Tuberculosis Policy. Target Audience. Who Should Read This Policy. All clinical staff

Transcription

1 Tuberculosis Policy Who Should Read This Policy Target Audience All clinical staff Version 1.0 January 2015

2 Management of Tuberculosis CONTENTS PAGE NUMBER Policy Information 1.0 Introduction Aim Objectives Definitions Information About Tuberculosis Diagnosis Notification Specimens 8.1 Sputum Other Specimens Laboratory Testing Responsibilities of Staff 9.1 Occupational Health Nursing Staff Medical Staff Control of Infection Team Management of Patients Isolation 11.1 Non Pulmonary TB End of Isolation Action for Sputum Smear Positive Patients on Open Wards 8 Version 1.0 January 2015

3 13.0 Other Infection Control Measures Reducing Risk of Transmission Bronchoscopies 15.1 Disinfection of Equipment (e.g. Endoscopes) Post Mortem Finance Training Further Reading 9 Appendices 1. Procedure for Tuberculosis Control in Black Country Partnership NHS Foundation Trust Policy for Tuberculosis Control Management of Patients with HIV Related and Multidrug 18 Resistant Tuberculosis (MDR-TB) Version 1.0 January

4 1.0 INTRODUCTION The Department of Health requires every Trust to have a policy for the prevention and control of tuberculosis. This should integrate both hospital and community services. 2.0 AIM To ensure that patients with tuberculosis receive appropriate therapy, their contacts are fully investigated and other patients are protected from contracting tuberculosis by appropriate isolation measures. 3.0 OBJECTIVES The protection of Trust staff and patients from contracting tuberculosis by:- appropriate treatment of patients with tuberculosis contact tracing isolation and nursing care specific procedures 4.0 DEFINITIONS CCDC: NON PULMONARY Consultant in Communicable Disease Control Infection with tuberculosis in all sites apart from the lungs. This does not usually cause secondary infection and does not require isolation. INDEX CASE The first patient in an investigation with proven / probable tuberculosis. DOT MDR-TB COSHH Directly observed therapy. Multi drug resistant tuberculosis Control of Substance Hazardous to Health 5.0 INFORMATION ABOUT TUBERCULOSIS Tuberculosis (TB) is an infection caused by the organism Mycobacterium tuberculosis which may affect any part of the body but most commonly affects the lungs or lymph nodes. The infection is caught by inhaling the droplets coughed by a person with T.B. of the lungs. Non respiratory disease is most common in children, immigrants from countries with a high incidence of T.B. and people with impaired immunity e.g. H.IV. All patients with a diagnosis of clinical or laboratory confirmed tuberculosis are included in this category. About 40% of all clinical diagnosis are confirmed in the laboratory. Once an individual has acquired the infection, one of three things may follow:- the infection may heal spontaneously the active disease may develop over time the disease may be dormant for years and then may be re-activated by a reduction in the persons immunity due to an underlying disease, or simply old age. Version 1.0 January

5 6.0 DIAGNOSIS When a person acquires TB infection a skin sensitivity to T.B. proteins occurs, this can be demonstrated by a skin test called a HEAF or MANTOUX test. A positive reaction (a reddened blistered area) is useful only in showing exposure to infection or immunity. Active TB may be diagnosed by: the overall clinical view of the patient i.e. loss of weight, cough, night sweats, haemoptysis, pain in the chest. chest X-ray organisms seen on examination of sputum specimen. 7.0 NOTIFICATION Tuberculosis is a notifiable disease. This means the C.C.D.C. at the Health Authority must be informed. This allows the process of tracing contacts to begin and for epidemiological trends to be monitored. 8.0 SPECIMENS In order to identify Mycobacterium tuberculosis by laboratory methods it is necessary to obtain good quality specimens. It should not be forgotten that specimens can be classified as a hazard under the C.OS.H.H. Regulations 1994, therefore care must be taken to secure containers properly and place them in the necessary transport pouches. N.B. the request form must be in the separate pocket. labels must be attached to the pot and the form. BIOHAZARD 8.1 Sputum If the patient is not producing sputum, the aid of the physiotherapist should be sought. A specimen of sputum from 3 consecutive mornings should be collected. (This is to obtain the sputum which has been in the lungs overnight and is therefore concentrated and likely to carry the most organisms). N.B. Saliva specimens will not be acceptable in diagnosing Tuberculosis 8.2 Other Specimens Other specimens such as urine can also be tested. Urine should be collected in special containers available from the microbiology laboratory and are usually, the TOTAL amount of the first bladder emptying in the morning for 3 consecutive days. 8.3 Laboratory Testing Mycobacterium tuberculosis are identified by special staining methods which is why they are sometimes referred to as A.A.F.B. (Alcohol and Acid Fast Bacilli). If sufficient numbers of the bacteria are present following staining allowing them to be seen under the microscope, the patient is described Version 1.0 January

