Protocol for Management of Neutropenic Sepsis in Adult Patients within the First 24 hours of Presentation

Transcription

1 Protocol for Management of Neutropenic Sepsis in Adult Patients within the First 24 hours of Version One Date of Publication: May 2010 Original Author(s): Carole Connor Nurse Consultant Dr Beth Harrison Consultant Haematologist Edited & adapted by: N/A Name of responsible committee/individual: Target audience: Date of Ratification: August 2010 Arden Cancer Network Chemotherapy Group All front line staff involved in the management of neutropenic patients including emergency departments/assessment units and haematology/oncology day units, outpatient facilities and wards Ratified by: Arden Cancer Network Executive Group Date for review: May 2013

2 Version History Version Date Brief Summary of Change One May 2010 First version of Network Wide document Version one 2

3 Contents Section Page 1.0 Introduction Purpose High Risk Patients Assessment and Management Continuing Care Consultation and Communication Process Equality Impact Assessment Review and Revision Arrangements including Version Control Dissemination and Implementation Standards/Key Performance Indicators References Document Circulation Acknowledgements 11 Appendices Appendix A Appendix B Appendix C Appendix D The Management of Patients Presenting with Actual/Suspected Neutropenic Sepsis. Flow Chart for the Prescribing of First Line Antibiotics 14 Equality Impact Assessment Tool 15 Plan for Dissemination of Procedural Documents Version one 3

4 1.0 Introduction For haematology and oncology patients, all infective episodes need to be taken extremely seriously and treated promptly with antibiotic therapy. Reversible depression of the bone marrow is an inevitable consequence of many chemotherapy regimens. Chemotherapy and radiotherapy damage the membranes of the oropharynx, gut and lung, and thereby permit both Gram positive and Gram-negative organisms to enter the systemic circulation more readily (Souhami and Tobias 2005). Increased susceptibility to infection is likely when the neutrophil count falls below 1.00x10 9 /L, with escalating risk at <0.50x10 9 /L and at <0.1x10 9 /L (Dellinger, Carlet, Masur et al 2004). t all patients with neutropenic sepsis present with fever. It is important to consider that fever may be absent or mild in degree; the patient may present only with deterioration in general condition and non-specific symptoms e.g. confusion in the elderly. 2.0 Purpose This Arden Cancer Network wide document has been developed because there is a need to provide seamless services for cancer patients across the network. Additionally, this is also in response to the National Chemotherapy Advisory Group report Chemotherapy Services in England: Ensuring quality and safety (National Cancer Action Team 2009). This protocol is intended for use by practitioners for the first 24 hours when managing patients presenting with potential/actual neutropenic sepsis. te: Neutropenic sepsis is a medical emergency and an indication for immediate admission and prompt treatment with intravenous antibiotics. Infection may progress within hours to shock and death, especially when due to gram-negative bacilli. Therefore patients presenting with suspected sepsis must be assessed within 30 minutes of arrival to the hospital or, for inpatients, within 30 minutes of presentation and intravenous antibiotics started within 60 minutes of presentation. This protocol does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient, in consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this protocol. Version one 4

5 3.0 High Risk Patients Those who are already inpatients when fever and neutropenia develop. Patients with specific foci of infection e.g. intravascular catheter infection, tunnel infection, new pulmonary infiltrate. Acute leukaemia, post allogeneic or autologous stem cell transplant, patients who have received intensive chemotherapy. The elderly. Patients with co-morbidities. Patients with relapsed/recurrent disease. Neutropenic patients on intravenous or oral chemotherapy presenting with or developing grade 3 diarrhoea (increase of >7 stools per day over baseline). 4.0 Assessment and Management Appendix A summarises the management of patients presenting with actual/suspected neutropenic sepsis. te: Each Trust must have a neutropenic sepsis pathway which must be completed on all patients with suspected/actual neutropenic sepsis and must be undertaken within 30 minutes of patient arriving at the hospital or, for inpatients, within 30 minutes of presentation. 4.1 Assessment 4.1.1Take a Full History Diagnosis, disease status, date(s) and type of most recent chemotherapy. te any symptoms of infection: fevers, sweats, rigors, cough, sore throat, diarrhoea, dysuria, skin lesions, central venous catheter soreness or discharge, perianal pain. In patients with central venous access devices check to see if intravenous/blood products been administered or the line flushed within the previous 24 hours - This may account for a febrile episode or rigors that are associated with use or flushing of a central venous line. List drugs taken (especially prophylactic antibiotics and Granulocyte-Colony Stimulating Factors (G-CSF)). te: Many patients carry a written record of their chemotherapy drug regimen Examination Undertake a thorough clinical examination. Assess for signs of shock: including tachycardia, hypotension, tachypnoea, and peripheral shutdown. Search for a focus of infection, e.g. Hickman line/cannula sites, skin lesions, throat, chest, abdomen, perianal area (but DO NOT undertake a PR examination as there is a risk of causing a serious bacteraemia). Assess for influenza related symptoms. If present, the patient must be screened as per Trust policy and managed in appropriate isolation facilities. Version one 5

