The injured person is required to provide sufficient information to their employer to allow them to carry out this investigation. The extent of the investigation should be proportionate to the potential severity of the sharps injury. The purpose of the investigation should be to establish whether the employer’s existing risk control measures are adequate. It should look at underlying and root causes as well as the immediate factors that led to the individual injury. Any lessons to be learnt should be applied across the organisation (as appropriate), not just in the location of the injury.

In the case of an injury where there may have been exposure to a blood-borne virus or other significant infection, the
investigation may also involve establishing the infection status of the source patient (where it is possible to identify the individual).
If this information is known, it should be handled following usual patient confidentiality procedures.

If it is promptly shared with the medical professional who is treating the injured person, it can greatly assist with ensuring they receive the right treatment or that they do not take unnecessary prophylaxis or anti-viral treatments.

Treatment and follow-up of a sharps injury
The employer must ensure that, when notified of any incident in which an employee has been injured by a sharp that has or may have exposed them to a blood-borne virus, the employee:
•    Has immediate access to medical advice
•    Has been offered post-exposure prophylaxis and any other medical treatment, as advised by a doctor
•    The employer has considered whether counselling would be appropriate for the employee
Even if the employee works out-of-hours or off the employer’s premises, the employer should
have robust systems in place to enable employees to receive treatment promptly.

RIDDOR
RIDDOR stands for “Reporting of Injuries, Diseases and Dangerous
Occurrences Regulations”. Certain incidents require
reporting by RIDDOR, a list of such incidents can be found on the “types
of reportable incidents” page of the RIDDOR website, please follow the
link for further information.

http://www.hse.gov.uk/riddor/reportable-incidents.htm
HSE 
(Instruments in Healthcare Regulations 2013 Guidance for employers and employees. Health and Safety Executive).

PERSONAL HYGIENE

Hands and fingernails must be scrubbed clean with antibacterial soaps between each patient, where sterile gloves are not used. Paper masks must be used when in close contact with patients and whilst administering moxibustion. Use sterilised disposable gloves during needle insertion and withdrawal. Disposable hand towels are recommended. Medical non-allergy examination gloves must be worn when coming into contact with skin disease. Refrain from smoking or consuming food in the treatment area.

Needlestick injuries should be logged and a blood test taken, if the needle has penetrated the dermal layers see above

HAND HYGIENE

Practitioners must comply with the requirements of their Local Authority.

Local Authorities require handwashing rather than hand sterilizing gel, and also that there is a dedicated sink, preferably without overflow or plug, and with elbow control taps.  Please check with your local environmental health authority, if you are unsure.

Environmental health authorities issue practitioners with special treatment licensing and exemptions, so we are obligated to follow thier guidelines.

Hand decontamination

Hands must be decontaminated in all of the following circumstances:

• immediately before every episode of direct patient contact or care, including aseptic procedures
• immediately after every episode of direct patient contact or care
• immediately after any exposure to body fluids
• immediately after any other activity or contact with a patient’s surroundings that could potentially result in hands becoming contaminated
• immediately after the removal of gloves. 

An effective handwashing technique involves three stages:

preparation, washing and rinsing, and drying. Preparation requires wetting hands under tepid running water before applying liquid soap or an antimicrobial preparation. The handwash solution must come into contact with all of the surfaces of the hand. The hands must be rubbed together vigorously for a minimum of 10–15 seconds, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Hands should be rinsed thoroughly before drying with good-quality paper towels. 

An emollient hand cream should be applied regularly to protect the skin from the drying effects of regular hand decontamination.