6 as having active or open T.B. and is VERY INFECTIOUS. Referred to as SMEAR POSITIVE. If bacilli cannot be seen on examination of any the 3 specimens, the patient may still have T.B., but is not thought to be infectious as the bacteria are not present in great enough numbers to be coughed around. All specimens from patients suspected as having T.B. undergo CULTURE which takes 6 12 weeks. This process allows any bacteria present to multiply and grow on special culture medium so that a patient can be diagnosed and treated BEFORE they become highly infectious. Therefore a patient can be CULTURE POSITIVE after being SMEAR NEGATIVE. These patients pose a minimum threat to others but still need treatment to prevent the disease developing. 9.0 RESPONSIBILITIES OF STAFF 9.1 Occupational Health (pre-employment and post exposure) Appendix Nursing staff Patients with suspected or proven pulmonary tuberculosis must be nursed initially in isolation in a single side room. The nurse in charge must notify the infection control team of all newly diagnosed cases. 9.3 Medical staff Patients with tuberculosis (pulmonary and non pulmonary) should normally be under the care of a thoracic physician who will organise therapy and investigation of contacts. 9.4 Control of Infection Team Will ensure that appropriate isolation procedures are followed and that staff are offered training in control of infection procedures. The ward manager must liaise with the Infection Control Team to arrange this MANAGEMENT OF PATIENTS The Infection Control Team must be advised as soon as possible of all suspected and newly diagnosed cases of TB. Patients with tuberculosis (pulmonary and non-pulmonary) MUST be referred to Dr McLeod (chest physician) who will organise therapy and investigation of contacts (Appendix 2) ISOLATION (this policy should be read with reference to SHC\COI\006) In hospital ALL suspected and confirmed sputum smear positive patients including those previously negative who become smear positive after bronchoscopy should be nursed in a side ward (preferably with air extraction to the outside away from patients and inlets for air conditioning). The DOOR MUST BE KEPT CLOSED. Patients should not visit other wards or departments or use communal washing facilities or other public areas of the hospital. If the patients are coughing they should not walk or be moved through open wards (where there may be immuno suppressed patients) Version 1.0 January

7 unless they are wearing an appropriate particulate filter mask. (TECNOL PFR 95 Particulate Filter Respiratory Mask). Patients with suspected or proven pulmonary T.B. will normally be accommodated on Priory 5 or Lyndon 5. HIV patients with or without TB must NOT be admitted to Walkden Unit (Newton 5) where there are immunocompromised or oncology patients unless the physician in consultation with the infection control officer decides they are non infectious. The families of children with proven TB should be requested not to mix with other patients until the contact tracing procedures have been completed and risks identified Non pulmonary TB It is not normally necessary to isolate cases of non-pulmonary TB (seek infection control advice) End of Isolation Termination of isolation should be decided by the supervising physician in conjunction with the infection control team. Studies suggest that the majority of patients with uncomplicated sputum positive TB will become non infectious after two weeks compliance with standard multidrug chemotherapy and could then be transferred to an open ward, however, the ongoing results of sputum tests and/or the response to treatment should be considered. In some circumstances, three smear negative sputum examinations on successive days should be confirmed before a patient is removed from isolation e.g. (a) (b) (c) if the patient is thought to have been particularly infectious (i.e. known to have transmitted infection to more than 10% of close household contacts and/or to casual contracts. if resistant disease is possible or confirmed. if the patient is to be transferred to an open ward or bay containing HIV positive or immuno-compromised results. If a combination of more than one of these criteria exist, consideration will be given as to whether the patient should be transferred to Heartland s Hospital where negative pressure ventilation is available. The possibility of DRUG RESISTANT DISEASE should be considered if there is: a history of previous incomplete or non compliant treatment. contact with a patient with known drug resistant disease. disease probably acquired in a country with an incidence of drug resistant disease. disease not responding to treatment. If there is doubt about the degree of isolation required the case should be discussed with the Infection Control Officer. Version 1.0 January

