NUH Drugs and Therapeutics Committee Joint Formulary Group. NUH Antimicrobial Guidelines Committee. April January 2019

Transcription

1 Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc.) Author: Contact Name and Job Title Directorate & Speciality Adults and Children Guidelines for Patients with Absent or Dysfunctional Spleen Sarah Partridge (Antimicrobial Pharmacist) Anneka Sareen (Senior Clinical Pharmacist) Diagnostics and Clinical Support Date of submission January 2016 Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Version 5.2 All patients (including children and adults) with an absent or dysfunctional spleen Changes from previous guideline If this version supersedes another clinical guideline please be explicit about which guideline it replaces including version number. Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-6) 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a 2b 3a 3b meta-analysis of randomised controlled trials at least one randomised controlled trial at least one well-designed controlled study without randomisation at least one other type of well-designed quasiexperimental study 4 well designed non-experimental descriptive studies (i.e. comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process Ratified by: Date: Target audience Review Date: (to be applied by the Integrated Governance Team) Men. B (Bexsero) s incorporated in line with new DoH guidance. Layout changed and contents page added. July 2015 minor amendment: reference to sickle cell patients is made. August 2015 amendments made to schedule in line with Chapter 22 - Meningococcal update. Version 4.0 guideline no These guidelines have been produced by microbiology and pharmacy infectious diseases, References include: Department of Health Immunisation against infectious disease The Green Book Updated version available online: John M. Davies et al. Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. British Journal of Haematology, 2011; 155, Summary of Product Characteristics - Prevenar 13 Pfizer - Sept 2014 Summary of Product Characteristics - Pneumococcal Polysaccharide Vaccine - Sanofi Pasteur MSD June 2014 Summary of Product Characteristics - Menitorix GlaxoSmithKline - Oct 2013 Summary of Product Characteristics - Menveo Novartis Oct 2014 Summary of Product Characteristics - Bexsero Novartis Oct 2014 BNF for Children BMJ Group, RPS and RCPCH Publications Personal correspondence with Public Health England: August NUH Antimicrobial Guidelines Committee NUH Drugs and Therapeutics Committee Joint Formulary Group NUH Antimicrobial Guidelines Committee April 2015 All Trust Doctors, Pharmacists January 2019 A review date of 5 years will be applied by the Trust. Directorates can choose to apply a shorter review date; however this must be managed through Directorate Governance processes. This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. Page 1 of 18

2 Adults and Children Guidelines for Patients with Absent or Dysfunctional Spleen Contents 1. Introduction 2. Identification of patients 3. Vaccination guidelines 4. Antibiotics prophylaxis guidelines 5. Additional information Page NUH Splenectomy Audit Form Equality Impact Assessment Report Page 2 of 18

3 Adults and Children Guidelines for Patients with Absent or Dysfunctional Spleen 1. Introduction Patients with an absent or dysfunctional spleen have an increased risk of complications from infectious diseases. These guidelines outline the appropriate s and antibiotic prophylaxis that should be given. 2. Identification of patients with an absent or dysfunctional spleen Clear identification of these patients is essential, so as to prevent fever being misdiagnosed as viral, before bacterial infection has been ruled out. All information concerning immunisation and antibiotic prophylaxis must be conveyed to the patient s GP, using the notification letter - available on the intranet via the antibiotic website: nectomy/asplenicpatients.aspx. Patients should be given, and encouraged to carry, a Department of Health (DH) splenectomy-warning card which can be obtained from pharmacy. (Surgical satellite pharmacy at QMC campus, ext and the inpatient pharmacy at the City campus ext ). Patients can also sign up for Medic-Alert bracelets ( or Freephone ). 2.1 Selective embolisation of the spleen This is performed for a number of indications, in particular splenic trauma. The clinician performing the procedure should decide and document if splenic function is likely to be preserved. If hyposplenism is expected then the patient should be managed according to this guideline. Page 3 of 18

