South Staffordshire and Shropshire Healthcare NHS Foundation Trust

Transcription

1 South Staffordshire and Shropshire Healthcare NHS Foundation Trust Document Version Control Document Type and Title: Authorised Document Folder: Immunisation Policy YELLOW - Clinical New or Replacing: Document Reference: New C/YEL/mm/13 Version No. v1.0 Implementation Date: May 2011 Author: Approving body: Cathy Riley Quality, Effectiveness & Risk Committee Approval Date: 14 th April 2011 Ratifying body: Board of Directors Ratified Date: 28 th April 2011 Committee, Group or Individual Monitoring the Document: Medicines Management Committee Review Date: May 2013

2 Immunisation Policy 1. Policy Statement I. Immunisation is the most effective method of preventing disease and maintaining the public health of the population (DH 2006). In the South Staffordshire & Shropshire Healthcare Foundation Trust (SSSFT) the aim of immunisation is to prevent vaccine preventable disease. II. Effective immunisation requires the active participation of all local health professional involved with immunisation. The Department of Health s (DH) immunisation programme is described in Immunisation against Disease (DH 2006), also known as The Green Book. All vaccinations undertaken in SSSFT must be inline with the Department of Health guidelines, the Health Protection Unit guidelines and 'The Green Book. III. Immunisations should be seen as a public health approach and operate within a clinical governance framework, which includes this policy, the patient group directions for immunisations, the Medicines Code, and Infection Control policies. IV. This policy is written in accordance with the Department of Health guidance Immunisation against Infectious Disease (The Green Book, DH 2006) and in conjunction with guidance from the Health Protection Unit standards of competence and guidelines on immunisation. The terms immunisation and vaccination will be used interchangeably through out this policy. 2. Objectives of the Immunisation Policy 3. Scope To improve or maintain vaccination rates across SSSFT To have a percentage reduction in infectious diseases To clarify roles and responsibilities of the health professionals involved in immunisations To describe the clinical governance arrangements for carrying out vaccinations To build professional and public confidence in immunisation To achieve targets/standards recommended in the Green Book, World Health Organisation (WHO), and Department of Health (DH) I. The policy applies to all medical and registered healthcare personnel, employed by SSSFT, whether on a permanent or temporary contract, or agency staff, and support staff. II. Professionals providing immunisations are accountable for their work as defined by their Professional Body. III. All staff involved in the Childhood and Adult Immunisation programmes, where they can verify they have been adequately trained and can confirm their competence, may immunise. Immunisation Policy (C/YEL/mm/13) Page 2 of 9

3 IV. Immunisation programmes should be based on a multi-professional team approach where each member s skills and knowledge contribute to improving the public health of the local population. V. The following SSSFT health professionals may be involved with immunisation and giving professional advice: Nurses Immunisation support staff e.g. health care assistants, clerical Paediatric community nurses Pharmacists Doctors VI. All who administer, or advise about immunisations must be proficient and competent in the following areas of core knowledge (HPA 2005), or know where to obtain the relevant information. Aims of immunisation: national policy and schedules Immune system and how vaccines work Vaccine preventable disease (relevant to their service) Different types of vaccine used (in their specific service in SSSFT) and their composition Current issues and controversies regarding immunisation (relevant to the vaccines used) Communication with patients and/or parents Legal aspects of vaccination Storage and handling of vaccines Correct administration of vaccines Anaphylaxis and other adverse events Documentation, record keeping and reporting Strategies for improving immunisation rates Professional responsibilities and competencies specified in specific Patient Group Directions 4. Mental Capacity Act I. All immunisations must be given with reference to the Mental Capacity Act, ensuring that the five (5) main principals are adhered to: 1) A person must be assumed to have capacity unless it is established that s/he lacks capacity. 2) A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success. 3) A person is not to be treated as unable to make a decision merely because he makes an unwise decision. 4) An act done or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his/her best interests. 5) Before the act is done, or the decision is made, regard must be given to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person s rights and freedom of action. (OPSI 2005). II. When administering immunisations or vaccinations, the immunisers should be familiar with the principles of the Mental Capacity (2005). Free mandatory training on the Mental Capacity Act is provided by the Trust to all employees. Immunisation Policy (C/YEL/mm/13) Page 3 of 9