8 12.0 ACTION FOR SPUTUM SMEAR POSITIVE PATIENTS ON OPEN WARDS If a patient is found to be sputum smear positive after spending more than 24 hours in an open ward the Infection Control Nurse will liaise with ward staff and: (a) (b) (c) Make a list of all patients in the bay, and if necessary the ward. Give this list to the CCDC to enable contact tracing. The CCDC will write to the GP s of all patients listed identifying the possibility of exposure to TB 13.0 OTHER INFECTION CONTROL MEASURES For sputum smear positive patients: Visitors should, as far as possible, be limited to those who have already been in close contact with the patient before diagnosis. Staff who have contact will the patient should be kept to a reasonable minimum without compromising patient care REDUCING RISK OF TRANSMISSION Patients should be provided with tissues and sputum pots and educated to cough into them, they must wear a particulate filter mask if being moved through public or patient areas. Staff must wear masks when direct exposure to respiratory secretions is unavoidable, e.g. during cough inducing procedures, bronchoscopy, or prolonged care of high dependency patient (patients may cough profusely for hours after cough inducing procedures). Cough inducing procedures such as inhalation of pentamidine, or procedures for production of sputum, must never be performed in an open ward or bay. Infected body secretions should be disposed of as other clinical waste, i.e. by incineration. Sputum specimens must be transported in appropriate pots in plastic bags labelled biohazard BRONCHOSCOPIES All bronchoscopies must be done in a theatre environment to remove the risk of cross infection. Staff must wear masks and goggles. The only exception to this is the ITU where patients on a ventilator can have a bronchoscopy with no risk of cross infection due to the cuffed endotracheal tube Disinfection of Equipment (e.g. Endoscopes) Mycobacteria are more resistant to disinfectants than most viruses, bacteria and fungi. Bronchoscopes require thorough manual cleaning followed by disinfection according to the manufacturers instructions. The British Thoracic Society recommends soaking for 20 minutes in freshly prepared 2% Gluteraldehyde after a careful pre-wash POST MORTEM Post mortems should not be done on patients with pulmonary TB FINANCE Will be met through existing Directorate budgets. Version 1.0 January

9 18.0 TRAINING Managers of wards and departments where patients with TB are nursed have a responsibility to arrange for appropriate education for their staff FURTHER READING The Department of Health, The Interdepartmental Working Group on Tuberculosis. Guidance on Tuberculosis Control & Version 1.0 January

10 Appendix 1 Procedure for Tuberculosis Control in Black Country Partnership NHS Foundation Trust 1.0 Introduction The aim of this procedure is to protect all Health Care Workers from contracting Tuberculosis, where their work involves patient contact. Human Tuberculosis may involve any part of the body, this procedure is concerned with the respiratory system where the source of infection has produced sputum smear positive bacillus. Only pulmonary tuberculosis is potentially infectious for other patients/staff. 2.0 Pre-employment Screening All new employees whose work involves patient contact will have their immunity to Tuberculosis assessed and the relevant test or vaccination administered. (See procedure for Pre-employment screening of Trust Employees and Heaf Testing Procedure) 3.0 Exposure to cases of Tuberculosis on wards Any employee who has been in contact with infectious Tuberculosis will have their Heaf or BCG status checked and updated if necessary. All results to be recorded in the employee s manual and computer records. The Occupational Health Nurse Adviser will liaise with the Ward Manager regarding the above to ensure all employees are protected. The Occupational Health Nurse Adviser will liaise with the Consultant Microbiologist or Consultant in Communicable Diseases or Public Health when necessary. 4.0 Tuberculosis Surveillance Employees who work in the mortuary such as Pathologists and Anatomical Pathology Technicians will be informed annually of the need to inform the Occupational Health unit of any unexplained fever, loss of weight or a cough for more than three weeks. Version 1.0 January

