Document Authorisation Control SURVEILLANCE POLICY. Document Control Information

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1 Author: Dr Parnaby, Consultant Microbiologist Sponsor: Director of Infection Prevention and Reviewer(s): Approval body: Members of the Infection Committee Integrated Governance Committee Infection Committee Reporting to Integrated Governance Committee Type: Scope: Policy Trust Reference Number: Status: Published Effective Date: February 2008 Review Date: February 2011 Disposal Date: February 2033 Document Authorisation Prepared By: Dr Parnaby, Consultant Microbiologist Signature: Authorised Officer Martin Wakeley Chief Executive Signature: Page 1 of 25

2 DOCUMENT CONTROL Winchester & Eastleigh Healthcare NHS Trust Document Amendments Number Details By Whom Date 1.0 Restructured Infection Team/Increased Mandatory Dr R Parnaby 20 December 2004 Surveillance 2.0 Full revision Dr R Sept Amended to match Trust Policy for the Management of led Documents and NHSLA Standard Parnaby IC team February 2008 Review Timetable Date Reason By Whom Date Completed February2011 Three yearly review cycle for Infection policy document. If national guidance changes the policy will Team be reviewed sooner Distribution List Title 1 Core policy holders 2 Trust Intranet 3 WEHCT Website Page 2 of 25

3 RELATED TRUST POLICIES CP022 Isolation and infectious disease policy CP071 outbreak plan CP077 Policy for ward closure due to an infection control issue CP076 Standard precautions and Personal Protective Equipment CP073 Hand hygiene Policy Risk management and patient safety policy CP072 Training policy for employees of WEHCT in infection control CP028 Management of suspected cases of viral haemorrhagic fever CP029 SARS/new strain influenza CP047 tuberculosis and multiple drug resistant tuberculosis CP055 MRSA policy CP064 Clostridium difficile policy CPr031 CJD and other transmissible spongiform encephalopathy guidelines Page 3 of 25

4 Contents Section Title Page 1.0 PURPOSE SCOPE DUTIES, ROLES AND RESPONSIBILITIES STATEMENT OF INTENT MANDATORY 6 REPORTING TO HPA 5.0 ALERT ORGANISM SURVEILLANCE TARGET SURVEILLANCE WARD BASED ALERT ORGANISM 7 SURVEILLANCE 8.0 CLINICAL REPORTING WEEKLY IC TEAM MEETING RATES OF INFECTION DEFINITIONS OF HCAI INVESTIGATION OF MRSA HCAI INVESTIGATION OF CDAD RELATED DEATH OR 10 SERIOUS MORBIDITY 14.0 ANY OTHER HCAI TRAINING IMPLICATIONS MONITORING OF COMPLIANCE AND 11 EFFECTIVENSS 17.0 DEFINITIONS REFERENCES 12 Appendix A Alert Organism Surveillance 13 Appendix B Targeted Surveillance 14 Appendix C Ward-based Alert Organism Surveillance 15 Appendix D Clinical reporting 16 Appendix E Weekly Infection Meeting 17 Appendix F Derivation of Rates of Infection 18 Appendix G Mandatory reporting to the DH 19 Appendix H RCA flowchart 20 Appendix I Equality impact assessment tool 21 Appendix J Communication log 22 Page 4 of 25

5 Policy for Management of led Drugs 1 PURPOSE The Winchester and Eastleigh Healthcare NHS Trust wishes to be at the forefront of best Infection practice for which active and appropriate surveillance is pivotal. Surveillance should guide the Trust towards relevant strategies for the control of hospital acquired infection. It is not an end in itself. Infection is everyone s business in clinical practice. Properly conducted surveillance, requires clinical commitment and ownership in partnership with Infection expertise. This policy is ratified in accordance with the Trust s Policy for the Management of led Documents 2 SCOPE Surveillance of alert organisms and infections will be carried out Trust wide. This will include all patients, whether elective or trauma and in some circumstances staff will be involved in surveillance. This policy is for the use of all staff of the Winchester and Eastleigh Healthcare NHS Trust. All staff involved directly and indirectly in care have a responsibility to reduce the risk of infection to patients and also to work in a way that affords themselves protection against occupationally acquired infection. By identifying trends in infections or colonisations the Trust can instigate strategies to reduce the risk to patients and staff. 3 DUTIES, ROLES AND RESPONSIBILITIES FOR SURVEILLANCE 3.1 General 1. To inform and improve local practice 2 To comply with DOH guidelines and requirements. 3 To comply with regional surveillance and assurance programmes. 3.2 Specific The Chief Executive has overall responsibility for Infection, Standards Assurance and Healthcare Governance The Infection Team (ICT) must facilitate and support appropriate surveillance and ensure that most effective Page 5 of 25