4 2.2 Sickle Cell Patients Patients with sickle cell disease should be regarded as hyposplenic and be managed according to this guideline. Re-vaccination with a pneumococcal is important and is normally recommended every 5 years for life. 3. Vaccination guidelines for immunising individuals with absent or dysfunctional spleen 3.1 When to immunise and give antibiotics? Figure 1: Outline of when immunisations and antibiotics should be given. When to Immunise ELECTIVE SPLENECTOMY EMERGENCY SPLENECTOMY Immunise at least TWO (ideally four to six) weeks prior to surgery, normally given by GP. Prophylactic antibiotics to start immediately post-surgery. Immunise at least TWO weeks post-surgery and when sufficiently well. Antibody response to pneumococcal is poorer if it is given within two weeks of splenectomy. Note - prophylactic antibiotics to be started immediately post-surgery. 3.2 Recommended schedules for immunisation Schedules for immunising individuals with absent or dysfunctional spleen vary depending on the age at which their condition is first diagnosed. See table 1 for infants under 2 years old and table 2 for children (> 2 years old) and adults. Page 4 of 18

5 Table 1: Vaccination schedule for infants under 2 years old Age at which patient presents with splenectomy or splenic dysfunction Vaccine doses (infants) 0.5ml IM (Meningococcal Group B ) Influenza 0.5ml IM (Influenza ) Menitorix 0.5ml IM (Haemophilus influenza type b plus meningococcal C Hib/MenC) 0.5ml IM (Meningococcal ACWY conjugate ) Pneumococcal 0.5ml IM (PPV) Prevenar ml IM (Pneumococcal conjugate (adsorbed) PCV 13) NeisVac-C 0.5ml IM (Meningitis C conjugate -MenC) Month 0 Month 1 Month 2 Later Under 6 months Complete routine childhood immunisation schedule including booster doses Prevenar-13. If NeisVac-C not already given give Menveo instead. Note: 3 doses of Bexsero should be given at 2, 3 and 4 months* (at least 1 month apart). A dose of Menveo conjugate should be given at least one month after the NeisVac-C / Menveo and Prevenar-13 booster doses A Bexsero booster and additional doses of Prevenar- 13 and Menveo should be given at least 2 months after 12-month boosters. After the second birthday, one additional dose of Menitorix and a dose of Pneumococcal should be given at least 2 months after the last dose of Prevenar-13 First diagnosed at 6-11 months (previous s up to date) Note routine 12 month boosters should additionally be given If NeisVac-C not already given as part of routine schedule- give Menveo instead. A dose of Bexsero should be given if not previously received as part of routine childhood immunisations Give Influenza (if Sept.- April). An additional dose of Menveo should be given at least one month after previous dose of NeisVac-C / Menveo. If not given as part of routine childhood immunisations, an additional dose of Bexsero should be months after last dose of Bexsero (may be given with 12-month boosters). Additional doses of Prevenar- 13 and Menveo should be given at least 2 months after 12 month Menitorix booster given as part of routine schedule. After the second birthday, one additional dose of Menitorix, Bexsero booster and a dose of Pneumococcal should be given at least 2 months after the last dose of Prevenar-13 First diagnosed at months (previous s up to date) If not yet administered give routine 12-month boosters. Give Influenza (if Sept.- April). Additionally Bexsero should be given if not previously received as part of routine childhood immunisations Additional doses of Prevenar-13 and Menveo should be given at least 2 months after 12 month Menitorix and Prevenar-13 boosters. If not give as part of routine childhood immunisations, an additional dose of Bexsero should be months after last dose of Bexsero After the second birthday, one additional dose of Menitorix, and a dose of Pneumococcal should be given at least 2 months after the last dose of Prevenar-13 A Bexsero booster should be given months after primary course. *Prophylactic paracetamol is advised where Bexsero is given with the routine s in infants under one year of age. Three 2.5ml doses of liquid paracetamol (infant paracetamol 120mg/5ml) should be given orally, with the first dose provided as soon as possible after vaccination, and two subsequent doses at intervals of four to six hours. Page 5 of 18