HAND WASHING FACILITIES

1. You must have suitable hand-washing facilities
2. You must avoid possible cross-infection from treatment surfaces
3. You must maintain high levels of hand hygiene
4. You must insert and remove needles hygienically and safely
5. You must use well-fitting single-use disposable surgical gloves for blood or body fluid spills
6. You must have suitable hand washing and sanitary facilities
7. You must ensure that there are hand washing facilities with supply of clean hot and cold running water located in the treatment room or in the near vicinity.
8. You must ensure the provision of antibacterial liquid soap in a suitable dispenser, disposable paper towels and an adequately sized bin which should be foot pedal operated if lidded and placed close to the basin.
9. You must cover any cuts and wounds with a waterproof dressing, and wear gloves in these circumstances.
10. You must keep your nails short and clean. You must not wear artificial nails or use nail polish that could compromise hand hygiene.
11. You must maintain high levels of hand hygiene.
12. You must wash your hands thoroughly with antibacterial soap if they are visibly soiled or physically dirty. 
13. You must wash your hands with antibacterial soap before and after every treatment. 
14. You must sanitise your hands with alcohol gel before and after removing any needles.
15. You must wash your hands in accordance with Environmental health requirements before touching the patient, and if your hands have become contaminated by handling anything which could transfer infection from patient to patient, or patient to practitioner.
16. You must wash your hands after coming in contact with blood and body fluids,  gloves must in any case be worn in such circumstances. Hands must be washed after gloves have been removed
17. Once you have needled a point, you must not re-palpate the point with your bare finger during that treatment session unless the fingertips have been cleaned by hand washing.
18. You must use well-fitting single-use disposable surgical gloves for blood or body fluid spills If the patient is bleeding profusely. If blood or body fluid is spilt, you must ensure that any spillage is cleaned up promptly using appropriate cleaning agents. If the patient has open lesions. If the patient has a contagious disease. If you have cuts or wounds on your hands which cannot be covered adequately with a waterproof dressing. If you have a skin infection. When handling any blood-soiled items, body fluids, excretions or secretions, or touching any contaminated surfaces, materials, or objects.
19. Wear vinyl or latex gloves if you have a skin disease, have sweaty fingers, cuts, abrasions, lesions or suffer from an infectious disease. Some needle types allow for aseptic puncture without the use of guide tubes by holding the needle handle, whilst others require the use guide tubes. Never allow your fingers or anything else which is not sterile to touch the needle shank prior to insertion. For longer needles we recommend the use of guidetube or wearing sterile gloves. Needles must be used directly from the sterile pack and not placed on non-sterile surfaces before use.

 

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For your interest, although these more recent Nice and NHS recommendations can be seen below,  Practitioners are still required to adhere to the Local Authority Licensing standards and any use of hand sterilizing gel would be in addition to the Local Authority Required Licensing Standards

NICE Healthcare-associated infections: prevention and control in primary and community care Clinical guideline [CG139]Published: 28 March 2012 Last updated: 15 February 2017

Note: The use of ABHRs (or in Scotland and Wales non-alcoholic hand rubs that meet the required specification), can be used after hands have been washed, as an additional step, but do not, as yet, constitute an alternative to hand washing.

Nice standard

https://www.bing.com/ck/a?!&&p=7e85d220847e1a19JmltdHM9MTcxNTEyNjQwMCZpZ3VpZD0zYjBlYTcwZC00NWFkLTYxZmYtMWViYy1iMzRlNDQ2NjYwYjUmaW5zaWQ9NTIzNQ&ptn=3&ver=2&hsh=3&fclid=3b0ea70d-45ad-61ff-1ebc-b34e446660b5&psq=NICE+HAND+HYGIENE+REQUIREMENTS&u=a1aHR0cHM6Ly93d3cubmljZS5vcmcudWsvZ3VpZGFuY2UvY2cxMzkvY2hhcHRlci9yZWNvbW1lbmRhdGlvbnM&ntb=1

NHS National infection prevention and control manual for England 15 February 2024 V2.9

https://www.bing.com/ck/a?!&&p=065eb737e2a72d3fJmltdHM9MTcxNTEyNjQwMCZpZ3VpZD0zYjBlYTcwZC00NWFkLTYxZmYtMWViYy1iMzRlNDQ2NjYwYjUmaW5zaWQ9NTIwNA&ptn=3&ver=2&hsh=3&fclid=3b0ea70d-45ad-61ff-1ebc-b34e446660b5&psq=NHS+National+infection+prevention+and+control+manual+for+England+15+February+2024+V2.9&u=a1aHR0cHM6Ly93d3cuZW5nbGFuZC5uaHMudWsvd3AtY29udGVudC91cGxvYWRzLzIwMjIvMDQvUFJOMDA5MDgtTmF0aW9uYWwtaW5mZWN0aW9uLXByZXZlbnRpb24tYW5kLWNvbnRyb2wtbWFudWFsLWZvci1FbmdsYW5kLXZlcnNpb24tMi45LUZlYnJ1YXJ5LTIwMjQucGRm&ntb=1