6 Winchester & Eastleigh Healthcare NHS Trust surveillance systems are in place within the constraints of its resources The Infection Committee (ICC) must support and guide the ICT and agree and monitor the hospital s surveillance strategy The Trust s Integrated Governance Committee must monitor the effectiveness of the ICC and reports its findings to the Board. An integrated approach which embraces infection control with governance and risk management issues assures the most effective approach The Board must ensure adequate support for and interest in the work of the ICT to empower its activities. Surveillance is labour intensive and inadequate or poorly performed surveillance will not inform clinical practice or Trust Management appropriately Clinical ownership of surveillance is critical to its success. Data collection is meaningless without clinical input. Surveillance data itself is impotent without receptiveness to change when the need for this is demonstrated Infection is everyone s business. 4.0 STATEMENT OF INTENT MANDATORY REPORTING TO HPA From April 2001 Trusts are expected to undertake specified forms of surveillance and to report these centrally to the Health Protection Agency (HPA). From these data league tables of HCAI are produced e.g. for MRSA bacteraemias and Clostridium difficile toxin positive patients. For operational details please refer to Appendix G. The Trust will comply fully with mandatory surveillance reporting schemes as required by the Department of Health. 5.0 ALERT ORGANISM SURVEILLANCE 5.1 This is the routine and regular monitoring by the Infection Team (ICT) of key organisms which pose a risk of cross infection or healthcare associated infection (HCAI) to patients. For operational details please refer to Appendix A. 5.2 On receipt of information from the Microbiology Laboratory of the presence of any of the alert organisms listed in Appendix A, the Infection Nurse (ICN) or Infection Doctor/ Consultant Page 6 of 25

7 Microbiologist (ICD) will alert the appropriate clinician or ward staff. Advice on management of the individual case and the relevant infection control precautions to prevent spread will be given as necessary. Much of this advice is routinely available in existing Infection Policies e.g. the MRSA policy, Clostridium difficile policy and staff should familiarise themselves with this information. In unusual circumstances the ICT will always provide advice and support. 5.3 Ward staff, clinicians and bed managers should liaise to expedite optimal infection control practice including isolation where indicated, once information from alert organism surveillance is received. 5.4 Follow up surveillance (e.g. MRSA clearance screening swabs) should be undertaken by ward staff in accordance with the relevant infection control policy or on the advice of the ICT in more unusual circumstances. 5.5 Specific organisms are followed up by the ICNs e.g. MRSA who liaise regularly with ward staff. 5.6 Enhanced Clostridium difficile surveillance is undertaken twice weekly by the ICNs. Clinically severe or non resolving cases are referred to the Consultant Microbiologist for advice. 6.0 TARGETED SURVEILLANCE 6.1 This form of surveillance, as its name suggests, involves regular monitoring of areas in which patients at high risk of infection are cared for e.g. the Intensive Therapy Unit (ITU) and Neonatal Unit (NNU). For operational details please refer to Appendix B. 7.0 WARD BASED ALERT ORGANISM SURVEILLANCE 7.1 This had been shown to be the most cost effective form of surveillance (Glennister 1991). It combines the alert organism method described above with regular liaison between clinical ward staff and the Infection Team. The latter allows investigation of cases where there is clinical suspicion of infection eg. wound infections, earlier than might otherwise occur. It requires investment in Infection Team time in regular ward rounds and timely reporting of infection suspicion by ward staff and clinicians. For operational details please refer to Appendix C. 8.0 CLINICAL REPORTING Page 7 of 25

