Tuberculosis (TB) Policy

Tuberculosis (TB) Policy
Reference Number:
604
Author & Title:
Julia Bloomfield, Infection Prevention and Control
Nurse
Responsible Directorate:
Corporate
Review Date:
October 2014
Ratified by (committee):
Operational Governance Committee
Date Ratified:
October 2011
Version:
10
•
•
•
Related Procedural documents
•
•
•
Cleaning Policy for Infected Ward Areas
Hand Decontamination Policy
Universal/ Standard Infection Control
Precautions
Isolation Policy
Staff Health Policy
Incident reporting and management etc. policy
(213)
Index:
Tuberculosis (TB) Policy _____________________________________________ 1
1.
Introduction ___________________________________________________ 3
2.
Purpose of this policy ___________________________________________ 3
3.
Infectivity______________________________________________________ 3
4.
Diagnosis _____________________________________________________ 4
5.
Treatment _____________________________________________________ 6
6.
Staff Responsibilities ____________________________________________ 6
6.1
Senior Sisters/Charge Nurses ___________________________________ 6
6.2
Infection Prevention and Control Team ___________________________ 6
6.3
Respiratory Nurse Specialist ___________________________________ 6
6.4
Occupational Health___________________________________________ 6
6.5
All Healthcare Staff ___________________________________________ 6
6.6
Respiratory Physician _________________________________________ 7
7.
Infection Prevention and Control Precautions _______________________ 7
7.1
7.2
7.3
NON RESPIRATORY TB __________________________________________ 7
RESPIRATORY TB (not MDR TB suspected or confirmed) _____________ 7
MULTI DRUG RESISTANT TUBERCULOSIS (MDRTB) _________________ 9
8.
Cleaning _____________________________________________________ 10
9.
TB and Staff __________________________________________________ 10
10.
Contract Tracing_____________________________________________ 11
10.1
Cases in hospital inpatients ___________________________________ 11
11.
Monitoring Compliance _______________________________________ 12
12.
References _________________________________________________ 12
Appendix 1:
Consultation Schedule ________________________________ 14
Appendix 2:
Isolation Decisions: Patients with Suspected Respiratory TB 15
Appendix 3:
TB Patient Contact Tracing Form _______________________ 15
Appendix 4:
Staff Contact Tracing Form ____________________________ 17
Equality Impact Assessment Tool ____________________________________ 18
Ratification Checklist_______________________________________________ 19
Document Name: Tuberculosis Policy
Issue Date: October 2011
Ref: 604
Status: Approved
Page 2 of 19
1.
Introduction
This policy applies to all individuals in the employ of the Royal United Hospital
Bath NHS Trust and it is specifically aimed at staff who are likely to come into
contact with patients who have known or suspected tuberculosis.
Tuberculosis (TB) is one of the most common diseases worldwide particularly
in developing countries. It is now increasing in western countries due to the
immunocompromised (e.g. HIV patients) and poor communities (Irving et al
2005). There are approximately nine million new cases of TB and nearly two
million deaths each year around the world (Health Protection Agency - HPA
2009a).
In the UK, 8679 new cases of tuberculosis have been reported in 2008. Fifty-two per
cent of cases were reported to have pulmonary TB. London continued to account for
the greatest proportion of cases (39%) (HPA 2009b).
TB is a slowly progressing chronic disease of humans and animals caused mainly by
Mycobacterium tuberculosis, less commonly by M.bovis and rarely by M.microti and
M.africanum.
Mycobacteria are aerobic, slow growing, Gram positive, intracellular bacilli. M.
tuberculosis primarily infects the lungs leading to respiratory TB but it can also infect
other organs including bone, kidneys and meninges (Irving et al 2005). This is what is
commonly known as tuberculosis. The organism can survive in the body for many
years in a dormant or inactive state. In this instance people are infected, but non
infectious and show no signs of TB disease, this is called latent TB.
2.
Purpose of this policy
To ensure that staff care for patients with Tuberculosis (TB) safely. It also
gives operational guidance on when to isolate patients, when and how to use
personal protective equipment and other infection control precautions.
Occupational Health guidance for staff is also included.