11 BCPFT POLICY FOR TUBERCULOSIS CONTROL Appendix Introduction Tuberculosis continues to be a serious infectious disease. Recently there has been a rise in the number of cases notified, particularly in the West Midlands and particularly in the Black Country. The continued control of tuberculosis depends upon general public health measures, neonatal BCG vaccination of babies born to mothers from groups with a high risk, the schools BCG programme, screening of persons arriving from areas with a high prevalence of tuberculosis and the investigation of contacts of each and every case of tuberculosis. The purpose of this document is to lay down the policy in BCPFT in relation to this last activity. It is expected that this procedure will be followed by all groups of staff involved in the treatment and follow-up of patients with tuberculosis, their families and contacts. In England and Wales statutory responsibility for the screening of contacts rests with the Local Authority and its Proper Officer, generally the Consultant in Communicable Disease Control. However, the examination of contacts, Heaf testing, Chest X-Rays and chemo-prophylaxis are undertaken by several groups of professionals most notably Consultant Chest Physicians (CCP) and Thoracic Care Advisers (TCA) working in the Chest Clinic. The names and telephone numbers of current post holders appears at the end of this appendix. The measures required for the protection of health care staff and of patients within the NHS are matters for the Occupational Health Service and are dealt with separately. 2.0 Identification of Contacts 2.1 Close contacts are people, usually family members and other relatives, who share a household with the index case, and are most at risk. Investigation is justified even when the index case is not smear positive, when the risk is lower. 2.2 Casual contacts are all other people who come into occasional, social contact with a person with TB. Most workplace contacts will be casual contacts. In general, casual contacts need not be investigated. The exceptions are very young children and immunocompromised adults. Very occasionally a workplace contact can be sufficiently close to be classified as a close contact and would need investigating. Version 1.0 January

12 2.3 School contacts are in a special category. If the index case is a teacher, and is either smear positive or culture positive, then all child contacts as well as staff should be investigated. If the index case is a child and is smear positive then all children in the same year should be investigated. A flow chart developed by the British Thoracic Society to decide which contacts to investigate is included. 3.0 Flow chart for Investigating Contacts Contacts of a case should be investigated with three aims in mind: a) to identify the source of the infection in the index case b) to identify other, hitherto undetected, cases which may or may not be infectious, and who may or may not necessarily have acquired the infection from the index case c) to identify others who may have acquired the infection from the index case A clinical flow chart for the systematic investigation of contacts of a case has been developed by a subcommittee of the Joint Tuberculosis Committee of the British Thoracic Society. This flow chart will be followed in the investigation and follow up of contacts. 4.0 Organisational Matters In certain situations the investigation of all the contacts may become a major operation and require adequate organisation and clear understanding of the roles of different groups of professionals involved. 4.1 Domestic contacts. At present contacts are identified and followed up by the TCAs of the Chest Clinic. This practice will continue. When any of the contacts identified are residents of districts other than Sandwell, Chest Clinic staff will notify their counterparts in the district of residence by telephone. They should also pass on details of such contacts to the CCDC who will confirm the details in writing to the relevant Authorities in the district of residence. Similarly the CCDC may receive information about Sandwell residents who may be contacts of a case who is not a Sandwell resident. This list will be passed on to the Chest Clinic staff who will initiate contact procedures according to the flow chart. 4.2 Workplace contacts. Occasionally sufficient concern arises when one or more cases are detected in a factory or other place of work. The general rule is that workplace contacts are casual contacts and investigation is not justified. Each such incident must be decided individually. The CCDC will decide whether to investigate any contacts at all and if so will draw up a list of close contacts in discussion with the personnel department at the workplace. Since the Heaf test has poor discriminatory value in adults, arrangements will be made by the CCDC for such contacts to have a chest X-Ray in the hospital Radiology department. The reports on these X-Rays will be received by the CCDC and those whose X-Ray is suspicious will be referred to Version 1.0 January