The NHS Scotland National Infection Prevention and Control Manual (NIPCM) was first published on 13 January 2012, re-launch of NIPCM by the CNO on 11 July 2022

https://www.bing.com/ck/a?!&&p=4a3ac4e040c7ff42JmltdHM9MTcxNTEyNjQwMCZpZ3VpZD0zYjBlYTcwZC00NWFkLTYxZmYtMWViYy1iMzRlNDQ2NjYwYjUmaW5zaWQ9NTIxMA&ptn=3&ver=2&hsh=3&fclid=3b0ea70d-45ad-61ff-1ebc-b34e446660b5&psq=NNHS+Scotland+National+Infection+Prevention+and+Control+Manual+(NIPCM)+was+first+published+on+13+January+2012%2c+re-launch+of+NIPCM+by+the+CNO+on+11+July+2022&u=a1aHR0cHM6Ly93d3cubmlwY20uaHBzLnNjb3QubmhzLnVrLw&ntb=1

Wales is as per Scotland.

Northern Ireland Regional Infection and Prevention Control Manual HSC Public Health Agency Hand Hygiene

https://www.bing.com/ck/a?!&&p=2399828f0c93e329JmltdHM9MTcxNTEyNjQwMCZpZ3VpZD0zYjBlYTcwZC00NWFkLTYxZmYtMWViYy1iMzRlNDQ2NjYwYjUmaW5zaWQ9NTIxMg&ptn=3&ver=2&hsh=3&fclid=3b0ea70d-45ad-61ff-1ebc-b34e446660b5&psq=Northern+Ireland+Regional+Infection+and+Prevention+Control+Manual+HSC+Public+Health+Agency+Hand+Hygiene&u=a1aHR0cHM6Ly93d3cubmlpbmZlY3Rpb25jb250cm9sbWFudWFsLm5ldC8&ntb=1

Government Guidlines on Preventing and Controlling Infections

https://www.bing.com/ck/a?!&&p=642f9b42485bbbb4JmltdHM9MTcxNjE2MzIwMCZpZ3VpZD0zYjBlYTcwZC00NWFkLTYxZmYtMWViYy1iMzRlNDQ2NjYwYjUmaW5zaWQ9NTI2Mw&ptn=3&ver=2&hsh=3&fclid=3b0ea70d-45ad-61ff-1ebc-b34e446660b5&psq=HSE+GOV+LEGISLATION+HAND+HYGIENE+&u=a1aHR0cHM6Ly93d3cuZ292LnVrL2dvdmVybm1lbnQvcHVibGljYXRpb25zL2hlYWx0aC1wcm90ZWN0aW9uLWluLXNjaG9vbHMtYW5kLW90aGVyLWNoaWxkY2FyZS1mYWNpbGl0aWVzL3ByZXZlbnRpbmctYW5kLWNvbnRyb2xsaW5nLWluZmVjdGlvbnM&ntb=1

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Although Hand Sanitiser Gel is a useful addition to Hand Washing, we are still required to follow the Environmental Health Requirement under Special Treatment Licencing which has not yet been updated to include Hand Sanitising Gel,

We are in discussions with other Acupuncture Societies and Associations to bring this to the attention of Environmental Health Authorities, we will update this Code of Safe Practice if and when there are any changes.

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Detailed Example of Client Consultation, Questionnaire, Consent, Continued Consent & Exclusions Form:

https://docs.google.com/document/d/1n755JanAnSxl-bQkUjziO12OfAoQyxvpqHoJpAkPNrQ/edit?usp=sharing

 

 

The information below is intended for practitioners to stay up to date with exclusions and precautions:

Medical Exclusions and Precautions for Acupuncture:

Absolute Contraindications (Situations where acupuncture should not be used):

 * Bleeding Disorders and Anticoagulant Medication: Individuals with conditions like haemophilia or those taking blood-thinning medications (anticoagulants) are at a higher risk of bleeding and bruising from the needles.

 * Pacemakers and Implanted Cardioverter-Defibrillators (ICDs), Electro-acupuncture< Tens, EMS  should be avoided as it can interfere with the function of these devices.

