Download 144KB - South West Yorkshire Partnership NHS Foundation Trust

Document name:
Tuberculosis Policy
Document type:
Policy
What does this policy replace?
This policy replaces one previously in place
for Barnsley and is now a Trust-wide policy
Staff group to whom it applies:
All staff within the Trust
Distribution:
The whole of the Trust
How to access:
Intranet
Issue date:
February 2016
Next review:
September 2018
Approved by:
Executive Management Team February 2016
Developed by:
Lead TB Nurse
Director Leads:
Director of Nursing
Contact for advice:
Health Integration Team / TB Service
01226 731686
Management of Tuberculosis and Measures for its Prevention and Control
Section
1
1.1
2
2.1
3
4
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
4.12
4.13
4.14
4.15
5
5.1
5.2
5.3
5.4
5.5
6
6.1
Introduction
Evidence
Purpose
Scope
Definitions
Duties
Chief Executive
Trust Board
Executive Management Team
Clinical Governance and Clinical Safety
Committee
TB Team
Employees
Practice Governance Coaches
Infection Prevention and Control
Consultants
Chest Physicians
Occupational Health
Microbiology
Health and Safety
Health Protection Unit
Managers
Procedure and Guidance
Mode of transmission
Infection with TB and disease progression
Latent TB infection
Who is at risk of TB
Common symptoms of TB
Diagnosis
Diagnosis active pulmonary TB
Page
5
5
6
6
6
6
7
7
7
7
7
8
8
9
9
9
10
10
10
10
10
11
11
11
11
11
11
12
12
2
Section
6.2
7
7.1
7.2
7.3
7.4
7.5
7.6
7.7
7.8
7.9
7.10
7.11
7.12
7.13
7.14
7.15
7.16
7.17
7.18
7.19
8
8.1
9
9.1
9.2
9.3
9.5
9.6
10
11
11.1
Diagnosis of Non respiratory TB
Treatment
Treatment regimes
Potential side effects
Monitoring treatment regimens and treatment
completion
Directly observed treatment
HIV / TB
Admission to hospital and other in patient
areas
Risk Assessment
Care of a service user residing in an Initial
Accommodation Centre (Wakefield)
Drug Resistance
Care of the service user with suspected drug
resistant TB
Isolation
Practice recommendations for TB service users
admitted to hospital and in patient areas
Care of a service user nursed in a single room
Termination of Isolation
Spirometry
Care of service users attending outpatient
departments
Care of service user in their own home
Discharge and transfer of a service user with TB
Death
Contact Tracing
Assessment for contact tracing
BCG Vaccination
Maternity services
Children’s services
New Entrants BCG
Contacts requiring BCG
Other groups
Terms and Acronyms
Developmental Processes
Identification of Need
Page
13
14
14
15
16
17
17
17
17
18
18
19
20
20
20
21
22
22
22
23
23
23
24
24
24
25
25
26
26
26
28
28
3
11.2
11.3
11.4
Stakeholder involvement
Equality Impact Assessment
Dissemination and implementation
arrangements (including training)
11.5
Implementation
11.6
Training
11.7
Monitoring compliance
11.8
Effectiveness of policy
11.9
Further advice and support
12
Review and revision arrangements (including
version control)
12.1
Process of reviewing
12.2
Version control
13
References and further reading
14
Any other policies which should be referred to
Appendix Equality Impact Assessment
one
Appendix Checklist for review and approval of
two
procedural document
29
29
29
29
29
29
30
30
30
30
30
30
31
32
34
4
Management of Tuberculosis and Measures for its Prevention and Control
1. Introduction
Tuberculosis (TB) is caused by the bacterium Mycobacterium tuberculosis (M
tuberculosis or M.TB). It is transmitted by inhaling the bacterium in droplets or
aerosols produced during coughing/sneezing or by or aerosol producing procedures
carried out on someone with infectious tuberculosis.
People with respiratory tuberculosis, and who have bacteria in sputum, which can be
seen on a simple microscopic examination are considered to be highly infectious,
these service users are referred to as smear positive.
People with other forms of tuberculosis i.e. those affecting sites other than the
respiratory tract, are not generally considered to be as infectious. However, if the site
is manipulated and aerosols are produced, transmission may still occur, especially if
the sample is smear positive.
The risk of becoming infected with TB varies depending on the length and intensity
of exposure to the bacterium. The risk is greatest in those with prolonged, close
exposure e.g. household contacts, those with added risk factors such as people who
are immuno-compromised and staff who are carrying out close aerosol producing
procedures e.g. intubation and suction.
The incidence of Tuberculosis is influenced by risk factors such as exposure to, and
susceptibility to, Tuberculosis and levels of deprivation (poverty, housing, nutrition
and access to healthcare). The most important intervention in regards to the control
of Tuberculosis is effective treatment. Hence, the completion of treatment is vital to
reduce onward transmission of Tuberculosis and support successful clinical
outcomes for service users, resulting in the reduction of the development of multi
drug resistant Tuberculosis. The control of Tuberculosis requires targeted screening
of high risk individuals and groups, identifying close contacts and effective treatment.
Therefore the need to implement a clinically robust guidance is of paramount
importance.
1.2 Evidence
This local policy reflects the NICE guidelines 2011 (Including amendments January
2016) for Tuberculosis: clinical diagnosis and management of tuberculosis, and
measures for its prevention and control and has been specifically written to cover the
requirements for diagnosis and management within the South West Yorkshire
Partnership NHS Foundation Trust.
5
2. Purpose
To provide clinical staff of all disciplines working for or on behalf
Yorkshire Partnership NHS Foundation Trust, with guidelines
procedures that are based on NICE guidelines for the management
infected cases and for the prevention of potential transmission to
inclusion of staff members, service users and visitors.
of South West
and standard
of Tuberculosis
other, with the
2.1 Scope
This policy is applicable to all staff in the Trust and is designed to provide guidance
and support to staff in relation to the management, prevention and control of
tuberculosis in order to ensure consistent practice across the Trust.
Although there nationally accepted and evidence based standards for the
management, prevention and control of tuberculosis identified within the policy it is
inappropriate for the Trust to make a blanket statement in relation to these.
The policy cannot anticipate any given situation, therefore professional judgement
should be used to identify when a risk assessment is needed to protect those who
have been compromised, are vulnerable / or at risk. The risk assessment process
will enable staff to identify the level of vulnerability and the risks posed to each
individual concerned resulting in appropriate action being taken. Professional
judgement should derive from a robust disciplinary team discussion
3. Definitions
This document is a policy, which clearly specifies its’ purpose and scope.
4. Duties
The Trust has a duty and is committed to the management, prevention and control
of tuberculosis by providing assurance systems and resources required to ensure
safe working practice and the ongoing education and audit to ensure compliance. All
staff are responsible for demonstrating compliance with this policy.
The following specific duties apply:
4.1 Chief Executive
The Chief Executive has overall accountability for reducing the risk of Tuberculosis
infection by ensuring that there are arrangements and systems in place within the
organisation to assist with its prevention and management.
6
4.2 Trust Board
Trust board is responsible for the signing and approval, dissemination and
implementation of this policy.
4.3 Executive Management Team
The Executive Management Team is responsible for approving the contents of the
policy.
4.4 Clinical Governance and Clinical Safety Committee
The Clinical Governance and Clinical Safety Committee is responsible for the
dissemination and implementation of this policy on behalf of the Trust Board
4.5 Tuberculosis Service Team
The team consists of Lead Nurse Tuberculosis, Tuberculosis Specialist Nurse, and
Clerical Officer.
The Tuberculosis Service Team is responsible for working with the Service
Managers, Practice Governance Coaches / Modern Matrons other health care
professionals to improve the care of service users. In order to achieve this they will:




Develop, disseminate, implement and review this policy as required
Audit compliance with this policy
Provide training as identified to educate and monitor staff awareness of the
policy content
Ensure that Directors of the Business Delivery Units are made aware of
issues as they arise within their care groups
Deliver quarterly reports in order to monitor practice with the inclusion of all
incidents reported via the DATIX system
Provide other timely reports as required to Trust Board, Executive
Management Team, the Clinical Governance and Clinical Safety Committee,
Business Delivery Units, Modern Matrons and any other relevant groups
which will include lessons learnt.
Provide specialist tuberculosis advice to management, clinicians and
practitioners and any other relevant agencies.
Liaise with other TB Specialist Nurses
Work closely with both the acute hospital and Public Health England
TB Nurse to perform Chest Clinic with the Chest Physician in charge of TB
management
Give support to service users, carers and family whilst having treatment.


Carry out contact tracing and refer to Chest Physician as indicated.
Act as a resource on TB for other professionals







7


Provide education sessions as required, including attending community health
events
The TB Specialist Nurses to liaise with Public Health England, Consultant in
Communicable Disease Control in relation to
 Outbreaks and Incidents
 Collation of all notifiable cases of tuberculosis
 COHORT review process
 Specialist advice and support to all staff within the trust.
 Comply with the Tuberculosis policy
4.6 Employees will:
 Co-operate and assist with the implementation of this Policy, and its
associated procedures.
 Bring to the notice of management, any problems or failings associated with
the control of Tuberculosis
 Attend training as required.
 Make themselves aware of, and follow safe systems of work and control
methods (including personal protective equipment) provided for their safety
and the safety of others.
 Promptly report all incidents concerning the risks of exposure to
Tuberculosis in accordance with the Trusts’ Policy and procedure on reporting
incidents.
 Report to the Occupational Health Department if they consider they are at risk
of transmitting Tuberculosis to service users.
 Be responsible for liaising with appropriate personnel when service users are
discharged or transferred.
 Comply with the Tuberculosis policy.
4.7 Practice Governance Coaches will:





Ensure that the policy is integrated into clinical practice.
Liaise and work closely with the TB Specialist Nurse to control
Tuberculosis.
Advise service users and carers to contact TB Specialist Nurse for TB
related information if required
Participate in audit monitor practice and compliance with standards.
Comply with the Tuberculosis policy
4.8 Infection Prevention & Control Team will:




Promote good infection control practices in line with the policy.
Provide information, advice and training to enable managers and users to
undertake risk assessments as required in association with the TB Nurse
Report on incidents to the Infection Prevention and Trust Action Group
Play an active role in outbreak management associated to Trust premises, in
coordination with TB Specialist Nurse and the Health Protection Unit.
8




Communicate and liaise with the appropriate personnel (especially TB
Specialist Nurse) on the care and management of positive individuals.
Liaise with the TB Specialist Nurse and Occupational Health in the screening
of contacts.
Liaise with TB Specialist Nurse if any laboratory results show possible TB
infection.
Comply with the Tuberculosis policy.
4.9 Consultants will:



Refer all suspected or confirmed cases of Tuberculosis to the chest
physicians for treatment and follow up.
Ensure that service users with Tuberculosis receive appropriate clinical care
and management.
Comply with the Tuberculosis policy
4.10 Chest Physicians will:








Be responsible for the diagnosis and clinical management.
Be responsible for the clinical follow up of cases of TB.
Advise all service users on TB treatments of the benefits of having a HIV test.
Are responsible for completing notification forms to the HPU.
Work closely with the TB Specialist Nurse to facilitate contact tracing and
service user support.
Be the key members of local TB Working Groups.
Be the key members of Outbreak Control Team.
Discuss options for organising care for people with MDR TB with specialists.

Comply with the Tuberculosis policy
4.11 Occupational Health Department will:







Formulate and regularly review OHD policies for the protection of staff.
Provide pre-employment health assessment for prospective employees and
for those on change of post.
Provide protection by way of BCG (Bacillus Calmette-Guerin) immunisation
appropriate to risk, following NICE Guidance.
Provide further medical screening when advised by the TB Specialist Nurse
for staff who have been exposed to a significant risk of TB.
Provide information and advice to staff on the protection/prevention of TB.
Arrange further medical investigations and referral to a Consultant Respiratory
Physician as appropriate, for employees who develop symptoms suggestive
of TB.
Advise managers and employees on current guidelines and the Trust’s
reporting procedures.
9



Work closely with the Consultant Communicable Disease Control, TB
Specialist Nurse, Infection Prevention and Control Team and managers of the
Trust.
Maintain records of exposure, treatment and follow up of staff.
Comply with the Tuberculosis policy
4.12 Microbiology Laboratory:
The service level agreement with the laboratories will specify that the labs will;
 Advice on appropriate sample for diagnosis and screening
 Report any positive to the Infection Prevention and Control Team, consultant
in charge and the Health Protection Unit as soon as possible.
 Provide TB Specialist Nurse with details of patients who have laboratory
results that could indicate TB infection.
 Comply with the Tuberculosis policy
4.13 Health and Safety will:

Record all exposure incidents reported via the Datix system.
4.14 Health Protection Unit (South &West Yorkshire) will:


Collaborate with the Trust in reviewing its local guidance on the management
and protection of service users and staff from TB.
Collate all notified cases of TB.
4.15 Managers will:

Ensure staff comply with the policy.
5. Procedure and Guidance
5.1 Mode of transmission
People who have active infectious (open) pulmonary or laryngeal TB expel small
respiratory droplets when coughing and sneezing. These small droplet nuclei, carried
by air currents can be inhaled by susceptible people.
5.2 Infection with Tuberculosis and disease progression.
Once inhaled, the bacteria reach the lung and grow slowly over several weeks. The
body’s immune system is stimulated, which can be shown by a tuberculin skin test
(Mantoux).
The majority of exposed persons will kill off the inhaled bacteria, and be left only with
a positive skin test as a marker of exposure. In a small number of cases a defensive
barrier is built round the infection, this results in the bacteria not being killed, but
instead lying dormant. This is called latent Tuberculosis infection, in such cases the
person is not ill and is not considered to be infectious. Reactivation of the latent
10
infection can occur at any time, and may be many years later, becoming active
tuberculosis disease.
5.3 Latent Tuberculosis
Latent TB is defined as infection with Mycobacterium tuberculosis, where the
bacteria are alive but not currently causing active disease. The purpose of treating
those patients identified as having latent TB is to kill any dormant bacteria in order to
reduce the likelihood or prevent later reactivation of tuberculosis into active disease.
Treatment for Latent TB infection should be considered for certain individuals once
active TB disease has been excluded, this will require a respiratory consultant review
by chest X-ray and physical examination.
5.4 Who is at Risk of TB?
Whilst anyone may catch TB certain groups are recognised at being at an increased
risk. These are generally:







Close contacts of infectious cases
Those who have lived or travelled to places where TB is still common
(endemic)
Those who have visitors from places where TB is common (endemic)
Those who live in ethnic minority communities originating from places where
TB is common (endemic)
Those with immune systems weakened by Human Immuno-deficiency Virus
(HIV) infection or other medical problems.
The very young and elderly as their immune systems are less robust
Those with chronic poor health as a result of lifestyle, such as homelessness
and/or substance misuse e.g. drugs and alcohol
5.5 What are the common symptoms of TB?
TB is mostly found in the lungs (pulmonary) but can affect any part of the body, such
as brain, lymph node and bones. TB symptoms in other parts of the body/systems
can be extremely varied, but may include pain and swelling in the affected area.
Typical Symptoms of Pulmonary TB include:






Chronic cough / Haemoptysis
Loss of appetite
Weight loss
Extreme lethargy
Intermittent fever
Drenching night sweats
11
6 Diagnosis
6.1 Diagnosis of Active Pulmonary TB

Sputum
For individual’s suspected of having pulmonary Tuberculosis three sputum samples
taken on three consecutive days are required. These should preferably be obtained
in the morning as these yields the highest number of organisms if present. The
specimen request form and sample must be labelled with high-risk stickers. Samples
will be tested for Acid Alcohol Fast Bacilli (AAFB) which if positive is suggestive of
infection with mycobacterium (although TB cannot be confirmed at this point).
Sputum samples will then be cultured to determine the species of mycobacteria, at
which point TB will be confirmed, however, as the organism is slow growing, culture
results can take several weeks. Spontaneous sputum should be obtained where
possible; however bronchoscopy and lavage may be considered where clinically
indicated.
In children who are not able to expectorate sputum, gastric washings may be
considered. Advice can be sought from the Consultant Medical Microbiologist as to
the significance of any bacterial growth identified on sputum. All sputum specimens
confirmed as AAFB positive on microscopy or culture will be faxed from the
Microbiology laboratory directly to the TB specialist nurse to action.
Sputum and Bronchial washings from known or suspected TB patients MUST be
treated as high-risk samples i.e. danger of infection or high-risk labelling on both the
sample and request form and MUST NOT UNDER ANY CIRCUMSTANCES BE
TRANSPORTED BY AN AIR TUBE SYSTEM

Chest X-Ray
A posterior-anterior chest x-ray should be taken, and if suggestive of TB further
investigation should be carried out by referral to either respiratory consultant or
paediatrician.

Management of Contacts
Treatment and follow up of contacts of patients with active pulmonary TB infection
should not be delayed whilst awaiting culture results, but should be based on other
microbiological results (AAFB positive) and clinical findings. Culture only confirms
the mycobacterium species and indicates which drugs Where x-ray or sputum
specimen results are suggestive of TB then urgent referral to the respiratory
Consultant or Paediatrician should be made.

Enhanced surveillance
TB is a notifiable disease and therefore patients suspected or confirmed with
pulmonary TB must be notified to Public Health England.
12
Notification to Public Health England (notification and data collection form for
enhanced tuberculosis surveillance) is the statutory responsibility of the doctor who
makes a provisional or definite diagnosis of Tuberculosis under the Public Health
(Infectious Disease) Regulations 1988. Notification should not wait until confirmation
of culture results, notification must be sent at time of clinical diagnosis.
Notifications must be sent initially to the TB Nurse Specialist who will then complete
the relevant database online and forward them on to the Consultant in
Communicable Disease Control at Public Health England
6.2 Diagnosis of active non respiratory TB:

Specimens
Where there is a clinical indication of active non respiratory TB infection samples
from biopsy or aspiration should be sent for TB culture. These may include:





lymph node biopsy
Aspiration sample (any fluid)
Tissue sample
Bone biopsy
Autopsy sample
All lymph node specimens and other tissue samples should be divided and part sent
in formalin for histology and part sent in saline to microbiology for TB stain and
culture.

Chest X-Ray
Chest X-Rays are also required to exclude or confirm co existing respiratory TB
disease

Additional Tests
The Mantoux Tuberculin Skin Test (TST) and gamma interferon blood tests (T spot)
can identify people exposed to TB or who may have latent TB infection.