8 8.1 This form of surveillance involves the immediate reporting of similar symptoms in two or more patients by clinical staff to the Infection Team. This will usually precede specimen results from the laboratory. Such vigilance allows the earliest intervention and may prevent the development of an outbreak by implementation of early and effective control measures. For operational details please refer to Appendix D and for management of specific potential outbreaks please refer in detail to the Ward Closure policy plus the MRSA policy, Clostridium difficile policy, Enteric policy or Outbreak Plan as appropriate. 9.0 WEEKLY INFECTION CONTROL TEAM MEETING 9.1 This regular review meeting by the Infection Team will monitor significant findings from the preceding week and the subsequent actions. It will highlight further needs and allow for timely planning to meet these. Such follow up is labour intensive. 9.2 When appropriate, eg in outbreak control, the Infection Nurse and the Infection Doctor will meet on a daily basis or more frequently if the situation requires it. For further details please refer to Appendix E. 9.3 When necessary to control a more significant incident an Incident or Outbreak Group will be convened by the ICD or one of the Trust Executives. Details can be found in the Ward Closure policy and Outbreak Plan RATES OF INFECTION 10.1 These are clearly more valuable than collecting raw data since they relate to hospital activity Rates can be developed for a particular patient group (e.g. maternity) or procedure e.g. (total hip replacement, see Appendix C) or for a particular organism e.g. (MRSA) The denominator will vary depending on the indicator e.g. for the above examples respectively per thousand deliveries, per percentage of procedures or per thousand patient bed days. For operational details please refer to Appendix F DEFINITIONS OF HEALTHCARE ASSOCIATED INFECTIONS HCAI are usually defined as infections which were not present at the time of a patient s admission to hospital. In some circumstances this Page 8 of 25

9 may be complicated by the need to delineate previous hospital admissions e.g in prosthetic joint infections which may take time to manifest or in tuberculosis or hepatitis which have a long incubation period. Frequently however 48 hours or 72 hours after admission are used as the cut off point e.g pre and post 48 hour admission surveillance in MRSA bacteraemias (see Appendix G) and 72 hour post admission criteria in the definition of hospital CDAD INVESTIGATION OF MRSA HCAI 12.1 All MRSA bacteraemias (pre and post 48 hours) are subject to Root Cause Analysis (RCA) If hospital acquired the RCA should be started within 24 hours of notification of the bacteraemia and completed within 5 days The lead ICN will alert the appropriate divisional lead of the need for an RCA and record the incident on the Prism system It is the responsibility of the division in which the bacteraemia was found to undertake the RCA. It should be performed with clinical and nursing input and facilitated by the lead ICN for RCA as appropriate The learning from the RCA should be fed back in a timely manner within the division The RCA itself should be collated by the divisional lead and circulated to the lead ICN. It will then be forwarded to the Director of Infection Prevention and (DIPC) and ICD and other interested parties RCAs should be taken to Executive and Board level by the DIPC or other designated Executive, after review at the quarterly Infection Committee so learning can be assimilated Trust wide. See Appendix H for a flowchart summary The Strategic Health Authority (SHA) may ask to see evidence of RCA activity and learning A pre 48 hour bacteraemia will be investigated jointly with the Primary Care Trust (PCT) and should ideally be completed within 14 days. The lead ICN will initiate the internal RCA as above and will liaise with the DIPC for the PCT to trigger the community RCA process. Learning points for both organisations should be considered and again, the SHA may have an interest in the trends which emerge. Page 9 of 25

10 13.0 INVESTIGATION OF CDAD RELATED DEATH OR SERIOUS MORBIDITY 13.1 CDAD deaths are notified to the ICT by the Relatives Officer on receipt of a death certificate. Any death which has CDAD as cause 1a, 1b or 1c will be subject to an RCA performed at divisional level in accordance with the same process as above CDAD RCAs may need extensive medical input and it is appropriate for the Consultant IC divisional lead or the Consultant under whose care the patient was to perform the RCA There is currently no Department of Health timescale for CDAD RCAs but the Trust is looking for a reasonably timely turnaround of 21 days. This is to promote feedback and learning which is timely whilst acknowledging the constraints on the time of the personnel involved Feedback is at local, divisional and Trust Committee and Board level as for MRSA RCA Any Consultant who records Clostridium difficile as cause 2 on the death certificate should lead or initiate an RCA if he/she feels it to be indicated. The divisional lead may also lead or undertake this Likewise, any case of serious CDAD morbidity such as colectomy for pseudomembranous colitis should have an RCA performed, led by the Consultant involved in the patient s care or the IC divisional lead. The lead ICN and Risk Manager are happy to facilitate this process which should follow the steps laid out above See Appendix H for a flow chart summary ANY OTHER HCAI 14.1 Any other serious HCAI should be discussed by the clinician or ward staff caring for the patient with the Infection Nurse or ICD on the regular ward rounds (See Appendix B) or at any other time 14.2 RCAs can be performed on any such HCAI should the circumstances so deem necessary The process outlined in Appendix H and/or section 13 should be followed. Page 10 of 25

