staff immunisation policy · louise jones senior hr manager best practice development 28.8.15, ......
TRANSCRIPT
1 Immunisation Policy Version 3 March 2017
SH HR 59
Staff Immunisation Policy
Version: 3
Summary:
This policy provides guidance on the immunisation requirements with SHFT to ensure that employees, patients and visitors to the organisation are protected as far as is reasonably practical from vaccine preventable disease
Keywords (minimum of 5): (To assist policy search engine)
Immunisations, vaccinations, healthcare associated infections, infectious diseases, Occupational Health Service.
Target Audience:
All staff employed by Southern Health NHS Foundation Trust including volunteers and students who may be at risk of vaccine-preventable diseases.
Next Review Date: November 2019
Approved and Ratified by:
Infection Prevention and Control Group.
Date of meeting: 3 February 2017
Date issued:
March 2017
Author:
Theresa Lewis Lead Nurse Infection Prevention and Control
Director :
Sara Courtney Acting Chief Nurse
2 Immunisation Policy Version 3 March 2017
Version Control
Change Record
Date Author Version Page Reason for Change
07.11.13 Theresa Lewis 1 This is a new policy
20.8.15 Jacky Hunt 2 Includes risk assessment of actions if staff refuse immunisation and lists the employees responsibilities
Feb 17 Theresa Lewis 3 Throughout Transfer of Occupational Health provider in Jan 2017
Reviewers/contributors
Name Position Version Reviewed & Date
Theresa Lewis IPC Lead Nurse 28.8.15
Angela Roberts/Louise Piper IPC Nurses 28.8.15
Sara Courtney Associate Director of Nursing, AHP & Quality E ISD 15.9.15
Toni Scammell Modern Matron 15.9.15
Taylor, Liz Associate Director of Nursing and Allied Health Professionals Children's Services
15.9.15
John Stagg Head of LD Services Bucks 15.9.15
Laura Rothery Area Director 15.9.15
Paula Hull Associate Director of Nursing, AHP & Quality SW ISD 15.9.15
Scott Jones Head of Facilities and Environment 15.9.15
Tim Coupland Associate Director of Nursing, AHP & Quality Learning Disability and Mental Health
15.9.15
Kevin Page Associate Director of Nursing 15.9.15
Carol Cleary Interim Head of Services (Hampshire) 15.9.15
Shelly Mason Modern Matron 15.9.15
Louise Jones Senior HR Manager Best Practice Development 28.8.15, 15.9.15
Wendy Sharp Occupational Health Services (OH Assist) 15.9.15
Ann Lesser Occupational Health Services (OH Assist) 15.9.15
Darren Hedges Health and Safety Officer Southern Health 28.8.15,15.9.15
IPC Group IPC Group members 3.11.15
IPC Group IPC Group Members V3 03.02.17
IPC Team IPC Nurses V3 03.02.17
Louise Jones Senior HR Manager V3 03.02.17
Ross Taylor Regional Business Manager PAM V3 02.02.17
Janet O’Neil Head of PAM Acadamy V3 02.02.17
3 Immunisation Policy Version 3 March 2017
Quick Reference Guide Southern Health NHS Foundation Trust (SHFT) values its staff and regards their health and
safety as paramount. In the context of this policy, SHFT recognises the risk from infectious
diseases that may be acquired in the course of work and in the importance of staff preventing
spread to patients and clients and will ensure that employees, patients and visitors to the
organisation are protected so far as is reasonably practicable from these diseases (COSHH
2002).
Workers have a duty to take care of their own health and safety and that of others who may be affected by their actions at work (Health and safety at Work Act 1974). Immunisations are not mandatory under Trust policy (except for those performing Exposure Prone Procedures) however by declining vaccination you may be putting yourself and others at risk. Keep a record of any vaccinations you receive.
See - Appendix 1 Immunisation Required per NHS Employee Category
Managers have a responsibility to ensure:
All new staff must be referred to the Occupational Health Service (OHS) who will be responsible for ensuring that appropriate pre-employment screening and immunisation procedures are followed in line with national guidance
That no healthcare worker is allowed to undertake any exposure prone procedure (EPP) eg surgery unless they have received written clearance by OHS(see Appendix 2 for more details)
Staff are allowed reasonable time to attend the Occupational Health department for any consultation.
Providing appropriate personal protective equipment for any tasks staff are required to undertake
That their staff attend mandatory Infection Control and Health and Safety training updates
Ensuring that infection incidents reported in their areas are appropriately investigated and remedial action taken to reduce future risk of transmission where necessary
The Occupational Health Service will:
Vaccinate staff where immunisation is required as set out in ‘Immunisation Required per NHS Employee Category’ (please see Appendix 1)..
Provide regular updates on ‘Did Not Attend’ (DNA) rates in monthly Management Information report
Inform manager when a staff member is cleared to perform EPP.
Maintain accurate and contemporaneous records of staff vaccinations and inform Managers when staff are unprotected against vaccine preventable infections
Provide clearance on new employees if fit to commence work, or advice regarding work restrictions following pre-employment assessment.
Individuals
Have a duty to take care of their own health and safety and that of others who might be affected by their actions at work.
Take responsibility for their own health and to keep a record of vaccinations they have received and know when they are due to expire.
4 Immunisation Policy Version 3 March 2017
Contents
Section Title Page
1. Introduction
5
2. Who does this policy apply to?
6
3. Definitions
6
4. Duties and responsibilities
7
5. Main policy content
9
6. Training requirements
12
7. Monitoring compliance
12
8.
