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Varicella Zoster Virus Chickenpox NHS Western Isles

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					                Western Isles Health Board



     Policy/Protocol/Procedure/Guideline
                  Document


Title:                   Varicella Zoster Virus
                           (Chickenpox)

                                    Version 1



Author          Christina Macaskill Specialist Practitioner Infection Control


Date of issue      SECC approval       Next review due date      Reviewers/review team
                   22/10/2009          November 2011             To be assigned by
09/11/2009                                                       Infection Control Team
Varicella Zoster Virus (Chickenpox)                  Infection Control         Western Isles Health Board



Document Control
                                      Latest
                                                                         Reason for change and
Version          Date                 changes made        Status
                                                                         reviewers
                                      by


Version 1                             Christina
                 28/04/2009                               Draft          Draft 1
Draft 1                               Macaskill




                                      Christina
Version 1                                                                Equality Impact Assessment
                 07/09/2009           Macaskill/Jane      Draft
Draft 2                                                                  and Proof Reading
                                      Montgomery




                                      Christina
Version 1        09/11/2009           Macaskill/Jane      Published
                                      Montgomery




Document Approval – ICC


Reviewers Name                         Reviewers Role                                 Review Date

Nigel Hobson                           Chief Operating Officer                        11/09/2009

Dr Craig Williams                      Consultant Microbiologist                      11/09/2009




Distributed to the Following for Information

Name                         Job title                 Role and responsibility

Ellena Macdonald             Risk Manager              To inform Risk Management Committee

                             Partnership
Jenny Porteous                                         For Information
                             representative

Wards/Departments            Managers                  For dissemination to all staff




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Varicella Zoster Virus (Chickenpox)                                Infection Control                      Western Isles Health Board


CONTENTS
1 Introduction .....................................................................................................4
    1.1    GENERAL INFORMATION.......................................................................................................... 4
2     All Involved ......................................................................................................4
3     Policy Statement .............................................................................................5
    3.1    EQUALITY AND DIVERSITY ....................................................................................................... 5
    3.2    PATIENT FOCUS PUBLIC INVOLVEMENT.................................................................................... 5
4     Transmission Based Precautions for Chickenpox .......................................7
    4.1    ACCOMMODATION (PATIENT PLACEMENT) ............................................................................... 7
    4.2    CLINICAL WASTE .................................................................................................................... 7
    4.3    CONTACTS ............................................................................................................................. 7
      4.3.1       Patients .............................................................................................................. 7
      4.3.2       Healthcare Workers (HCWs)............................................................................. 7
    4.4    CROCKERY/CUTLERY ............................................................................................................. 7
    4.5    ENVIRONMENTAL CLEANING.................................................................................................... 7
    4.6    EQUIPMENT............................................................................................................................ 7
    4.7    HAND HYGIENE ...................................................................................................................... 8
    4.8    LAST OFFICES........................................................................................................................ 8
    4.9    LINEN .................................................................................................................................... 8
    4.10     MOVING BETWEEN W ARDS, DEPARTMENT, HOSPITALS ......................................................... 8
    4.11     NOTICE FOR DOOR ............................................................................................................. 8
    4.12     OUTBREAK ......................................................................................................................... 8
    4.13     PRECAUTIONS DURATION .................................................................................................... 8
    4.14     PROPHYLAXIS..................................................................................................................... 8
    4.15     RISK ASSESSMENT ............................................................................................................. 8
    4.16     SCREENING ON ADMISSION/READMISSION ........................................................................... 9
    4.17     SPECIMENS ........................................................................................................................ 9
    4.18     TERMINAL CLEANING OF ROOM ........................................................................................... 9
    4.19     VISITORS............................................................................................................................ 9
5     Accountability..................................................................................................9
    5.1    NHS W ESTERN ISLES IS RESPONSIBLE FOR:............................................................................ 9
    5.2    CLINICAL MANAGERS ARE RESPONSIBLE FOR:.......................................................................... 9
    5.3    HEALTHCARE W ORKERS (HCWS) ARE RESPONSIBLE FOR: ....................................................... 9
    5.4    HOTEL SERVICES MANAGER IS RESPONSIBLE FOR: ................................................................ 10
    5.5    INFECTION CONTROL TEAM IS RESPONSIBLE FOR:.................................................................. 10
6     Education and Training.................................................................................10
7     Monitoring and Reviewing............................................................................10
8     Risk Assessment...........................................................................................11
9     References .....................................................................................................14
10     Appendices .................................................................................................15
    10.1      EQUALITY IMPACT ASSESSMENT TOOL ............................................................................... 15
    10.2      AUDIT CHECKLIST ............................................................................................................. 23