13 the Chest Clinic. Where other lesions are detected the GP will be informed. This group of contacts will not have a Heaf test as part of the initial screening and this is one area where the policy deviates from the flow chart (local arrangement). 4.3 School contacts. Where an index case is likely to have contacts in a school, the CCDC will be responsible for initial liaison with the school authorities. The identification of contacts to be investigated will be governed by the flow chart and will be the responsibility of the School Health Nurse who will work in association with the School authorities. It is unreasonable to expect large numbers of school children to be given appointments to attend a clinic for investigation as is the case for domestic contacts. They will have to be investigated initially in the school and the responsibility for the initial investigation (mainly with Heaf testing) will rest with the Community Child Health Service working through the School Nurses acting on behalf of the CCDC. Those children with a Heaf test result that suggests the possibility of recently acquired infection will be referred to the Chest Clinic. Where adults (mainly teachers) need to be investigated, Chest X-Rays will be arranged in the hospital. Those whose X-Rays are suspicious will be referred to the Chest Clinic. 4.4 Special situations The situations outlined above represent the usual arrangements for initiating contact procedures when a case of tuberculosis is detected. There may be other situations which do not fall into one of these categories, or even if they do, evolve into a large investigation calling for substantial resources in staff time and facilities. To meet this contingency the CCDC will retain the authority to call an outbreak control team if he/she thinks the situation warrants it. Such a team will comprise: the Consultant in Communicable Disease Control (chair) the Consultant Chest Physicians the Consultant Microbiologist the Infection Control Nurses Senior nursing representative Management Representative other officers depending on the nature of the situation such as Consultant Occupational Physician, Consultant Community Paediatrician, Local Education Authority Representative, Social Services Representative, Representative from factory/firm/club or other institution which may be involved in the outbreak and Environmental Health Officers In such circumstances the outbreak control team will be responsible for agreeing a plan of action to identify, and investigate contacts. It will also be responsible for allocating specific tasks to specific groups of professionals. Version 1.0 January

14 5.0 Enquiries and Comments Any enquiries and comments regarding this policy please contact BCPFT Infection Control Team at Delta House 6.0 References Watson J M, Fern KJ, Porter JDH, Whitmore JE. Notifications of tuberculosis in England & Wales Comm Dis Rep 1991;1:R13-R16. Subcommittee of the Joint Tuberculosis Committee of the British Thoracic Society. Control and prevention of tuberculosis in Britain: an updated code of practice. Br Med J 1990;300: Version 1.0 January

15 BCPFT Policy INVESTIGATION OF TB CONTACTS YES? BCG Given NO Heaf Test (*) (*) Heaf Test X-Ray X-Ray? Index case smear positive Normal Normal Yes No No Age < 16 Yes Repeat Heaf at 6 weeks No? Asian Yes ? Index case - smear positive Age < 35 No Age < 35 No Yes Yes No Yes? High Yes BCG Was Index case risk Pulmonary TB? No Yes 1 Year 2 Years No Chest Clinic (@) Chemoprophylaxis Discharge Periodic X-Ray Discharge Discharge Examination Version 1.0 January

16 BCPFT Policy Tuberculosis in Schools - Who to Screen Index Case Teacher Child? Positive smear? Positive smear No Yes Yes No No action Screen staff Screen No action screen children children in relevant in same year teaching/games groups? Further case (s) No Yes Screen staff Notes: 1. Subjects not given chemoprophylaxis should have chest X/Rays at intervals for 2 years. 2. Negative Heaf test does not exclude Tuberculosis in immunosuppressed individuals. Version 1.0 January

17 Version 1.0 January

18 Appendix 3 MANAGEMENT OF PATIENTS WITH HIV RELATED AND MULTIDRUG RESISTANT TUBERCULOSIS (MDR-TB) 1. The care of all patients in this category should be jointly managed by a chest physician in collaboration with a HIV/GUM specialist (if required). Patients with drug sensitive tuberculosis regardless of HIV status do not necessarily require admission to hospital, however, out patient management is NOT appropriate for infectious or potentially infectious patients who live in a hostel or other communal establishment NOR is it likely to be appropriate for most patients with MDR-TB who will normally require an initial assessment and treatment in hospital. If admission to hospital is required, the appropriate facility for their care should be decided by the Consultant after discussion with the Infection Control Doctor, taking into account local policy, the potential infectiousness of the patient, the immune status of other patients and any known or suspected drug resistance. The type of isolation required will depend upon consideration of all these factors. 2. Patient Isolation Minimum requirements for the isolation of patients with suspected or proven tuberculosis Type of patient/contacts Drug-sensitive disease Infectious Potentially Infectious* Noninfectious Other patients Immunocompetent Other patients immunocompromised Single room Negative pressure room* Open ward Single room Open ward Open ward Drug resistant disease Other patients Immunocompetent Other patients immunocompromised Single room Negative pressure room** Open ward Single room Open ward Open ward MDR-TB Other patients Immunocompetent Other patients immunocompromised Negative pressure room* Negative pressure room** Single room Negative pressure room Open ward*** Single room Version 1.0 January 2015