 * Active Infections: Needling into an area with an active infection or open wounds can risk spreading the infection.

 * Metal Allergies: People with a known allergy to the metals used in acupuncture needles should not undergo treatment.

 

Relative Contraindications (Situations requiring caution and practitioner judgment):

 * Pregnancy: While acupuncture is often used to treat pregnancy-related symptoms, certain acupuncture points, especially on the abdomen and sacral region, are contraindicated as they could potentially induce labour. 

We do not, however, recommend treating pregnant women, as many complications can occur which are beyond your control. Further, you could be blamed if you hit a nerve on any point, which could accidentally cause miscarriage.

 * Cancer: Acupuncture is sometimes used to help manage symptoms associated with cancer and its treatments (like nausea from chemotherapy). However, it should be used with extreme caution, and the practitioner should be fully aware of the patient’s condition, including any active tumours or compromised immune status. Acupuncture should never be used as a replacement for conventional cancer treatment, nor should tumours be needled.

 * Compromised Immune Systems: People with weakened immune systems (e.g., from severe neutropenia, HIV, or diabetes) have a higher risk of infection.

 * Epilepsy: There is a small risk that acupuncture could trigger a seizure in some people with epilepsy, and caution should be exercised.

 * Unstable Spine: Needling in areas of spinal instability could potentially lead to spinal cord compression if surrounding muscles relax too much.

 * Patients/Clients Unable to Give Consent: Individuals who are unable to understand the procedure and give informed consent, or who cannot remain still during the treatment, should not be treated with acupuncture.

Important Considerations:

 * Informed Consent: Practitioners must always explain the risks and benefits of acupuncture and get the client’s informed consent before treatment.

 * Sterile Needles: To prevent infections and the transmission of diseases, only single-use, sterile, disposable needles must be used.

* Complex cases:

Ask your client to consult with their GP to determine whether acupuncture treatment would be suitable in a complex or difficult case. 

* Do not undertake treatments which are beyond your understanding and refer them appropriately to a suitable practitioner or their GP

 

 

Contra-Indications and Guidance for Safe Cupping

 

Cupping to the point of purple bruising or even leaving magnetic cupping on for too long is to be avoided, as in the UK, this can result in complaints to the authorities.
Patients must be clear as to what to expect
No abdominal or lumbar sacral cupping during pregnancy
No facial cupping, except mild slide silicon cupping as fixed cups, will result in lasting unsightly red marks on the face.
Avoid cupping patients who are prone to bleeding easily or have allergic skin conditions
Where fire cups are used, extra care must be taken (we recommend cold cupping with a suction pump, as there is more control and less risk of burning accidents)
Cups must not be left on for too long, as heavy bruising is generally not appreciated and can result in a complaint being made against you.
Wet Cupping/Hijama,  if you use this technique, you really need to make sure that you’re covered on your insurance policy

Absolute Contraindications

These conditions mean that cupping therapy should not be performed under any circumstances.

• Bleeding Disorders or Anticoagulant Medication: People with haemophilia, or those taking blood thinners like warfarin, are at a high risk of excessive bleeding, severe bruising, or hematoma formation due to the suction.
• Deep Vein Thrombosis (DVT): Cupping is strictly contraindicated over a confirmed DVT or any area suspected of having a blood clot, as the suction can dislodge it, leading to a life-threatening embolism.
• Open Wounds, Skin Ulcers, or Severe Burns: Applying suction over broken skin, fresh cuts, or burns can worsen the injury and increase the risk of infection.
• Active Skin Conditions: Areas with active rashes, eczema, psoriasis flare-ups, or dermatitis should not be cupped, as the suction can aggravate the condition and cause further irritation.

• Recent Surgery: Avoid cupping near surgical sites, especially if the scars are not fully healed, to prevent reopening the wound or disrupting the healing process.
• Fever or Acute Infections: Cupping can increase blood circulation, which may spread the infection throughout the body and intensify symptoms.

