Document name: Vaccination and Immunisation Policy and Procedure for Registered Nurses
Document type: Policy
What does this policy replace? Update of version 1
Staff group to whom it applies: All registered nurses within the Trust
Distribution: All Staff
How to access: Intranet
Version 2
Issue date: January 2016
Next review: January 2019
Approved by: Executive Management Team February 2016 Developed by: Professional Lead 0 to 19 Children’s Services
Director leads: Director of Nursing Clinical Governance and Safety
Contact for advice: Professional Lead 0 to 19 Children’s Services
Content Page Number
1.Introduction 3 2.Purpose and scope 3
3.Definition and Abbreviations 4
4.Principles 4
5. Consent 5
6. Declined Vaccination and Immunisations 6
7. Storage of Vaccines 6
8. Immunisation Schedule 7
9. Clinical Procedure 9
10. Anaphylaxis 11
11. Documentation 11
12. Training 12
13. Duties 13
14. Policy development, approval and review process 13
15. Dissemination and implementation process 14
Page 2 of 24 16. Monitoring compliance and effectiveness 14
14.References and further reading 14
15. Appendices
Equality Impact Assessment (see appendix A); 17 Checklist for the Review and Approval of Procedural Document (see appendix B); 21 Version control sheet (see appendix C).
24
1. Introduction
1.1 This policy aims to provide a framework for registered nurses involved in vaccination and immunisation. This policy applies to all registered nurses in the employment of South West Yorkshire Partnership Foundation Trust (SWYPFT) who have undertaken recommended training, and who administer vaccinations and immunisations
1.2 This document outlines SWYPFT’s policy on immunisation practice, the arrangements for keeping staff up to date, vaccine storage, consent and the management of anaphylaxis and the procedure for vaccination and immunisation administration. This applies with immediate effect to all nurses administering vaccines.
1.3 This policy has been developed in accordance with SWYPFT’s, Policy for the development, approval and dissemination of policy and procedural documents (Policy on Policies) and incorporates other polices such as:
Medicines Code Hand Hygiene. Care records management. Safe Handling and disposal of sharps. Sharps injury and exposure to body fluids procedure. Guidelines for obtaining consent to examination and treatment or clinical intervention.
Page 3 of 24 1.4 Each registered nurse administering vaccine must have access to a copy of this policy. This policy must be read alongside the Department of Health ‘Immunisation against Infectious Diseases’ also known as the ‘Green Book’ available online at https://www.gov.uk/government/organisations/public-health- england/series/immunisation-against-infectious-disease-the-green-book
2. Purpose and scope
2.1 The aim of the policy is to enable staff to fulfil the requirements of their professional role to promote good public health and where necessary deliver a range of national immunisation programme, alongside any targeted immunisation schedules safely and competently.
2.2 The policy will ensure that clear, robust coordinated processes exist around vaccination and immunisation schedules. Including defined pathways to follow up non-responders and ‘hard to reach’ families or vulnerable groups (including looked after children), ensuring improved rates for individuals initiating and completing vaccination programmes within SWYPFT.
2.3 The purpose of this policy is to support the safe administration of vaccination and immunisation in Barnsley to achieve the national immunisation programmes.
3. Definitions and Abbreviations
3.1 Definitions Immunisation provides active immunity against infectious disease. The principal aims of immunisation are threefold: To protect the individual against infectious diseases, with associated mortality, morbidity and long- term consequences To prevent outbreaks of disease. Ultimately to eradicate some diseases world-wide.
3.3 A vaccine is a prescription only medicine, and can be administered by a registered nurse in accordance with a prescription from a registered prescriber or by a designated authorised registered nurse under a Patient Group Directive (PGD). Where a nurse is administering a vaccine in accordance with a PGD, the PGD must be valid, be specific for each immunisation product, and be signed by the registered nurse.
