Procedure - Griffith University

© Copyright Mater Misericordiae Health Services Brisbane Limited. All Rights Reserved.

Procedure

Document Title: Immunisation and Vaccination of Mater People Procedure

Document ID: PR-PAL-001130

Document Name: PR-PAL-001130

Version Number: 1

Revision Date: 10/03/2014 10:54:00 AM

Key Words

Internal Use Only: The Material within this document has been developed solely for the internal business purposes of Mater Health Services. Disclosure of information of this classification may result in a breach of statutory or regulatory obligations by the Mater.

NOTICE OF CURRENCY: If viewing a printed copy of this document, NEVER assume that the printed copy being viewed is current. Always check the online Mater Document Centre to confirm you are viewing the current version of this procedure.

Our Mission Our Vision Our Values

In the spirit of the Sisters of Mercy, Mater Health Services offer compassionate service to the sick and needy, promotes an holistic approach to healthcare in response to changing community needs and foster high standards in health-related education and research. Following the example of Christ the healer, we commit ourselves to offering these services without discrimination.

In the Mercy tradition, Mater will be renowned as a leader in the delivery of exceptional healthcare and experienced by all as a community of compassion.

Mercy

Dignity

Care

Commitment

Quality

Affirmation

This governance document is consistent with the Mater Values and supports the Mater’s Mission and Vision by establishing and mandating appropriate controls to support the delivery of health care services.

© Copyright Mater Misericordiae Health Services Brisbane Limited. All Rights Reserved.

Table of Contents

1 Document Controls .................................................................................................................................... 3

1.1 Document Revision History ............................................................................................................... 3

1.2 Document Review and Approval ....................................................................................................... 3

1.3 Governing Document ........................................................................................................................ 3

1.4 Supporting Documents ...................................................................................................................... 3

1.5 Related Documents ........................................................................................................................... 3

1.6 References ......................................................................................................................................... 4

2 Introduction ............................................................................................................................................... 5

2.1 Scope and Context ............................................................................................................................. 5

2.2 Definitions ......................................................................................................................................... 5

3 Procedures ................................................................................................................................................. 8

3.1 Occupationally Required or Recommended Immunity ..................................................................... 8

3.2 Requirements for Existing Employees ............................................................................................... 8

3.3 Requirements for New Employees .................................................................................................... 8

3.4 Requirements for students and their respective educational institution, and personnel from other organisations and their respective employers .............................................................................................. 9

3.5 Requirements for other areas within Mater Health Services ......................................................... 10

3.6 Management of Unprotected/Unscreened New Employees and Existing Employees ................... 10

3.7 Where there is a Genuine and Significant Risk to Service Delivery ................................................. 11

3.8 Management of potential exposure to vaccine preventable diseases ........................................... 11

4 Appendix .................................................................................................................................................. 12

4.1 Appendix 1: Management of Unprotected/Unscreened New Employees and Existing Employees 12

4.2 Appendix 2: Risk Profile on Role Requirements .............................................................................. 13

4.3 Appendix 3: Unprotected and Unscreened Acknowledgement Form ............................................ 14

4.4 Appendix 4: Response Template ..................................................................................................... 15

Document ID: PR-PAL-001130 Last Revised: 3/10/2014 10:54:00 AM Document Title: Immunisation and Vaccination of Mater People Page | 3

1 Document Controls

1.1 Document Revision History

Version Date Description

1 16/01/2014 Initial Draft

1.2 Document Review and Approval

Person Name / Committee Position (if applicable) Function

(Owner | Approve | Review)

Anna Eves Director People Performance and Capability

Owner

Caroline Hudson Executive Director People and Learning

Review

Corporate Policy Governance Committee

Approve

1.3 Governing Document

Document Type Policy

Document ID PY-PAL-000001

Document Title Commitment to Work Health and Safety Policy

1.4 Supporting Documents

The following documents have been developed in support of this document:

Document Type Document ID Document Title

Work Instructions

Forms / Templates NF-PAL-001131 Statutory Declaration Form

NF-PAL-001132 Acknowledgement Form

NF-PAL-001133 Risk Profile Template

NF-PAL-001134 Response Template

1.5 Related Documents

The following documents should be read in conjunction with this document:

Document Type Document ID Document Title

Policies PY-PAL-000001 Commitment to Work Health and Safety Policy

PY-PAL-010011 Recruitment pre-commencement policy

Procedures PR-PAL-001010 Work Health and Safety Risk Management


1.6 References

The following information should be read in conjunction with this document:

1 The Workplace Health and Safety Act 2011

2 The Private Health Facilities Act 1999

3 Private Health Facilities (Standards) Notice 2000

4 Private Health Facilities Regulations 2000

5 The Australian Immunisation Handbook 10th Edition, Australian Government ACT (2013)

6 The Mater Health Services Infection Control Manual 2011

7 The Australian Council on Healthcare Standards (ACHS) EQuIPNational Guidelines Standard 15. Sydney Australia; ACHS; 2012.

8 National Health and Medical Research Council Australian Guidelines for the Prevention and Control Of Infection in Healthcare (2010)

9 Department of Health, NSW. Occupational Assessment, Screening and Vaccination Against Specified Infectious Diseases 21 Jan 2011. Available from: http://www0.health.nsw.gov.au/policies/pd/2011/pdf/PD2011_005.PDF


2 Introduction

Mater Health Services is committed to meeting its legal and regulatory workplace health and safety (WHS) obligations and to discharge its duty of care to Mater People, patients and other users of Mater Health Services. This commitment extends to reducing the incidence and risk of transmission of vaccine preventable diseases. Mater Health Services will identify, assess and manage infectious disease risk within a risk control framework and inform Mater People of their rights and responsibilities in relation to these WHS requirements. This procedure will also define the roles and responsibilities of relevant organisations that work in partnership with Mater Health Services, with regard to immunisation and vaccination.

2.1 Scope and Context

This mandatory procedure applies to all Mater People at all Mater Health Service owned or controlled facilities.

All Mater People who commenced or are scheduled to commence with Mater Health Services post 18 October 2010 must be compliant with this procedure prior to their start date.

All existing employees who commenced with Mater Health Services prior to 18 October 2010 must be compliant with this procedure by 1 January 2017.

The medical, dental, nursing faculties at colleges and universities who have partnerships with Mater Health Services must draw students’ attention to this procedure and ensure students’ compliance prior to commencement at a Mater Health Services facility.

2.2 Definitions

Term Definition

Appropriately trained clinical personnel

Refers to a person who has a medical, nursing or specialist training in the interpretation of immunological test results and vaccination.

Conscientious Objector

An individual who declines to be vaccinated due to personal, philosophical, religious or medical beliefs.

Direct Contact Refers to Mater Health Service roles with direct physical contact with patients/clients, deceased persons, blood, body substances or infectious material or surfaces/equipment that might contain these, or contact that would allow acquisition and/or transmission of a vaccine preventable disease by respiratory means.

Existing Employee For the purposes of this procedure refers to an individual who is currently employed by Mater Health Services and commenced prior to 18 October 2010.

High risk client groups Refers to;

children incompletely vaccinated including neonates and premature infants

Pregnant women

Immunocompromised patients

High risk clinical areas Refers to Mater Health Service work areas commonly providing services to high risk patient groups, including but not limited to:


Ante-natal, peri-natal and post-natal areas including labour wards and recovery rooms

Neonatal Intensive Care Units and Special Care Units

Paediatric Units

Transplant and Oncology Units

Intensive Care Units

Emergency Departments

Operating theatres, and recovery rooms

Laboratories

Immunocompromised patients

Refers to persons whose immune system’s ability to fight infectious disease is reduced or totally absent due to a primary immunodeficiency syndrome, human immunodeficiency virus (HIV), chemotherapy, some forms of cancer such as leukaemia, and persons on immune suppressing treatment such as following an organ transplant.