3.
Infectivity
Only the pulmonary form of TB disease is infectious (some surgical
procedures and post mortems can transmit to TB to staff). Transmission
occurs through coughing of infectious droplets, and usually requires prolonged
close contact with an infectious case (HPA 2009a).
TB develops slowly in the body and it usually takes several months for
symptoms to appear.
Any of the following symptoms may suggest TB:
• Fever and night sweats
Document Name: Tuberculosis Policy
Issue Date: October 2011
Ref: 604
Status: Approved
Page 3 of 19
•
•
•
Persistent cough
Losing weight
Blood in the sputum (phlegm or spit) at any time
Anyone exposed to TB bacteria can be infected but people at particular risk
are:
• Those who are close contacts of infectious cases
• People who have lived in, travel to or receive visitors from places
where TB is still very common
• Immunocompromised
• The very young and the elderly
•
•
•
People living in overcrowded, poor housing
Those who are dependent on drugs or alcohol
People with chronic poor health
General measures of prevention include isolation of patients with active TB,
effective treatment, contact tracing close contacts and offering
chemoprophylaxis, improved social conditions and nutrition. BCG
immunisation is only 70% protective in the UK and is not universally
considered effective (Irving et al 2005). Therefore the schools' immunisation
programme nationally has been replaced by targeted immunisation of children
at increased risk of TB (HPA 2009a).
4.
Diagnosis
TB can be detected in sputum smears, tissue biopsies or detection of mycobacterial
DNA by PCR (Irving et al 2005). The Mantoux test is a skin test based on the body’s
cell-mediated immune reaction to antigens in mycobacteria, but is not specific for M.
tuberculosis. It is usually positive in those who have received BCG vaccination.
Mantoux tests are often falsely negative in patients who are immunosuppressed.
Interferon gamma release assays (IGRA) are also available which exploit the body’s
immune cell (T-lymphocytes) response to determine whether a person has been
infected with M. tuberculosis (HPA 2009a). IGRA tests do not react to BCG.
To diagnose latent TB: (NICE 2011):
• Mantoux testing should be performed
• Those with positive results (or in whom Mantoux testing may be
less reliable) should then be considered for interferon-gamma
immunological testing, if available.
To diagnose active respiratory TB: (NICE 2011):
• PA chest X-ray should be taken;
• Minimum of 3 sputum samples should be sent for TB
microscopy and culture for suspected respiratory TB before
starting treatment if possible or, failing that, within 7 days of
starting
Document Name: Tuberculosis Policy
Issue Date: October 2011
Ref: 604
Status: Approved
Page 4 of 19
•
Bronchoscopy and bronchial washings or bronchoalveolar
lavage may be necessary to obtain samples in patients who are
not producing sputum.
To diagnose active non-respiratory TB: (NICE 2011):
• The advantages and disadvantages of both biopsy and needle
aspiration should be discussed with the patient, with the aim of
obtaining adequate material for diagnosis
Table 1.
Suggested site-specific investigations in the diagnosis and
assessment of non-respiratory TB (NICE 2011)
Site
Imaging
Lymph node
Biopsy
Culture
• Node
• Node or aspirate
• Plain X-ray and
• Site of disease
computed tomography
(CT)
• Magnetic resonance
imaging (MRI)
• Ultrasound
• Omentum
• CT abdomen
• Bowel
• Biopsy or paraspinal abscess
• Site or joint fluid
Genitourinary
• Intravenous urography • Site of disease
• Ultrasound
Disseminated
• High-resolution CT
thorax
• Ultrasound abdomen
• Lung
• Liver
• Bone marrow
Central nervous
system
• CT brain
• MRI
• Tuberculoma
• Early morning
urine
• Site of disease
• Endometrial
curettings
• Bronchial wash
• Liver
• Bone marrow
• Blood
• Cerebrospinal
fluid
Bone/joint
Gastrointestinal
Skin
• Biopsy
• Ascites
• Site of disease
• Site of disease
Pericardium
• Echocardiogram
• Pericardium
• Pericardial fluid
Cold/liver
abscess
• Ultrasound
• Site of disease
• Site of disease
Document Name: Tuberculosis Policy
Issue Date: October 2011
Ref: 604
Status: Approved
Page 5 of 19
5.