3.1 Abbreviations The following abbreviations have been used within the policy
DOH – Department of Health EG – For example HPA – Health Protection Agency NHS – National Health Service NMC – Nursing & Midwifery Council UK – United Kingdom
Page 4 of 24 PCHR – Personal Child Health Record PHE -Public Health England PGD -Patient Group Directive SWYPFT – South West Yorkshire Partnership Foundation Trust
4. Principles
4.1 The Immunisation programme in the UK continues to evolve, thus meeting the demand to improve the control of infectious diseases through vaccination. Vaccines are the safest and most successful public health measure available for preventing infectious diseases and their associated complications.
4.2 This policy provides registered nurses employed by NHS Barnsley with a framework for undertaking immunisations either in a surgery, clinic, school or domiciliary setting without the presence of a medical practitioner.
The principles of this Policy are to;
4.3 Identify the responsibilities of everyone involved in the vaccination and immunisation process
4.4 Ensure that adequate information is available for registered nurses trained in vaccination and immunisation to immunise safely and effectively having accurate evidence based information with which to underpin their clinical practice. 5. Consent
5.1 Consent must be obtained before starting any treatment or physical investigation or before providing personal care for a patient. This includes the administration of all vaccines. The giving and obtaining of consent is viewed as a process, and not a one- off event. Please read SWYPFT’s Guidelines for obtaining consent to examination and treatment or clinical intervention.
5.2 Obtaining consent has two functions. Firstly, a clinical function to foster trust and co-operation with patients and secondly a legal function to ensure that a person's right to autonomy has been addressed in order to prevent a charge of battery. This applies to both adults and children.
5.3 Before examining, treating or caring for a child, you must also seek consent (Guidelines for obtaining consent to examination and treatment or clinical intervention).Young people aged 16 and 17 are presumed to have the competence to give consent for themselves. Younger children who understand fully what is involved in the proposed procedure can also give consent (although their parents should wherever possible be involved). In other cases, someone with parental responsibility must give consent on the child's behalf, unless they cannot be reached in an emergency. If a competent child consents to treatment, a parent cannot over- ride that consent. Legally, a parent can consent if a competent child refuses, but it is likely that taking such a serious step will be rare. For further information refer to consent policy. 5.4 Parental consent to participate in a programme of vaccination
Page 5 of 24 and Immunisation should be obtained in writing. For further clarification see the ‘Guidelines for obtaining consent to examination and treatment or clinical intervention’.
5.5 Informed consent operates when the nature, purpose and effects of the immunisation programme and procedures have been explained to the parent(s)/guardian(s), and that the practitioner is confident that understanding has been achieved. This process must be completed when the child is offered for immunisation on each occasion.
5.6 In accordance with the Mental Capacity Act 2005 and SWYPFT Mental Capacity Act Policy, all staff should assess the patient’s ability to understand and retain information about their condition and care decisions. The practitioner should ensure all reasonable steps are taken to maximise their appropriate involvement in decision making about their care this applies to consent for vaccination and immunisation. If the person is still unable to be involved in decisions about their care ensure best interest decision making policy is adhered to and ensure any advanced care planning is considered. See also www.dh.gov.uk/mentalcapacityact
5.7 For further information refer to ‘The Green Book’ section 2 on Consent https://www.gov.uk/government/organisations/public-health- england/series/immunisation-against-infectious-disease-the-green-book
6. Declined Vaccination and Immunisation
6.1 If parents or carer’s decline vaccination for their children, the reason for their decision should be explored (with consideration given to parental capacity to make these decisions) and further information offered or advice sought. However, parents should not be unduly pressured, though need to be making an informed choice.
6.2 If parents decide not to accept the offer of the vaccination and immunisation programme, this should be recorded in clinical notes and on the Child Health information system. This should also be recorded this information in the PCHR.
6.4 If parents decline the vaccination and immunisation programme consideration should be made as to whether other health care needs are/are not being met. If concerns are raised discuss with safeguarding/professional lead.
7. Storage of Vaccines
7.1 All vaccines have a predetermined shelf life, and expiry dates will be clearly marked on the outer packaging of each product. The expiry date is dependent upon the vaccine being stored in the correct manner and maintenance of the cold chain, throughout the shelf life of the product. Breaks in the cold chain may result in loss of potency of a vaccine and ultimately to vaccine failure. Most vaccines must be kept at
Page 6 of 24 temperatures between 2° and 8°C and nurses should consult the product packaging to ensure vaccines are being stored at the correct temperature.