Policy review 12
9.
Associated trust documents 12
10.
Supporting references 13
Appendices
1 Immunisations required per NHS employee category
14
2 What constitutes an exposure prone procedure (E.P.P)
16
3 Equality Impact Assessment Tool
19
4 Employee Immunisation Declaration Form (declined vaccination)
20
5 Risk management- vaccine preventable infections in staff 22
5 Immunisation Policy Version 3 March 2017
Staff Immunisation Policy
1. Introduction
1.1 The overall purpose of this policy is to promote arrangements for preventing exposure to
vaccine-preventable diseases.
Southern Health NHS Foundation Trust (SHFT) values its staff and regards their health
and safety as paramount. In the context of this policy, SHFT recognises the risk from
infectious diseases that may be acquired in the course of work and in the importance of
staff preventing spread to patients and clients and will ensure that employees, patients
and visitors to the organisation are protected so far as is reasonably practicable from
these diseases.
1.2 The Health and Social Care Act 2008 Code of Practice on the prevention and control of
infections and related guidance (DH 2015) states that registered providers must ensure
that:
All staff can access occupational health services (OHS) or access appropriate
occupational health advice
Occupational health policies on the prevention and management of communicable
infections in care workers are in place.
Decisions on offering immunisations should be made on the basis of a local risk
assessment as described in ‘Immunisations against Infectious Disease’ (‘The Green
Book’). Employers should make vaccines available free of charge to employees if a
risk assessment indicated that it is needed (COSHH Regulations 2002)
There is a record of relevant immunisations
Occupational health service procedures should include risk-based screening for
communicable diseases and assessment of immunity after a conditional offer of
employment and on-going health surveillance including offer of relevant
immunisations (See Appendix 1 of this policy).
Occupational health service procedures should include having arrangements in
place for regularly reviewing the immunisation status of care workers and providing
vaccinations to staff as necessary in line with ‘Immunisations Against Infectious
Disease’ (‘The Green Book’) and other guidance from Public Health England.
1.3 Transmission of disease may occur in any healthcare, work or domestic setting if a
person acquires an infection from a patient, client or colleague.
The Sharps and Inoculation Management Procedure (IP&C Policy Appendix 10)
addresses infection risk from a puncture wound, bite, cut or abrasion to their skin, or
contamination of broken skin, eye or mucous membranes which exposes them to the
blood, secretions or excretions of an infected person.
6 Immunisation Policy Version 3 March 2017
It is normally difficult to know whether another person is infected with a transmissible
disease or a blood-borne virus, and therefore not only should standard infection control
precautions be used by staff when dealing with any patient, but also if any inoculation
incident is suffered, the affected person should always follow the procedures set out in
the Sharps and Inoculations Management Procedure (Infection Prevention and Control
Policy: Appendix 10)
2. Who does this policy apply to?
This policy is applicable to all existing and prospective employees of the Trust or any individual who has a contract for services and whose work exposes them to direct contact with service users. This includes: Category 1 Staff involved in direct patient care eg doctors, nurses, healthcare support worker, occupational therapists, physiotherapists, radiographers, chiropodists, pharmacists, dieticians, plaster technicians, audiology staff, and psychology staff. Students and trainees of these disciplines who are working directly with patients Category 2 Laboratory and pathology staff (including mortuary staff) eg technical staff this may include cleaners porters and secretaries and receptionists in labs Category 3 Staff in healthcare settings whom only have social contact with patients but are not directly involved in their care eg receptionists, volunteers directly employed by the Trust, ward clerks, porters and housekeepers, Estates staff
3. Definitions
3.1 Inoculation incident – Being pricked by a needle or cut by a sharp object that has been
exposed to the body / body fluids of another person; or contamination of broken skin, eye or mucous membranes by the blood, secretions or excretions of another person
3.2 Vaccination - The administration of antigenic material (a vaccine) to stimulate an
individual's immune system to develop adaptive immunity to a pathogen. Vaccines can prevent or reduce morbidity from infection.
3.3 Immunisation: The process of inducing immunity to an infectious organism or agent in
an individual or animal through vaccination 3.4 Exposure Prone Procedures (EPP): Are invasive procedures where there is a risk that
injury to the worker may result in exposure of the patients open tissues to the blood of the worker. These procedures include those where the workers gloved hands may be in contact with sharp instruments, needle tips or sharp tissues (eg spicules of bone or teeth) inside a patients open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible. These procedures mainly occur in surgery, A&E, dental and some podiatry settings. Some examples include suturing and insertion of a chest drain. Please see Appendix 2 for more details of what constitutes an EPP.