11 14.4 It is most important to ensure clinical feedback and to promote Trust wide learning from these initiatives: they are not ends in themselves. 15 TRAINING IMPLICATIONS Infection control training on basic principles is part of the Trust wide mandatory training scheme for all staff and is monitored via attendance records. Training is provided to all staff at induction Training is provided to all staff at annual update Antibiotic and infection control audits and updates are made quarterly to the Infection Committee and sent to every clinical team and ward Specialty based training is offered via divisional meetings on an ongoing basis. The link nurses participate in a specialist programme of on going training. It is the responsibility of individuals and their line managers to ensure attendance at training. The Training Department feedback non attendance to line managers and it is their responsibility to follow up non attenders and ensure their subsequent attendance. e learning for infection control is an acceptable alternative on alternate years once face to face induction is completed. E learning is accompanied by certification which can be used in evidence at appraisal. 16 MONITORING COMPLIANCE AND EFFECTIVENESS Alert organism surveillance and trends are reported to the Infection Committee (ICC) Mandatory surveillance is reported to the ICC, divisions and Trust Board. There is a regular programme of audits, led by the DIPC and co-ordinated by the Infection Team, which are reported to the Infection Committee e.g. Hand Hygiene, use of Isolation facilities, infection control policy compliance, High Impact Interventions. Page 11 of 25

12 Divisional audits are reported via the divisions to the Infection committee and Integrated Governance Committee Serious Untoward Incidents (Infection) are discussed at ICC and reported to the Integrated Governance Committee, Health Protection Agency and Strategic Health Authority Training and education attendance is monitored by the Education Centre and reported to individual managers and collectively to the Integrated Governance Committee Monthly reports on infection control and surveillance are taken by the DIPC to the Trust Board. Training attendance reports are presented to the Integrated Governance Committee. 17 DEFINITIONS HCAI- Healthcare associated infection Healthcare-Associated Infections (HCAI) are those infections that develop as a direct result of any contact in a healthcare setting. They occur in hospitals and in the community healthcare facilities; and affect both patients and healthcare workers MRSA methicillin resistant Staphylococcus aureus is used to describe those examples of this organism that are resistant to commonly used antibiotics. Methicillin was an antibiotic used many years ago to treat patients with Staphylococcus aureus infections. C.diff Clostridium difficile infection is the most important cause of hospital-acquired diarrhoea. Clostridium difficile is an anaerobic bacterium that is present in the gut of up to 3% of healthy adults and 66% of infants. When certain antibiotics disturb the balance of bacteria in the gut, Clostridium difficile can multiply rapidly and produce toxins which cause illness. 18 REFERENCES Glenister HM, Taylor LJ, Cooke EM, A Study of Surveillance Methods for Detecting Hospital Infection, 1991, Public Health Laboratory Service. Healthcare Commission; Standards for Better Health, 2007 HMG: The Health Act, 2006 Page 12 of 25

13 Appendix A ALERT ORGANISM SURVEILLANCE The Microbiology Laboratory and Infection Team liaise on a daily basis about the following new isolates from in patients (and in some instances out patients, OP) This list includes: Staphylococcus aureus MRSA (Methicillin Resistant Staphylococcus aureus) - includes OP Group A Streptococci Group B Streptococci (in pregnancy and neonates) Streptococcus pneumoniae Neisseria meningitides (N.meningitidis) Salmonella sp - includes OP Shigella sp includes OP Escherichia coli (E coli) 0157 includes OP Extended Spectrum Beta Lactamase (ESBL) organisms includes OP Campylobacter sp includes OP Isolates from Cerebrospinal fluid Blood culture isolates includes OP Gentamicin resistant gram negative organisms Multi resistant organisms e.g. resistance to mupirocin in MRSA or vancomycin or teicoplanin gram positives eg Glycopeptide Resistant Enterococci Positive Clostridium difficile toxin tests includes OP Positive rota/adeno virus tests includes OP Isolates submitted from the Occupational Health Department In addition any unusual resistance pattern must be brought to the attention of the Consultant Microbiologist and the Infection Team by the Senior Biomedical Scientist on duty for a particular bench in the laboratory. It is the responsibility of the laboratory staff from the relevant section to submit isolates to reference facilities for further work, when appropriate. The sender should also monitor and follow up results and delays in reporting. These referred isolates include: 1. Typing of Staphylococcus aureus, including MRSA isolates, in outbreaks and from clinically relevant sites, if appropriate. Page 13 of 25

