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Why we have a procedure?

Adherence to this procedure will ensure the Trust meets its statutory obligation to report alert organisms, and other HCAI, to the regulatory bodies. It will also provide evidence of local surveillance and the use of comparative data in the monitoring of infection rates. Timely reporting of this data to clinical areas should assist in the reduction of any healthcare associated infection. It will also ensure compliance with the Health and Social Care Act 2008: Code of Practice for the NHS for the Prevention and Control of Healthcare Associated Infections (revised January 2015). This document has been developed to provide a framework to:

Monitor the incidence of infection.

Provide early warning and investigation of problems and subsequent planning and intervention to control infection.

Monitor trends, including the detection of outbreaks.

Examine the impact of interventions.

Ensure compliance with mandatory surveillance systems.

Assist the IPCT and the Infection Prevention and Control Committee to identify risks of infection and reinforce the need for good practice.

What overarching policy the procedure links to?

This procedure is supported by the Infection Prevention and Control Assurance Policy

Which services of the trust does this apply to? Where is it in operation?

Group Inpatients Community Locations

Mental Health Services all

Learning Disabilities Services all

Children and Young People Services all

Who does the procedure apply to?

1. The Director of Infection Prevention and Control (DIPC) is responsible for providing reports on the surveillance of infection directly to the Chief Executive and the Trust Board. The CEO is required to sign off infection data collected via the HCAI DCS on the 15th of each month (this is usually undertaken in acute trust organisations).

Infection Prevention and Control Assurance - Standard Operating Procedure 3 (IPC SOP 3)

Surveillance of Infection and Data Collection

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2. The Infection Prevention and Control Committee is responsible for approving this procedure and monitoring compliance.

3. The Group/Divisional Management Teams are responsible for reviewing data relating to their Division and ensuring appropriate actions are being taken e.g. investigations into cases of C.difficile infection are undertaken using principles of root cause analysis, action plans formulated and learning shared monitoring any action plans through the Group/Divisional Governance Group.

4. Line Managers are responsible for the implementation of and compliance with this procedure within their own clinical area and reporting incidents of infection/ outbreaks etc. to the IPCT

5. Ward/Unit Managers are responsible for ensuring weekly in-patient infection surveillance data form is submitted weekly (every Monday by 10am) to the IPCT using the on-line data collection form: http://luna.smhsct.local/documents/trust-forms/1757-weekly-infection-surveillance-data-returns

6. The Medical Microbiologist is responsible to ensure that appropriate tests are available to support surveillance activities and test results are reported promptly to the relevant Clinicians responsible for the care of the patient/staff member. In addition via an enhanced surveillance system, information is collected via a web-based surveillance system (Healthcare Associated Infection Data Capture System (HCAI DCS)) which is reported nationally).This system collects mandatory reporting data on the following HCAIs: - MRSA bacteraemia - MSSA bacteraemia - E.coli bacteraemia - Pseudomonas aeruginosa bacteraemia - Klebsiella spp. bacteraemia - Clostridium difficile infection This enhanced data provides a platform to identify potential interventional targets and provides robust local and national data with the potential for benchmarking and comparison within organisations and regions over time.

7. The Infection Prevention and Control Team (IPCT) is responsible for:

a) Co-ordinating surveillance activities.

b) Collating the data and feeding back surveillance data to wards/departments and advising on specific infection prevention and control procedures to minimise risk of transmission and monitor trends.

c) Ensuring that data required as part of the mandatory surveillance programme are reported on the PHE web based HCAI data capture system and is ‘signed off’ by the 15th of each month (with the Acute Trust entering the data as/ when necessary).

d) Producing surveillance reports to relevant committees and groups.

e) Co-ordinating post infection reviews following incidents of bacteraemia or C. difficile.

f) Supporting the investigation of, and learning from other types of health care associated infection as relevant.

g) Investigating suspected incidents of cross infection and outbreaks.

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8. Clinicians – the Clinician in charge of the patient has a statutory duty to report notifiable communicable diseases to the Consultant in Communicable Disease Control at Public Health England, Midlands and East Regional Office.

9. Individual staffs have a responsibility to actively participate in systems of surveillance as required by the IPCT and know how/when to contact the IPCT to notify them of any HCAIs, alert conditions, potential outbreaks or areas for concern.

All staffs have a responsibility for ensuring that the principles outlined within this document are universally applied.

When should the procedure be applied?