Treatment
Full guidelines can be found in the TB Management Guidelines (NICE 2011)
at http://www.nice.org.uk/guidance/index.jsp?action=byID&o=13422
6.
Staff Responsibilities
6.1
•
6.2
•
•
•
•
•
6.3
Senior Sisters/Charge Nurses
Ensure all staff have access to this policy and have sufficient supplies
of Personal Protective Equipment required.
Infection Prevention and Control Team
Review and update Tuberculosis policy regularly
Give additional advice regarding safe practice where required
Include information on TB in all induction and update training for clinical
staff
Promote good practice and challenge poor practice
Conduct contact tracing if required.
•
Respiratory Nurse Specialist
Notify CCDC
Enter details onto national database
Conduct contract tracing if required
Visit in-patients providing information
Liaise with ward staff for support and advice
Liaise with GP.
Follow up and monitoring of treatment of index case
Assistance with arranging Tuberculin skin testing and interferon
gamma release assays
Provision of information leaflets
•
•
•
•
Occupational Health
Ensure all staff have TB health checks prior to commencement of work
Provide immunisation to all staff if required
Conduct contact tracing for staff if required
Provide information on the signs and symptoms of TB to staff
•
•
•
•
•
•
•
•
6.4
6.5
•
•
•
•
All Healthcare Staff
Must be familiar with and adhere to the relevant infection control
policies to reduce the risk of cross infection of patients
Promote good practice and challenge poor practice
Report any TB symptoms promptly to Occupational Health
Ensure the patients infection control status is discussed in any
discharge summary written.
Document Name: Tuberculosis Policy
Issue Date: October 2011
Ref: 604
Status: Approved
Page 6 of 19
•
6.6
Collecting details of inpatient contacts of sputum smear positive TB
using the forms at the end of the policy
Respiratory Physician
•
Assistance with diagnosis
• Medication prescribing
• Follow up of all TB patients (including non-respiratory)
7.
Infection Prevention and Control Precautions
Please refer to the most appropriate section depending on the patient’s
diagnosis.
7.1
NON RESPIRATORY TB
Isolation requirements
TB smear negative pulmonary infection and TB infection at other sites, e.g.
renal tract, joints, are much less infective and do not require isolation.
However aerosol-generating procedures such as abscess or wound irrigation,
may require isolation in a single room.
Personal Protective Equipment
Use Standard Universal Precautions as required, when in contact with bodily
fluids with respect to the use of aprons and gloves.
7.2
RESPIRATORY TB (not MDR TB suspected or confirmed)
Isolation requirements (See Appendix 1)
• Suspected or confirmed cases of respiratory TB (who are still
considered infectious) must be admitted to an Isolation Room with ensuite facilities and should remain there for 14 days following start of
treatment or until discharged home. For MDR TB see procedures
below.
• The isolation room door must remain closed with an isolation sign
on the outside.
• Aerosol-generating procedures such as sputum induction or nebuliser
treatment should only be carried out in an Isolation Room.
Bronchoscopes’ will be undertaking in the Endoscopy Department with
full Personal Protective Equipment as explained below.
•
Patients with respiratory TB should be separated from HIV positive
patients or other immunocompromised patients, by admission to a
single room on a separate ward; Advice from the Infection Control
Team is advised. A Patient with TB and a Patient with HIV must not be
nursed on the same ward.
Document Name: Tuberculosis Policy
Issue Date: October 2011
Ref: 604
Status: Approved
Page 7 of 19
Personal Protective Equipment
• Standard Universal Precautions should be adopted, with respect to the
use of aprons and gloves.
• Masks are not required for routine care.
•
FFP2 masks are required for aerosol generating procedures only.
However if MDR- TB is suspected FFP3 masks must be used at all
times. See page 9
•
FFP2 respirator mask should be worn for aerosol generating
procedures only i.e. Intubation and other ventilation procedures,
suction, chest physiotherapy, bronchoscopy, non invasive ventilation
and nebuliser treatment or on the advice of the Infection Control Team.