Mater People Anyone who carries out work for Mater Health Services including employees, contractors, subcontractors, visiting medical officers, employees of labour hire companies (e.g. nursing agency staff), outworkers, apprentices and trainees, students, volunteers, and Person(s) Conducting a Business or Undertaking who are individuals if they perform work for Mater Health Services.

The term Mater People may refer to one or more individuals. The term ‘Mater Person’ is the singular of ‘Mater People’.

The Mater Health Services terms ‘Mater People’ and ‘Mater Person’ have the same meaning as the term ‘worker’ under the Work Health and Safety Act (2011) QLD and exclusion of subsidiaries.

Unless explicitly stated otherwise, the term Mater People does not apply to workers (as defined by the Work Health and Safety Act 2011) of Mater Health Services subsidiary companies.

Medical

contraindication to

vaccination

Refers to a condition that precludes a person from receiving a vaccine as it may increase the chance of a serious adverse event. A medical contraindication may be permanent, for example, anaphylaxis to vaccine component(s) or time-limited/temporary, for example, pregnancy.

New Employee For the purposes of this procedure refers to an individual who is currently employed by Mater Health Services and commenced after 18 October 2010, or an individual who has yet to commence.

Non-Contact Refers to Mater Health Service roles with no direct physical contact with patients/clients, deceased persons, blood, body substances or infectious material or surfaces/equipment that might contain these, and no greater risk of acquisition and/or transmission of a vaccine preventable disease than that of the general community.

Ongoing care Refers to necessary consultation, serological testing, assessment and vaccinations that are offered and provided by appropriately trained clinical personnel subsequent to initial stages of care.

Protected Refers to persons who provide evidence of immunity to vaccine preventable diseases either by completed vaccination schedules, evidence of prior infection or serological test results.

Responsible Supervisor

A person who directs and / or supervises work in a Mater Health Services workplace. Note that the term ‘Responsible Supervisor’ does not correlate with any particular classification, title or status within the organisation.

Risk categorisation Refers to the process of assessing a person or role according to the risk of transmission of the


vaccine preventable diseases. Roles are categorised as either direct contact or non-contact.

Serological Assessment

Refers to the full evaluation of a person’s level of protection against the infectious diseases covered in this procedure by appropriately trained clinical personnel.

SHAW Unit Safety, Health and Wellbeing Unit at Mater Health Services

Unprotected/Unscreened

Refers to persons who cannot provide evidence of immunity as required by this procedure and are therefore classed as susceptible to one or more of the vaccine preventable diseases.

Vaccine non-responders

Refers to persons who have completed a vaccination schedule in full, but do not have adequate evidence of immunity.

Vaccine preventable diseases

Refers to;

Hepatitis B

Measles, Mumps, Rubella

Diphtheria, Tetanus, Pertussis (Whooping Cough)

Varicella (Chickenpox)

Influenza (not mandatory)


3 Procedures

The following sections describe the requirements and procedures for Mater People with regard to vaccination and immunisation.

3.1 Occupationally Required or Recommended Immunity

The role of all Mater People will be categorised as either Direct Contact or Non-Contact with consideration of potential contact with patients, exposure to bodily fluids, infectious materials and/or contaminated articles. According to the risk categorisation as Direct Contact or Non-Contact, Mater People are either required or recommended to obtain immunity to the following vaccine-preventable diseases:

Vaccine Preventable Disease Direct Contact Role Non-Contact Role

Hepatitis B Required Recommended

Measles Required Recommended

Mumps Required Recommended

Pertussis (Whooping Cough) Required Recommended

Rubella Required Recommended

Varicella (Chickenpox) Required Recommended

Influenza Recommended Recommended

3.2 Requirements for Existing Employees1

Existing Employees must:

Through the provision of evidence of protection against the vaccine preventable diseases specified in this procedure, comply with procedural requirements prior to 1 January 2017 or;