These procedures outline the Trust’s infection prevention surveillance and reporting processes, and the methods used to ensure timely reporting of Healthcare Acquired Infections (HCAI) to Public Health England (PHE). Surveillance provides good information to patients and clinical teams and is the cornerstone of infection control (DH 2003). It consists of the routine collection of data on infections among patients or staff, its analysis and the dissemination of the resulting information to those who need to know, so that appropriate action can result. Surveillance also forms part of clinical audit and clinical governance: it assists in reducing the frequency of adverse events such as infection or injury. High quality information on infectious diseases, healthcare associated infection and antimicrobial resistant organisms is essential for monitoring progress, investigating underlying causes and applying prevention and control measures (DH, 2003). Definitions

Alert organisms Alert organisms are identified in the microbiology laboratory and include organisms of clinical interest within a health care setting that may result in infection for the patient e.g. MRSA, Glycopeptide Resistant Enterococci (GRE), Extended Spectrum Betalactamases (ESBLs) and other multi-resistant organisms, Clostridium difficile, Norovirus and may result in outbreaks (see Appendix 1)

Alert conditions Alert conditions for example infectious diseases e.g. diarrhoea/vomiting, Chickenpox/Shingles, Infestations etc. (see Appendix 1)

Bacteraemia Organisms present in the bloodstream that may cause infection.

CDI Clostridium difficile infection (CDI) detected by a positive test for Clostridium difficile. Symptoms include diarrhoea.

HCAI data capture system

Web based computer database for recording HCAI episodes of bacteraemia and Clostridium difficile. The database is managed by Public Health England (PHE).

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Healthcare associated infection (HCAI)

Infection acquired by a patient as a result of contact with a healthcare provider.

Invasive devices Includes all devices that break through the skin.

Multi-resistant organism Microbiological organisms resistant to common antimicrobials.

Notifiable diseases Diseases notifiable to local authority proper officers under the Health Protection (Notification) Regulations 2010. This is a legal term denoting diseases that must by law be reported to the “proper officer” i.e. the Consultant in Communicable Disease Control (CCDC) who is based at the Regional Public Health office.(see Appendix 2 for list of diseases) It is the responsibility of the Doctor in charge of the patient to make the notification.

Root Cause Analysis (RCA)

Root Cause Analysis (RCA) is a formal investigation following an incident using a specific format ending in action plan. (See IPC SOP 18: Undertaking a post infection review).

Surveillance Surveillance is a systematic method for continuous monitoring of diseases in a population in order to be able to detect changes, analyse the data, disseminate the results and put into practice effective prevention and control mechanisms.

Surveillance - Laboratory The Trust will agree with the Local Microbiology Laboratory and with the advice of the Consultant Microbiologist the organisms which will be reported by the Laboratory to the IPCT e.g. alert organisms (reviewed annually).

Surveillance - Mandatory Some surveillance is mandatory MRSA bacteraemia and Clostridium difficile positive data are used by the DH and the CQC as infection control performance indicators. The Trust must comply with all requests for Mandatory Surveillance of Healthcare associated Infection in accordance with the requests made by the Department of Health.

Surveillance - Targeted Refers to the collection of data on healthcare associated infections occurring in a defined subgroup, such as those on a particular ward, those undergoing a particular procedure or those acquiring a particular infection.

Surveillance - Voluntary The IPC Committee decides on specific surveillance programmes to undertake in response to local need.

How to carry out this procedure

All surveillance systems have four key components (DH/PHLS, 1995): 1. Data collection using standard case definitions

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2. Collation of data

3. Analysis and interpretation of the data

4. Timely dissemination of information to clinical teams

Alert organisms and alert conditions are those that may cause outbreaks. The IPCT will provide advice on the control measures and management of cases and will investigate clusters of cases. It is the responsibility of the clinical team to access and follow up any microbiology results for their patients in a timely manner.

Some national surveillance schemes are mandatory, others are voluntary. Surveillance Objectives and Process Objectives of Surveillance

Assessment of infection incidence over a period of time.

Timely investigation and instigation of prevention and control measures.

To assess the effectiveness of prevention and control measures and interventions.

The prevention and early detection of outbreaks.

Mandatory reporting to Department of Health where applicable. Surveillance Process

Yearly plan agreed by the IPC Committee and reported in the Infection Prevention Annual Work-plan and Annual Report.

Data collection using standard definitions by IPCT.

Analysis and interpretation of data by IPCT.

Reports produced using standard formats.

Feedback of surveillance data by IPT.

Incidence reports produced for Group/Divisions performance management information via the Governance Assurance Unit for action by Clinical Teams and the IPCT.

Reporting Mechanisms

See IPC SOP 4: Reporting Incidents of Infection to Public Health England or the Local Authority, for further details.

Appendix 3 explains the surveillance processes used within the Trust.

Additional Information/ Associated Documents

Infection Prevention and Control Assurance Policy.