6 4.1.3 Investigations Take bloods for full blood count (FBC), urea and electrolytes (U&E), liver function tests (LFT s), calcium, C-reactive protein (CRP), lactate and clotting. Blood cultures must be taken both peripherally and from each lumen of any central venous access devices), and carefully labelled accordingly (N.B. Only those assessed and qualified to do so may handle central venous access devices; if you are not qualified please request help from an appropriately trained, qualified nurse). Culture the central venous access site (if in situ), urine, throat and sputum if available. Stool cultures must be obtained if diarrhoea present. Ensure Clostridium difficile toxin is requested in addition to culture and sensitivity Respiratory viruses may present with non-specific signs and so these should be looked for in all patients who do not have an obvious bacterial infection. Please send dry nose and throat swabs for respiratory viruses PCR. If using E-requesting, choose Full respiratory screen from the Molecular/Antigens drop down menu. Consider requesting CMV viral load in transplant patients known to be CMV IgG positive using an EDTA tube. If using E-requesting, choose CMV viral load which appears under Immunocompromised screen on the Molecular/Antigens drop down menu. An urgent chest x-ray (CXR) if clinically indicated. An ECG should be obtained in patients presenting in septic shock or with irregular heart beats, presenting with tachycardia, bradycardia, hypotension or hypertension. te: If the patient is, or potentially is, clinically septic IV antibiotics must be administered immediately. Do not wait for FBC result or for completion of investigations. Antibiotics must be administered with 60 minutes of presentation Observations Baseline observations must include: Temperature, pulse, respiratory rate, blood pressure and arterial O 2 saturation by oximetry. The early warning score must be calculated. te: If possible, arterial blood gases should be avoided in thrombocytopenic patients. Observations must be continued according to the patients clinical condition and at a minimum of 4 hourly Initial Management If the patient is, or potentially, clinically septic start intravenous antibiotics immediately as per Trust policy. Antibiotics must be started within 60 minutes of the patient s arrival at hospital and for inpatients, within 60 minutes of presentation and must never wait until the patient is transferred to a ward, or the result of the full blood count. In cases where central venous access devices are being preserved, antibiotics must be given through each lumen of an involved IV catheter on a rotational basis if there is a suspected/actual infection of a multi-lumen catheter. Version one 6