7.2 Each practice area should have a designated person responsible for the ordering and storage of vaccines.
7.3 Vaccines should be stored in a lockable pharmacy or vaccine refrigerator. Domestic refrigerators are not designed for storage of vaccines and should not be used. Food or clinical samples should never be kept in the same fridge as vaccines.
7.4 Care should be taken to avoid over-ordering or stockpiling vaccines. Systems should be developed to ensure stock rotation, and regular checks should be made to remove time expired vaccines. Vaccines should be stored in the refrigerator, allowing air to circulate around the packages. Door opening should be kept to a minimum.
7.5 Care should be taken to ensure that the electricity supply to the vaccine storage refrigerator cannot be accidentally interrupted e.g. by using a switchless socket or by placing cautionary notices on plugs and sockets.
7.6 A maximum/minimum thermometer should be used in refrigerators where vaccines are stored, and the temperature should be monitored and recorded daily. The calibration of thermometers should be checked annually to ensure that they are working correctly. Temperature record logs are best kept close to the refrigerator for ease of reference and be retained until the next audit. A Datix should be initiated if the refrigerator temperature deviates to below or above the recommended temperature.
7.7 Ice should not be allowed to build up within the refrigerator, as this reduces effectiveness. Special care should be taken during defrosting to ensure that the temperature of the vaccine does not go outside the specified range. An alternative refrigerator or insulated containers should be used for vaccine storage during defrosting of the main refrigerator.
7.8 Vaccines must be kept in the original packaging, wrapped in bubble wrap (or similar insulation material) and placed into a cool box with cool packs as per the manufacturer’s instructions. This will prevent direct contact between the vaccine and the cool packs and will protect the vaccine from any damage. When transporting vaccines, the named individuals are responsible for ensuring that only the amounts of vaccines necessary for each session are removed from the vaccine refrigerator. These should be placed quickly into the validated cool boxes and opening must be kept to a minimum. If there are any unused vaccines left over at the end of a vaccination session, providing there is evidence from the temperature monitoring that the cold chain has been maintained, the vaccines can be returned to the vaccine refrigerator. Returned vaccines should be used at the earliest opportunity. If the cold chain cannot be guaranteed, a risk assessment should be done, as described in the previous section.
8. Immunisation Schedule
Page 7 of 24 8.1 This policy covers all child and adult vaccinations undertaken in various primary care settings; 1. Routine Childhood Immunisation programme 2. Non routine immunisation for children 3. School based immunisations 4. Influenza / Pneumococcal National programme 5. Travel vaccinations 6. En masse campaigns as per DOH and HPA guidance 7. Domiciliary Immunisations
8, 2 Routine Childhood Immunisation programme The National Immunisation programme covers children from birth to 19 years of age Information regarding these immunisations are constantly being updated. For information regarding the up to date programme staff should access https://www.gov.uk/government/organisations/public-health- england/series/immunisation-against-infectious-disease-the-green-book
8.3 Pre-school children 0-5 years Parents will be advised of the Childhood Immunisation programme by the Health Visitor at their initial birth visit, who will continue to promote and encourage parents to attend for immunisations. Appointments for scheduling are sent by the Child Health Department, and in some instances, direct from the GP to the child’s home address.
Immunisations commence at two months of age. Parents will consent to immunisations at each immunisation appointment.
8.4 School age children 5-19 years It is the responsibility of the GP and the School Health Service to ensure all children are up to date with the current national programme. Children in this age range may be immunised in the school or college setting or at the GP practice.
8.5 Non routine immunisation for children Hepatitis B: The neonatal schedule for post exposure prophylaxis for babies born to Hepatitis B positive mothers. The Screening co-ordinator at BHNFT Maternity service notifies Child Health Records Department, GP Practice and the PHE Screening and Immunisation team (South Yorkshire and Bassetlaw). An initial dose is given prior to discharge from maternity services, with the 2nd dose at 1 month, 3rd dose at 2 months and 4th dose at 12 months, all administered through GP practices.