6 Table 2: Vaccination schedule for children over 2 years old and adults Vaccine doses (adult and children) Bexsero 0.5ml IM (Meningococcal Group B ) Influenza 0.5ml IM (Influenza ) Menitorix 0.5ml IM (Haemophilus influenza type b plus meningococcal C Hib/MenC) Menveo 0.5ml IM (Meningococcal ACWY conjugate ) Pneumococcal 0.5ml IM (PPV) Prevenar ml IM (Pneumococcal conjugate PCV 13) Over 2 years but under 5 years (Previously fully vaccinated inc. Prevenar- 13 ) Over 2 years but under 5 years (Previously fully vaccinated inc. Prevenar- 7 ) Over 2 years but under 5 years (Unvaccinate d or previously partially vaccinated with Prevenar 7 ) Month 0 Month 1 Month 2 Later Pneumococcal (if not months after last previously received) Menitorix dose. Influenza (if Prevenar-13 (if not previously received) Influenza (if Prevenar-13 Influenza (if (if not previously received) Pneumococcal months after last Menitorix and Prevenar-13 Prevenar-13 months after last Menitorix Pneumococcal This should be given at least two months after last Prevenar- 13 Over 5 years of age but under 11 years old (Vaccination history irrelevant). Over 11 years old including adults (Vaccination history irrelevant). Pneumococcal Influenza (if Pneumococcal Influenza (if given at least one month after last Menitorix dose. months after last Menitorix dose. Page 6 of 18

7 3.3 Re-immunisation Recommendations of which s should be re-administered are detailed below in table 3. Table 3: Recommendations for re-immunisation Influenza Pneumococcal Yearly - from Sept. to Nov. Usually required every 5 years for life (Antibody levels may decline more rapidly in some patients and therefore pneumococcal antibody level testing may help guide timing of vaccinations. Contact Immunology for further advice.) 3.4 Informing health-professionals It is essential that a pre-printed letter is completed and sent to the GP outlining which s have been administered by NUH, see appendix 1. This is available from the antibiotics website: nectomy/asplenicpatients.aspx. 3.5 Administration of s For elective splenectomies, vaccinations should be administered by the patient s own G.P., at least TWO (ideally four to six) weeks prior to surgery. Where multiple s are advised on pages 4 and 5 (e.g. Month 0) these can be administered during one sitting, preferably rotating the injection site. Vaccines are routinely given intramuscularly into the upper arm or anterolateral thigh. This is to reduce the risk of localised reactions, which are more common when the is given subcutaneously. For individuals with a bleeding disorder, however, s should be given by deep subcutaneous injection to reduce the risk of bleeding. Vaccines must be administered by a suitably qualified member of staff who is competent to do so. Page 7 of 18

8 All staff administering the should have received the appropriate training provided via occupational health and staff must have completed basic life support and anaphylaxis training. Staff administering the should ensure that the exact name/ brand of, batch number and site at which the is given are accurately recorded in the patient notes or on the prescription chart. 3.6 Chemotherapy (or other immunosuppressive treatment) Immunisations should be delayed if treatment is short term, whilst ensuring adequate antibiotic cover is prescribed in the interim. 3.7 Pregnancy / Breast-feeding All s within this guideline are inactivated but have limited or no evidence for use in pregnancy and lactation. Since inactivated s cannot replicate they cannot cause infection in either the mother or the foetus. As asplenic patients are at high risk of infection and sepsis, the benefit of administration of s is generally considered to outweigh the potential risk to the foetus. 4. Antibiotic prophylaxis guidelines 4.1 Background Following splenectomy, patients are at risk of overwhelming infection. The length they remain at risk is unknown. Some papers report the risk to be greatest during the first few years, but Waghorn et al, (1997) discovered that 60% of cases of overwhelming postsplenectomy infection (OPSI) occurred years later. Page 8 of 18

9 Susceptibility to infection may be greatest in the first few years following splenectomy, but persists lifelong. However, compliance with lifelong antibiotics can be a problem. 4.2 Who should be given antibiotic prophylaxis? All adults should therefore be offered antibiotic prophylaxis lifelong (preferably) following splenectomy however if compliance is an issue this can be reduced. Patients must receive prophylactic antibiotics for 2 years post splenectomy. Children should receive antibiotic cover until 16 years of age (NB. older children should still receive at least a minimum 2 year course). Lifelong antibiotic prophylaxis is always advised for all patients considered at continued high risk of pneumococcal disease. High risk patients include: o Patients who are under 16 or over 50 years of age. o Patients who have an inadequate serological response to pneumococcal vaccination o Patients with a history of previous invasive pneumococcal disease o Patients undergoing splenectomy for an underlying haematological malignancy particularly in the context of on-going immunosuppression The Department of Health Immunisation against infectious disease, The Green Book, states that antibody levels are likely to decline rapidly in individuals with no spleen and therefore re-immunisation would be recommended every five years, as per table 3. For more detailed information refer to chapter 25 of The Green Book : Table 3 in section 3.3 discusses further a potential need to monitor a serological response. This is routinely done is some specialities, for example haematology. Immunology should be contacted for further advice. Page 9 of 18