Submit a written declaration stating that they: o do not consent to the assessment, screening and vaccination requirements of this

procedure; and o are aware of the potential risks to themselves and/or others; and o are aware that their employer will be required to manage them as unprotected or

unscreened as described in Section 3.5 Case Management of Unprotected/Unscreened employees and existing employees

3.3 Requirements for New Employees2

New employees must:

Provide evidence of protection against the vaccine preventable diseases specified in this procedure and comply with the requirements of this procedure at their own cost, prior to commencement or;

Submit a written declaration stating that they:

1 Refer to 2.2 Definitions page 5

2 Refer to 2.2 Definitions page 6


o do not consent to the assessment, screening and vaccination requirements of this procedure; and

o are aware of the potential risks to themselves and/or others; and o are aware that their employer will be required to manage them as unprotected or

unscreened as described in Section 3.5 Case Management of Unprotected/Unscreened employees and existing employees

It is recognised that it may not be practical for all employees to complete a required vaccination schedule prior to commencement. The employee may only commence work if they have provided documented evidence that they have received at least the first dose of the required vaccine schedule and must complete the vaccination schedule within the appropriate timeframes as recommended in the Australian Immunisation Handbook (current edition).

3.4 Requirements for students and their respective educational institution, and personnel from other organisations and their respective employers

This section applies to students and external personnel such as contractors or agency staff when commencing in a direct contact role at Mater Health Services: Students placed in a direct contact role must provide evidence of protection against the vaccine preventable diseases specified in this procedure to their respective educational institution and comply with the requirements of this procedure, prior to commencement.

It is recognised that it may not be practical for all students to complete a required vaccination schedule prior to commencement. The student may only commence placement if they have provided documented evidence to their respective educational institution that they have received at least the first dose of the required vaccine schedule and must complete the vaccination schedule within the appropriate timeframes as recommended in the Australian Immunisation Handbook (current edition). Any student who is not compliant with this procedure must not be placed within Mater Health Services.

Personnel from other organisations or agencies who are working for Mater Health Services in a direct contact role must provide evidence of protection against the vaccine preventable diseases specified in this procedure to their respective employer and comply with the requirements of this procedure, prior to commencement.

It is recognised that it may not be practical for all other personnel to complete a required vaccination schedule prior to commencement. Other personnel who are not able to comply may only commence placement if they have provided documented evidence to their respective employer that they have received at least the first dose of the required vaccine schedule and must complete the vaccination schedule within the appropriate timeframes as recommended in the National Health and Medical Research Council Australian Immunisation Handbook (current edition). Any other personnel who are not compliant with this procedure must not be placed within Mater Health Services.

Respective employers from other organisations and educational institutions who provide staff/students for direct contact roles at MHS must:

Have a current written agreement with Mater Health Services acknowledging the mandatory requirement to comply with this procedure

Inform all students and other personnel of the requirements of this procedure and ensure compliance

Ensure that students and other personnel are not placed within Mater Health Services if they do not comply with the requirements of this procedure


3.5 Requirements for other areas within Mater Health Services

The SHAW Unit The SHAW Unit will carry out risk categorisation on individual positions within Mater Health Services to classify them as Direct Contact and Non-Contact (see 3.1) and document these in the core HR system. The SHAW Unit will assess the individual’s evidence of immunity against the vaccine preventable diseases and allocate appropriately trained clinical personnel to offer and provide serological testing, serological assessment, vaccinations and ongoing care to existing employees, where required, and new employees. The SHAW Unit will ensure that New Employees and Existing Employees who do not consent to the assessment, screening and vaccination requirements of this procedure:

Understand the requirements of this procedure and the risks to patients, self and others arising from their unprotected/unscreened status including disease specific information and relevant exposure management guidelines

Have an opportunity to discuss and clarify any issues or concerns

Have an opportunity to reconsider any decision made regarding assessment, screening and vaccination

Are actively engaged in their own case management

The SHAW Unit will facilitate the case management of unprotected/unscreened New Employees and Existing Employees in accordance section 3.5 in this document. Responsible Supervisors All Responsible Supervisors must inform all Existing Employees of their requirement to comply with this procedure by 01 January 2017.