7 Immunisation Policy Version 3 March 2017
4. Duties and responsibilities 4.1 Chief Executive and Trust Board ensure:
The overall implementation, monitoring and effectiveness of this policy
The allocation of resources to provide compliance with this policy
That managers are aware of their responsibilities and implement the policy 4.2 Executive Director with responsibility for Infection Prevention and Control
(currently the Executive Director of Nursing and AHP)
Has delegated responsibility from the Chief Executive for the operation of this policy
Ensures that the Trust Board is advised of the effectiveness of this policy and any shortfalls in meeting the standards set
Chairs the Infection Prevention and Control Committee which will monitor compliance with the effectiveness of this policy
4.3 Health and Safety Committee:
Reviews the effectiveness of the arrangements in place to manage the risks associated with vaccine-preventable diseases by:
Processing reports received from the OHS
Reporting numbers of staff appropriately vaccinated against target to Divisional Managers and department heads
4.4 Infection Prevention and Control Group: Reviews the effectiveness of the arrangements in place to manage the risks
associated with inoculation incidents by:
Receiving and monitoring regular reports on the number and type of inoculation incidents reported within SHFT through monthly Management Information – this will come to IPCT via HR Contact Manager
Receiving information on Flu vaccinations and staff uptake 4.5 Infection Prevention and Control Team: Are responsible for:
Providing some education on the need for appropriate immunisations required for work in the Trust according to exposure/contact risks as part of the Trust’s Induction, and mandatory training programme
Safe use and disposal of sharps as part of the Trust’s Induction and mandatory training programme
4.6 Department Managers: Are responsible for:
Ensuring that all new staff must be referred to the Occupational Health Service (OHS) who will be responsible for ensuring that appropriate pre-employment screening and immunisation procedures are followed in line with national guidance
Providing appropriate personal protective equipment for any tasks staff are required to undertake
Ensuring that no healthcare worker is allowed to undertake any EPP unless they have received written clearance by OHS.
Ensuring that their staff attend mandatory Infection Prevention and Control and Health and Safety training updates
Ensuring that infection incidents reported in their areas are appropriately investigated and remedial action taken to reduce future risk of transmission where necessary
8 Immunisation Policy Version 3 March 2017
Staff are allowed reasonable time to attend the Occupational Health department for any consultation.
4.7 Individual Responsibility: every member of staff is responsible for ensuring they:
Familiarise themselves with this policy, and where additional screening and vaccinations are required in order to comply with the policy, they should arrange for these to be completed through the OHS.
Are up to date with the mandatory IP&C training
Disclose their pregnancy status to OHS prior to immunisation if female
Take responsibility for their own health and keep a record of any vaccinations they receive and when they are due to expire.
Workers have a duty to take care of their own health and safety and that of others who may be affected by their actions at work (Health and Safety at Work Act 1974)
Seek and follow confidential advice from OHS about whether to undergo testing if exposed to a serious communicable disease. Affected staff members must notify their line manager so that contact can be made with the OHS in a timely manner to bring vaccination status up to date and in-line with Trust and departmental guidelines
If you acquire a serious communicable disease you must promptly seek and follow advice from the Occupational Health Service regarding whether and in what ways you should modify your professional practice and whom to inform. You must not rely on your own assessment of the risk you pose to patients If you know or have good reason to believe that a colleague has a serious communicable disease and is practising or has practised in a way which places patients at risk you must inform an appropriate person eg Occupational Health Service. Wherever possible you should inform the healthcare worker concerned before passing information to an employer or regulatory body (General Medical Council, Nursing and Midwifery Council)
4.8 Occupational Health Service (OHS) Responsibilities
The Trust Occupational Health Service is responsible for vaccinating or assessing immunity of Trust staff in line with the recommendations as outlined in ‘The Green Book’ where the need arises out of:
Work undertaken to fulfil job requirements or duties.
To meet the requirements of Southern Health NHS Trust to obtain health clearance for staff
The Occupational Health Service will vaccinate staff where immunisation is required as set out in the vaccination table (please see Appendix 1). The Trust OHS does not provide vaccinations for: leisure or sporting activities, holiday travel except for holiday taken as an extension of an overseas trip on Trust business or personal health reasons incidental to work The OHS will:
Notify the line manager when staff fail to attend OH appointments
Notify the line manager when an individual declines vaccination with a report stating that OH clearance cannot be provided
Provide regular updates on Did Not Attend (DNA) rates and compliance rates for staff vaccination to the SHFT contract manager through monthly reports
Inform manager when a staff member is cleared to perform EPP.
Maintain accurate and contemporaneous records of staff vaccinations and inform Managers when staff are unprotected against vaccine preventable infections
9 Immunisation Policy Version 3 March 2017
Provide clearance on new employees if fit to commence work, or advice regarding work restrictions following pre-employment assessment.
4.9 Voluntary Workers
Volunteers directly employed by the Trust should be made aware of the Trust Immunisation Policy (see Matrix in Appendix 1) . They should be advised that it will be a requirement of their continued voluntary service that they undergo screening and immunisation in line with this policy via the OHS.
5 Main policy content 5.1 This section outlines the OHS recommendations for staff working in the Trust.
Additional vaccinations may be required as a result of DH guidance or local prevalence of disease. All staff are advised to comply with the immunisation schedule as outlined in appendix 1 for their own health and the health of others.
5.2 Work where vaccination is strongly recommended:
Staff who have regular contact with patients/service users and who are directly involved in patient care
Staff in healthcare settings whom only have social contact with patients but are not directly involved in their care
Staff who are involved in culturing or handling of human pathogens or purified biological toxins
Staff involved in the handling or processing of human blood, serum or tissue specimens
Contact with human waste
Clinical duties or fieldwork outside of the Trust premises e.g. patients homes
It is expected that front line healthcare workers participate in the uptake of the annual flu vaccine
NB All staff that carry out Exposure Prone Procedures (EPP) must be vaccinated and proven to be immune to Hepatitis B before commencing EPP.