 

• Pregnancy: It’s generally advised to avoid cupping on the abdomen and lower back, especially during the first trimester, due to the risk of stimulating uterine contractions. Specialised prenatal cupping can be safe for other areas, but only with a trained practitioner.
• Cancer: Cupping is generally not recommended for cancer patients without a physician’s clearance. It should be avoided over tumors, metastatic sites, or areas of compromised bone structure.
• Severe Chronic Diseases: People with organ failure (heart, kidney, or liver), severe anaemia, or pacemakers should consult their doctor before receiving cupping therapy.
• Extreme Fatigue or Frailty: Individuals who are very weak, dehydrated, or have fragile skin (common in the elderly) should be treated with very light pressure or avoid cupping altogether to prevent injury and exhaustion.
• High Blood Pressure: Cupping can be beneficial for hypertension, but it should be performed with caution and under the guidance of a professional to avoid sudden changes in blood pressure.
• Vulnerable Areas: Avoid cupping directly over major arteries (like the carotid artery in the neck), superficial veins (like varicose veins), or lymph nodes. The front of the neck, eyes, ears, and any orifice should also be avoided.

 

Contra-Indications and Guidance for Safe Moxibustion 

*Please note from Holistic Insurance Services Policy Schedule: 

This schedule of insurance excludes any claims arising from the use of Moxibustion directly onto the skin. It also excludes the use of Moxibustion for the correction of breech position during pregnancy. This policy excludes all cover in respect of wet cupping. This schedule of insurance excludes any claims arising from Gua Sha, Cupping and Plum Blossom Needling when the client has not signed and dated a consent form, which contains information relating to the treatment.

Skin to be protected at all times, and hot ash droppage must be prevented. Serious attention must be given to the prevention of burns, and moxa must not be applied on oils or Vaseline, as this can result in serious burning

Absolute Contraindications

These are conditions where moxibustion should be avoided completely.

• Fever and Excess Heat Conditions: Moxibustion is a warming therapy. Applying it when a patient has a fever, high blood pressure, or a diagnosed TCM pattern of excess heat can worsen the symptoms and aggravate the condition.
• Open Wounds and Inflamed Areas: Moxibustion should never be performed directly over open cuts, sores, burns, or acutely inflamed skin, as it can cause infection or further tissue damage.
• Allergy to Mugwort: Individuals with a known allergy to mugwort or its smoke may experience an allergic reaction, including skin rashes, coughing, or nausea.
• Certain Anatomical Locations: Direct moxibustion (with burning cones on the skin) is contraindicated on the face, breasts, genitals, and over major blood vessels, tendons, or arteries, as it can cause severe burns and injury.
• Acute Contagious Diseases: Similar to massage, moxibustion is avoided during active infections like a cold or flu to prevent the spread of the pathogen.

• Pregnancy: While moxibustion is sometimes used to turn a breech baby, it should only be performed by a highly trained and experienced practitioner. It is contraindicated over the abdomen and lumbosacral region throughout the pregnancy.
• Diabetes: Individuals with diabetes may experience reduced sensation in their extremities, which increases the risk of a burn without feeling it.
• Nerve Impairment: For similar reasons to diabetes, moxibustion should be avoided on areas with numbness or sensory nerve damage, as the patient may not be able to accurately report if the heat is too intense.
• Children and the Elderly: These populations often have delicate skin or may be unable to communicate effectively, so extreme caution is required to prevent burns.
• Certain Cancer Conditions: Moxibustion is not generally used on or near tumours. Consultation with an oncologist is essential.
• Asthma or Respiratory Conditions: The smoke from moxibustion can be an irritant and may trigger an asthma attack or other respiratory symptoms. Smokeless moxa sticks can be used as an alternative.

 

Contra-indications and Guidance for Safe Acupressure, Oriental Massage, Tuina and Shiatzu

 

Absolute Contraindications

These are conditions where massage is strictly prohibited, as it could cause serious harm, worsen the condition, or put the therapist at risk.