10 If compliance is a problem, a seven day emergency supply of amoxicillin could be given to the patient, which would be available for them to take at the first signs of any infection. Likewise following the two-year prophylaxis course an emergency supply of amoxicillin 500mg or clarithromycin 500mg can be prescribed for use at home prior to seeking urgent medical attention. 4.3 Recommended antibiotics Recommended antibiotic therapies post-splenectomy for adults (table 4) and children (table 5) are below. Table 4: Recommended Antibiotic Prophylaxis in Adults Adults Without Penicillin Allergy Penicillin V (oral) 250mg bd I Penicillin I V (oral): Adults With Penicillin Allergy Clarithromycin (oral) 250mg bd (if pregnant use Erythromycin 500mg bd) Table 5: Recommended Antibiotic Prophylaxis in Children Children Without Penicillin Allergy Children With Penicillin Allergy <1yr: 62.5mg bd 1 month 2 yrs 125mg bd 1-5years: 125mg bd 2 8 years 250mg Erythromycin bd (Oral): >5 years 250mg bd 8 18 years 500mg bd If a patient becomes nil-by-mouth following a splenectomy, IV benzylpenicillin should be given: Adults: IV benzylpenicillin = 1.2g bd Children: IV benzylpenicillin = 25mg/kg bd Page 10 of 18

11 Additional cover with IV benzylpenicillin is not required if the patient is already receiving antibiotics with appropriate activity (e.g. cephalosporins, other - lactam agents if unsure check with microbiology). If patient is allergic to penicillin discuss with microbiology. 5. Additional Information 5.1 Travel Patients with an absent or dysfunctional spleen are at increased risk of severe falciparum malaria. Guidance should be given on appropriate malaria prophylaxis and the need for close adherence to it. 5.2 Animal Bites All animal bites need to be treated quickly, to reduce the chance of infection from Capnocytophaga canimorsus, which can lead to fulminant sepsis. Antibiotics are usually prescribed see antibiotic website for more details ( ). 5.3 Tick Bites Approximately 1/3 of cases of clinical human babesiosis have occurred in splenectomised individuals. It is a rare tick borne infection that can cause moderate to severe disease, including haemolytic anaemias. Therefore it is essential to take precautions against being bitten in endemic areas (if camping, cover exposed skin). 5.4 Infection Patients should be advised to see a doctor immediately if they develop any signs of infection e.g. sore throat, fever, malaise, severe headache, and flu-like symptoms. Page 11 of 18

12 5.5 Patient Information Patients should be given a Public Health England patient information leaflet Splenectomy information for patient (available from the city inpatient pharmacy dispensary and QMC surgical satellite pharmacy and here: /Splenectomy_DL_Leaflet_06_WEB 2_.pdf). A patient card should also be issued. Page 12 of 18

13 Appendix 1: pre-printed GP letter Splenectomy Notification To Dr.. (Patient s G.P) Patient: Address: Date of Birth: Hospital No: A splenectomy was performed on the above named patient, on.(date) under the care of (consultant team) at... campus. Vaccines Received as an Inpatient Please see primary-care antibiotic guidelines or overleaf to confirm remaining vaccinations required Pneumococcal Date given Menitorix (Hib / Men. C) Date given Menveo (ACWY) See immunisation schedule below for if further doses are required Date given If not given, see immunisation schedule below for when required Bexsero (Men. Grp B) Date given If not given, see immunisation schedule below for when required Influenza Date given Re-immunise: each year (Sept-Nov) Antibiotic Prophylaxis - Adults should receive a minimum of two years prophylaxis. Children should receive prophylaxis until at least the age of 16 years (minimum two years). Penicillin V (oral) Adult Child <1yr 1yr - 5 yrs Without penicillin allergy: 250mg bd 62.5mg bd 125mg bd >5 yrs 250mg bd Tick ( ) appropriate box Min. 2 yrs Life Long At least to age 16 + Min. 2 yrs Life Long Alternative Prophylaxis advised: Clarithromycin (oral) With penicillin allergy: Tick ( ) appropriate box Min. 2 yrs Life Long 250mg Adult bd Erythromycin (oral) Min. 2 yrs Life Long Adult (if pregnant) 500mg bd Child (Erythromycin oral - state dose below) At least to age 16 + Min. 2 yrs Life Long DH Splenectomy Card and Information Leaflet given to patient (please tick) Dr / Pharmacist Signature:.. Date: Page 13 of 18