At the 4th dose at 12 months it is a local agreement for GP practices to complete a Dried Blood Spot test that is supplied through the PHE Screening and Immunisation team co-ordinator.
It is GP practices responsibility to ensure babies receive timely doses and a completed Dried Blood Spot test at 12 months, with the outcome recorded in the child’s clinical record.
Hepatitis B vaccinations can be given at the same time as other vaccinations.
Page 8 of 24 It should be noted Hepatitis B may be given for other reasons e.g. parental lifestyle, household contact, abstinence syndrome or travel – these are not post exposure and do not fall under the remit of the SIT and the notification pathway described in point.
8.7 Other Vaccines recommended for “at risk” groups of children, includes such immunisations as the seasonal influenza for children with “at risk medical conditions” (see the Green Book 2006). The GP is responsible for identifying and following up children to complete the relevant vaccines advised.
8.8 School based immunisations The generic School based immunisation programme is currently led by SWYPFT as an integral element of the School Nursing Service. School nurses should have a comprehensive and up to date knowledge of school immunisation issues in accordance with the HPA’s National Immunisation Standards.
8.9 Influenza and Pneumococcal immunisation SWYPFT supports GP practice’s to protect their most vulnerable/ housebound patients by providing seasonal influenza, shingles and pneumococcal vaccinations in the home. Alongside this SWYPFT also offer these vaccines to at risk groups on all in-patient wards.
SWYPFT is also required to offer seasonal flu vaccines to staff. This is facilitated by Occupational Health Department.
8.10 Travel vaccines SWYPFT does not provide direct access to travel vaccinations; however GPs provide this service for their patients. It is the responsibility of the GP to ensure that these are given by a competent registered nurse, trained in travel assessment and vaccines.
8.11 General en masse immunisations SWYPFT has an en masse immunisation action plan which may be adapted to target any age group in the population. This is mainly for pandemic flu immunisations, but may be adapted for any large scale Immunisation programme.
8.12 Domiciliary Immunisations Immunisations may be performed in the patient’s home. For young children this may be to assist access for those parents unable to attend clinic. For adults who are housebound domiciliary visits would be arranged to give immunisations such as flu / pneumococcal vaccinations. In all cases, the health professional is required to carry their own emergency adrenaline pack and a charged mobile phone. The immuniser should be accompanied by another member of staff if this is their preference.
9. Clinical Procedure
9.1 Recommendations on immunisation procedure within this policy are based on currently available evidence of best clinical practice (from current expert advice received from the Joint Committee on Vaccination and Immunisation). Refer to ‘The Green Book’ or Public Health England(PHE)Vaccine Updates if required. https://www.gov.uk/government/collections/vaccine-update
Page 9 of 24 9.2 Preparation of vaccines Each vaccine should be removed from the refrigerator, reconstituted and drawn up individually for each patient. This will reduce the risk of vaccine error, as well as maintaining vaccine efficacy and stability. Vaccines should not be drawn up in advance of an immunisation session.
9.3 Different vaccines must not be mixed in the same syringe unless specifically licensed and recommended for such use. Unless supplied in a prefilled syringe, the diluent should be drawn up using an appropriately sized syringe and green needle, and added slowly to the vaccine to avoid frothing. Using a needle no larger than a green needle ensures that no glass fragments are able to be drawn up from the ampoule in to the syringe.
9.4 Prior to administration Vaccinators must ensure that there are no contraindications to the vaccine/vaccines being given. Vaccinators must ensure that the patient or carer is fully informed about the vaccines to be given and that they understand the vaccination procedure. Vaccinators must ensure that the patient or carer is aware of any possible side effects and how best to treat them.
Vaccinators must ensure that they have obtained informed consent Vaccinators must ensure that they have signed the appropriate Patient Group Directive. Vaccinators must ensure that they have an Anaphylaxis pack to hand, and that the Adrenaline enclosed within it is in date. Vaccinators must wash their hands thoroughly prior to drawing up vaccine, then prior to, and following immunisation. Refer to SWYPFT’s Hand Hygiene Policy for further clarification.