14 2. Sero typing of Streptococci in outbreaks or from clinically relevant sites e.g. CSF. 3. Referral of all isolates N.meningitidis for grouping and typing 4. Further identification of all relevant enteric, including viral outbreaks, isolates including verotoxin testing of E.coli Confirmation of unusual antibiotic resistance patterns to the Antibiotic Reference Laboratory at Colindale. 6. Any further work requested by the Consultant Microbiologists. The Microbiology Laboratory maintains full accreditation with the Clinical Pathology Accreditation board and as such fulfils the Standards for Better Health criterion for appropriate laboratory support for infection control. Page 14 of 25

15 Appendix B TARGETED SURVEILLANCE Daily significant findings from these areas are communicated to the ICT by laboratory personnel and thence to the wards or units involved. These findings include alert organisms and results on significant specimens e.g. blood cultures and cerebro spinal fluids (CSFs). The Intensive Therapy Unit (ITU) is visited every working day by a member of the Infection Team usually one of the Consultant Microbiologists. The ITU, Neonatal Unit (NNU) and other clinical areas are visited on ICN ward rounds weekly and as required. This allows monitoring by the ICT of all areas but most frequently the highest risk patient group. Page 15 of 25

16 Appendix C WARD-BASED ALERT ORGANISM SURVEILLANCE The ITU is visited daily and all other areas weekly (please see details in appendix B). Mandatory orthopaedic surgical site surveillance is undertaken by the orthopaedic clinical staff and facilitated by a designated ICN. This has provided continuous monitoring of infection rates in elective prosthetic hip and knee surgery since April Standardised data are returned quarterly to the Health Protection Agency for analysis and their subsequent reports are fedback contemporaneously to the orthopaedic sub directorate and Trust Management and quarterly to the Infection Committee. Page 16 of 25

17 Appendix D CLINICAL REPORTING Any similar symptoms suggestive of infection in a cluster of two or more patients should immediately be reported by clinical staff to the Infection Team. These may include wound infections, diarrhoea and/or vomiting and/or nausea, urinary or intravenous catheter infections, respiratory infection etc. It is the responsibility of the nurse in charge of the ward to inform the Infection Team during the working day and out of hours the on-call Microbiologist via the bed manager or night sister in charge. If an outbreak is confirmed the incident should be reported on the Trust Incident Reporting Management System Please see the Ward Closure policy, Isolation policy, Enteric Outbreak policy or Outbreak Plan as appropriate for more details. Page 17 of 25

18 WEEKLY INFECTION CONTROL TEAM MEETING Appendix E This is held between the Infection Doctor(s) and other members of the Infection Team once a week or more frequently should the need arise. A member of the laboratory staff may be co-opted if necessary. The purpose is to review any issues or concerns which any team member may have, including the surveillance and management of patients with alert organisms. 1. It is the responsibility of the Infection Team and Infection Doctors to bring to the meeting any issue of concern and to share the outcome as appropriate either urgently or at a routine forum. It is the responsibility of any member of the Infection Team to alert other members to urgent problems between meetings so these can be effectively dealt with on a daily basis and so that they are subsequently monitored via the most appropriate mechanism. 2. Consultant Microbiologists will hand over issues to each other as appropriate, and will receive further briefing from the Infection Team. Page 18 of 25

19 Appendix F DERIVATION OF RATES OF INFECTION Close collaboration between the clinical team and the disciplines of infection control, information technology and audit is required to produce and evaluate such data. Infection rates are initially labour intensive to produce but with familiarity and increased understanding allow regular monitoring of trends with concomitant successful early intervention if necessary. Intermittent monitoring e.g. 3 months per year may be acceptable in some circumstances. From June 2003 to the introduction of the NCRS hospital information system in 2006 collaboration between the ICT and IT departments allowed rates of infection per 1000 patient bed days to be established, eg for MRSA colonisation and infection. This is not currently possible until the NCRS system is upgraded. The Trust is intending to adopt the ICNet software package in 2008 to expedite collection of infection control surveillance data, interfaced with NCRS, to allow production of infection rates once more. Page 19 of 25