• Fever or acute infections: Massage increases circulation, which can spread the infection throughout the body and intensify the fever.
• Contagious diseases: To prevent the spread of illnesses like the flu, a cold, or infectious skin conditions (e.g., impetigo, scabies), massage should be postponed until the client is no longer contagious.
• Deep Vein Thrombosis (DVT): A blood clot in a deep vein, typically in the legs. Massaging the area could dislodge the clot, causing it to travel to the lungs (pulmonary embolism), heart, or brain, which is a life-threatening emergency.
• Acute inflammation or recent injuries: Massage can worsen inflammation, swelling, and pain in the immediate aftermath of an injury like a sprain, strain, or fracture. The body needs time for the initial healing process (usually 48-72 hours).
• Open wounds, sores, or severe burns: Direct contact with these areas can lead to infection or further damage to the tissue.
• Recent surgery: Massage should be avoided for a period of time after a major surgery to allow the body to heal and to avoid complications at the incision site.
• Under the influence of drugs or alcohol: The client may not be able to accurately perceive pressure or give informed consent.
• Certain heart conditions: In cases of severe, unstable, or uncontrolled heart conditions like severe high blood pressure (hypertension), certain types of heart failure, or arrhythmia, massage can put an unnecessary strain on the cardiovascular system.

• Pregnancy: While prenatal massage is safe and beneficial, it should only be performed by a therapist with specialised training. Certain points and techniques, especially deep abdominal massage, are avoided.
• Cancer: Massage for cancer patients can be very helpful for managing pain and side effects of treatment, but it should only be done by a therapist with specific training in oncology massage and often requires a doctor’s consent.
• Varicose veins: The affected area should be avoided to prevent damage to the fragile veins.
• Osteoporosis: Due to the risk of bone fractures, deep tissue or percussive massage should be avoided.
• Bruises or sunburn: The affected areas should be avoided to prevent further pain and tissue damage.
• Diabetes: People with diabetes may have reduced sensation in their extremities, so a therapist must be careful with pressure to avoid injury.
• Certain medications: Blood thinners (anticoagulants) or steroids can make a client more prone to bruising, so lighter pressure and care are needed.

Contraindications for Safe Use of Chinese Herbal Medicine 

Pregnancy 

Chinese herbal medicine can be dangerous during pregnancy, as some herbs may cause miscarriage, induce premature labour, or harm the fetus. Therefore, pregnant women should avoid the following:

• Herbs that promote blood circulation and break up blood stasis, such as san qi (notoginseng) and hong hua (safflower), can induce miscarriage.
• Herbs that are hot or very cold in nature can cause complications by disrupting the body’s natural balance.
• Herbs that are toxic, such as fu zi (aconite), which is highly poisonous.

Pre-existing Medical Conditions 

Individuals with certain medical conditions should exercise extreme caution or completely avoid specific herbs:

• Patients with bleeding disorders should avoid herbs that promote blood circulation.
• Individuals with liver or kidney disease must avoid certain herbs that can be metabolised in these organs, potentially causing further damage.
• Patients with digestive issues should be cautious with herbs that are difficult to digest.

Drug Interactions 

Chinese herbs can interact with prescription and over-the-counter medications, leading to a loss of efficacy or dangerous side effects:

• Blood thinners (anticoagulants): Herbs like dang gui (angelica sinensis) and chi shao (red peony root) can increase the risk of bleeding when taken with drugs like Warfarin.
• Diuretics: Some herbs, when taken with diuretics, can cause excessive fluid loss and electrolyte imbalance.
• Antidepressants: Herbs like St. John’s Wort can interact with antidepressants, leading to a condition called serotonin syndrome.

 

Allergies and Side Effects 

Allergies to specific herbs are possible, and some individuals may experience side effects:

• Allergic reactions: Symptoms can range from skin rashes and itching to more severe anaphylactic shock.
• Digestive discomfort: Nausea, vomiting, and diarrhoea are common side effects of some herbs.
• Dizziness and headaches: Certain herbs can cause these symptoms, particularly when the dosage is too high.

_______________________________________________

HERBAL MEDICINE

The EU laws concerning Herbal medicine came into force in April 2011, which only apply to patent medicines and preparations made up in factories for thirds parties. Those practitioners and retail outlets who are trading in patent medicines will be able to apply for a licence to continue to supply these patent or factory prepared formulations from the HPC (see the written ministerial statement below published 16 February 2011).
UK legislation due in early 2013 is likely to require registration of Herbal Practitioners with the HPC, it’s anticipated that this will greatly increase our acceptance within the orthodox medical community. There will be a consultion process begining in late 2012 leading to legislation expected in 2013, there will be grandparenting arrangements for all those qualified prior to the legislation becoming active. Until the White Paper is published it is not yet clear what exactly it will contain, but its expected to follow simillar processes that occured when previous aspirant therapies attained registration to the HPC in the past. The Acupuncture Society is seeking to attain automatic grandparenting for all its Herbal Members.