5.3 Notification of new work:
Departments must have in place arrangements to notify the Trust OHS of new areas of work e.g. work with biological agents; or teaching activities where a risk assessment identifies vaccination as a control measure. The OHS will require advance warning of when the activity will commence and the numbers of individuals involved. The person-in-charge of new work or treatment programmes for which specific vaccination will be needed should inform the Trust OHS of the work. The person in charge of the work should ensure staff & students are informed of the need for vaccination & arrangements for getting vaccinated
5.4 Vaccinations for clinical work/ NHS clearance;
Staff who will be involved in patient care or who require NHS health clearance to work in or visit Trust health care institutions should complete a Pre-Employment Health Questionnaire and comply with arrangements to attend for assessment with the Trust OHS as required. They should bring to the appointment any documentary evidence of prior vaccinations or immunity. Clearance to commence work or advice regarding work restrictions will be provided by Occupational Health once the
10 Immunisation Policy Version 3 March 2017
assessment is complete. Inclusion in the immunisation programme will be instigated once the employee has commenced work. Immunisations, where required, should be commenced during the induction period.
Undergraduate medical students are seen for vaccinations and health clearance at the commencement of their course by direct arrangement with the Faculty of Medicine Education Office of their institution. Their immunisation requirements remain the responsibility of the institution and not the Trust.
Taught postgraduates who will have clinical contact with patients should complete a health care work clearance questionnaire and arrange a health clearance appointment with the Trust OHS.
Nursing students –the university will be responsible for ensuring that nursing students receive the correct immunisations
All staff who carry out Exposure Prone Procedures must be vaccinated and proven to be immune to Hepatitis B before commencing EPP. Offers of employments will not be given where the primary function includes EPP unless immunity to hepatitis B can be demonstrated. Staff already employed by Southern Health must refrain from EPP unless immunity to hepatitis B can be demonstrated.(See Flow Chart 1 and 2)
Staff member already employed by
Southern Health NHS Foundation
Trust whose role includes EPP
Written clearance
obtained by manger
from OHS, stating
staff member is
immune to
Hepatitis B
Staff member
authorised to
perform EPP
Staff member can
still work but must
not perform EPP
until clearance has
been given by OHS
No written clearance
obtained by
manager from OHS
as immune to
Hepatitis B (either
staff member
refused vaccination
or didn’t respond
successfully to the
vaccine, or is
currently infected
Written
clearance given
by OHS to
manager stating
staff member is
immune to
hepatitis B
OHS will check hepatitis
B immunity during pre-
employment screening
of new employee
Prospective
employee whose
role involves EPP
es EPP
Prospective
employee
refuses
hepatitis B
immunisation
or fails to
respond to
hepatitis B
immunisation
Do not employ
staff member
to perform EPP
If employing
staff member
authorised to
perform EPP
Flow chart 1 Prospective Employee
whose prime role will include EPP
Flow chart 2 Existing employee whose role
includes EPP
11 Immunisation Policy Version 3 March 2017
5.5 Risk Assessment (restricting staff that are not immune to Hepatitis B from EPP):
Although Hepatitis B is not common amongst the general UK population 1.04 cases per 100,000 populations (PHE 2012) it can have severe consequences to health (even causing death) and is readily transmitted via microscopic amounts of contaminated blood/blood stained body fluid entering another’s body eg via a puncture wound, broken skin, via mucous membranes. EPP is an invasive procedure where there is a risk that injury to the worker may result in exposure of the patients open tissues to the blood of the worker. These procedures include those where the workers gloved hands may be in contact with sharp instruments, needle tips or sharp tissues (eg spicules of bone or teeth) inside a patients open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible. It would therefore be quite possible that cross infection could take place without the staff being aware. Once infected the healthcare worker eg surgeon could transmit hepatitis B to other patient during EPP.
Likelihood score of cross infection with Hepatitis B: Possible (3) Consequences of cross infection with Hepatitis B: Catastrophic (5) Risk score: 3x5 =15
5.6 Completing schedules;
Where a person will need to attend more than one appointment to complete a vaccination schedule, the OHS will arrange a series of appointments and issue reminders to the individual when their next appointment is due by text where mobile numbers are known or email.
Individuals will receive a text or email 24hrs prior to the date / time of their appointment
Where periodic re-vaccination is recommended to maintain protection for work the OHS will actively recall individuals when a booster dose falls due.
Individuals who fail to attend a booked appointment, must be re-booked onto another appointment by their manager
5.7 Notification of compliance;
OH will not routinely provide the employee with appropriate certification to confirm that they have met all of the immunisation requirements. Individuals can request this information via a subject access request
The OHS will inform managers of staff or students defaulting from a vaccination programme.
5.8 Costs
Vaccinations recommended as a control measure for work in the Trust will be provided to staff without charge.
5.9 Non Immune staff
There are some staff members who decline/do not respond to vaccinations or for some individual vaccination is contra-indicated on health grounds. Please see Appendix 5 for risk management of these staff.
12 Immunisation Policy Version 3 March 2017
5.10 Staff declining
Workers have a duty to take care of their own health and safety and that of others who may be affected by their actions at work (Health and Safety at Work Act 1974). Immunisations are not mandatory under Trust policy (except for those performing EPP) however by declining vaccination you may be putting yourself and others at risk.
A staff member wishing to decline vaccination will be required to sign a
declaration confirming that they are aware of the risk from vaccine preventable infection that may be acquired in the course of their work (see Appendix 4).
The Occupational Health Practitioner will hold copies of the ‘Declaration Form’ at the clinic where the staff member is seen for the staff member to complete if declining vaccination. The OHS will retain a copy and an electronic version will be emailed from the OHS to the generic Human Resources email inbox. Human Resources will arrange for this to be forwarded to the relevant manager so that the manager can file the form in the staff member’s personal files on site.