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Varicella Zoster Virus (Chickenpox)                                        Infection Control
                                                                              Department




1 Introduction

1.1    General Information
Communicable                      Chickenpox Varicella Zoster Virus (VZV)
Disease/Alert
Organism
Clinical Condition                    •   Acute onset of slight fever and skin eruptions that
                                          become vesicular for 3-4 days then form a
                                          granular scab
                                      • Adults and especially non-immune pregnant
                                          women may develop life-threatening pneumonitis
                                      • May cause serious disease in the foetus in the first
                                          20 weeks gestation
                                      • Babies born to mothers with Chickenpox within 4-
                                          7 days either side of birth are at risk of developing
                                          serious disease
                                      • Life-threatening in immunosuppressed patients
                                          due to dissemination
Mode of Spread                    Direct contact, droplet or airborne
Incubation Period                 14-21 days
                                      • May be less in immunosuppressed patients
                                      • May be up to 28 days in patients on regular
                                          intravenous immunoglobulin (IVIG) or given
                                          Varicella Zoster immunoglobulin (VZIG)
Notifiable Disease                Medical staff must complete Notification Form and send
                                  to Public Health Department Health Board Offices South
                                  Beach Street , Stornoway
Period of                             • 5 days before spots/vesicles appear and until all
Communicability                           lesions are dry and crusted
                                      • Maximum infectivity period is 1-2 days either side
                                          of spots/vesicles appearing
Persons most at risk                  • Neonates whose mothers are not immune to VZV
                                          or who develop chickenpox around the time of
                                          delivery
                                      • Patients with leukaemia, cancer, transplant
                                          patients, immunosuppressed patients, patients on
                                          steroids and non-immune pregnant women may
                                          develop severe, prolonged or fatal chickenpox
Evidence of Immunity                  • A history of Chickenpox
                                      • Infection usually results in lifelong immunity
High Risk Environment             Oncology/Haematology, Transplant, Maternity


2 All Involved

This Policy and Procedure was developed in collaboration with the Infection Control
Team. Recommendation for approval was sought from the Infection Control
Committee. Health Board approval for its implementation was sought from the NHS
Western Isles Safe and Effective Care Committee.


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3         Policy Statement

NHS Western Isles is committed to providing a service that supports and promotes
the wellbeing and safety of patients and staff.

Every Healthcare Worker (HCW), trainee and volunteer affiliated with NHS Western
Isles has a duty to adhere to the Policy and Procedure within this document in order
to inspire public confidence and to protect themselves and patients by minimising the
risk of spreading infection.



3.1       Equality and Diversity

Fair care is ensured to all without any discrimination between persons on grounds of
sex, marital status, race, disability, age, sexual orientation, language, social origin,
other personal attributes, including beliefs or opinions, such as religious beliefs or
political opinions.

Equality groups have been considered during the research for this policy. Reference
is made to the NMC Code of Professional Conduct: Standards of Conduct,
Performance and Ethics (see section 9 of this document).

An assessment for equality and diversity was made on this document on 7th
September 2009, findings documented and appropriate amendments made. An
Equality Impact Assessment Tool was completed in relation to this policy and sent to
the Operational Diversity Lead for comment. A copy can be requested from the
Infection Control Team, Western Isles Hospital.