9.5 Route of injection Injection technique, choice of needle and injection site are all important aspects of the immunisation process, since these factors can affect both the immunogenicity of the vaccine and the risk of local reactions at the injection site. Most vaccines should be given by intramuscular (IM) injection. (Exceptions to this rule are BCG, which is given by intradermal injection, and Japanese encephalitis and Varicella vaccines, which are given by deep subcutaneous SC injection).
For individuals with a bleeding disorder, vaccines normally given by an IM route should be given by deep SC injection to reduce the risk of bleeding. Please refer to ‘The Green Book’
9.6 Changing needles Unless the vaccine is supplied in a prefilled syringe with an integral needle, a new needle should always be used to inject the vaccine. This reflects best practice. However, in certain instances a prefilled syringe with attached needle is either prefilled with vaccine, or has been sent from the PHE/DH for the sole purpose of use for pandemic flu vaccine. In these instances it will not be possible to change the needle prior to immunisation.
Page 10 of 24 9.7 Suitable sites for vaccination The preferred site for IM and SC immunisations are the anteriolateral aspect of the thigh or the deltoid muscle of the upper arm. These sites ensure that the injection avoids major nerves and blood vessels. The gluteal muscle should not be used for immunisation as the vaccine is unlikely to reach muscle, only fat, and there is also risk of sciatic nerve damage.
9.8 The anteriolateral aspect of the thigh is the preferred site for babies and toddlers up to around one year of age or so. This is because the thigh provides a large muscle mass into which the vaccine can be safely administered. For older children and adults the deltoid muscle can be used.
9.9 For BCG immunisation the preferred site of injection is over the insertion of the left deltoid muscle, regardless of age. The tip of the shoulder must be avoided because of the increased risk of keloid formation at this site.
9.10 For babies requiring two injections, one injection should be administered into each thigh. If more than two injections are required then two should be given in the same thigh and the other in the opposite thigh. Where two injections are administered in the same thigh, they should be given at least 2.5cm apart. The site at which each immunisation is given should be documented in the individual’s records.
9.11 Cleaning the skin It is no longer deemed necessary to clean or disinfect the skin with alcohol swabs prior to immunisation, since evidence has concluded that this makes no difference to the incidence of bacterial complications of injections. Only visibly dirty skin needs to be washed with soap and water.
9.12 Choice of needle size A blue needle should be used for administering the majority of immunisations. Studies have shown that the use of blue needles can reduce the risk of local reactions at the injection site and increase dispersion of the immunisation. For pre- term or tiny babies an orange needle is suitable for IM injection.
9.13 Injection technique The vaccinator should ensure that the patient is relaxed to ensure that the vaccine is administered into relaxed muscle. This allows for better distribution of the vaccine. Intramuscular (IM) Injections should be given at a 90 degree angle to the skin and the skin should be stretched, not bunched. If the skin is bunched there is a risk of giving the vaccine intended for IM route into the subcutaneous layer of the skin.
If subcutaneous injection is required, this should be administered at a 45 degree angle to the skin and the skin bunched rather than stretched, for the reason given above.
It is not necessary to aspirate the syringe after the needle is introduced into the patient and prior to giving the immunisation. This former practice has been discontinued. Research suggests no aspiration, rapid injection and rapid withdrawal as the ideal technique for administering immunisations (2006, cited in Diggle 2010).
Page 11 of 24 9.14 Recipients should be observed for immediate adverse reactions to the administration of the vaccine. However, there is no evidence to support the practice of observing the patient in surgery for a period of time post vaccination. Equipment used for vaccination, including needles, syringes, used vials and ampoules should be safely disposed of in a ‘sharps bin’. Disposal of all items should comply with current waste regulations. Needles should never be re-sheathed, thus reducing the risks of contamination incidents. Used cotton wool should not be placed in the sharps bin, but disposed of in household waste.
10. Anaphylaxis
10.1 Anaphylactic reactions following immunisation are extremely rare but have the potential to be fatal. Onset of anaphylaxis is rapid, typically within minutes, and its clinical course is unpredictable with variable severity and clinical features.
10.2 All health professionals responsible for immunisation must be familiar with techniques for resuscitation of a patient with anaphylaxis to prevent disability and loss of life. A protocol for the management of anaphylaxis and an adrenaline pack must always be available whenever vaccines are given.