FFP2 respirator masks should be applied and removed as per
manufacturer’s instructions. They are single use items and must be
disposed of as clinical waste.
•
If the patient needs to leave their single room i.e. to visit the X-ray
Department, the patient should wear a surgical mask until they have
had 2 weeks treatment.
•
Patients should receive training and supplies to ensure that they cough
into tissues or cover their mouths when tissues are not available.
Time Period That Precautions Apply
If hospital care is required respiratory cases of TB must be nursed in isolation
until discharge or until all of the following have been achieved:
•
•
•
•
two weeks of appropriate drug therapy
tolerance of the prescribed treatment
ability and agreement to adhere to the prescribed treatment
Signs of clinical improvement for example remaining afebrile
for a week.
If patients are transferring to areas where they are coming into contact with
HIV positive or immunocompromised patients, they must have at least three
negative sputum microscopy smears, taken on separate occasions, over a
minimum of 14 days plus any cough must have resolved completely in
addition to above.
Visitors
Household contacts may visit and will be offered screening by the respiratory
nurse specialist. For sputum smear positive patients, other visitors should be
discouraged from attending for the first two weeks of treatment and if they
chose to visit should be offered masks to wear in the side room.
Document Name: Tuberculosis Policy
Issue Date: October 2011
Ref: 604
Status: Approved
Page 8 of 19
7.3
MULTI DRUG RESISTANT TUBERCULOSIS (MDRTB)
Multi-drug resistant (MDR) TB describes strains of TB that are resistant to at
least isoniazid and rifampicin, two of the first line drugs used in the treatment
of TB.
Extensively drug resistant TB (XDR-TB) refers to MDR-TB that is also
resistant to any of a group of drugs called fluoroquinolones and at least one of
three injectable second line anti-TB drugs (capreomycin, kanamycin or
amikacin). (HPA2009a).
In the UK in 2005, only 1.1% of all TB isolates were classed as MDR, only a very
small proportion of which may now be classed as XDR-TB using the new definition.
There is no suggestion that XDR-TB cases are increasing in the UK (HPA 2009a)
A risk assessment for drug resistance and HIV should be made for each
patient with TB, based on the following risk factors:
•
•
•
•
•
•
•
•
History of prior TB drug treatment or prior TB treatment failure
Failure to respond clinically to treatment with standard anti-tuberculosis
therapy or remains culture positive after 4th month of treatment.
Contact with a known case of MDRTB
HIV infection
Birth or residence in a foreign country, particularly high incidence
countries. (Countries with more than 40 cases per 100,000 per year as
listed by the Health protection agency – www.hpa.org.uk and search for
‘ WHO country data TB’)
Residence in London
age profile, with highest rates between ages 25 and 44
male gender
Isolation requirements
• Adults and children with suspected or known infectious MDR TB
must be admitted to a negative-pressure isolation room
immediately. As the RUH does not have this facility, the patient
should be transferred to the John Radcliffe NHS Trust in Oxford or
Southampton University Hospitals NHS Trust which has appropriate
negative pressure isolation rooms for the management of these
patients.
•
Alternative arrangements can be sourced through the local Health Protection
Unit, Avon Health Protection Team Tel. 0117 9002620
Personal Protective Equipment
•
Standard Universal Precautions for care should be adopted, with
respect to the use of aprons and gloves.
•
FFP3 respirator masks must be worn by all staff and visitors during
all patient contact whilst that patient is considered infectious. FFP3
Document Name: Tuberculosis Policy
Issue Date: October 2011
Ref: 604
Status: Approved
Page 9 of 19
respirator masks are single use items and following use must be
disposed of as clinical waste.
Time Period That Precautions Apply
• If patients have MDRTB, precautions must only be discontinued after
consultation with the respiratory and infection control teams.
8.
Cleaning
Deep cleaning of the patient’s room is required on discharge. See Cleaning
of Infected Areas Policy
9.
TB and Staff
New employees
New employees to the trust must be seen by the Occupational Health
Department for a TB screen or health check prior to the commencement of
work if they are unable to provide documentary evidence of a BCG
vaccination or previous positive immunity check from GP records or an
Occupational Health Department.