3.2       Patient Focus Public Involvement

NHS Western Isles is working with patients and members of the public to improve the
quality of health service provided.

A patient-focused NHS will:

      •    Maintain good communications, including listening and talking to patients,
           public and communities
      •    Know about those using the service and understand their needs
      •    Keep users of the service informed and involved
      •    Have clear, explicit standards of service
      •    Maintain politeness and mutual respect
      •    Have the ability to respond flexibly to an individual’s specific needs
      •    Ensure effective action is taken to improve services
      •    Talk with users, the wider public and communities

Effective public involvement can:

      •    Act as a catalyst for change
      •    Help achieve a major improvement in the health of the public
      •    Help strengthen public confidence in the NHS


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                         THIS PAGE INTENTIONALLY LEFT BLANK




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4         Transmission Based Precautions for Chickenpox

4.1       Accommodation (Patient Placement)

      •    Patients who require admission should be placed in a negatively pressured
           side room to ensure airborne precautions.
      •    The door must remain closed
      •    Only HCWs who are immune to chickenpox should be in contact with these
           patients
      •    Standard Infection Control Precautions must be implemented.

4.2       Clinical Waste

      •    Orange waste stream

4.3       Contacts

      •    Contact in the same room for a period of 15 minutes or more, e.g. in a house,
           classroom, 2-6 bed hospital bay
      •    Face-to-face contact, e.g. while having a conversation

4.3.1      Patients
    •      Immediate assessment of high risk patients i.e. neonates whose mothers are
           not immune and immunosuppressed patients must be carried out by
           appropriate Consultant

4.3.2      Healthcare Workers (HCWs)
    •      HCWs who are not immune or who are not sure of their immune status and
           who have had direct patient contact must self refer to Occupational Health
           Department

4.4       Crockery/Cutlery

      •    No special requirements

4.5       Environmental Cleaning

      •    Daily/Terminal Cleaning of Isolation Rooms as appropriate

4.6       Equipment

      •    Wherever possible Single Use or Single Patient Use Equipment should be
           used
      •    Single Patient Use Equipment should be cleaned using ‘Actichlor Plus’
           solution and then dried thoroughly or according to manufacturer’s instructions


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4.7       Hand Hygiene

      •    Hands must be decontaminated before and after each direct patient contact
      •    Hands must be decontaminated after contact with the patient’s environment

4.8       Last Offices

      •    Standard Infection Control Precautions

4.9       Linen

      •    While the patient is infectious, used linen must be placed in a red alginate bag
           and dropped into a clear plastic bag outside the room, see Management of
           Linen Policy section for Infected Linen.

4.10 Moving between Wards, Department, Hospitals

      •    Not recommended unless emergency
      •    Receiving area must be informed of patient’s condition prior to transfer

4.11 Notice for Door

      •    Infection Control Notice must be placed on the outside of the isolation room
           door

4.12 Outbreak

      •    Possible – see Outbreak Policy (Hospital) for information and instructions

4.13 Precautions Duration

      •    Until all lesions are dry and crusted



4.14 Prophylaxis

      •    Follow Link to Green Book chapter 38 www.doh.gov.uk/greenbook



4.15 Risk Assessment

      •    A risk assessment must be carried out
      •    Seek advice from ICT and Occupational Health as required




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4.16 Screening on Admission/Readmission

     •     A patient presenting with a rash/vesicular spots must be assessed by medical
           staff for Chickenpox
     •     Pregnant women with Chickenpox presenting with respiratory symptoms
           require urgent referral to medical staff


4.17 Specimens

     •     Swabs from lesions to be taken on advice of clinician
     •     Place in viral transport medium – refer to Collection and Transportation of
           Microbiological Specimens
     •     Do not label ‘Danger of Infection’

4.18 Terminal Cleaning of Room

     •     The room must be terminally cleaned once the patient is considered to be
           non-infectious