4 Further information on the Mental Capacity act can be downloaded at: /MentalCapacityAct2005/index.htm 5. Consent Consent must be obtained before each and every immunisation. There is no legal requirement for consent to immunisation to be in writing. A signature on a consent form is not conclusive proof that consent has been given, but serves to record the decision and discussions that have taken place with the patient/client, or person giving consent on a child s behalf (DH 2006). 5.1 Adult Immunisations Adult Immunisations will be administered in line with DH guidelines as per Immunisation against infectious disease (The Green Book, DH 2006). 5.2 Childhood Immunisations Not administered by SSSFT staff members, although health visitors (employed by another organisation) may administer to children on wards, i.e. Brockington unit, working to their employers policies. In this instance, the patient is asked for consent, but if the parent (who is a patient) lacks capacity, another person with parental responsibility is asked instead. 5.3 School Based Immunisations Not routinely administered by SSSFT staff. 6. Cold Chain 6.1 Storage of Vaccines (see Medicines Code) Vaccines are sensitive to temperature. Some vaccines are damaged if they get too warm, others if they are frozen. In order to maintain their effectiveness vaccines have to be maintained within a specific temperature range (normal range 2-8 Centrigrade ( C)), from the time of manufacture through distribution until they are administered. This is called the Cold Chain. It is essential to ensure that the Cold Chain is maintained at all times and that vaccines are stored in conditions specified by the manufacturer to prevent any deterioration in potency or effectiveness (DH 2006). It is essential that vaccines are stored under the recommended storage guidelines to maintain their potency and effectiveness, therefore: All vaccine fridges should have a maximum and minimum thermometer in order to keep a regular check on the temperature within the fridge. A temperature check should be done daily and recorded by a designated person/s. If when recording the temperature, and the maximum or minimum temperatures are too high or too low, it should be reported immediately to the appropriate line manager, and the pharmacist contacted for further advice on usage of these vaccines. The vaccine fridge should be defrosted regularly and checked every six months. Please see the individual fridge manufacturer's instructions for defrosting the fridge. The pharmacist can be contacted for further advice, if required. The vaccine fridge should only be used for storing vaccines. Immunisation Policy (C/YEL/mm/13) Page 4 of 9

5 No food or specimens are to be stored in the vaccine fridge. To maintain airflow around the vaccines, the vaccines should not touch the side of the fridge or be packed too tightly together. Rotate the vaccine stock so that those with the shortest expiry dates are used first. Make regular checks to remove expired vaccines. A record should be kept of when this activity was carried out. Unused and outdated vaccine should be returned to pharmacy for disposal. 6.2 Transportation of Vaccines Vaccines are transported from central depots or pharmacy departments to healthcare centres adhering to the cold chain system. This is to ensure vaccines maintain their potency. To ensure this cold chain is continuous: The courier should hand the vaccines directly to the designated staff member. The vaccines should immediately be placed in the designated vaccine fridge and not left at room temperature. The courier should obtain the signature of the person to whom the vaccines are handed to at each clinic. 6.3 Spillages and breakages Sharps should be disposed of, safely, in a sharps bin. Inactivated or toxoid vaccine spillages should be wiped up using a paper towel and general purpose detergent and disposed of as clinical waste. For live vaccine spillages, the COSHH regulations decontamination procedure should be followed. Additional information is available on the vaccine information leaflet or direct from the vaccine manufacturer. 7. Immunisation Queries I. The majority of immunisation queries will be answered by referring to the The Green Book (DH 2006). II. Useful websites: The NHS immunisation website: III. The World Health Organisation (WHO) website for International Immunisation Schedules: t. cfm IV. Health Protection Agency website for guidance on children with uncertain or incomplete immunisation status (Immunisations algorithm) and other Immunisation information: VI. Additional information and support may also be obtained from the Stafford Health Protection Unit (HPU) on Tel: Responsibilities 8.1 SSSFT It is the responsibility of the SSSFT to provide appropriate immunisation training for the health professionals who will carry out the immunisations. Immunisation Policy (C/YEL/mm/13) Page 5 of 9