A TB Screen will include:
1.
2.
3.
assessment of personal or family history of TB
symptom and signs enquiry, possibly by questionnaire
documentary evidence of TB skin testing (or interferon-gamma
testing) and/or BCG scar check by an occupational health
professional, not relying on the applicant’s personal assessment
4. Mantoux result within the last 5 years, if available.
If a new employee has no evidence of prior BCG vaccination or positive
immunity check, a Mantoux or interferon-gamma test must be performed. Line
manager will be notified if refused.
BCG vaccination will be offered to new employees, whatever their age, if they
will have contact with patients and/or clinical specimens, are Mantoux
negative (less than 6 mm) and have not been previously vaccinated.
Employees should have an individual risk assessment before BCG
vaccination is given.
New employees from countries of high TB incidence, or who have had contact
with patients in settings with a high TB prevalence should have a Mantoux
test. If positive (6 mm or greater), the person should be referred for clinical
assessment for TB disease.
Document Name: Tuberculosis Policy
Issue Date: October 2011
Ref: 604
Status: Approved
Page 10 of 19
If a new employee, without prior BCG vaccination, has a positive Mantoux or
interferon-gamma test, they should have a medical assessment and a chest
X-ray. If required they should be referred to a TB clinic for consideration of TB
treatment if the chest X-ray is abnormal, or for consideration of treatment of
latent TB infection if the chest X-ray is normal.
If a prospective or current healthcare worker who is Mantoux negative (less
than 6 mm) declines BCG vaccination, the risks should be explained and the
oral explanation supplemented by written advice. If the person still declines
BCG vaccination, he or she should not work where there is a risk of exposure
to TB. The employer will need to consider each case individually, taking
account of employment and health and safety obligations.
Occupational health management
Staff that are in regular contact with TB patients, clinical materials or have
worked in a high-risk clinical setting for 4 weeks or longer must be notified of
the risks, signs and symptoms of TB on commencement of work, during and
following contact.
Healthcare workers who are found to be HIV-positive during employment
should have medical and occupational assessments of TB risk, and may need
to modify their work to reduce exposure.
10. Contract Tracing
Contact Tracing must be undertaken once a person has been diagnosed
with active TB, the diagnosing physician should inform the TB Specialist
Nurse and Infection Control Team so that contact tracing can be assessed
without delay. Contract Tracing Forms can be found in appendix 3 & 4.
10.1 Cases in hospital inpatients
Following diagnosis of TB in a hospital inpatient, a risk assessment should be
undertaken with advice from the infection control team or respiratory nurse
specialists. This should take into account:
•
•
•
•
the degree of infectivity of the index case
the length of time before the infectious patient was isolated
whether other patients are unusually susceptible to infection
the proximity of contact.
Contact tracing and testing should be carried out only for patients for whom the risk is
regarded as significant.
Patients should be regarded as at risk of infection if they spent more
than 8 hours in the same bay as an inpatient with sputum smear-positive
TB who had a cough. The risk should be documented in the contact’s
clinical notes, for the attention of the contact’s consultant. The contact should
be given ‘Inform and advise’ information, and their GP should be informed.
Document Name: Tuberculosis Policy
Issue Date: October 2011
Ref: 604
Status: Approved
Page 11 of 19
This notification of exposure to patients and GPs is part of contact tracing and
is the responsibility of the respiratory nurse. The ward staff are responsible for
completing appendix 2 to assist with this process.
If patients were exposed to a patient with sputum smear-positive TB for long
enough to be equivalent to household contacts (as determined by the risk
assessment), or an exposed patient is known to be particularly susceptible to
infection, they should be managed as equivalent to household contacts. This
information can be found in the Tuberculosis Management Guidelines (NICE
2011) at www.nice.org.uk/guidance/CG33
If an inpatient with sputum smear-positive TB is found to have MDR TB, or if
exposed patients are HIV-positive, contact tracing should be in line with The
Interdepartmental Working Group on Tuberculosis guidelines 1998 found
at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyA
ndGuidance/DH_400619698.