4.19 Visitors

     •     Close contacts of the patient who are not immune should not visit
     •     Non-immune pregnant women should not visit
     •     Non-immune children should not visit
     •

5 Accountability

     5.1     NHS Western Isles is responsible for:

 •       Providing adequate resources to enable this Policy and Procedure to be
         implemented

     5.2     Clinical Managers are responsible for:

     •     Ensuring staff adhere to the requirements of this Policy and Procedure
           document
     •     Liaising with and seeking advice from the Infection Control Team as required
     •     Taking appropriate action to deal with adverse incidents

     5.3     Healthcare Workers (HCWs) are responsible for:

 •       Complying with the requirements of this Policy and Procedure
 •       Reporting to Manager, anything that does not enable them to fulfil the
         requirements of this document
 •       Reporting any adverse incidents to their Line Manager using an IR1 Form

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5.4       Hotel Services Manager is responsible for:

      •     Ensuring staff are appropriately trained in up to date decontamination
            processes
      •     Ensuring staff adhere to the requirements of this Policy and Procedure
            document
      •     Taking appropriate action to deal with adverse incidents reported by staff
      •     Liaising with ICT

      5.5     Infection Control Team is responsible for:

      •     Keeping this Policy and Procedure up to date
      •     Auditing and assisting others to audit the implementation of and compliance
            with this Policy and Procedure
      •     Providing education/training as appropriate

6 Education and Training

Western Isles NHS Board shall ensure that:

      •     This document forms an adequate education solution
      •     This document will be published on the Infection Control Intranet pages which
            are available to all staff

7 Monitoring and Reviewing

The Policy shall be reviewed annually. In addition the Policy shall be revised as and
when new research based evidence becomes available or as a result of deficiencies
identified during the course of audit.

The Infection Control team will audit practice against this document at least twice
annually with the audit form included in Appendix 2. Note that the Infection Control
team includes the IC link persons. Contact the IC Team for a list of these persons.




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8 Risk Assessment

 Site                    Western Isles       Risk Category
                         Hospital            (See list)

 Dept/Ward               Infection Control   Assessors name (person who                     Christina Macaskill
                                             documents the risk)

 Risk Ref No.                                Risk status
                                             (active-being reduced, inactive-tolerated,
                                             active-escalated)

 Date risk                                   Register for Escalation
 raised                                      (Hosp or CHAScP))

 Operation/Activity                                                                               Describe the setting and the
                                                                                                  work being undertaken
 NHS Western Isles Chickenpox Policy
 Observations                                                                                     What can be seen or
                                                                                                  envisaged that might lead to
 Non compliance with the policy                                                                   a risk?
 Risk(s)                                                                                          What is the risk? What
                                                                                                  might happen? Start with
 There is a risk that non compliance with this policy may lead to cross                           “there is a risk that….”
 infection
 Hazard(s)                                                                                        All hazards associated with
                                                                                                  the activity should be
                                                                                                  entered here. e.g. physical
                                                                                                  hazards, machinery,
                                                                                                  electricity, working at
                                                                                                  heights, substances, access,
                                                                                                  adverse clinical event,
                                                                                                  equipment, vehicles, etc.
 People at Risk                                                                                   Highlight the people at risk
                                                                                                  i.e. nursing staff, Domestics,
 Staff and patients                                                                               Estates, Visitors, the likely
                                                                                                  numbers exposed
 Current Control Measures                                                                         List current and interim
                                                                                                  control measures, including
 Chickenpox Policy                                                                                physical controls but do not
                                                                                                  forget to include other
                                                                                                  controls including safe
                                                                                                  working, policies,
                                                                                                  procedures, information,
                                                                                                  instruction and training




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a) CURRENT STATE
QUANTIFICATION OF RISK RATING WITH CURRENT CONTROL MEASURES IN
PLACE
                                                                                          Estimate of likelihood and severity
                                                                                          Refer to key below, and to the Risk
 Likelihoo                           Severit                      Risk
     d           1          X
                                       y           4      =
                                                                 Rating         4         Quantification Criteria. Select numbers
                                                                                          according to the likelihood and severity. Enter
                                                                                          the numbers at a and at b , multiply them
                                                                                          together and record the resultant risk rating at c.