3.6 Management of Unprotected/Unscreened New Employees and Existing Employees3

It is recognised that it may not be practical for certain New Employees and Existing Employees to comply with the requirements of this procedure. Mater Health Services will individually manage New Employees and Existing Employees who identify as having a medical contraindication to vaccination, are a vaccine non-responder or are a conscientious objector.

Medical Contraindication:

New Employees and Existing Employees who are unable to be vaccinated due to a temporary or permanent medical contraindication are required to provide documentation to the SHAW Unit confirming their inability to receive vaccination from a medical practitioner, including a review date where applicable.

It is the responsibility of the New Employee or Existing Employee to notify the SHAW Unit should their condition change in a way that may affect their unprotected/unscreened status.

Vaccine Non-Responder:

This describes New Employees or Existing Employees who have provided evidence of compliance with the relevant vaccination schedule as recommended by the Australian Immunisation Handbook (current edition) but do not have sufficient immunity.

Conscientious Objector: This includes New Employees and Existing Employees who do not consent to the assessment, screening and vaccination requirements of this procedure.

3 This section applies to New Employees, and will apply to Existing Employees subsequent to January 1 2017


Management of these cases is facilitated by the SHAW Unit and all cases are treated confidentially. The SHAW Unit will follow the process outlined in Appendix 1 Management of unprotected/unscreened New Employees and Existing Employees which involves the following:

SHAW Unit complete a risk profile – NF-PAL-001133 (see appendix 2)

SHAW Unit send notification of case, risk profile and appropriate link to specific disease information (Queensland Health Communicable Disease Control Guideline http://www.health.qld.gov.au/cdcg/default.asp) to PPC Director and HR Business Partner

SHAW Unit advise Recruitment team of escalation of case

HR Business Partner to send risk profile and link to Queensland Health Communicable Disease Control Guideline to Executive Director People and Learning and relevant Executive Director

Relevant Executive Director to review the risk profile and specific disease information (via link) to consider the options for the employee which include:

o Accept risk and approve commencement o Arrange suitable duties to minimise risk o Redeploy or revoke offer of employment

The relevant Executive Director may require assistance to make this decision – this can be provided through consultation with an infectious disease consultant.

The relevant Executive Director is required to disclose the outcome of their decision to relevant parties, including the HR business partner and the SHAW unit, and delegate associated actions appropriately.

The HR Business Partner is to notify the hiring manager of the relevant Executive Director decision.

3.7 Where there is a Genuine and Significant Risk to Service Delivery

Mater Health Services recognises that in certain circumstances there may be a genuine and significant risk to service delivery if an unprotected/unscreened new employee or existing employee is unable to commence or continue work due to an inability to comply with this procedure. Such situations would normally be limited to circumstances where:

The employee is highly specialised or there is a current workforce shortage in their respective field

It would be difficult to re-fill the position resulting in a significant disruption to service delivery In these circumstances, the employee may be managed in accordance with Appendix 1 Management of unprotected/unscreened Employees and Existing Employees at the discretion of the relevant Executive Director and with endorsement from the Executive Director of People and Learning.

3.8 Management of potential exposure to vaccine preventable diseases

In the event that Mater People are exposed or potentially exposed to a vaccine preventable disease, the SHAW Unit will offer and provide serological testing, assessment, vaccination and ongoing care.

Document ID: PR-PAL-001130 Last Revised : 3/10/2014 10:54:00 AM Document Title: Immunisation and Vaccination of Mater People Page | 12

4 Appendix

4.1 Appendix 1: Management of Unprotected/Unscreened New Employees and Existing Employees4

4 Refer to section 3.5 of Immunisation and Vaccination of Mater People Procedure (PR-PAL-001130)


4.2 Appendix 2: Risk Profile on Role Requirements


4.3 Appendix 3: Unprotected and Unscreened Acknowledgement Form


4.4 Appendix 4: Response Template