7 Intravenous fluids should be given to maintain circulating volume. Oxygen must be administered if evidence of hypoxia. Inform the on-call consultant haematologist/oncologist. te: If in doubt always admit or review inpatients, observe and seek advice from either the on call consultant haematologist or oncologist anytime day or night. Oral Chemotherapy te: If a patient is on oral chemotherapy and is neutropenic or clinically septic, oral chemotherapy must be stopped immediately. The decision to restart oral chemotherapy must be discussed with and agreed by the consultant haematologist/oncologist Antibiotic Management Appendix A The Management of Patients Presenting with Actual/Suspected Neutropenic Sepsis details the drug management details. Prescription and administration of first line antibiotics must not wait until transfer to the ward and must be commenced within 60 minutes of presentation. Also refer to Appendix B which details a flow chart for the prescribing of first line antibiotics First Line Antibiotics Patients NOT allergic to Penicillin Give PIPERACILLIN/TAZOBACTAM 4.5g 6 hourly IV. If the patient has had infections with Extended Spectrum Beta-Lactamase (ESBL) producers in the past, use MEROPENEM 1g 8 hourly IV infusion instead of piperacillin/tazobactam. AND GENTAMICIN 5mg/kg (estimated lean body mass) daily IV infusion (maximum dose 400 mg daily). One dose only should be prescribed. The decision to continue gentamicin must be made in consultation with either the consultant haematologist for haematology patients or the consultant oncologist for oncology patients. Precautions Renal impairment: Refer to Trust antimicrobial guidelines. The first dose of gentamicin, however, is 5mg/kg (estimated lean body mass) (maximum 400mg) and it should be given immediately on presentation. Patients Allergic to Penicillin te: Nausea, vomiting or diarrhoea do not, by themselves, constitute an allergic reaction. Therefore they are not a contraindication for penicillin use. Allergies to penicillin are categorised into either an anaphylactic reaction or an accelerated allergic reaction. These are described below. If a patient reports any of these symptoms DO NOT prescribe Piperacillin/Tazobactam or Meropenem. An anaphylactic reaction related to histamine release occurs minutes after previous administration of penicillin. Symptoms may include erythema or pruritis, angioedema, hypertension or shock, urticaria, wheezing, rhinitis. Version one 7

8 An accelerated allergic reaction occurs 1-72 hours after previous administration of penicillin. Symptoms may include erythema or pruritis, angioedema, urticaria, wheezing, rhinitis (particular caution if symptoms include laryngeal oedema) (Definition from Network anti-microbial guidelines). Patients WHO DO NOT report a history of an anaphylactic or accelerated allergic reaction including delayed non-urticarial rash MEROPENEM 1g, IV infusion, 8 hourly. AND GENTAMICIN 5mg/kg (estimated lean body mass) daily IV infusion. One dose only should be prescribed. The decision to continue gentamicin must be made in consultation with the consultant haematologist or oncologist. Patients WHO DO report a history of an anaphylactic or accelerated allergic reaction CIPROFLOXACIN 400mg IV infusion, twice daily. AND TEICOPLANIN 600mg IV bolus 12 hourly for first 3 doses and then 600mg 24 hourly thereafter. te: The dose is 800mg for patients with an estimated lean body mass of >80kg. PLUS GENTAMICIN 5mg/kg (estimated lean body mass) daily IV infusion. One dose only should be prescribed. The decision to continue gentamicin must be made in consultation with the consultant haematologist or oncologist Probable Venous Access Device Infections For patients with a high probability of venous access device infection (rigors on flushing line, purulent discharge or red and tender exit site) consider adding TEICOPLANIN 600 mg intravenous bolus 12 hourly for the first 3 doses then 600mg 24 hourly thereafter if the patient is not already receiving it. te: The dose is 800mg for patients with an estimated lean body mass of >80kg Perianal sepsis / abdominal pain Consider adding METRONIDAZOLE 400 mg three times daily orally or 500mg IV infusion 8 hourly Diarrhoea /Possible Clostridium difficile associated disease Consult the section on Clostridium difficile associated disease in the Trust antibiotic treatment guidelines. Consider empirical treatment with METRONIDAZOLE 400mg TDS orally (or Vancomycin 125mg 6 hourly in case of severe infection). te: If the patient develops Clostridium difficile associated disease, discuss urgently with Consultant Haematologist / Oncologist. Version one 8

9 4.3 Platelet Infusions Blood transfusion support may also be required. Discuss with on call consultant haematologist / oncologist. Refer to the Arden Cancer Network Guidelines on Blood Products in Haematology/Oncology Patients. 5.0 Continuing Care Where possible patients admitted to hospital should be managed in a single side room and barrier nursed using protective isolation precautions. Patients should have a full medical review within 24 hours of admission. This must then be discussed with either the consultant haematologist for haematology patients or the consultant oncologist for oncology patients. (7 days a week) The patient must be examined frequently as they may deteriorate rapidly, especially if there are clinical and radiological signs in the chest. Refer patient to the acute oncology nurse Refer to the Arden Cancer Network Protocol for the Continuing Management of Neutropenic Sepsis. 6.0 Consultation and Communication Process The consultation process involves dissemination of draft documents for comment to: the Arden Cancer Network Chemotherapy Group, consultants haematologists, oncologists and microbiologists, haematology/oncology specialist nurses, ward managers and pharmacists and clinical leads in accident and emergency/emergency medicine at George Eliot Hospital, Reddich Hospital (part of Worcestershire Acute Hospitals NHS Trust), University Hospitals Coventry and Warwickshire and South Warwickshire NHS Foundation Trust. 7.0 Equality Impact Assessment See Appendix C 8.0 Review and Revision Arrangements including Version Control The Chair of the Arden Cancer Network Chemotherapy Group will nominate an individual to undertake a review of the protocol 3 months prior to the revision date. 9.0 Dissemination and Implementation Once documents are ratified, notification will be sent by to the lead chemotherapy clinician, nurse and pharmacist for each Trust. It will be their responsibility to disseminate and implement the protocol locally. The final version of documents will be placed on the Arden Cancer Network intranet and each individual Trusts intranet via a designated lead for each Trust. Hard copies will not be circulated. It will be the responsibility of departmental managers to include the process to remove outdated copies and to ensure Version one 9

