Staff Immunisation Policy · Louise Jones Senior HR Manager Best Practice Development 28.8.15, ... Staff Immunisation Policy ... (COSHH Regulations 2002)

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


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


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.


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


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.


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.


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


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


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


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


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.


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


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]

http://www.gov.uk/

http://www.legislation.gov.uk/

http://www.gov.uk/

http://www.gov.uk/


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


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.


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


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


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


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


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


Race


Religion No adverse impacts have been identified at this stage of screening

Sex


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

http://www.legislation.gov.uk/ukpga/2010/15/contents


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:

……………………………………………………………………………………………

……………………………………………………………………………………………


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


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


Identify the hazard



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


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


Identify the hazard



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.


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


Identify the hazard



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


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


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

Documents

Staff Immunisation Policy · Louise Jones Senior HR Manager Best Practice Development 28.8.15, ... Staff Immunisation Policy ... (COSHH Regulations 2002)