11. Documentation
11.1 Accurate and timely recording of any vaccinations administered are necessary in order to; ensure that the individual’s records are correct for monitoring immunisation uptake within the Barnsley area to facilitate the recall of individuals for immunisation as required.
11.2 Best practice ensures that the following information is documented this includes the vaccine name, dose given, site, batch number and expiry date.
11.3 This information should be recorded in the patient’s records, patient held record /Personal Child Health Record (The Red Book) where appropriate; GP computer system and Child Health scheduled/unscheduled immunisation form (if appropriate)
11.4 Where appropriate a designated person should also complete the vaccine stock book and claim forms for reimbursement and item of service payment if appropriate, or ensure the details are passed on to the relevant member of staff.
11.5 The sticky labels which can be removed from the barrel of some prefilled syringes and ampoules containing the batch number and expiry date may be used to speed up documentation.
11.6 All vaccinations should be highlighted within a patient’s records in order to help ascertain an individual’s vaccine status at a later stage.
12. Training
Page 12 of 24 12.1 The DH, developed guidance on the Minimum Standards for Immunisation Training (DOH 2005) with the aim that all health professionals engaged in immunisation are: Able to provide accurate and up to date information about the diseases and vaccines to their patients. Able to give a high standard of care.
12.3 Any person who administers any immunisation must be on the relevant Professional registers i.e. the Nursing and Midwifery Council. Staff giving and advising on Immunisation must receive essential role specific training in line with the Health Protection Agency’s National Minimum Standards for Immunisation Training (HPA 2005) and include
Aims of Immunisation: national policy and schedules Immune system and how it works Vaccine preventable disease Different types of vaccine used and their composition Current issues and controversies regarding immunisation 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
12.4 Registered nurses are professionally accountable for their practice. Practitioners who have undergone training and demonstrated competency in practice may administer vaccines in accordance with this policy.
12.5 Staff must Keep up to date and develop knowledge, skills and competence. Recognize the limits to personal knowledge and skill and remedy deficiencies Ensure that existing care is not compromised by new developments and responsibilities Acknowledge personal and professional accountability
13. Duties
13.1 Chief Executive Has overall accountability for this policy.
13.2 District directors District directors are accountable for ensuring implementation of this policy within their respective BDUs and for ensuring that minimum training standards are being met.
Page 13 of 24 13.3 Director of nursing, clinical governance and safety The lead director will be responsible for engaging relevant stakeholders in the development of the policy and, in consultation with the district directors, ensuring that appropriate arrangements are in place for managing any resource implications including dissemination and training.
13.4 BDU clinical leads Are responsible for ensuring that a clinical leader is identified to represent the BDU.
13.5 General managers/service manager’s General Managers and service managers are responsible for ensuring that identified staff within the BDU are appropriately trained in the administration of Vaccination and Immunisations. BDU clinical leads, general managers and service managers are also responsible for highlighting any difficulties in the implementation of this policy.
13.6 All trained registered staff administering vaccination and immunisations a responsibility to ensure that they read, understand and follow this policy at all times. They must ensure that they have signed the appropriate Patient Group Directives and carry out an annual self-assessment of their competencies in this area as part of the appraisal process. They are professionally accountable for their practice and must ensure that they access up to date information on vaccination and immunisation, visit
14. Policy Development, Approval and Review Process
14.1 Equality impact assessment The Trust is committed to providing services that meet the diverse needs of our service users, population and workforce. An equality impact assessment has been completed by the policy authors and approved by the EMT as part of the policy approval process in accordance with trust policy. The equality impact assessment has been published on the Equality and Diversity webpage of the SWYPFT website.
14.2 Policy review process This document will be reviewed in line with the Trust policy for the development, approval and dissemination of policy and procedural documents. It will be reviewed every three years to ensure that it is up-to-date and reflects recognised practice, and reissued on or before the review date identified on the front cover. It may be amended more frequently than this to reflect any major changes in external or trust policies and procedures. All amendments will be approved by the Executive Management Team.