10 staff are aware of the new version (Appendix D). It is the responsibility of departmental managers to implement any identified training or support Standards/Key Performance Indicators National Chemotherapy Advisory Group report Chemotherapy Services in England: Ensuring quality and safety (National Cancer Action Team 2009), National Chemotherapy Measures (Department of Health 2004) References Cochrane Database of Systematic Reviews 2003; Issue 3.Art..: CD Dellinger P, Carlet JM, Masur H et al. (2004) Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock Intensive Care Medicine 30(4) Department of Health and National Cancer Action Team (2009) A Report from the Chemotherapy Advisory Group - Chemotherapy Services in England: Ensuring quality and safety, London, Department of Health Department of Health (2004) Manual for Cancer Service Chemotherapy measures, London, Department of Health Souhami and Tobias (2005).Cancer and its Management Oxford, Blackwell 12.0 Document Circulation Name Title Trust Dates Circulated Dr Mark Hocking/Dr Jag Gandla* Clinician George Eliot Hospitals NHS Trust Emma Johnson Melanie Taylor Stephanie Cooke Fay Lanham Dr Anton Borg Nurse Pharmacist Pharmacist Nurse Clinician Reddich Hospital South Warwickshire , , , , , , , Version one 10

11 Carole Connor* Nicola Evans Dr Lydia Fresco Dr Clive Irwin Sam Neale* Sue Marsh Dr Beth Harrison Dr Peter Munthali Stephanie Connell Nurse Pharmacist Clinician Chair of the Arden Cancer Network Chemotherapy Group Nurse Pharmacist Chair of the Haematology NSSG Consultant Microbiologist+ Service Improvement Facilitator NHS Foundation Trust University Hospitals Coventry and Warwickshire NHS Trust Arden Cancer Network , , , , , , , , , , , , , , , , , Responsible for circulating to relevant staff within their Trust including clinical nurse specialists, lead acute and accident emergency physicians and ward managers. + Responsible for circulating to all microbiologists and virologists within the network. 13. Acknowledgements George Eliot NHS Trust, South Warwickshire NHS Foundation Trust, University Hospital Coventry and Warwickshire NHS Trust and Worcestershire Acute Hospitals NHS Trust for forwarding their individual Trust protocols. Version one 11

12 Appendix A - The Management of Patients Presenting with Actual/Suspected Neutropenic Sepsis If the patient is clinically, or potentially septic start IV antibiotics immediately. Do not wait for FBC result. Antibiotics must be administered with 60 minutes of presentation. If in doubt, admit or review inpatients later. Seek advice from either the consultant haematologist on call for haematology patients or consultant oncologist on call for oncology patients (24 hours, 7 days a week). Potential Signs & Symptoms Pyrexia of 38 C or more Flu-like symptoms Rigors, fevers, sweats Tachycardia Sore throat Productive cough Hypotension Severe vomiting Diarrhoea OR Significantly unwell with no localising signs OR Rising CRP NB: All signs may not be present. Some patients may have septicaemia but not be pyrexial Obtain history and undertake general examination. Look for evidence of infection. Check Temperature, Pulse, Respiration, BP & O 2 saturations. Send urgent FBC, U&E, LFT, Lactate, CRP and clotting. Undertake ECG if heartbeat irregular or there is evidence of tachycardia, bradycardia, hypertension or hypotension. Take peripheral blood cultures and blood cultures from each lumen of any central venous access device. Screen for focus of infection: CXR if indicated, MSU, throat swab and sputum sample. Swab exit site of central venous access device and obtain other relevant samples i.e. stool if diarrhoea present. Do not let this delay starting IV antibiotics 1. If the patient is clinically, or potentially septic start IV antibiotics immediately. Do not wait for FBC result. 2. Intravenous fluids should be given to maintain circulating volume 3. Oxygen must be administered if evidence of hypoxia Version one 12