RISK QUANTIFICATION - KEY
 LIKELIHOO                      SEVER             RISK RATING            RISK        See RISK
      D                          ITY                   (c)               COLOU       QUANTIFICATIO
     (a)                          (b)                                    R           N CRITERIA
 1   Rare               1       Negligible
 2   Unlikely           2       Minor             1 to 3 = Low           (Green)
 3   Possible           3       Moderate          4 to 9 = Medium        (Yellow)          C:\Risk
 4   Likely             4       Major             10 to 16 = High        (Orange)    Quantification Criteria.doc
 5   Almost             5       Extreme           17 to 25 = Very High   (Red)
     certain

 Current Control Measures                          Wholly                      Weak/Require                        Satisfactory
 (Please mark appropriate box with an X)           Inadequate                  Strengthening                                             X

 With these controls, are the risks at a level that is as low as reasonably practicable? (Yes or No)                                Yes

If the answer to the above question is NO, please continue to b) and complete a Risk
Control Action Plan

b) FUTURE STATE
            Risk Control Action Plan                       Who will do it     When will             Dependencies
  (Complete if further control measures required.               (name)        action be             (give details e.g.
             Use one row per action)                                          completed by          * Financial – amount
                                                                              (estimate   date)     * Resources – people or equipment
                                                                                                    * Commitment/priority




 Risk Control Action Plan Costs                                             Amount £                                            Amount £
 (Please mark appropriate box with an          Under £5000                                   Over £5000
 X and specify total estimated cost)


 Can the Risk Control Action Plan be implemented locally? Yes or No, or Partially


QUANTIFICATION OF TARGET RISK RATING WITH RISK CONTROL ACTION
PLAN IMPLEMENTED
                                                                                          Estimate of likelihood and severity
 Likelihoo                           Severit                      Risk                    Refer to key below, and to the Risk

     d           a          x
                                       y           b      =
                                                                 Rating         C         Quantification Criteria. Select numbers
                                                                                          according to the likelihood and severity. Enter
                                                                                          the numbers at a and at b , multiply them


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                                                                      together and record the resultant risk rating at c.


 Risk Assessor:              Christina Macaskill           Signatur                            Date:         27/04/2
 (Print Name)                                              e:                                                009
 Service Head /              Denise Wilson                 Signatur                            Date:
 Nominated:                                                e:
 Deputy (Print Name)

c) PERIODIC REVIEW
REVIEW THE RISK EVERY THREE MONTHS. UPDATE TO REFLECT CURRENT
STATUS
 Review Date
 Reviewer
 Action

 Send copy of completed Risk Assessment to Line Manager for inclusion on the Ward/Department/Unit Risk
 Register

 Date Sent:                           Line Manager Name:




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9 References

Department of Health., (1996) Immunisation against Infectious Diseases; Green
Book. HMSO. London

Heymann, D.L., (2004) Control of Communicable Diseases Manual 18th Ed.
     American Public Health Association.

Nursing & Midwifery Council., (2008) Code of Professional Conduct:Standards of
       Conduct, Performance and Ethics for Nurses and Midwives. London.