20 Appendix G MANDATORY REPORTING TO THE DOH It is the overall responsibility of the Chief Executive to ensure that the required reporting is undertaken but the Infection Team will ensure that the data are collected and provided in a timely fashion. Mandatory reporting at September 2007 includes: MRSA bacteraemia rates Clostridium difficile rates Glycopeptide Resistant Enterococcal rates Orthopaedic surgical site surveillance (see Appendix C) Serious untoward (infection-related) incident reporting. MRSA bacteraemia data This has been used since 2001 to inform national league table based on reported data. In 2005 a data capture System for MRSA Enhanced Surveillance (MESS) was introduced which captures a more comprehensive and contemporaneous data set alongside the mandatory reporting scheme. MESS was renamed the Healthcare Associated Infection (HCAI capture) dataset in 2007 and has been extended to include additional data for Clostridium difficile toxin positive patients (see below). Enhanced reporting: Enables real time reporting of incidents as they occur Allows specification of the department or specialty where the infection occurred Allows calculation of specialty specific MRSA rates where appropriate Allows for separation of MRSA bacteraemias identified within two days of admission to hospital care from those identified two days afterwards. This informs the Root Cause Analysis process see section 10. The DH aims for a 50% reduction in MRSA bacteraemia nationally from Each Trust is set an annual target of reduction and is monitored closely (weekly) by the SHA against its target. Page 20 of 25

21 Clostridium difficile (CDAD) toxin positive data CDAD enhanced surveillance was introduced in WEHCT in 2006 and from 2007 CDAD data is entered contemporaneously on the national HCAI capture system for CDAD (akin to the MESS capture system already running for MRSA bacteraemias). HCAI capture for CDAD: Enables real time reporting as CDAD is found Allows specification of community acquired CDAD from hospital acquired and of new cases from relapsed Includes data on all aged over 2 (previous data collection pre April 2007 focussed on the over 65s only) Allows specification of the specialty or department where the infection occurred Allows calculation of specialty specific CDAD rates where appropriate The DH aims for a 15% reduction in Trusts with smaller CDAD rates by 2008 (this is the group which WEHCT falls into) and for a yearly target has been agreed by the PCT and SHA for WEHCT. This is broken down into monthly targets. Future DH and local targets are anticipated and will be addressed. Serious untoward infection (SUI) reporting These reports are made, usually by the ICD but may be from the Trust Risk Manager if appropriate, to the Health Protection Unit for Hampshire/IOW. Similar risk reporting is required by the SHA but runs parallel to, rather than replacing, the mandatory scheme managed by the HPA. SUIs might include a ward closure due to an infectious outbreak, CDAD Root Cause Analyses for mortality/serious morbidity, a breakdown in the sterilisation process or a Legionella incident but is not confined to these examples. Reporting to the Strategic Health Authority For performance management Trusts are required to report to the SHA their monthly MRSA bacteraemia and CDAD figures in addition to SUIs. This parallel reporting is authorised at Executive level from data supplied weekly by the ICNs Page 21 of 25

22 Appendix H Flow chart for Root Cause Analysis of HCAI A patient has an MRSA positive blood culture Lab informs Consultant Microbiologist & Infection Nurses Microbiologist reviews patient and logs on MESS ICNs Complete PRISM Complete IC Bacteraem ia Inform Nursing staff Inform Lead nurse & ward manager Inform Kevin Stewart Juliet Beale Paula Shobbrook Divisional clinical leads Patient s Consultant Divisional Risk Co-ordinator Ward mgr & lead nurse complete RCA form within 5 days & sends to Div. Risk Coordinator Div. Risk Co-ordinator signs off RCA Div. Risk Co-ordinator checks RCA once Implement Action Plan Review Action Plan Sends RCA to ICNs Sue Dailly Theresa Lewis Register RCA on PRISM & sends to Trust Risk M ICNs Electronic copy kept on computer file Paper copy placed in Department file Page 22 of 25 Send copy of RCA to Kevin Stewart Juliet Beale Paula Shobbrook Divisional Clinical leads Dr Roberta Parnaby Dr Matthew Dryden

23 Appendix I - Equality Impact Assessment Tool To be completed and attached to any controlled document when submitted to the appropriate committee for consideration and approval. Yes/ Comments 1. Does the policy/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 no 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? If you have identified a potential discriminatory impact of this procedural document, please refer it to the Head of Corporate Services, 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: Peter Jenkinson Head of Corporate Services Tel : Page 23 of 25

24 Policy for Management of led Drugs Appendix J Communications Log Ref Policy Date of To Whom Signed as Issue read and Understood OP999 An example 09/09/1999 A Member of Staff Page 24 of 25

25 Ref Policy Date of Issue To Whom Signed as read and Understood Page 25 of 25