14 Advised Immunisation Schedules Schedules for immunising individuals with absent or dysfunctional spleen vary depending on the age at which their condition is first diagnosed. See table 1 for infants under 2 years old and table 2 for children (> 2 years old) and adults. Table 1: Vaccination schedule for infants under 2 years old Age at which patient presents with splenectomy or splenic dysfunction Under 6 months First diagnosed at 6-11 months (previous s up to date) Note routine 12 month boosters should additionally be given First diagnosed at months (previous s up to date) Vaccine doses (infants) 0.5ml IM (Meningococcal Group B ) Influenza 0.5ml IM (Influenza ) Menitorix 0.5ml IM (Haemophilus influenza type b plus meningococcal C Hib/MenC) 0.5ml IM (Meningococcal ACWY conjugate ) Pneumococcal 0.5ml IM (PPV) Prevenar ml IM (Pneumococcal conjugate PCV 13) NeisVac-C 0.5ml IM (Meningitis C conjugate -MenC) Month 0 Month 1 Month 2 Later Complete routine childhood immunisation schedule including booster doses Prevenar-13. If NeisVac-C not already given give Menveo instead. Note: 3 doses of Bexsero should be given at 2, 3 and 4 months* (at least 1 month apart). If NeisVac-C not already given as part of routine schedule- give Menveo instead. A dose of Bexsero should be given if not previously received as part of routine childhood immunisations Give Influenza (if Sept.- April). If not yet administered give routine 12-month boosters. Give Influenza (if Sept.- April). Additionally Bexsero should be given if not previously received as part of routine childhood immunisations A dose of Menveo conjugate should be given at least one month after the NeisVac-C / Menveo and Prevenar-13 booster doses An additional dose of Menveo should be given at least one month after previous dose of NeisVac-C / Menveo. Page 14 of 18 If not give as part of routine childhood immunisations, an additional dose of Bexsero should be months after last dose of Bexsero (may be given with 12-month boosters). Additional doses of Prevenar-13 and Menveo should be given at least 2 months after 12 month Menitorix and Prevenar-13 boosters. A Bexsero booster and additional doses of Prevenar- 13 and Menveo should be given at least 2 months after 12-month boosters. After the second birthday, one additional dose of Menitorix and a dose of Pneumococcal should be given at least 2 months after the last dose of Prevenar-13 Additional doses of Prevenar- 13 and Menveo should be given at least 2 months after 12 month Menitorix booster given as part of routine schedule. After the second birthday, one additional dose of Menitorix, Bexsero booster and a dose of Pneumococcal should be given at least 2 months after the last dose of Prevenar-13 After the second birthday, one additional dose of Menitorix, and a dose of Pneumococcal should be given at least 2 months after the last dose of Prevenar-13 If not give as part of A Bexsero booster should routine childhood be given months after immunisations, an n primary course. additional dose of Bexsero should be months after last dose of Bexsero *Prophylactic paracetamol is advised where Bexsero is given with the routine s in infants under one year of age. Three 2.5ml doses of liquid paracetamol (infant paracetamol 120mg/5ml) should be given orally, with the first dose provided as soon as possible after vaccination, and two subsequent doses at intervals of four to six hours.