13 Antibiotic Therapy (NB: Consult Product Information literature for dose reductions in liver and renal impairment) First Line Antibiotic Therapy Patients NOT Allergic to Penicillin Give PIPERACILLIN/TAZOBACTAM 4.5g 6 hourly IV (If the patient has had infections with ESBL producers in the past, use MEROPENEM 1g 8 hourly IV infusion instead of PIPERACILLIN/TAZOBACTAM). AND GENTAMICIN 5mg/kg ONCE daily IV infusion (estimated lean body mass) (maximum dose - 400mg daily) One dose only should be prescribed. The decision to continue gentamicin must be made in consultation with the consultant haematologist or oncologist. Precautions: Gentamicin in renal impairment - The first dose, is the same, i.e. 5mg/kg (estimated lean body mass) (maximum 400 mg) and it should be given immediately on presentation (caution in hypotensive patients discuss dose urgently with either the haematologist for haematology patients or the on call oncologist for oncology patients). Dose adjustments for renal impairment must be considered for subsequent doses. Refer to Trust antimicrobial guidelines and the product information literature. Patients Allergic to Penicillin If there is a history of an anaphylactic reaction, or an accelerated allergic reaction DO NOT prescribe Piperacillin/Tazobactam or Meropenem (see note below). te: GI symptoms do not, by themselves, constitute an allergic reaction and are not therefore a contraindication to use of penicillins. Symptoms of allergic reactions may include erythema, puritis, angioedema, hypertension or shock, urticaria, wheezing, rhinitis. An anaphylactic reaction occurs minutes after administration of penicillin. An accelerated allergic reaction occurs 1-72 hours after administration of penicillin. Patients WHO DO NOT have an anaphylactic or accelerated allergic reaction including delayed non-urticarial rash MEROPENEM, 1g, IV infusion 8 hourly. PLUS GENTAMICIN 5mg/kg (estimated lean body mass) ONCE daily IV infusion. One dose only should be prescribed. The decision to continue gentamicin must be made in consultation with the consultant haematologist for haematology patients or the consultant oncologist for oncology patients. Patients WHO HAVE an anaphylactic or accelerated allergic reaction CIPROFLOXACIN 400mg IV infusion, twice daily. AND TEICOPLANIN 600mg IV bolus 12 hourly for first 3 doses and then 600mg 24 hourly thereafter. te: The dose is 800mg in patients with an (estimated lean body mass) >80kg. PLUS GENTAMICIN 5mg/kg (estimated lean body mass) daily IV infusion One dose only should be prescribed. The decision to continue gentamicin must be made in consultation with the either the consultant haematologist for haematology patients or the consultant oncologist for oncology patients. Probable Line Infection - For patients with a high probability of line infection (rigors on flushing line or red and tender exit site) consider adding TEICOPLANIN 600mg IV 12 hourly for first 3 doses and 24 hourly thereafter if the patient is not already receiving it. te: The dose is 800mg in patients with an (estimated lean body mass). Perianal sepsis / abdominal pain - Consider adding METRONIDAZOLE 400mg TDS orally or 500mg IV every 8 hours. Diarrhoea /Possible Clostridium difficile associated disease - Consider empirical treatment with METRONIDAZOLE 400mg TDS orally (or VANCOMYCIN 125mg 6 hourly in case of severe infection). Always discuss with either the consultant haematologist or consultant oncologist. Consult the section on Clostridium difficile associated disease in local Trust antibiotic treatment guidelines. Platelet Infusions Platelets may be required (one adult dose) if platelet count <20x10 9 /L (<50x10 9 /L if bleeding). Discuss with consultant haematologist or consultant oncologist. Version one 13