6. Training requirements 6.1 Immunisations requirements will be covered as part of the individuals induction
programme. 7. Monitoring compliance
Element to be monitored
Lead Tool Frequency Reporting arrangements
DNA figures HR Electronic report
Monthly OHS will share with HR. Reported to Infection Control Committee but monitored by the H&S Committee.
Compliance Figures with Immunisation
HR Electronic report
Monthly OHS will share with HR. Reported to Infection Control Committee but monitored by the H&S Committee
8. Policy review
This policy will be reviewed by the OHS and IP&C team every 4 years or earlier to meet with national guidance
9. Associated trust documents
Occupational Health Pre Employment Guide
Management of Infected Healthcare Worker Policy – Hepatitis B, C or HIV and advising on Fitness to Work
IP&C Policy, Appendix 5 Standard Precautions
IP&C Policy, Appendix 6 Hand Hygiene
IP&C Policy, Appendix 10 - Sharps and Inoculation Management
SFHT Waste Policy
SH CP 157 Exposure Prone Procedures (EPPs) and Blood Borne Viruses (BBVs) - Management of the Infected Healthcare Worker
13 Immunisation Policy Version 3 March 2017
10. Supporting references
Salisbury, D., Ramsay, M., & Noakes, K. (2013) Immunisation against infectious disease (The Green Book). Department of Health
Department of Health (rev 2015) The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance
Department of Health (2007) Hepatitis B infected healthcare workers and antiviral therapy.
Department of Health (2007) Health clearance for tuberculosis, hepatitis B, hepatitis C and HIV: New healthcare workers
Department of Health (2005) HIV Infected Health Care Workers: Guidance on Management and Patient Notification
Department of Health (2002) Hepatitis C Infected Health Care Workers
Immunization against infectious disease: the green book www.gov.uk
The Control of Substances Hazardous to Health Regulations 2002 www.legislation.gov.uk
The Management of HIV infected Healthcare Workers who perform exposure prone procedures: updated guidance, January 2014 PHE www.gov.uk
Health and Safety at Work etc. Act 1974 (Commencement No.1) Order 1974, 1974/1439, art.2(a)/ Sch.1
Public Health England (2012) Hepatitis B Epidemiology in London 2012 data available on www.gov.uk [accessed 22.10.15]
14 Immunisation Policy Version 3 March 2017
Appendix 1: Immunisation Required per NHS Employee Category
Staff Group Hep B Immunity to TB
MMR Evidence of immunity
History of vaccination Tetanus, Polio, Diphtheria
Hep A Varicella history born and raised UK
Non UK varicella screening
Influenza
Category 1 Staff involved in direct patient care eg doctors, nurses, healthcare support workers, occupational therapists, physiotherapists, psychology staff, radiographers, chiropodists, pharmacists, dieticians, plaster technicians, audiology staff. Students and trainees of these disciplines with patients
Individuals with a requirement for tetanus, polio and diphtheria are referred to their GP
×
Category 2 Laboratory and Pathology staff (including mortuary staff) eg technical staff this may include cleaners porters and secretaries and receptionists in labs
for lab staff who may have direct contact with patients’ blood or blood stained body fluids.
for technical staff in microbiology and pathology
(if handling faeces specs offer booster polio) If may be exposed to diphtheria may require booster dose of a diphtheria containing vaccine
The following vaccines are recommended for those who work/handle these specific organisms: Hepatitis A, Japanese encephalitis, Cholera Meningococcal ACW 135 Small pox, tickborne encephalitis typhoid, yellow fever, influenza, varicella However this is N/A for SHFT as the Trust does not employ staff who would routinely handle these specimens
Category 3 Non clinical staff in healthcare settings whom only have social contact with patients but not directly involved in their care eg receptionists, ward clerks, porters, estates staff, housekeepers, volunteers directly employed by the Trust
for workers at risk of contact with blood and blood stained body fluids including those at risk injury from blood contaminated sharp instruments or of being deliberately injured or bitten by patients
Offer × Except required for Estates staff working with raw sewage
Offer
15 Immunisation Policy Version 3 March 2017
EPP Groups include:
Health Clearance for Exposure Prone Procedures
EPP Groups TB Screening Hep B Screen (Surface
antigen and core antibody
screening)
Hep B surface antibody
titre (if previous
immunised for Hep B)
Hep C antibody
Screen
HIV Screen
Surgeon performing open surgical
procedures
√ √ √ √ √
Anaesthetist if inserting chest drains
AE, placement of portocaths
Practitioner performing surgical
endoscopic procedures eg
laparoscopy, cystoscopy
Accident and Emergency (Dr or Nurse)
√ √ √ √ √
Urology
√ √ √ √ √
Ophthalmology – enucleation only
√ √ √ √ √
ENT - surgical procedures (except
simple ear or nasal procedures
performed using endoscope provided
fingers always visible)
√ √ √ √ √
Theatre staff who scrub for procedures
√ √ √ √ √
Podiatry (extended practice only) if
performing surgery on nails, bones and
soft tissue of the foot and lower leg
√ √ √ √ √
The above lists are based on the Green Book 2013 and are not exhaustive, and in the event of an outbreak vaccination may be offered more widely NHS Trusts are obliged to undertake risk assessments to determine which roles are and are not EPP (see Appendix 2)
Please refer to refer to ‘Trust Policy SH CP 157 Exposure Prone Procedures (EPPs) and Blood Borne Viruses (BBVs) - Management of the Infected Healthcare Worker’ for guidance on occupational health and EPP.