14.3 Version control The front cover indicates the version, date of issue and review date of this document. Following each review the policy will be issued as a new version, whether or not any changes have been made to the actual content of the document. The most recent version will be available on the trust intranet. Previous versions will be archived in accordance with trust policy.
15. Dissemination and Implementation arrangements
Page 14 of 24 15.1 Once approved, the SWYPFT integrated governance manager will be responsible for ensuring the updated version is added to the document store on the intranet and included in the staff brief. Implementation of the policy will be cascaded via the district directors to clinical leaders/general managers and then to teams and services through BDU management structures.
16. Monitoring compliance and effectiveness
16.1 The Executive Management Team (EMT) is responsible for assuring the overall management of incidents within the trust through the EMT and through individual director accountability.
16.2 Business Delivery Units monitor incidents and investigations within operational services, which include: Managing issues in relation to incident management, reporting and recording, including inputting onto the Datix system. Receiving quarterly reports about incidents, complaints, claims and legal issues, analysing trends and identifying learning to be shared across services and with other care groups. Receiving information pertaining to ‘learning from incidents’ within the care group, in other care groups and some specialist advisors, commissioning work to address the identified risk issues.
14. References and further reading
All of the following can be accessed from the Department of Health Immunisation Page: http://immunisation.dh.gov.uk/ Immunisation Against Infectious Diseases 2006 (Green Book) Official Immunisation letters i.e. Chief Medical Officer, Chief Nursing Officer Vaccine Update The vaccine supply newsletter Key vaccine information, local coordinators toolkit, immunisation research papers. ImmForm Helpsheet
DH/PHE Immunisation against Infectious Diseases (The Green Book) JCVI DOH. Great Britain https://www.gov.uk/government/organisations/public-health- england/series/immunisation-against-infectious-disease-the-green-book
NMC Code, http://www.nmc.org.uk/standards/code/
Public Health England Vaccine Update https://www.gov.uk/government/collections/vaccine-update
Public Health England – www.hpa.org.uk Immunisation pages containing guidelines, training and further web links (including an immunology animation); http://www.hpa.org.uk/HPA/Topics/InfectiousDiseases/InfectionsAZ/1204012992543/
Page 15 of 24 SWYPFT (2012) Care records management policy.
SWYPFT (2012) Guidelines for obtaining consent to examination and treatment or clinical intervention.
SWYPFT (2015) Hand hygiene policy.
SWYPFT (2015) Safe handling and disposal of sharps policy.
SWYPFT (2014) Sharps injury and exposure to body fluids procedure
Equality Impact Assessment (see appendix A);
Checklist for the Review and Approval of Procedural Document (see appendix B);
Version control sheet (see appendix C).
Page 16 of 24 Appendix A - Equality Impact Assessment Tool
To be completed and attached to any policy document when submitted to the Executive Management Team for consideration and approval.
Date of Assessment: ______
Equality Impact Assessment Evidence based Answers & Actions: Questions:
1 Name of the document that Vaccination and Immunisation Policy and you are Equality Impact Procedure for Registered Nurses Assessing .
2 Describe the overall aim of The overall aim of the policy is to provide your document and context? staff with best practice guidance relating to the administration of vaccination and immunisations. The policy is reflective of the Who will benefit from this national programme for vaccination and policy/procedure/strategy? immunisation. All registered nurses who administer vaccination and immunisations
3 Who is the overall lead for this Director of Nursing, Clinical Governance & assessment? Safety
4 Who else was involved in Anita McCrum Professional Lead 0 to 19 conducting this assessment? Children’s Services
5 Have you involved and All staff involved in the administration of consulted service users, vaccination and immunisations. The policy carers, and staff in developing has also been shared at the trust wide this policy and procedure group. policy/procedure/strategy?
What did you find out and how have you used this Additions and amendments made in line information? with expert feedback
Page 17 of 24 Equality Impact Assessment Evidence based Answers & Actions: Questions:
6 What equality data have you Information and data from national used to inform this equality guidelines impact assessment?