Enhanced surveillance
Active Non respiratory TB is a notifiable disease and therefore patients suspected or
confirmed with non -pulmonary TB must be notified to Public Health England.
7 Treatment
Once a diagnosis of active tuberculosis is suspected the clinician responsible for
care should refer the person with TB urgently to a physician/paediatrician with
experience and training in the treatment of people with TB. If there are clinical signs
13
and symptoms consistent with a diagnosis of TB, treatment should be started without
waiting for culture results.
The treatment regime will be determined by the treating physician based on clinical
and microbiological assessment and in accordance with NICE guidelines, TB
treatment is currently free of charge (DOH 2007) and this is achieved by providing a
prescription obtained from the hospital pharmacy. If an FP10 prescription is
necessary the patient will have to pay for the medication if they are not exempt. (This
will be the exception). Prior to commencing medication in adults diagnosed with TB
the following are required as a base line:


Visual acuity
Liver function blood test and urea and electrolyte
Abnormalities with either may require adjustment to service users’ doses of
medication.
7.1 Treatment Regimes
The standard regime of Six month, four drug regimens should be used to treat
Active respiratory TB in:



Adults not known to be HIV positive
Adults who are HIV positive
Children
The standard drug regime (as per NICE guidelines) is also applicable for patients
with:



Active peripheral lymph node TB
Active spinal TB (with no direct spinal cord involvement)
TB other bone and joint.
(Please refer to NICE guidelines for further recommended treatment regimes)
The majority of bacteria are sensitive to




Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
The standard NICE recommended regime is six months of Isoniazid and Rifampicin,
supplemented by Pyrazinamide and Ethambutol for the first two months.
Occasionally this standard regime is amended by the hospital consultant or TB nurse
to support concordance. Fixed dose combination tablets are recommended for
14
adults. The medication should be taken all together first thing in a morning on an
empty stomach wherever possible.
Although currently low in the UK, drug resistance is on the increase worldwide, with
approximately 1% of cases occasionally Being resistant to both Rifampicin and
Isoniazid. These isolated cases are referred to as Multi-drug Resistant TB (MDR
TB), and are recognised as being more difficult to treat.
For those service users in whom samples have been sent for culture, the sensitivity
tests are required prior to the change to the continuation phase of treatment.
7.2 Potential side effects of Treatment:
Staff should be aware of these in order to inform, advise and support the patients in
the their care. (Please see most current British National Formulary [BNF] for full
details).
Rifampicin





Gastro intestinal symptoms including anorexia, nausea, vomiting and
diarrhoea
Alterations to Liver function tests (contra-indicated in jaundice/hepatic
disorders)
Urticaria and rashes
Menstrual disturbance (contraindications if patient is taking oral
contraceptives, advise to use barrier method of contraception)
urine saliva and other body secretions coloured orange-red
Isoniazid



Gastro intestinal symptoms as above
Peripheral neuritis with high doses (pyridoxine prophylaxis is given to those at
increased risk such as diabetics, alcohol dependent, malnourished and
pregnant and breast feeding mothers)
Patients with Hepatic impairment caution is needed
Pyrazinamide


Aggravate or cause Gout
Hepatotoxicity including fever, anorexia etc
Ethambutol



Caution needed in renal impairment
Potential side effect of optic neuritis, red/green colour blindness
Visual acuity check before commencement of treatment
15
7.3 Monitoring adherence to treatment regimens and treatment completion
To promote adherence, service users should be involved in treatment decisions at
the outset of treatment for active TB Disease or latent TB infection. Service user
verbal consent should be obtained to share relevant information with other health
care professionals and recorded on System One. The importance of adherence and
potential impact on outcome and possible consequences of non-compliance must be
explained and emphasised to the patient.
Consent is not required to inform public health England as TB is a notifiable disease
The service user should be informed that they will be allocated a named key worker/
TB Nurse Specialist who will continue to support them throughout the course of their
treatment. Service user’s individual beliefs must be respected and their dignity
maintained at all times. Service users who are diagnosed with TB still do feel that a
stigma exists with a diagnosis of Tuberculosis and will need much individual support.
They are often worried about how family and friends react as well as the
transmission to those closest to them. Correct information in a timely manner is
essential to avoid unnecessary anxiety. If you are unable to answer questions
directly and accurately you should contact the TB Nurse Specialist for advice.
7.4 Directly observed therapy (DOT)
Directly observed therapy is the supervised swallowing of medication to support
concordance. Directly observed therapy (DOT) is rarely necessary with any
requirement being risk assessment by treating clinician and TB specialist nurse. It is
likely to be considered for those who have adverse risk factors, in particular street or
shelter dwelling homeless people with active TB and patients with likely poor
adherence due to lifestyle etc. or those with a history on non-adherence
7.5 HIV and TB
Staff should refer to the British HIV Association (BHIVA) treatment guidelines for
TB/HIV 2011, which were drawn up by the BHIVA guidelines writing committee to
help physicians manage adults with HIV/TB co infection.
Starting antiretroviral therapy in service users who have TB is a balance between
potential overlapping toxicities, drug interactions and possible immune reconstitution
versus the risk of further immune suppression with its associated increase in
morbidity and mortality.
Mantoux testing is not recommended in HIV/TB co-infected patients or as a routine
screening test for tuberculosis in HIV infected service users as, there are high
numbers of false negative rates, especially in those with low CD4 counts.
Gamma interferon testing (T Spot) appears to have a better sensitivity than
tuberculin skin tests but is currently not recommended as routine. All patients
16
diagnosed with active TB should be offered a HIV test, where accepted this should
be a direct referral from chest clinic or the TB Nurse. Positive results are referred to
the Genito-Urinary Medicine Consultant with the consent of the service user .The
offer and outcome of offer should be documented in the service users’ clinical notes.
7.6 Admission to hospital and other inpatient areas
It is important to prevent unnecessary hospitalisation as treatment can proceed in a
service users’ home, considering that the household contacts will be picked up by
the contact tracing process and that the infectiousness declines rapidly once
treatment begins. Service users who are considered infectious may be required to
stay at home for a minimum of two weeks of treatment in order to isolate themselves
from and prevent new contacts.
7.7 Risk Assessment
Service users admitted to hospital or other inpatient units who are suspected of
having respiratory TB must be admitted to a single room with Respiratory Infection
Control Precautions as per individual Trust’s Transmission Based Isolation Policy.
Service users with a productive cough must be nursed in a single room, until all
three sputum results are available and cleared by the Infection Prevention and
Control Team.
Service uses who are an inpatient and who are diagnosed smear positive (with no
risk factors for MDRTB) must be cared for in a single room until they have completed
at least two weeks of the standard treatment and an appropriate risk assessment
has been carried out by responsible consultant. The risk assessment must be
documented in the medical notes and the infection and prevention and control team
should be consulted prior to any move from the cubicle.
Service users who are smear positive (with no risk factors for MDRTB) and who are
deemed fit enough for discharge should remain in the cubicle until the point of
discharge from the hospital. If a service user is suspected of TB after admission to
hospital, they must be allocated to a cubicle as priority. Contact the Infection
prevention and control team along with bed management team.
Service users who are smear positive pulmonary TB must be isolated as soon as
possible and before the exposure of other service users reaches 8 hours. For those
who are suspected or diagnosed with active pulmonary TB, who are smear positive
and who have been nursed with other service users in a bay area for more than 8
hours should be identified and referred to infection and prevention and control nurse
as soon as possible on the same day.
7.8 Care of service users residing in an Initial Accommodation Centre
(Wakefield)
Initial Accommodation Health Care Nurses to identify service users at risk or
suspected TB at point of initial assessment. To refer to TB Specialist Nurse for
17
further assessment and screening as appropriate and dependent on the findings
undertake baseline bloods LFT / U&E /FBC/ HIV/Vitamin D request a CXR if
symptomatic request sputum samples and discuss isolation and contact screening
with initial accommodation staff. To be referred to the consultant. TB Specialist nurse
to discuss with consultant infectivity risk, contact screening and establish if a delayed
dispersal is required. The TB nurse will then make the necessary arrangements and
liaise with the UKBA / Home Office. On dispersal TB nurse to refer on to appropriate
TB Service
7.9 Drug resistance
Drug resistance is an important issue in the management of TB, as it may prolong
the period during which patients are infectious to others as well as compromising the
effectiveness of treatment. .A clinical risk assessment for drug resistance must be
made by the medical team responsible for the service users care (advice and
support is available from the Medical Microbiologist, the Infection prevention and
Control Team, the TB Nurse Specialist or the Consultant for Communicable Disease
Control, based at Public Health England in Sheffield).
The risk assessment for resistance is based on the following risk factors:







History of prior TB drug treatment; prior TB treatment failure
Contact with a known case of drug-resistant TB
Birth in a foreign country, particularly high incidence countries as defined by
the public health England www.phe.gov.uk
HIV infection
Residence in London
Age profile, with the highest rates of resistance being between 25 and 44
years of age.
Gender higher incidence of resistance in male gender.
If after clinical risk assessment, there is considered to be a significant risk of drug
resistance, urgent molecular tests for Rifampicin resistance should be performed on
smear positive material. This will be arranged through microbiology.
7.10 Care of the service user with suspected drug resistance TB
Service users with suspected or known MDR TB who are admitted to hospital must
be nursed in a continually monitored negative pressure room. The infection
prevention and control team must be contacted as a priority as, such patients will
require urgent transfer to a neighbouring facility (currently only available at Royal
Hallamshire Hospital Sheffield or Sheffield children’s hospital for Barnsley service
users St James in Leeds for Wakefield patients).The reason for transfer must be
explained to the service user and their carer(s)/relatives.
18
Service users at increased risk of drug resistance should be closely monitored and if
there is no clinical improvement, or if cultures remain smear or culture positive after
the fourth month of treatment, then drug resistance should be suspected. Referral to
Consultant Microbiologist is necessary and transfer to the appropriate hospital.
For service users known to have or suspected of having MDR TB, staff and visitors
must wear an FFP3 mask during contact while ever the patient is considered
infectious. These masks require training prior to use, to ensure appropriate and
adequate fit
Before discharge, any service users who have been identified as drug resistant need
secure arrangements to be made for the supervision and administration of all anti-TB
treatment. Liaison with the TB Nurse Specialist in a timely manner to arrange directly
observed Therapy (DOT) is necessary
7.11 Isolation
There are three levels of isolation for infection prevention and control in an inpatient
setting:
1. Negative pressure rooms, which have air pressure continuously or automatically
measured as defined by NHS Estates. These must be used for Service users
with suspected or confirmed MDR TB and are currently only available at the
Royal Hallamshire Hospital and Sheffield children’s hospital.
2. Single rooms that are not negative pressure but are vented to the outside – used
for:


Smear positive service users with a productive cough
Suspected respiratory TB service users until a full risk assessment has been
carried out by the clinician responsible for their care in conjunction with
Microbiology
3. Beds on a ward, for which no particular engineering standards are required (these
must not be used for service users with a productive cough, unless proven to be
smear negative and as directed by the Infection Prevention and Control Team.
7.12 Practice recommendations for TB service users admitted to hospital and
to inpatient areas

Inform the admitting ward/area. Service user to be isolated in a cubicle until
an assessment of the service user has been carried out and advice obtained
from Infection Prevention and Control Team.

Children admitted with TB of any site must be admitted to a cubicle as a
visitor may be an undiagnosed and unidentified index case of infectious
Tuberculosis.
19


Inform infection Prevention and Control Nurses.
Inform TB Services 01226 731686.
7.13 Care of a patient nursed in a single room when respiratory precautions
are required
Service users can find isolation a very stressful experience and if personal protective
equipment is required then the service user requires adequate explanation and
reassurance.
Consult with the Infection Prevention and Control Nurses for assessment/advice.
Service users to remain in the room with the door closed.
If respiratory infection control precautions apply, the sign must be displayed clearly
at the entrance to the side room (Green isolation sign).
Masks: Service users visiting other departments who are identified as infectious
must wear a FFP2 mask (duck billed).
Linen from patients who are coughing and assessed as an infection risk must be
handled as ‘infected’.
Close household contacts should be allowed to visit with no precautions unless drug
resistance is suspected.
Visitors of newly diagnosed service users should, as far as is possible, be limited to
those who have already been in close contact with the service user before
diagnosis as these people will be followed up routinely as contacts. Others, who are
immuno-compromised or children under two years should not visit unless the
situation deems absolutely necessary. Individual risk assessment is required and
masks may be required.
Any visitors of a child with TB must be screened as part of contact tracing and kept
separate from other service users until they are excluded as the source case. One of
the visitors could potentially be the source of TB and hence a risk to others on the
ward.
After assessment by Infection prevention and Control Team, health care workers
may not be required to wear masks or gowns unless:


MDR TB is suspected
Aerosol generating procedures are being performed (e.g. use of BiPAP,
CPAP etc.)