Infection Prevention and Control Assurance - Standard Operating Procedure 5 IPC SOP 5: Recognition and Management of Outbreaks

Infection Prevention and Control Assurance - Standard Operating Procedure 4 IPC SOP 4: Reporting incidents of infection to PHE or the Local Authority

National enhanced mandatory surveillance of Gram-Negative Bacteraemia https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/725648/HCAIDCS_Gram_Negative_2017_Submission_Form.pdf (accessed January 2019)

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Update on the reporting and monitoring arrangements and post-infection review process for MRSA bloodstream infections (March 2018) (accessed January 2019)

https://improvement.nhs.uk/documents/2512/MRSA_post_infection_review_2018_changes.pdf

Mandatory Healthcare Associated Infection Surveillance: Data Quality Statement (June 2018) https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/713604/Mandatory_Healthcare_Associated_Infection_Surveillance_Data_Quality_Statement.pdf (accessed January 2019)

Hospital Norovirus Outbreak Reporting Tool http://bioinformatics.phe.org.uk/noroOBK/

(accessed January 2019)

Clostridium difficile infection objectives for NHS organisations in 2018/19, guidance on sanction implementation and notification of changes to case attribution definitions from 2019 (March 2018) https://improvement.nhs.uk/documents/808/CDI_objectives_18_19_FINAL_Oct2018.pdf (accessed January 2019)

Department of Health (2015) The Health and Social Care Act 2008: code of practice on the prevention and control of infections and related guidance. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/449049/Code_of_practice_280715_acc.pdf (accessed January 2019)

Department of Health (2003) Winning ways. Working together to reduce Healthcare Associated Infection in England. Report from the Chief Medical officer. London. DH. Available at: http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_4064682 (accessed

January 2019)

Where do I go for further advice or information?

Infection Prevention and Control Team

Your Service Manager, Matron, General Manager, Head of Nursing, Group Director

Your Group Governance Staff Training Staff may receive training in relation to this procedure, where it is identified in their appraisal as part of the specific development needs for their role and responsibilities. Please refer to the Trust’s Mandatory and Risk Management Training Needs Analysis for further details on training requirements, target audiences and update frequencies. Monitoring / Review of this Procedure In the event of planned change in the process(es) described within this document or an incident involving the described process(es) within the review cycle, this SOP will be reviewed and revised as necessary to maintain its accuracy and effectiveness.

Equality Impact Assessment Please refer to overarching policy

Data Protection Act and Freedom of Information Act Please refer to overarching policy

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Appendix 1

Alert Organisms and Alert Conditions NB This list is not exhaustive and all incidents of infection, infestation, suspected outbreak etc. must be reported to the Infection Prevention and Control Team.

Alert Organisms Alert Conditions

Acinetobacter Adenovirus Campylobacter Carbapenamase producing

enterbacteraciae (CPE) Clostridium difficile Coronavirus Creutzfeldt Jakob Disease (CJD) Cryptosporidium Escherichia coli 0157 Escherichia coli bacteraemia Extended spectrum beta lactamase

producers (ESBLs) Gardia Glycopeptide resistant enterococci

(GRE) Haemophilus influenza (Type B) Influenza virus Legionalla spp. Meticillin-resistant Staphylococcus

aureus (MRSA) as colonization or infection

Meticillin Sensitive Staphylococcus aureus (MSSA) bacteraemia

Middle Eastern Respiratory Syndrome (MERS)

Multi-resistant Gram negative bacilli Neisseria Norovirus Parvovirus Penicillin resistant Streptococcus

pneumoniae Respiratory syncytial virus Rotavirus Salmonella or Shigella spp Streptococcus pyogenes (Beta

Haemolytic Group A) Streptococcus agalactiae (Strep

group B) Varicella zoster Any unusual bacteria

Acute rash illness Cellulitis Chickenpox Diarrhoea and/or vomiting Diarrhoea with blood (dysentery) Diphtheria Food poisoning Hepatitis B Hepatitis C Infestations e.g. Scabies/head lice Influenza Measles Meningitis Meningococcal septicaemia Mumps Ophthalmia neonatorum Poliomyelitis Pyrexia of unknown origin with history of

foreign travel Rubella Scarlet fever Shingles Soft tissue infections including

nectrotising fasciitis Suspected legionellosis Suspected outbreaks Tuberculosis (chronic productive cough) Typhoid and paratyphoid fevers Viral hepatitis Viral haemorrhagic fever Whooping cough

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Appendix 2

Notifiable Infectious Diseases

Diseases that are notifiable are:

Acute encephalitis

Acute infectious hepatitis

Acute meningitis

Acute poliomyelitis

Anthrax

Botulism

Brucellosis

Cholera

Diphtheria

Enteric fever (typhoid or paratyphoid fever)

Food poisoning

Haemolytic uraemic syndrome (HUS)

Infectious bloody diarrhoea

Invasive group A streptococcal disease

Legionnaires’ disease

Leprosy

Malaria

Measles

Meningococcal septicaemia

Mumps

Plague

Rabies

Rubella

Severe Acute Respiratory Syndrome (SARS)

Scarlet fever

Smallpox

Tetanus

Tuberculosis

Typhus

Viral haemorrhagic fever (VHF)

Whooping cough

Yellow fever

Report other diseases that may present significant risk to human health under the category ‘other significant disease’.