Follow this link to the hpc website page on herbal regulation http://www.hpc-uk.org/aboutregistration/ aspirantgroups/aspirantgroups/

Herbalist’s must not use endangered species animal and mineral substances in their formulae nor use patient medicines nor ask third parties to prepare them or their insurance may be void.

List of Banned Herbs and legal implications of new EU herbal regulation

A: RESTRICTED UNDER THE CONVENTION ON INTERNATIONAL TRADE IN ENDANGERED SPECIES (CITES) Herbs which are endangered in the wild are restricted but may be traded with the appropriate CITES certification. In the case of Appendix I this is normally only permitted for scientific purposes if at all. Suppliers can trade in herbs listed in Appendix II but only when obtained from an authenticated cultivated supply. An example of this is XI YANG SHEN which is available from farmed sources.

APPENDIX I
HU GU (Os tigris)
SHE XIANG (Secreto Moschus)
XI JIAO (Cornu Rhinoceri)
XIONG DAN (Vesica Fellea Ursi)
BAO GU (Os Leopardis)
DAI MAO (Carapax Ertmochelydis)
MU XIANG (Saussurea lappa) NOTE: Vladimira species are permitted as a substitute herb.

APPENDIX II
CHUAN SHAN JIA (Squama Mantis Pentadactylae)
HOU ZAO (Calculus Macacae)
LING YANG JIAO (Cornu Antelopis)
GUI BAN (Chinemys reevesii)
SHI HU (Dendrobium species)
BAI JI (Bletilla striata)
TIAN MA (Gastrodia elata)
GOU JI (Cibotium barometz)
LU HUI (Aloe ferox)
XIAO YE LIAN (Podophyllum emodii)
ROU CONG RONG (Cistanches deserticola)
XI YANG SHEN (Panax quinquefolius) NOTE: Only applies to the whole and sliced root.
HU HUANG LIAN (Picrorrhiza kurroa)

B: RESTRICTIONS UNDER STATUTORY INSTRUMENTS

SI 2130 1997 These herbs were listed as an in addition to those listed in the Medicines Act 1968 as being potent and hence in need of dosage regulation. In some cases they are forbidden at any level of internal dosage.

MD= Maximum single dose MDD=Maximum Daily Dose

FU ZI/CAO WU (Aconitum species) NOTE: Permitted to use externally at a dose of 1.3% or below. Internal use prohibited.
SHI LIU PI (Punica granitum). Internal use prohibited.
BING LANG (Areca catechu) Pharmacy use only.
DA FU PI (Areca catechu) Pharmacy use only
MA HUANG (Ephedra sinica). MDD: 1800 mg. MD: 600 mg.
YANG JIN HUA (Datura stramonium). MDD: 150 mg. MD: 50 mg.
YANG JIN HUA (Datura stramonium). MDD: 150 mg. MD: 50 mg.
DIAN QIE CAO (Atropa belladona). MDD: 150 mg. MD: 50 mg.
TIAN XIAN ZI (Hyocyamus niger). MDD: 300 mg. MD: 100 mg.

NOTE: SI 2130 also applies to other herbs not employed in Chinese medicine. S1 1841 2002
This ban relates to all Aristolochia species and also includes herbs which have been confused with Aristolochic species due to poor quality assurance.

The sale, supply and importation of the following is banned:
MU TONG (Aristolochia manshuriensis). NOTE: this ban also applies to Akebia quinata, Akebia trifoliata, Clematis montana and Clematis armandii.
FANG JI (Aristolochia fangji). NOTE: this ban also applies to Stephania tetrandra, Cocculus laurifolius, Cocculus orbiculatus and Cocculus Trilobus
MA DOU LING (Aristolochia contorta, Aristolochia debilis)
TIAN XIAN TENG (Aristolochia contorta, Aristolochia debilis)
QING MU XIANG (Aristolochia debilis)

SI 548 2008
All species of Senecio are prohibited for internal use due to the presence of toxic pyrrolizidine alkaloids
(PA). This mainly applies to the use of Senecio scandens QIAN LI GUANG