In cases of doubt when planning contact tracing after diagnosing sputum
smear-positive TB in an inpatient, further advice should be sought from the
regional or national Health Protection Agency.
11. Monitoring Compliance
Monitoring of compliance against this policy will be done by review of
incidents reported to the Infection Prevention and Control Team and the
Respiratory Nurse Specialists.
Incidents will be reported through the divisional governance meetings and
actions monitored this route and also at the Saving Lives Implementation
Committee.
12. References
Health Protection Agency (2009a) Tuberculosis. Available
from http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Pa
ge/1191942150134?p=1191942150134 (accessed September 2011).
Health Protection Agency (2009b) Tuberculosis General Information March 2009.
Available
from http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Tuberculosis/Ge
neralInformation/ (accessed September 2011).
Irving W, Boswell T & Ala’Aldeen D (2005) Medical Microbiology. Abingdon. Taylor
and Francis.
Document Name: Tuberculosis Policy
Issue Date: October 2011
Ref: 604
Status: Approved
Page 12 of 19
NICE – National Institute for Health and Clinical Excellence (2011). Clinical diagnosis
and management of tuberculosis and measures for its prevention and
control. Clinical Guideline 117 developed by the National Collaborating Centre for
Chronic Conditions. Available
from http://www.nice.org.uk/nicemedia/live/13422/53643/53643.doc (accessed
September 2011).
The Interdepartmental Working Group on Tuberculosis. (1998)The prevention and
control of tuberculosis in the United Kingdom: UK guidance on the prevention and
control of transmission of 1. HIV – related tuberculosis 2. Drug – resistance, including
multiple drug resistance, tuberculosis. London. Department of Health.
Document Name: Tuberculosis Policy
Issue Date: October 2011
Ref: 604
Status: Approved
Page 13 of 19
Appendix 1:
Consultation Schedule
Name and Title of Individual
Date Consulted
Yvonne Pritchard - Senior Infection
Prevention and Control Nurse
Dr Mohammed Abrishami - Consultant
Microbiologist & Infection Control Doctor
Dr Sarah Meisner – Consultant Microbiologist
Infection Prevention and Control Team
Mark Grover - Respiratory Nurse Specialist
Dr Noeleen Foley – Consultant Respiratory
Physician
Dr Vidan Masani- Consultant Respiratory
Physician
Suzie Slade – Respiratory Ward Manager
Jo Miller - Assistant Director of Nursing
Patient Safety/Assistant DIPC
Gareth Howells - Assistant Director of
Nursing for Medicine
Stephen Roberts – Occupational Health
Manager
Neil Boyland – Matron Critical Care Services
September 2011
September 2011
June 2009
September 2011
September 2011
September 2011
August 2009
September 2011
September 2011
August 2009
June 2009
October 2009
Name of Committee
Date of Committee
Specialty Division
SLIC
Medical Division
Surgical Division
Policy Group
7th July 2009
October 2009
6th August 2009
October 2009
December 2009
Document Name: Tuberculosis Policy
Issue Date: October 2011
Ref: 604
Status: Approved
Page 14 of 19
Appendix 2: Isolation Decisions: Patients with
Suspected Respiratory TB
Yes
No
Known or
suspected
MDR TB
(see page
Admit to Negative
Pressure Room
Admit to single
room
No
Sputum
smear
positive (1
or more
from 3
Clinical
high risk
of TB
No
Yes
Yes
Risk
identified
for MDRYes
TB
No
Standard
ward
Yes
Does ward
have
immunocompromis
ed patients
Yes
Negative
Pressure
Room
No
Single side room
Appendix 3:
TB Patient Contact Tracing Form
Document Name: Tuberculosis Policy
Issue Date: October 2011
This form is to Ref:
be completed
by the
604
nurse in chargeStatus:
and toApproved
be used in cases
of19
confirmed or suspected smear positive
Page 15 of
pulmonary TB.
Completed forms should be sent to the
respiratory nurse specialist.
Date……………………………………………
Name of person completing form…………..
Name of index case……………………...…..
Ward…………………………………………...
Date of Admission……………………………
Date of Positive Culture……………………..