16 Immunisation Policy Version 3 March 2017
Appendix 2: What constitutes an exposure prone procedure (E.P.P)
An Exposure Prone Procedure (EPP) is any invasive procedure where there is a risk that injury to the health care worker could result in the exposure
of the patient’s open tissue to the blood of the worker (called bleed back). EPPs are defined by the Department of Health as:
"Procedures where the health care worker’s gloved hands may be in contact with sharp instruments, needle tips or sharp tissues inside the patient’s
open body cavity, wound or confined anatomical space where the fingertips may not be completely visible at all times" (Department of Health, 2005).
EPPs generally occur in surgery, obstetrics, and specialist nursing, such as operating theatre nursing. If routine infection control procedures are
followed meticulously, the following procedures are not considered as EPPS:
Procedures where the health care worker’s hands and fingertips are visible and outside of the patient’s body at all times. Internal examinations or procedures that don’t involve possible injury to the health care worker’s gloved hands.
Table of Examples of what is Exposure Prone Procedure (EPP) and what is not
EPP Not EPP
Anaesthetics The only procedures currently performed by anaesthetists which would constitute EPPs are:
a) the placement of portacaths (very rarely done) b) the insertion of chest drains in A&E trauma cases such as
patients with multiple rib fractures (probably go to acute A&E). The insertion of a chest drain may or may not be considered to be exposure- prone, depending on how it is performed. Where a larger incision is made, and a finger is inserted into the chest cavity, as may be necessary for example with a flail chest, and where the healthcare worker could be injured by the broken ribs, the procedure should be considered exposure-prone.
Resuscitation Resuscitation performed wearing appropriate protective equipment does not constitute an EPP. The Resuscitation Council (UK) recommends the use of a pocket mask when delivering cardio-pulmonary resuscitation. Pocket masks incorporate a filter and are single-use
Gynaecology Open surgical procedures are exposure-prone. Performing cone biopsies with a scalpel (and with the necessary suturing of the cervix) would be exposure-prone. Cone biopsies performed with a loop or laser would not in themselves be classified as exposure-prone, but if local anaesthetic
Gynaecology Many minor gynaecological procedures are not considered exposure-prone, examples of which include dilatation and curettage, suction termination of pregnancy, colposcopy, surgical insertion of depot contraceptive implants/devices, fitting intrauterine contraceptive devices
17 Immunisation Policy Version 3 March 2017
EPP Not EPP
was administered to the cervix other than under direct vision (ie with fingers concealed in the vagina), then the latter would be an EPP. (See also Laparoscopy).
(coils) and vaginal egg collection, provided that fingers remain visible at all times when sharp instruments are in use. Routine vaginal or rectal examinations are not EPP
Orthopaedics EPPs include: • open surgical procedures; • procedures involving the cutting or fixation of bones, including the use of K-wire fixation and osteotomies; • procedures involving the distant transfer of tissues from a second site • acute hand trauma; • nail avulsion of the toes for in-growing toenails and Zadek’s procedure(this advice may not apply to other situations such as when nail avulsions are performed by podiatrists).
Orthopaedics: • manipulation of joints with the skin intact; • arthroscopy, provided that if there is any possibility that an open procedure might become necessary, the procedure is undertaken by a colleague who is able to perform the appropriate open surgical procedure;
Endoscopy EPP risk if surgical endoscopic procedures (eg cystoscopy, laparoscopy)
Endoscopy Simple endoscopic procedures (eg gastroscopy, bronchoscopy) have not been considered exposure-prone
Ear, nose and throat (ENT) surgery (otolaryngology) ENT surgical procedures generally should be regarded as exposure-prone, with the exception of simple ear or nasal procedures, and procedures performed using endoscopes (flexible and rigid), provided that fingertips are always visible.
Ear, nose and throat (ENT) surgery (otolaryngology) Non-exposure-prone ear procedures include stapedectomy/ stapedotomy, insertion of ventilation tubes and insertion of a titanium screw for a bone-anchored hearing aid
Podiatrists Podiatry undertaken by podiatric surgeons include surgery on nails,
Podiatrists Routine procedures undertaken by podiatrists who are not trained in and
18 Immunisation Policy Version 3 March 2017
EPP Not EPP
bones and soft tissue of the foot and lower leg, and joint replacements. In a proportion of these procedures, part of the operator’s fingers will be inside the wound and out of view, thereby making them EPPs.
do not perform surgical techniques are not exposure-prone
Surgery Open surgical procedures are exposure-prone
Surgery
superficial surgery involving the soft tissues of the hand;
work on tendons using purely instrumental tunnelling techniques that do not involve fingers and sharp instruments together in the tunnel;
procedures for secondary reconstruction of the hand, provided that the operator’s fingers are in full view;
carpal tunnel decompression, provided that fingers and sharp instruments are not together in the wound;
closed reductions of fractures and other percutaneous procedures
minor surface suturing;
the incision of external abscesses
None Radiology All percutaneous procedures, including imaging of the vascular tree, biliary system and renal system, drainage procedures and biopsies as appropriate, are not EPPs.