6 8.2 Managers It is the responsibility of Service Managers, to ensure that all immunisation staff have access to, and attend suitable immunisation training sessions. In addition, that systems are in place to achieve competency in immunisation. 8.3 Employees I. It is the responsibility of each health professional, employed by SSSFT, who practices immunisation, to ensure that they are appropriately trained, informed, and competent to administer the correct vaccination to the appropriate age groups, in order to meet the Health Protection Unit s minimum standards (2005). All immunisations must be given under a current Patient Group Directions (PGD) or Patient Specific Directions (PSD) or in-patient prescription. Each professional is responsible for reading, and signing the current PGD or PSD. II. Health care professionals should follow the guidelines set out in The Green Book (DH 2006). III. All team members are responsible for ensuring that the environment is appropriate for the immunisation service to be delivered. 9. Training I. Registered health professionals are professionally accountable for their practice. Practitioners who have undergone training and demonstrated competency in medicines administration (usually intramuscular into deltoid muscle) may administer vaccines in accordance with this Trust policy. II. Registered health professionals, new to immunisations, should contact the Senior Nurse for Quality & Medicines Management to discuss training requirements. Experienced mentors or supervisors will assess demonstration of competency and safe practice. III. All registered health professionals who immunise should access the half (½) days update (usually prior to the influenza immunisation programme) on an annual basis, and ensure that they meet any specific training requirements listed on specific Patient Group Directions. IV. Assessment should include a formal medicines administration competency checklist demonstrating attainment against specified clinical competences. V. Recognition and treatment of anaphylaxis and basic life support (Cardio- Pulmonary Resuscitation) training must be completed annually. VI. All registered health professionals who undertake immunisations must be familiar and competent with the following: Immunisation against Infectious disease (The Green Book, DH 2006) Trust policies and procedures for immunisations, medicines, management of cardiac arrest and anaphylaxis Product Information Sheets / Summary of Product Characteristics Patient Group Directions (PGD) Patient Specific Directions (PSD) UK Guidance on Best Practice in Vaccine Administration (Royal College of Nursing 2001) (RCN 2001): Immunisation Policy (C/YEL/mm/13) Page 6 of 9

7 data/assets/pdf_file/0010/78562/ pdf VII. Clerical support staff should also receive training and fully understand their role in immunisation programmes. 10. Patient Group Directions (PGD) I. For nurse led sessions, vaccines are administered under Patient Group Directions (PGDs). These documents are drawn up locally by doctors, pharmacists and other appropriate health care professionals. The Medicines Management Committee ratifies these documents. II. All local immunisation PGDs are available through the Medicines Management & Pharmacy team (Tel ), and are available on the policies section of the intranet. III. All registered health professionals must ensure that they are signed up to the current relevant and ratified PGDs, as discussed in Medicines Management or PGD training sessions, and operating in their services. IV. Department of Health guidance on Patient Group Directions is available on Reference to Other Documents This policy should be read in conjunction with and reflect the principles of the following topics, covered in Trust documents and policies: Caldicott Guidelines Dignity and Respect Equality and Diversity Incident Reporting Infection Control Management of Clinical Sharp Injuries and Exposure to Blood and High Risk Body Fluids Medicine Management Mental Capacity Act Record Keeping 12. Policy Review The SSSFT s Immunisation Policy will be updated on a biannual basis, or more frequently, should there be a major change. 13. References DH (2006) Immunisation against Disease. The Green Book. The Stationery Office.( ok /DH_ ). HPA (2005) Core Curriculum for Immunisation Training. London ?p= HPA (2005a) National Minimum Standards for Immunisation Training. London. Immunisation Policy (C/YEL/mm/13) Page 7 of 9

8 376 OPSI (2005) Mental Capacity Act: RCN (2001) UK Guidance on Best Practice in Vaccine Administration: data/assets/pdf_file/0010/78562/ pdf Immunisation Policy (C/YEL/mm/13) Page 8 of 9

9 Appendix 1 Contact List: Pharmacy Pharmacist Contact Tel Number Opening Hours Queen s Hospital Pharmacy, Queen s Hospital, Belvedere Road, Burton upon Trent Pharmacy Dept, Samuel Johnson Hospital, Lichfield Pharmacy Dept, Sir Robert Peel Hospital, Tamworth Pharmacy Dept, The Marches Unit, Shelton Hospital, Bicton Heath, Shrewsbury Mrs Val Phillips Tel: ext 5638 Fax: Mrs Alison Hodgetts Tel: Fax: Mrs Angelina Dyche Tel: ext 8327 Fax: Ms Jane Lillington Tel: Fax: Saturday St Chad s Pharmacy, St George s Hospital Site, Corporation Street, Stafford Mrs Isobel Timmis Mr Richard Heys Tel: Fax: Trust-wide Medicines Management Team Mrs Cathy Riley Mrs Diane Thompson Ms Kerri Johnson Tel Monday- Friday Senior Nurse- Medicines Management Mr Nigel Neal Tel Monday- Friday Immunisation Policy (C/YEL/mm/13) Page 9 of 9