C: VOLUNTARY RESTRICTION Due the presence of Aristolochic Acid in Asarum species there is a voluntary ban on the use of: XI XIN (Asarum species)

D: RESTRICTIONS UNDER THE MEDICINES ACT 1968 Under Section 12(1) of the 1968 Medicines Act 1968, herbal remedies which are administered after a one-to-one consultation with a practitioner do not require a medicines licence (marketing authorisation). This legislation was enacted before traditional medicines from non-European cultures, which use non-plant substances, had any significant presence in the UK. Since the term ‘herbal remedies’ refers to plant materials, the MHRA has stated in its guidance on medicines law that the use of mineral and animal substances, which do not have a marketing authorisation, is illegal.

Section 12(1) is currently under review and the RCHM is working to re-establish the use of animal and mineral products. It is also expected that this redefinition of what constitutes a ‘herb’ will be clarified in European and UK legislation in the near future to include non-plant medicines.

In the meantime, members are warned that the use of these products may result in legal action by the MHRA and absence of insurance cover in the case of a claim. Hence all animal and mineral products should not be used until otherwise informed.

Whatever the outcome of this process, the following must never be used in any form:
ZHU SHA (Mercuric sulphide) Cinnabar
QING FEN (Mercuric chloride) Calomel
HONG FEN (Mercuric oxide) Realgar
HEI XI Lead

PRESCRIPTION ONLY MEDICINES (POM)
It is strictly prohibited to include any drug which is made available only through prescription by a registered medical doctor.
This includes the following:
YING SU KE (Papaver somnifera)
MA QIAN ZI (Strychnos nux vomica)
STEROIDS Including external use in creams such as PI YAN PING or 999 SKIN CREAMS.
FU ZI Internal use

E: PATENT FORMULAE
It should be noted that several patent formulae traditionally contain some of the above restricted herbs and toxic minerals, and recently some have been found to contain drugs. These include the following, which may present a health risk if used as a patent:

NIU HUANG JIE DU PIAN (May contain arsenic) TIAN WANG BU XIN DAN (May contain mercuric salts)

It is the responsibility of the practitioner to ensure that all patent formulae are obtained from ‘bonafide’ suppliers. In practice this means that all ingredients are listed and none of the above are included in the formula.

TREATMENT PROHIBITIONS

Patients should not be treated if they have consumed alcohol or combinations of alcohol, prescribed or recreational drugs or if they haven’t eaten two to three hours prior to treatment. They should have also taken their prescribed medicine to the prescribed dose prior to treatment. Patients should be treated whilst they are lying on the treatment couch and not whilst sitting on a chair as this will reduce the risk of syncope.

PROHIBITED TREATMENTS

Abortion. Pregnancy related symptoms against the advice of a midwife or a medical doctor. Controlled infectious disease which require hospitalization in isolation. Treatment for cancer and other serious diseases like diabetes, high cholesterol, blood pressure, thyroid or any other conditions requiring medication must not be offered as a replacement to conventional medical treatment.

ORIENTAL MASSAGE SAFE PRACTICE STANDARDS (INCLUDING TUINA, THAI, ACUPRESSURE AND CHINESE MASSAGE)

Oriental Massage or Bodywork Practitioner members will be able to demonstrate that they:

1. know and comply with their Professional the Acupuncture Society’s Code of Professional Conduct and Ethics.
2. keep clear and appropriate records.
3. understand cautionary techniques, and conditions requiring special consideration.
4. can offer appropriate lifestyle recommendations.
5. follow an accurate and appropriate assessment procedure.
6. use appropriate and accurate techniques.
7. can demonstrate reflective practice.
9. are working within the scope of practice of thier training.
10. have certificate or diploma qualification recognised by the Acupucture Society.
11. carry upto date professional indemnity/ public liability insurance cover.
12. have a minimum of anatomy and physiology qualification equivalent to the national standards of level 3.
13. hold a current a first aid certificate.
14. can refer clients to a more appropriate practitioner or a doctor when out of thier scope of practice.
15. can refer clients to their GP if any symptoms presented are not understood, are potentially dangerous or may require further investigation or medical treatment.
16. have undertaken the required annual CPD course hours and submitted them on the Society’s log.