They have very close prolonged contact with the service user where coughing
directly into the face is anticipated. This should be an individual risk
assessment and in consultation with infection prevention and control
team and TB specialist nurse.
20

Service users with respiratory
immunocompromised service users
TB
must
be
separated
from
7.14Termination of Isolation
The decision to terminate isolation should be taken by the supervising physician in
conjunction with the Infection Prevention and Control Team/TB Nurse Specialist.
There is evidence that the vast majority of service users with uncomplicated
pulmonary TB will be non–infectious after two weeks of compliance with two weeks
of appropriate anti-TB therapy. Results of sputum samples and response to
treatment should be taken into account.
7.15 Spirometry
Service users requiring spirometry will be assessed on an individual basis and
spirometry will be performed through a filter as per medical physics guidelines.
Carbon monoxide monitoring for the benefit of smoking cessation will not be
permitted.
7.16 Care of service users attending outpatient departments
Service users who attend clinic prior to commencing treatment for TB and who are
suspected as having pulmonary TB should be segregated from other patients by
sitting the patient in a private room(reassurance and explanation is required to
alleviate anxiety. For the baseline eye test prior to treatment the patient must wear a
FFP2 mask (duck billed). For any procedures such as bronchoscopy the patient
should be last on the list.
7.17 Care of service users in their own home
Often service users are cared for in their home and precautions are not usually
necessary unless drug resistance is suspected or the individual is particularly
infectious. All household contacts will be screened in a timely manner according to
their individual needs as assessed by the TB Nurse Specialist.
Health care workers may not be required to wear masks at home visits after an
assessment has been carried out by Infection Prevention and Control or TB
Specialist Nurse unless:


MDR TB is suspected
Aerosol generating procedures are being performed

They have very close prolonged contact with the service user where coughing
directly into the face is anticipated. This should be an individual risk
assessment by the healthcare worker (the service user can be asked to wear
the mask during a visit from a health care professional if individual risk
assessment deems it appropriate)
21
Infectious case service users should be advised to stay at home until they have
received 2 weeks continuous compliant anti-TB drugs. They should be educated
about the risks of spreading infection and advised about disposal of tissues (these
should not be thrown directly into the bin, but firstly into a plastic bag etc) and to
cover the mouth when coughing and turn away from contacts. Disposal of tissues etc
must be followed by rigorous hand washing. They should be advised not to make
any new contacts until they are non-infectious to others
7.18 Discharge and transfer of a service user with tuberculosis
The TB Nurse must be contacted prior to discharge (tel. 01226 731686)
If Directly Observed Therapy (DOT) is required the TB Nurse must be given notice
and the patient not discharged until the service has been arranged.
If a service user is to leave using the ambulance service then an assessment by
Infection prevention and Control Nurse is required for infection risk and the relevant
Inter-Healthcare Transfer Form to be completed. The ambulance service must be
informed at the time of booking that the patient has Tuberculosis and their infection
status at time of transfer – patients still considered to be infectious must wear FFP2
masks (duck billed)for the duration of the journey and must travel alone.
The room must be terminally cleaned in line with the Trust Decontamination Policy
following discharge, where service user’s results are unknown or have been proven
to be AAFB positive.
Service users visiting other departments who are identified as infectious must wear a
FFP2 mask (duck billed).
If service users are to attend other departments, the receiving department must be
informed so that they can take the necessary precautions to prevent exposure to
susceptible service users in awaiting area/department.
Service users with infectious TB must be placed last on the operating/procedure list
to facilitate cleaning and change of any equipment.
7.19 Death
If a service user with known or suspected TB (of any type and from anybody site)
dies, the mortuary and/or undertaker must be informed. The body must be placed in
a black heavy-duty cadaver bag suitable for “danger of infection”. Under no
circumstances must routine body pouches be used. The TB nurse must be informed
of any patient who dies and who has a confirmed diagnosis of Tuberculosis, as
contact tracing will be required.
22
8 Contact tracing
Contact tracing is performed by the TB Nurse Specialist after an individual is
diagnosed with Tuberculosis (the index case). Individual assessment of contacts by
the TB specialist looks at the infectivity of the index case, the contacts exposure to
the index case and the susceptibility of the individual contact. Identification of those
who require a BCG vaccination is also considered. Contacts that require screening
are referred to the nurse led contact clinic or referred to the Paediatrician with
special interest in TB and are seen in the children’s outpatients department in
accordance with specific pathway.
8.1 Assessment for contact tracing
Contact tracing should not be delayed until notification.
Screening is offered to the household contacts of any person with active TB,
irrespective of site of infection
For people with sputum smear-positive TB, other close contacts should be assessed.
Casual contacts of people with TB, which include the majority of workplace contacts.
Staff caring for a service users with TB do not usually require screening but for those
who are considered to have had a significant exposure to an infectious case of
Tuberculosis please refer to occupational health services staff policy “Control and
prevention of tuberculosis in healthcare” 2007. The need for Contact tracing service
users exposed to TB will assessed by the Infection prevention and Control Team in
collaboration with department manager and TB specialist nurse.
The assessment would take into account:







The infectivity of the index case
The length of time before appropriate infection control precautions were
introduced
Whether other patients were known or suspected to be unusually susceptible
to infection
The proximity of the contact with the index case
Any specific features (e.g. Drug resistance)
If associated cases of Tuberculosis disease are identified then the screening
of other casual contacts may be appropriate.
Latent TB infection if identified in contacts may require chemo prophylaxis.
This is offered on an individual assessment in line with NICE guidelines.
9. BCG vaccination
9.1Maternity Services
23
BCG vaccination will be given by suitably qualified midwifes to appropriate neonates
identified at an increased risk during the ante-natal assessment, while an inpatient
on the postnatal ward. Missed BCG babies are referred to the Paediatric with special
interest for TB, (Barnsley) and will receive an appointment for the children’s
outpatient clinic, or to TB Specialist Nurse in Wakefield who will arrange an
appointment in the community clinic.
BCG vaccination is offered to selected neonates who:



Were born in an area with high incidence of TB as defined by the HPA
Have one or more parents or grandparents who were born in a high incidence
country
Have a family history of TB in the past five years
Routine BCG vaccination for children aged 10-14 is no longer recommended as part
of the UK routine immunisation programme
9.2 Children’s Services
Healthcare workers should opportunistically identify unvaccinated children older than
4 weeks and younger than 16 years at increased risk of TB and who would have
qualified for neonatal BCG (High risk as above). Children up to the age of 12 years
are referred to Paediatrician with special interest in TB.
Children over 12 years are referred to the nurse led contact tracing clinic Mantoux
testing is not routinely done before BCG vaccination in children younger than 6 years
unless there is a history of residence or prolonged stay (more than a month) in a
country with a high incidence of TB.
9.3 New Entrants and BCG
BCG should be offered to Mantoux-negative new entrants who are:
From high incidence countries and


are previously unvaccinated, and
are aged 35 years or younger
Currently the screening service is only available to new entrants who are registered
at The Health Integration Team. Any new entrants identified as requiring BCG are
referred to either the Paediatrician with special interest in TB or the Respiratory
Consultant with special interest in TB in Barnsley. In Wakefield referral to TB service
Nurse Led Clinic
9.4 Health Care Workers and BCG
Please refer to Workplace Health and Wellbeing immunisation procedure. BCG
should be offered to healthcare workers irrespective of age, who:
24