7 What does this data say? Information relating to national programme
8 Taking into account Yes/N Evidence based Answers & Actions. the information o Where Negative impact has been gathered above, identified please explain what action you could this policy will take to remove or mitigate this /procedure/strategy impact. affect any of the following equality group unfavourably: 8.1 Race No N/A
8.2 Disability No N/A
8.3 Gender No N/A
8.4 Age No N/A
8.5 Sexual Orientation No N/A
8.6 Religion or Belief No N/A
8.7 Transgender No N/A
8.8 Maternity & No N/A
Pregnancy
8.9 Marriage & Civil No N/A partnerships
8.1 Carers*Our Trust No N/A 0 requirement*
9 What monitoring Monitoring is in place in line with national arrangements are you KPI’s implementing or already have
Page 18 of 24 Equality Impact Assessment Evidence based Answers & Actions: Questions:
in place to ensure that this policy/procedure/strategy:-
9a Promotes equality of opportunity for people who share the above protected characteristics;
9b Eliminates discrimination, harassment and bullying for people who share the above protected characteristics;
9c Promotes good relations between different equality groups;
9d Public Sector Equality Duty – “Due Regard”
10 Have you developed an Action No Plan arising from this assessment?
11 Assessment/Action Plan approved by
12 Once approved, you must forward a copy of this Assessment/Action Plan to the Equality and Inclusion Team:
Please note that the EIA is a public document and will be published on the web.
Failing to complete an EIA could expose the Trust to
Page 19 of 24 Equality Impact Assessment Evidence based Answers & Actions: Questions:
future legal challenge.
If you have identified a potential discriminatory impact of this policy, please refer it to the Director of Corporate Development or Head of Involvement and Inclusion together with any suggestions as to the action required to avoid/reduce this impact.
For advice in respect of answering the above questions, please contact the Director of Corporate Development or Head of Involvement and Inclusion.
Page 20 of 24 Appendix B - Checklist for the Review and Approval of Procedural Document
To be completed and attached to any policy document when submitted to EMT for consideration and approval.
Yes/No/ Title of document being reviewed: Comments Unsure 1. Title Is the title clear and unambiguous? YES Is it clear whether the document is a YES guideline, policy, protocol or standard? Is it clear in the introduction whether YES this document replaces or supersedes a previous document? 2. Rationale Are reasons for development of the YES document stated? 3. Development Process Is the method described in brief? YES Are people involved in the YES development identified? Do you feel a reasonable attempt has YES been made to ensure relevant expertise has been used? Is there evidence of consultation with YES stakeholders and users? 4. Content Is the objective of the document clear? YES Is the target population clear and YES unambiguous? Are the intended outcomes described? YES Are the statements clear and YES unambiguous? 5. Evidence Base Is the type of evidence to support the YES document identified explicitly?
Page 21 of 24 Yes/No/ Title of document being reviewed: Comments Unsure Are key references cited? YES Are the references cited in full? YES Are supporting documents referenced? YES 6. Approval Does the document identify which YES committee/group will approve it? If appropriate have the joint Human N/A Resources/staff side committee (or equivalent) approved the document?
7. Dissemination and Implementation Is there an outline/plan to identify how YES this will be done? Does the plan include the necessary YES The policy refers to training/support to ensure compliance? recommended training in line with national standards 8. Document Control Does the document identify where it YES will be held? Have archiving arrangements for YES superseded documents been addressed? 9. Process to Monitor Compliance and Effectiveness Are there measurable standards or YES KPIs to support the monitoring of compliance with and effectiveness of the document? Is there a plan to review or audit YES compliance with the document? 10 Review Date Is the review date identified? YES Is the frequency of review identified? If YES
Page 22 of 24 Yes/No/ Title of document being reviewed: Comments Unsure so is it acceptable? 11 Overall Responsibility for the . Document Is it clear who will be responsible YES implementation and review of the document?
Page 23 of 24 Appendix C - Version Control Sheet
This sheet should provide a history of previous versions of the policy and changes made
Versi Date Author Status Comment / changes on 1 March Jane Rand Final Final version approved by Trust 2011 Public Health Board Specialist Nurse 2 January Anita McCrum Updated policy 2016 Professional Lead 0 to 19 Children’s Services