15 Table 2: Vaccination schedule for children over 2 years old and adults Vaccine doses (adult and children) Bexsero 0.5ml IM (Meningococcal Group B ) Influenza 0.5ml IM (Influenza ) Menitorix 0.5ml IM (Haemophilus influenza type b plus meningococcal C Hib/MenC) Menveo 0.5ml IM (Meningococcal ACWY conjugate ) Pneumococcal 0.5ml IM (PPV) Prevenar ml IM (Pneumococcal conjugate PCV 13) Over 2 years but under 5 years (Previously fully vaccinated inc. Prevenar- 13 ) Month 0 Month 1 Month 2 Later Pneumococcal (if not previously received) (if not previously received) Influenza (if months after last Menitorix dose. Over 2 years but under 5 years (Previously fully vaccinated inc. Prevenar- 7 ) Over 2 years but under 5 years (Unvaccinated or previously partially vaccinated with Prevenar 7 ) Prevenar-13 (if not previously received) Influenza (if Prevenar-13 Influenza (if (if not previously received) Pneumococcal months after last Menitorix and Prevenar- 13 Prevenar-13 months after last Menitorix Pneumococcal months after last Prevenar-13 Over 5 years of age but under 11 years old (Vaccination history irrelevant). Over 11 years old including adults (Vaccination history irrelevant). Pneumococcal Influenza (if Pneumococcal Influenza (if given at least one month after last Menitorix dose. months after last Menitorix dose. Recommendations of which s should be re-administered are detailed below in table 3. Table 3: Recommendations for re-immunisation Influenza Pneumococcal Yearly - from Sept. to Nov. Usually required every 5 years for life. (Antibody levels may decline more rapidly in some patients and therefore pneumococcal antibody level testing may help guide timing of vaccinations. Contact Immunology for further advice.) Page 15 of 18

16 NUH Splenectomy Audit Form MS word copies available from the authors if adaption required Demographics NHS Number Initials DOB Allergies GP GP address GP Tel. No if for follow up. Relevant Past Medical History Indication: Date of Admission Date of Splenectomy Date of Discharge Surgery Emergency / Elective Vaccinations Vaccine Pneumovax II Prevenar - 13 Combined HIB/Men C (Menitorix ) Meningococcal ACYW (Menveo ) Meningococcal Group B (Bexsero ) Influenza Other Dates Given Antibiotic Prophylaxis given during inpatient stay (post-op including treatment courses) Regimen Started Finished Penicillin V 250mg bd Clarithromycin 250mg bd Penicillin V Clarithromycin Others: Discharge information Was the standard GP letter completed and a duplicate filed in the notes? If no, ensure suitable plan in place. Was information on what s were given during the stay provided on the TTO or discharge letter? Was information on what antibiotic prophylaxis should be given provided on the TTO or discharge letter? Comments Y / N Y / N Regimen Y / N Duration Y / N Page 16 of 18

17 Equality Impact Assessment Report 1. Name of Policy or Service Response to external best practice policy 2. Responsible Manager Tim Hills (Lead pharmacist antimicrobials and Infection control) 3. Name of person Completing EIA Annette Clarkson (Specialist clinical pharmacist antimicrobials and Infection control) 4. Date EIA Completed 15/01/ Description and Aims of Policy/Service This guideline provides guidance on the required immunisations and general management of patients with an absent or dysfunctional spleen. This procedure is required in order to encourage the delivery of excellent clinical practice for patients cared for by Nottingham University Hospitals NHS Trust, based on best evidence and local expertise. The procedure supports the Trust Clinical Effectiveness and Audit Policy. 6. Brief Summary of Research and Relevant Data See evidence base information from front page 7. Methods and Outcome of Consultation Consultations have been carried out with the following: Antimicrobial guidelines committee NUH Drug and Therapeutics committee Comments from the above consultations have been received and incorporated where appropriate. Page 17 of 18

18 8. Results of Initial Screening or Full Equality Impact Assessment: Equality Group Age Gender Race Sexual Orientation Religion or belief Disability Assessment of Impact No Impact Identified No Impact Identified No Impact Identified No Impact Identified No Impact Identified No Impact Identified Dignity and Human Rights No Impact Identified Working Patterns Social Deprivation No Impact Identified No Impact Identified 9. Decisions and/or Recommendations (including supporting rationale) From the information contained in the procedure, and following the initial screening, it is my decision that a full assessment is not required at the present time. 10. Equality Action Plan (if required) N/A 11. Monitoring and Review Arrangements Review: January 2019 Page 18 of 18