Are previously unvaccinated and
Will have contact with service users or clinical materials and
Are mantoux (or interferon-gamma) negative
Staff who have any concerns should contact the Workplace Health and Wellbeing
department.
9.5 Contacts Requiring BCG
This will be identified during contact tracing procedures. BCG should be offered to
mantoux–negative / IgRA negative contacts of people with pulmonary TB if they are
previously unvaccinated and are:


Aged 35 or younger
Aged 36 and older and a healthcare or laboratory worker who has contact
with service users or clinical materials
9.6 Other Groups
BCG should be offered to previously unvaccinated, mantoux-negative people less
than 35 years as per Department of Health, Immunisation against infectious disease
2006 ‘Green Book’





Veterinary and other staff such as abattoir workers
Prison staff working directly with prisoners
Staff at care homes for elderly people
Staff at hostels for homeless people and facilities accommodating refugees
and asylum seekers
Previously unvaccinated, tuberculin-negative individuals under 16 years of
age who were born in or who have lived for a prolonged period (at least three
months) in a country with an annual TB incidence of 40/100,000 or greater.
10 Terms and Acronyms
Terms
Index case
Any person who lives in the same household as the index case (sharing bedroom,
bathroom, kitchen or sitting room- e.g bedsits with some shared facilities). Contacts
with a cumulative total exposure to a smear positive case of TB exceeding 8 hours
within a restricted area equivalent to a domestic setting (this may include partners
who do not live in the same household).
Casual Contact
Will include the majority of workplace contacts and people who spend less than 8
cumulative hours with the index case.
25
Contact Tracing
Is screening to find associated cases, to detect people infected without evidence of
disease (latent TB), and to identify those not infected who may benefit from BCG
vaccination. Where recent infection has occurred (e.g. clinical disease in children)
contact tracing is done to find a source of infection and co primary cases (other index
cases).
Smear positive
Laboratory diagnosis of Acid and Alcohol Fast Bacilli by Ziehl Neilson or Auramine
phenol staining on Microscopy.
Smear negative
When a microscopy sample is stained by Ziehl Neilson or auramine phenol and Acid
and Alcohol Fast Baccilli are not seen.
Culture positive
Acid and Alcohol fast Baccilli are identified on culture.
Drug Sensitivity
Dependant on the species of mycobacterium identified, the reference laboratory will
provide confirmation of drug sensitivity and resistance.
Respiratory TB
TB present within the respiratory system - more easily transmitted to others.
Non Respiratory TB
TB present within other sites of the body - less easily transmitted to others.
Latent TB
Infection with Mycobacteria of the M Tuberculosis complex, where the bacteria are
alive, but not currently causing active disease.
Acronyms / Abbreviations
Drug regimens are often abbreviated to the number of months a phase of treatment
lasts followed by the letters for the drugs administered in that phase:
H
ISONIAZID
R
RIFAMPICIN
Z
PYRAZINAMIDE
E
ETHAMBUTOL
S
STRPTOMYCIN
For example: 2HRZE / 4HR is the standard regime
AAFB
Acid and Alcohol Fast Bacilli
BCG
Bacillus Calmette-Guerin vaccine
26
DIPC
Director of Infection Prevention and Control
HAART
Highly active anti-retroviral therapy
HIV
Human Immunodeficiency Virus
IGRA
Interferon Gamma Assay
IPCN
Infection Prevention and Control Nurse
IPCDC
Infection Prevention and Control and Decontamination
Committee
MDR-TB
Multi Drug Resistant Tuberculosis
PA
Posterior-anterior
STH
Sheffield Teaching Hospitals
TB
Tuberculosis
ZN
Ziehl Neilson
11 Developmental Processes
11.1 Identification of need
The need for a revised Tuberculosis policy or procedure may be prompted by
changes in national legislation, policy or guidance. It may also be identified within
theTrust either as a result of learning from experience, such as incidents or
complaints, or as a result of an identified risk. New policies may also be required as
a result of the development of a new service or a new way of working.
To reduce organisational risk, the policies of Barnsley BDU, needed to be
harmonised with those of SWYPFT to recognise service provision changes. This
policy is intended to meet the needs of the organisation as a whole.
11.2 Stakeholder involvement
The organisation recognises that policies need to be developed in consultation and
communication with a range of stakeholders. The following list identifies some of the
individuals or groups who have been consulted in the development of this policy.
Stakeholder
Executive Management Team
Public Health
Level of involvement
Approval
Commissioning, development,
consultation, dissemination,
27
implementation and monitoring
Infection Prevention and Control Team
Consultation, dissemination,
implementation.
Drugs and Therapeutic Committee
Consultation, dissemination,
implementation
Business Delivery
Units,
Practice Consultation, dissemination, monitor
Governance Coaches, Managers
Staff side
Consultation
11.3 Equality Impact Assessment
The Trust aims to ensure its policies and procedures promote equality both as a
provider of services and as an employer. Please see Appendix 1 for quality impact
assessment
11.4Dissemination and implementation arrangements (including training)
This policy is available in read only format via the document store and web page on
the Trust intranet and internet. Staffs are informed of any changes to the policy via
the weekly update.
11.5 Implementation
Advice to assist with the implementation of this policy is available from the TB Team.
11.6 Training
The TB Team will offer training to staff, other services and agencies in a variety of
formats in order to accommodate the diversity of services.
11.7 Monitoring compliance
Regular COHORT reviews in place to audit all compliance and effectiveness.
11.8 Effectiveness of the policy
Any incidents of known non-compliance will be highlight through the Datix incident
reporting system.
11.9 Further advice and support
Please contact Health Integration Team / TB Service 01226 731686
12 Review and revision arrangements (including version control)
12.1 Process for reviewing the policy
The review date for this policy will be September 2018 and three yearly thereafter
unless otherwise indicated by an identified need for change.
28
12.2 Version control
This policy has been revised from its previous format and is version 1.
13 References and further reading
BHIVA treatment guidelines for TB/HIV infection, 2011
http://www.bhiva.org/documents/guidelines/TB/HIV_954_online_final .pdf
Department of Health Health Clearance for tuberculosis, hepatitis b, hepatitis and
HIV: New Health care workers http://www.dh.gov.uk