N.B. ALL the diseases listed above MUST be notified to the Infection Prevention and Control Team IMMEDIATELY in addition to the local Public Health England Area Office:

West Midlands West HPT, 2nd Floor, Kidderminster Library Market Street Kidderminster Worcestershire DY10 1AB Phone: 0344 225 3560 (option 2) (Out of hours for health professionals only: please phone 01384 679 031)

Notification Form: https://www.gov.uk/government/publications/notifiable-diseases-form-for-registered-medical-practitioners (accessed January 2019)

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Appendix 3

Weekly Surveillance Alert Organisms/ Alert Conditions Undertaken by Clinical Teams and IPC Team

In-Patient Units

Each Unit collates data on the number of patients/staff with known or suspected infection

Clinical staff verbally inform the IPCT as/when these occur by phone on 0121 612 8068/8031 e.g. - when a positive microbiology result is received - when a case of infection/infestation is suspected - when an outbreak of infection is suspected - when there is a concern which increases the risks of infection

Clinical teams routinely complete the weekly infection control surveillance form and submit to the IPCT EVERY Monday before 11am reflecting on the previous 7 days (the form is available on the intranet: http://luna.smhsct.local/documents/trust-forms/1757-weekly-infection-surveillance-data-returns

Other Clinical Areas

Each Unit collates data on the number of patients/staff with known or suspected infection

Clinical staff verbally inform the IPCT as/when these occur by phone on 0121 612 8068/8031

Infection Prevention and Control Team

The IPCT checks laboratory results daily and collates and records information on the weekly prevalence record sheet, including any incidents/reports from other departments/teams

The IPCT checks NHS.net e-mail account daily for any laboratory notifications

The IPCT checks weekly surveillance forms every Monday and collates and records information on the weekly prevalence record sheet

The IPCT provide guidance and advice to clinical teams in relation to all cases identified

The IPCT report any areas of concern e.g. incidents/outbreaks to the DIPC as/when they occur

The IPCT notify the Regional PHE Office & CCG when any notifiable incidents/outbreaks of infection arise

The IPCT each month collates all the data collected

Each quarter the data collection and any issues identified/areas for concern etc. are detailed in the quarterly report presented to the DIPC/Infection Prevention and Control Committee

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Appendix 4

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Step 1: Open the BCFT intranet home page, from the top scroll down to Quick Links then select Infection Control

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Step 2: Under INFECTION CONTROL scroll down the page to Documents/sections & select Surveillance & Click to open document

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Step 3: This is the surveillance document – see list of in-patient units scroll down to find your unit - see diagram below. You should now have the surveillance form below ready to be completed – Complete ALL the areas all fields are mandatory - see example below:

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Step 4: In every case where a number other than zero has been entered previously, please provide the full patient information on this page. In some cases one patient may have more than one infection risk – record the patient once only but detail all the problems – e.g. Fred Smythe known MRSA previously + screening swabs obtained, see example:

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Step 5: Once the form is complete click once on the green bar at the bottom of the form to submit – this will automatically be sent to bcpft.infectioncontrol@nhs.net and a copy will remain in your sent items – there is no need to attach & send an e-mail!

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Standard Operating Procedure Details

Review and Amendment History

Version Date Description of Change

2.0 Jan 2019 Procedure reviewed and all internet links & contact details

updated

Appendix 4 added

1.0 Dec 2015 New Procedure established to supplement Infection Control Assurance Policy

Unique Identifier for this SOP is BCPFT-COI-POL-05-03

State if SOP is New or Revised Revised

Policy Category Control of Infection

Executive Director whose portfolio this SOP comes under

Executive Director of Nursing, AHPs and Governance

Policy Lead/Author Job titles only

Infection Prevention and Control Team

Committee/Group Responsible for Approval of this SOP

Infection Prevention and Control Committee

Month/year consultation process completed

n/a

Month/year SOP was approved January 2019

Next review due January 2022

Disclosure Status ‘B’ can be disclosed to patients and the public