Website
www.doh.gov.uk/greenbook




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                                                                             Department




10       Appendices

10.1 Equality Impact assessment Tool



                                                         EQUALITY IMPACT ASSESSMENT TOOLKIT



Name of policy                          Varicella Zoster Virus (Chickenpox)


                                                                                              Dates of
Review “Team”:                          Christina Macaskill and Infection Control Team        assessment:   7th September 2009

•    Names
•    Role of Assessment
     Team


P ART ONE: R APID IMP AC T ASSESSM ENT (INI TI AL SCREENING PROCESS)


SECTION ONE:                          AIMS OF THE POLICY

1.    Is this a new or existing policy? Update of existing policy




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Varicella Zoster Virus (Chickenpox)                                 Infection Control                                           Western Isles Hospital
                                                                       Department




2.    What is the aim or purpose of the policy?

      To educate healthcare workers to assist them in minimising the risk of varicella zoster virus (chickenpox) spreading.

3.    Who is this policy intended to benefit or affect? In what way? Who are the stakeholders?

      Healthcare workers and patients
4.    How have these people been involved in the development of this policy? Through consultation of various groups



5.    What outcomes are intended from this policy?

      Both patients and healthcare workers are aware of possible chickenpox infection and how to protect themselves from this infection.
6.    What resource implications are linked to this policy?

    Awareness Training to healthcare workers. Personal Protective Equipment and deployment of appropriate staff.
For new policie s only:
7.
    What research or consultation has been done?

      National Guidelines and other resources related to infection control
8.    What stage is the policy at? It is ready to go to Safe and Effective Care Committee (SECC)

9.    What is the target date for completion? September 2009


SECTION TW O:                         IMPACT ASSESSMENT

15.   Complete the following table, giving reasons or comments where:
      a) The policy could have a positive impact by contributing to the general duty by –
         • Eliminating unlawful discrimination


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Varicella Zoster Virus (Chickenpox)                                       Infection Control                                              Western Isles Hospital
                                                                             Department




           •    Promoting equal opportunities
           •    Promoting relations within the equality group
           •    Taking account of disabilities

      A - The policy could have an adverse impact by disadvantaging any of the equality groups. Particular attention should be given to
      unlawful direct and indirect discrimination.

      B - If any potential impact on any of these groups has been identified, please give details - including if impact is anticipated to be
      positive or negative.

Equality Target Groups

Women and                             Positive
Men
Minority ethnic groups inc            Positive
gypsy travellers, refugees
& asylum seekers
Religious or faith groups             If alcohol gel is not acceptable to any religious faiths, the alternative methods will be advised or provided
Children & young people               positive
Older people                          positive
People with disabilities              positive
(physical or learning)
Lesbians                              positive
Gay men                               positive
Bisexuals                             positive
Transgender people                    positive




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Varicella Zoster Virus (Chickenpox)                                         Infection Control                                            Western Isles Hospital
                                                                               Department




Equality Target Groups
Individuals with Mental                 Healthcare workers are made aware of the impact of alcohol gel on addictive patients.
Health issues
People in criminal justice              positive
system
People in poverty                       positive
Married/unmarried people/               positive
civil partnerships
People with language or                 Interpretation will be used if necessary to communicate the impacts of this policy to those whose English is not their
social origin issues                    first language
Staff                                   positive


SECTION THREE:                        Crosscutting issues:

What impact will the proposal have on lifestyles? For example, will the changes affect:

                                        N/A
Diet and nutrition?
Exercise and physical                   N/A
activity?
                                        To be aware that alcohol gel may have negative impacts therefore provide alternative methods of decontaminating
Substance use: tobacco,                 hands
alcohol or drugs?

    •    Risk taking                    Fear or worry of infection will be reduced
         behaviour?
    •    Education and                  Awareness training to healthcare workers will be provided



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Varicella Zoster Virus (Chickenpox)                          Infection Control                             Western Isles Hospital
                                                                Department




         learning, or skills?
    •    Other

SECTION FOUR:                         Crosscutting issues:

Does your policy consider the impact on the social environment? Things that might be affected include:


                                        N/A
    •    Social status
    •    Employment (paid or            N/A
         unpaid)
    •    Social/family support          positive
    •    Stress                         will be reduced
    •    Income                         N/A

    •    Will the proposal
         have any impact on
    •    Discrimination?                No
    •    Equality of                    Yes
         opportunity?
    •    Relations between              better
         groups?
    •    Other