Department of Health (2009) The Health and Social Care Act (2008). A Code of
Practice for the NHS on the prevention and control of healthcare associated
infections and related guidance (update July 2015) http://www.dh.gov.uk
Department of Health 2007 The NHS (Charges for Drugs and Appliances)
Regulations (the Charges Regulations) 2007 http://www.dh.gov.uk
Immunisation against infectious disease (Green Book) DOH 2011 chapter 32
NICE. Tuberculosis: clinical diagnosis and management of Tuberculosis and its
measures for its prevention and control, March 2011 www.nice.org.uk
South West Yorkshire Partnership NHS Foundation Trust -Patient group directive for
BCG vaccination
South West Yorkshire Partnership NHS Foundation Trust Patient Specific Direction
for Mantoux Tuberculin skin test
Public Health England. Collaborative TB strategy for England 2015-2020 Public
Health England January 2015 http://www.gov.uk/phe
14 Any other policies which should be referred to
This document should be read in conjunction with
 Infection Prevention and Control Policy
 Isolation Policy
 Confidentiality Policy
 Occupational Health Policy
 Health and Safety Policy
29
Appendix One
Equality Impact Assessment Tool
8
Taking into account the
Evidence based Answers
information gathered above,
&Actions. Where negative impact
could this policy /
has been identified please explain
procedure/strategy affect any
what action you will take to
of the following group
remove or mitigate this impact.
unfavourably:
To be completed and attached to any policy document when submitted to the
Executive Management Team for consideration and approval.
1
2
3
4
5
Equality Impact Assessment
Questions:
Name of the document that you
are Equality Impact Assessing
Describe the overall aim of
your document and context
Who will benefit from this
policy / procedure / strategy
Who is the overall lead for this
assessment?
Who else was involved in
conducting this assessment?
Have you involved and
consulted service users, carers
and staff in developing this
policy / procedure / strategy?
Evidence based Answers and Actions
Tuberculosis Policy
The overall aim of the policy is to provide
staff with clear and practical evidence
based information that can be translated
into working practice within the context of
the Health and Social care Act (2008).
NICE Guidance (2011) Management of
Tuberculosis and Measures for its
Prevention and Control and other external
standards.
All staff
Director of nursing, Clinical Governance
and Safety
Lead Tuberculosis Nurse
The Executive Management Team was
consulted on the original development of
the policy. Feedback form Infection
Prevention and Control Team.
What did you find out and how
have you used this
information?
It was identified that staff required clear,
practical evidenced based information;
which needed to be easily accessible.
6
What equality data have you
used to inform this equality
impact assessment?
7
What does this data say?
Information gathered from nurse led New
entrant screening highlights an increase in
positive results and a requirement for
further assessment for individuals from
Eastern Europe
High proportion of positive results which
need a central focus
30
8.1
Race
Yes
8.2
8.3
8.4
8.5
8.6
8.7
8.8
8.9
8.10
Disability
Gender
Age
Sexual orientation
Religion or Belief
Transgender
Maternity and Pregnancy
Marriage and civil partnerships
Carers *SWYFT Trust
requirement*
No
No
No
No
No
No
No
No
No
9
What monitoring arrangements
are you implementing or already
have in place to ensure that this
policy/procedure/strategy
This policy aims to provide staff with clear
and practical evidence based information
relating to Tuberculosis prevention and
management of this.
9a
Promotes equality of opportunity
for people who share the above
protected characteristics;
Eliminates discrimination,
harassment and bullying for
people who share the above
protected characteristics;
Promotes good relation between
different equality groups
Public Sector Equality Duty “Due
Regard”
Have you developed as action
plan arising from this
assessment?
9a
9c
9d
10
11
Assessment / Action plan
approved by
12
Once approved you must
forward a copy of this
Assessment and Inclusion
Team:
[email protected]
Target areas with high population of
European Workers
Yes the development of Satellite clinics and
And health events target in areas with a
high population of Eastern European
workers
Signed: Bev Jones Date: 02/11/2015
Title: Team Leader / Lead TB Nurse
Please note that EIA is a public document
and will be published on the web. Failing to
complete an EIA could expose the Trust to
future legal challenge
31
Appendix two
Checklist for the Review and Approval of procedural Document
To be completed and attached to any policy document when submitted to EMT for
consideration and approval.
Title of document being reviewed:
1
2
3
4
5
6
7
Title
Is the title clear and unambiguous?
Is it clear whether the document is a
guideline, policy, protocol or standard?
Is it clear in the introduction whether this
document replaces or supersedes a
previous document?
Rationale
Are reasons for the development of the
document stated?
Development Process
Is the method described in brief?
Are people involved in the development
identified?
Do you feel a reasonable attempt has
been made to ensure relevant expertise
has been used?
Is there evidence of consultation with the
stakeholders?
Content
Is the objective of the document clear?
Is the target population clear and
unambiguous?
Are the intended outcomes described?
Are the statements clear and
unambiguous?
Evidence based
Is there type of evidence to support the
document identify explicitly?
Are key references cited?
Are the references cited in full?
Are supporting documents referenced
Approval
Does the document identify which
committee/ group will approve it?
If appropriate have joint Human
resources /staff side committee or
equivalent approved the document?
Dissemination and Implementation
Is there an outline /plan to identify how
Yes
Comments
/no/unsure
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
yes
yes
N/A
Yes
32
8
9
10
11
this will be done?
Does the plan include the necessary
training /support to ensure compliance?
Document control
Does the document identify where it will
be held?
Have archiving arrangements for
superseded documents been addressed?
Process to monitor compliance and
effectiveness
Are there measurable standards or KPIs
to support monitoring of compliance with
the effectiveness of the document?
Is there a plan to review or audit
compliance with the document?
Review date
Is the review date identified?
Is the frequency of review identified? If so
is it acceptable?
Overall responsibility for the
document
Is it clear who will be responsible for the
implementation and review of the
document?
yes
Yes
no
Previous Barnsley
PCT Policy currently
archived
Yes
Yes
Yes
Yes
Yes
Date of Assessment: 09/11/2015
33