14 Appendix B Flow Chart for the Prescribing of First Line Antibiotics Does the patient have a penicillin allergy? Give PIPERACILLIN/TAZOBACTAM 4.5g 6 hourly IV. (If the patient has had infections with ESBL producers in the past, use MEROPENEM 1g 8 hourly IV infusion instead of PIPERACILLIN/TAZOBACTAM). AND Yes te: GI symptoms do not, by themselves, constitute an allergic reaction and are not therefore a contraindication to use of penicillins. Symptoms of allergic reactions may include erythema, puritis, angioedema, hypertension or shock, urticaria, wheezing, rhinitis. An anaphylactic reaction (Type 1 hypersensitivity) occurs minutes after administration of penicillin. An accelerated allergic reaction occurs 1-72 hours after administration of penicillin. GENTAMICIN 5mg/kg (estimated lean body mass) ONCE daily IV infusion (maximum dose mg daily) One dose only should be prescribed. Refer to Protocol for Management of Neutropenic Sepsis within the First 24 Hours of, Trust antimicrobial guidelines and the product information literature for full details and dosing in renal impairment and hypotension. Other Considerations Patients WHO DO NOT have an anaphylactic or accelerated allergic reaction including delayed non-urticarial rash MEROPENEM 1g, IV infusion 8 hourly. PLUS GENTAMICIN 5mg/kg (estimated lean body mass) ONCE daily IV infusion. One dose only should be prescribed. Probable Line Infection - Consider adding TEICOPLANIN 600mg IV 12 hourly for first 3 doses and 24 hourly thereafter if the patient is not already receiving it. te: The dose is 800mg in patients with an (estimated lean body mass) >80kg Perianal sepsis / abdominal pain - Consider adding METRONIDAZOLE 400mg TDS orally or 500mg IV every 8 hours. Diarrhoea /Possible Clostridium difficile associated disease - Consider empirical treatment with METRONIDAZOLE 400mg TDS orally (or VANCOMYCIN 125mg 6 hourly in case of severe infection). Always discuss with either the consultant haematologist or consultant oncologist. Patients WHO DO have an anaphylactic or accelerated allergic reaction CIPROFLOXACILLIN 400Mg, IV infusion Twice daily AND TEICOPLANIN 600mg IV bolus 12 hourly for first 3 doses and then 600mg 24 hourly thereafter. te: The dose is 800mg in patients with an (estimated lean body mass) >80kg PLUS GENTAMICIN 5mg/kg (estimated lean body mass) ONCE daily IV infusion. One dose only should be prescribed. Version one 14

15 Appendix C - Equality Impact Assessment Tool Yes/ Comments 1. Does the document/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? 4. Is the impact of the document/guidance likely to be negative? 5. If so, can the impact be avoided? N/A 6. What alternative is there to achieving the document/guidance without the impact? 7. Can we reduce the impact by taking different action? ne National requirement Version one 15

16 Appendix D Title of document: Date finalised: Previous document already being used? Plan for Dissemination of Procedural Documents Protocol for the Management of Neutropenic Sepsis with the First 24 hours of June 2010 Yes Dissemination lead: Carole Connor Nurse Consultant South Warwickshire NHS Foundation Trust If yes, in what format and where? Proposed action to retrieve out of date copies of the document: Each Trust has their own local policy for the management of neutropenic sepsis First Network Wide document. Chemotherapy lead nurse for each Trust to retrieve local neutropenic sepsis documents To be disseminated to: How will it be disseminated, who will do it and when? Format (i.e. paper or electronic) Comments: Carole Connor Nurse - South Warwickshire NHS Foundation Trust Dr J Gandla Clinician George Eliot Hospitals NHS Trust Fay Lanham Nurse Reddich Hospital Sam Neale Nurse University Hospitals Coventry and Warwickshire NHS Trust To inform all areas that revised network wide electronic version available on Trusts intranet and Arden Cancer network site within 7 days of receipt Electronic Dissemination Record - to be used once document is approved Date put on register / library of procedural documents: August 2010 Date due to be reviewed: May 2013 Disseminated to: (either directly or via meetings, etc.) Format (i.e. paper or electronic) Date Disseminated:. of Copies Sent: Contact Details / Comments: Designated leads Electronic One Re-circulated as minor changes made Version one 16