Add all patients that have shared the same area for 8 hours or more with the index
case in the table below.
Patient Name
Hosp
DOB
Date of
G.P. Name/telephone
/Address
No
admission
Address
If there are any queries contact Respiratory Nurse Specialist Mark Grover Ext 1499
or Infection Control Nurses Ext 4754
Document Name: Tuberculosis Policy
Issue Date: October 2011
Ref: 604
Status: Approved
Page 16 of 19
Appendix 4:
Staff Contact Tracing Form
Date ………………………………………...
This form is to be completed by the
Name of person completing………………
nurse in charge and to be used in cases
Index Case…………………………………
of confirmed or suspected smear positive
Ward ……………………………………….
pulmonary TB.
Date of Admission ………………………..
Completed forms should be sent to the
Date of positive culture……………………
occupational health department
Add the names of all staff who have been closely involved with index case to the list
below. For example
Staff who have performed Aerosol generating procedures i.e. mouth to mouth
resuscitation, intubation, chest physiotherapy or prolonged high dependency care,
before the diagnosis of TB was made, may be managed as "close contacts" for
contact purposes.
Name
DOB
Area worked
Date
If there are any queries please contact Occupational Health
Document Name: Tuberculosis Policy
Issue Date: October 2011
Ref: 604
Status: Approved
Page 17 of 19
Equality Impact Assessment Tool
To be completed and attached to any procedural document when submitted to the
appropriate committee for consideration and approval
Initial Screening
1. Policy, service, strategy, procedure or function: Policy
2. Lead (e.g. Director, Manager, Clinician):
Francesca Thompson
3. Person responsible for the assessment:
Name: Julia Bloomfield
Job Title: Infection Control Nurse
4. Is this a new or existing policy, service strategy, procedure or function?
New
Existing
5. Who is the policy/service strategy, procedure or function aimed at?
Patients
Carers
Any other
Please specify:
Staff
Visitors
6. Are any of the following groups adversely affected by the policy?
If yes is this high, medium or low impact (see attached notes):
Group
Disabled people:
Race, ethnicity & nationality
Male/Female/transgender:
Age, young or older people:
Sexual orientation:
Religion, belief and faith:
No
No
No
No
No
No
Affected?
Yes
Yes
Yes
Yes
Yes
Yes
High
High
High
High
High
High
Impact
Medium
Medium
Medium
Medium
Medium
Medium
Low
Low
Low
Low
Low
Low
If the answer is yes to any of these proceed to full assessment.
This applies whether the impact assessment is high, medium or low.
If the answer is no to all categories, the assessment is now complete
7. Does the policy, service strategy, procedure or function
include measures which promote equality?
8. If yes, what are these measures?
No
Yes
Ratification Checklist
Author; attach this to each copy of the policy being sent to a Committee for final ratification.
Dear Chairman
Please would you review this document at your next meeting and agree final approval and
organisational ratification.
Title of meeting: Operational Governance Committee
Date of meeting: October 2011
Title and Reference of document: Tuberculosis Policy
Name of author: Julia Bloomfield
Are there any elements of this policy which present
operational issues that require further discussion? If yes,
please provide a contact name for the author.
Yes
No
N/A
Does the document include a training plan?
Yes
No
N/A
Is the policy referenced?
Yes
No
N/A
Are up to date National Guidelines included?
Yes
No
N/A
If you are the appropriate forum, have the necessary
resources been agreed to implement this document?
Yes
No
N/A
Is there a plan for policy implementation?
Yes
No
N/A
Does your meeting recommend further consultation with
groups or staff other than listed at the front of the policy?
Yes
No
N/A
What are the cost implications of implementing this policy?
Yes
No
N/A
Equipment
£
Yes
No
N/A
Staffing (additional)
£
Yes
No
N/A
Training
£
Yes
No
N/A
Other
£
Yes
No
N/A
Document endorsed without further comment?
Yes
No
Further amendments to document suggested?
Yes
No
Name of Chair:
Carol Peden
Signature: ________________________________ Date: ________________________
Document name: Tuberculosis Policy
Issue date:
Ref.: 604
Status: Final
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