19 * Potentially infectious = three negative consecutive smears but one or more cultures positive or culture unknown/awaited. ** Room with continuously and automatically monitored negative pressure. ***Criteria for determining non-infectious more stringent than for drugsensitive and non MDR disease. PARTICULATE FILTER MASKS MUST BE WORN BY ALL PERSONS ENTERING THE ROOM OF A PATIENT WITH SUSPECTED OR CONFIRMED MDR-TB Patients requiring negative pressure room isolation should be referred immediately to Heartlands Hospital In practice in BCPFT, patients with possible or confirmed tuberculosis must NOT be nursed on Newton 5, but should be admitted to a side room on another ward (preferably Priory 5) until three sputum samples have been examined. Careful explanation should be made to patients about the need for strict adherence to infection control measures. They should be told why they must remain in a side room with the door closed and visitors should be limited to those who have had close prior contact before the diagnosis was made. Visits from immunosuppressed people should be discouraged, and patients should wear close fitting masks if they have to leave the room (particulate filter masks TECNOL PFR95). 3. Discontinuation of isolation the patient has had a minimum of two weeks of appropriate drug therapy; AND at least 3 consecutive negative sputum microscopy smears taken on different days (or complete resolution of cough) over a period appropriate for the drug susceptibility of the disease but at the minimum over 14 days; AND definite clinical improvement as a response to treatment e.g., remaining afebrile for at least one week; AND demonstrated tolerance of the prescribed treatment and an ability and agreement to adhere to treatment. 4. Discharge from hospital Individual patients with confirmed MDR-TB (may need isolation until sputum cultures are negative) should be discussed by the consultant chest physician, infection control team, CCDC and general practitioner. Patients must NOT be discharged to hostels with MDR-TB unless they have been shown to have 3 negative smears, be compliant with therapy, responding well to treatment and ideally have one culture negative specimen. Discharge from hospital should be carefully planned considering the proposed accommodation, potential infectivity, establishment of directly observed therapy (DOT) and any support services required have been arranged. Version 1.0 January 2015

20 5. Treatment 1. HIV Positive Patients The increased risk of Isoniazid resistance means a 4 drug combination should be used (under the guidance of a chest physician). Directly observed therapy (DOT) should usually be continued throughout the course of treatment to ensure compliance. 2. MDR-TB Usually 5 drugs initially, after discussion with chest physicians here and at Heartlands Hospital. Directly observed therapy (DOT) should usually be continued throughout the course of treatment. Further reading Department of Health. The Interdepartmental Working Group on Tuberculosis. The Prevention and Control of Tuberculosis in the United Kingdom. UK Guidance on the Prevention and Control of Transmission of HIV related Tuberculosis. Drug resistant, including Multi Drug resistant Tuberculosis. Version 1.0 January 2015

21 TB CONTROL IN HEALTHCARE WORKERS OF BCPFT PRE-EMPLOYMENT YES SUSPICIOUS SYMPTOMS? NO MEDICAL EXAMINATION NO WORK WITH PATIENTS YES CXR ABNORMAL NORMAL NO ACTION REQUIRED YES IS BCG SCAR DETECTABLE NO CHEST CLINIC NO HEAF TEST GRADE 2/3/4 YES BCG INFORM & ADVISE Version 1.0 January

22 Policy Details Title of Policy Tuberculosis Policy Unique Identifier for this policy State if policy is New or Revised New Previous Policy Title where applicable Policy Category Clinical, HR, H&S, Infection Control etc. Executive Director whose portfolio this policy comes under Policy Lead/Author Job titles only Committee/Group responsible for the approval of this policy Month/year consultation process completed * n/a Infection Control Month/year policy approved January 2015 Month/year policy ratified and issued January 2015 Next review date February 2016 Executive Director of Nursing, AHPs and Governance Infection Prevention and Control Team Infection Prevention and Control Committee Implementation Plan completed * Equality Impact Assessment completed * Previous version(s) archived * Disclosure status Yes Yes Yes B can be disclosed to patients and the public Key Words for this policy * For more information on the consultation process, implementation plan, equality impact assessment, or archiving arrangements, please contact Corporate Governance Review and Amendment History Version Date V1.0 January 2015 Details of Change Reformatted to meet new trust policy template Version 1.0 January 2015