SECTION FIVE:                         Crosscutting issues:

Will the proposal have an impact on the physical environment? For example, will there be impacts on:



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Varicella Zoster Virus (Chickenpox)                                         Infection Control                                Western Isles Hospital
                                                                               Department




                                        N/A
•     Living conditions?
                                        Positive impacts
•     Working conditions?
                                        N/A
•     Pollution or climate
      change?
•     Accidental injuries or            Public will be protected from infections
      public safety?
•     Transmission of                   Helps to reduce infections
      infectious disease?
•     Other


Will the proposal affect access to and experience of services? For example:
•  Health care              Helps to have infection free environment
•  Social Services          N/A
•  Education                Awareness training to healthcare workers
•  Transport                N/A
• Housing                   N/A




SECTION SIX:                          EXAMINATION OF AVAILABLE DATA AND CONSULTATION

Data could include: consultations, surveys, databases, focus groups, in-depth interviews, pilot projects, reviews of complaints made, user
                                      feedback, academic or professional publications, reports etc)

10.    Name any experts or relevant groups / bodies you should approach (or have approached) to explore their views on the issues.

       This policy was developed by the Infection Control Team and consulted with other relevant groups


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Varicella Zoster Virus (Chickenpox)                                  Infection Control                                        Western Isles Hospital
                                                                        Department




11.   What do we know from existing in-house quantitative and qualitative data, research, consultations, focus groups and analysis?

      It is applied and found that it works
12.   What do we know from existing external quantitative and qualitative data, research, consultations, focus groups and analysis?

      National guidelines and other relevant materials related to infection control
13.   What gaps in knowledge are there?

      None

SECTION: SEVEN:                       Have any potential negative impacts been identified?


      If so, what action been proposed to counteract these? Negative impacts (if yes, state how) e.g.
      •   Is there any unlawful discrimination? NO
      •   Could any community get an adverse outcome? NO
      •   Could any group be excluded from the benefits of the policy/function? NO
      •   Does it reinforce negative stereotypes? NO
                                      Monitoring
SECTION EIGHT:
      • How will the outcomes be monitored? Audits
      • What monitoring arrangements are in place? See audit checklist appendix 10.2
     •  Who will monitor? Infection Control Team, including Link Nurses
     •  What criteria will you use to measure progress towards the outcomes See audit checklist appendix 10.2
Recommendations
(This should include any action required to address negative impacts identified


Is a more detailed assessment needed?
(It is not necessary to subject all proposals to a detailed assessment.) No



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                                                                   Department




•   If so, for what reason?

Completed policy

    1. Who will sign this off? The chair of SECC
          When?
Publication

    1.    How will this be published? Intranet, Paper copy to each ward/department throughout NHS Western Isles
    2.    Copy given to Operational Diversity Lead Officer? Yes




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                                                                             Department



10.2     Audit Checklist


AUDIT CRITERIA                                  C    N/C O       COMMENTS
The Policy/Procedure document is present
in all locations required, and is the current
version


Staff know where the document is located
and can access it

(ask 2 HCWs)

HCWs know that patients who are
admitted with, or who develop a rash must
be assessed for an infectious disease
(ask 2 HCW’s)
Patients with Chickenpox are nursed in a
negative pressure isolation room



Standard Infection Control Precautions
plus Transmission Based Contact and
Airborne Precautions are in place

HCWs know that a history of chickenpox is
considered evidence of immunity
(ask 2 HCW’s)

Staff who are not immune should not
nurse patient
(ask 2 HCWs)

Staff know when a patient is no longer
considered infectious
(ask 2 HCW’s)

HCWs know the correct decontamination
procedures
(ask 2 HCW’s)




Key:     C Compliant        N/C Non-compliant   O Opportunity for improvement




07/09/2009 Version 1 Draft 2                                              Page 23 of 23

				
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