None Other
taking blood (venepuncture);
setting up and maintaining IV lines or central lines (provided that any skin-tunnelling procedure used for the latter is performed in a non-exposure-prone manner, ie without the operator’s fingers being at any time concealed in the patient’s tissues in the presence of a sharp instrument);
Staff working in areas posing a significant risk of biting should not be treated as performing EPPs
19 Immunisation Policy Version 3 March 2017
Appendix 3: Equality Impact Assessment The Equality Analysis is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by the Equality Act 2010.
Stage 1: Screening
Date of assessment: 25.8.15
Name of person completing the assessment: Jacky Hunt
Job title: Infection Control Nurse
Responsible department: Occupational Health, Infection Prevention and Control and Human Resources
Intended equality outcomes:
Who was involved in the consultation of this document?
OHS, HR, Legal Team, H&S Officer, IPC Group
Please describe the positive and any potential negative impact of the policy on service users or staff. In the case of negative impact, please indicate any measures planned to mitigate against this by completing stage 2. Supporting Information can be found be following the link: www.legislation.gov.uk/ukpga/2010/15/contents
Protected Characteristic Positive impact Negative impact
Age
No adverse impacts have been identified at this stage of screening
Disability
No adverse impacts have been identified at this stage of screening
Gender reassignment No adverse impacts have been identified at this stage of screening
Marriage & civil partnership No adverse impacts have been identified at this stage of screening
Pregnancy & maternity Risk assessments will be carried out by OHS
No adverse impacts have been identified at this stage of screening
Race
No adverse impacts have been identified at this stage of screening
Religion No adverse impacts have been identified at this stage of screening
Sex
No adverse impacts have been identified at this stage of screening
Sexual orientation No adverse impacts have been identified at this stage of screening
Stage 2: Full impact assessment – none required
What is the impact? Mitigating actions Monitoring of actions
20 Immunisation Policy Version 3 March 2017
Appendix 4: Employee Immunisation Declaration
Employee Details
Employee Name:
Reference Number:
Staff Number:
Manager Name:
Directorate:
Appointment Date:
Appointment Location:
Immunisation(s) Declined
I confirm that I have declined the following immunisations (please tick as appropriate):
Hepatitis B (Primary Course)
Hepatitis B (Immediate Booster)
Hepatitis B (5 Year Booster)
MMR 1
MMR2
Varicella
Mantoux Test
BCG
Other (please state below)
…………………………………………………………
Reason Declined (Optional)
Please explain the reason for your decision to decline the immunisation(s) offered to you today:
……………………………………………………………………………………………
……………………………………………………………………………………………
21 Immunisation Policy Version 3 March 2017
Employee Declaration
I am aware of the risk from vaccine preventable infections that may be acquired in the course of
my work and have had explained the potential benefits of vaccination.
I understand I must inform my Manager that I have declined a vaccination that is recommended
for my role, so that adjustments can be made to reduce my risk of contact with these vaccine
preventable infections where possible. I understand that I will not be able to perform exposure
prone procedures if I have declined vaccination to hepatitis B.
I understand that if at any point I wish to be given the above stated immunisation(s) that I can
discuss this with my Manager who will arrange for OH Assist to invite me for a further
appointment.
Signed:
Date:
A copy of this form to be retained on the OHS and Personnel File
22 Immunisation Policy Version 3 March 2017
Appendix 5: Risk Management – Vaccine Preventable Injections in Staff
Identify the hazard
Staff whom might be at risk Risk mitigation Risk Management if vaccination is declined or unsuccessful
Evidence of protection
Hepatitis B Staff at risk of contact with blood and blood stained body fluids including those at risk injury from blood contaminated sharp instruments or of being deliberately scratched or bitten by patients
1) Occupational Health Service will assess each staff member’s risk on pre-employment screening based on their job description, using matrix in Appendix 1.
2) Offer hepatitis B vaccination to staff who may be at risk
3) Staff member to implement ‘standard precautions’
Appropriate use of personal protective equipment (P.P.E)
Good hand hygiene Prompt decontamination of a clinical
spillage Decontaminate equipment as per
Decontamination of Medical Devices Procedure
Safe handling of waste and linen Safe management of sharps
4) Contact OH Service for advice if : a) accidental exposure to blood on
mucous membranes or broken skin or; b) if injury from blood contaminated sharp
instruments or; c) if scratched or bitten by patients
1) Implement ‘Standard Precautions’ 2) Contact OH Service for advice
urgently if:
a) Accidental exposure to blood on mucous membranes or broken skin or;
b) If injury from blood contaminated sharp instruments or;
c) If scratched or bitten by patient
Staff not immune to Hepatitis B must be restricted from performing E.P.P
Documented course of 3 vaccinations vaccination, with a level of antibody 100iu/l. A booster is recommended
23 Immunisation Policy Version 3 March 2017
Identify the hazard
Staff whom might be at risk Risk mitigation Risk Management if vaccination is declined or unsuccessful
Evidence of protection
Tuberculosis (TB)
Staff that may have close contact with infectious patients or their lab specimens or staff working in mortuaries. Pulmonary TB is spread through the airborne route.
1) Occupational Health Service will assess each staff member’s risk on pre-employment screening based on their job description, using matrix in Appendix 1
2) Offer BCG vaccination to staff whom may be at risk
3) Staff member to implement ‘Standard Precautions’ as highlighted above.
4) Care for known or suspected TB cases in their own room with the door shut in communal settings for first 14 days of treatment (assuming clinical improvement). Staff members must wear a FFP3 mask as well as single use gloves and aprons when in isolation room, if patient can’t cover mouth or drug resistant TB suspected.
5) Encourage patient to cover mouth when coughing
1) Non-immune individuals should be informed of the symptoms of TB and advised to report suspicious symptoms to the Trust OH service.
2) Non-immune staff must avoid known/suspected cases of TB and if accidental exposure occurs, the staff member must inform the Occupational Health Service
3) Practice ‘Standard Precautions’
Documented evidence of previous BCG or history of immunisation plus BCG scar or history of immunisation no BCG scar but documented positive heaf/mantoux test within the last 5 years
Measles Mumps and Rubella
Staff with direct patient contact Non clinical staff in healthcare settings whom only have social contact with patients but are not directly involved in their care Lab/pathology staff who may have direct contact with specimens from infected patients. Mumps, measles and rubella is spread through the droplet route.
1) Occupational Health will assess each staff member’s risk on pre-employment screening based on their job description, using matrix in Appendix 1
2) Offer MMR vaccination to staff whom may be at risk
3) Staff member to implement ‘Standard Precautions’ as highlighted above.
4) Care for patient in isolation room whilst infectious if in a communal setting.
1) Avoid known/suspected cases of measles /mumps / rubella and if accidental exposure occurs, staff member must inform the Occupational Health Service.
2) Implement ‘Standard Precautions’
Documented evidence of 2 doses of MMR or a positive antibody test for measles and rubella
24 Immunisation Policy Version 3 March 2017
Identify the hazard
Staff whom might be at risk Risk mitigation Risk Management if vaccination is declined or unsuccessful
Evidence of protection
Varicella (Chickenpox)
Staff with direct patient contact Non- clinical staff in healthcare settings whom only have social contact with patients but are not directly involved in their care Lab/pathology staff who may have direct contact with specimens from infected patients. Varicella can be spread via the droplet route or following contact of a non-immune individual with fluid from the rash (vesicle)
1) Occupational Health will assess each staff member’s risk on pre-employment screening based on their job description, using matrix in Appendix 1
2) If no definite clinical history of chickenpox is given, by staff identified to be at risk using the matrix in Appendix 1, serologically test a blood sample and vaccinate only those without the varicella zoster antibody.
3) Staff member to implement ‘Standard Precautions’ as highlighted above.
4) Care for patient in isolation room whilst infectious if in a communal setting.
1) Avoid known/suspected cases of chickenpox and if accidental exposure occurs staff member must inform the Occupational Health Service.
2) Implement ‘Standard Precautions’
UK born –with a good history of chickenpox or shingles Positive blood test for antibodies to varicella if not born in UK or unsure of past history of chickenpox infection.
Influenza Staff with direct patient contact. Non clinical staff in healthcare settings whom only have social contact with patients but are not directly involved in their care. Lab/pathology staff who may have direct contact with specimens from infected patients.
1) Annual immunisation 2) Good hand hygiene with soap and water or
alcohol hand rubs. 3) Practice Catch it (in a tissue) Bin It (discard
the tissue into a bin, Kill It ( Clean your hands)
4) Isolate symptomatic cases in a side room (staff not to work till symptom free). Staff must wear single use gloves, face mask and aprons when within 1m of the infected patient. If performing sputum inducing procedures FF3 masks, single use gloves and gowns are required.
5) Ensure good environmental cleaning with soap and water of isolation room
6) Encourage infected individual to cover their mouth when coughing
1) Avoid contact with known or suspected cases of influenza where possible.
2) Practice good hand hygiene with soap and water or alcohol hand rubs.
3) Practice Catch it (in a tissue) Bin It (discard the tissue into a bin, Kill It (Clean your hands)
4) Ensure thorough environmental cleaning with detergent and water
Annual Immunisation
25 Immunisation Policy Version 3 March 2017
Identify the hazard
Staff whom might be at risk Risk mitigation Risk Management if vaccination is declined or unsuccessful
Evidence of protection
Tetanus/ Pertussis Diphtheria/ Polio
Staff with direct patient contact. Non clinical staff in healthcare settings whom only have social contact with patients but are not directly involved in their care. Lab/pathology staff who may have direct contact with specimens from infected patients Staff who have contact with soil eg gardeners
1) Occupational Health Service will assess each staff member’s risk on pre-employment screening based on their job description, using matrix in Appendix 1
2) Offer vaccination to staff whom may be at risk if not already vaccinated
3) Staff member to implement ‘Standard Precautions’ as highlighted above.
4) Transfer patients suffering from Tetanus/Pertussis/Diphtheria/Polio promptly to acute care, report accidental exposure to OH Services for staff follow up.
5) Carry out isolation precautions until transfer if it occurs in a communal area.
6) Always wash hands after changing nappy or administering a polio vaccine
1) Staff member to implement ‘Standard Precautions’ as highlighted above.
2) Transfer patients suffering from Tetanus/Pertussis/Diphtheria/Polio promptly to acute care, report accidental exposure to OH Services for staff follow up.
3) Non immune staff to avoid contact with patients suffering from Tetanus/Pertussis/Diphtheria/Polio
4) Wear gloves when in contact with the soil or rusty items if not immunised against tetanus, if accidental puncture of skin occurs with rusty/dirty object seek medical advice.
5) Avoid administering polio vaccine if not immunised (it is a live vaccine) and avoid changing nappies of a polio vaccinated person until 6 weeks after vaccination.
evidence of routine vaccination checked at pre-employment screen