Surveillance of Infection and Data Collection

Transcription

1 Infection Prevention and Control Assurance - Standard Operating Procedure 3 (IPC SOP 3) Surveillance of Infection and Data Collection 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 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 2. The Infection Prevention and Control Committee is responsible for approving this procedure and monitoring compliance Surveillance of Infection and Data Collection Page 1 of 10 Version 1.0 December 2015

2 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: 6. The Medical Microbiologist is responsible to ensure that appropriate tests are available to support surveillance activities and results are reported promptly to relevant Clinicians responsible for the care of the patient/staff member. 7. The Infection Prevention andcontrol 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 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 staff 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 staff 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 Surveillance of Infection and Data Collection Page 2 of 10 Version 1.0 December 2015

3 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 conditions Bacteraemia CDI HCAI data capture system Healthcare associated infection (HCAI) Invasive devices Multi-resistant organism Notifiable diseases Root Cause Analysis (RCA) Surveillance 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 for example infectious diseases e.g. diarrhoea/vomiting, Chickenpox/Shingles, Infestations etc. (see Appendix 1) Organisms present in the bloodstream that may cause infection Clostridium difficile infection (CDI) detected by a positive test for Clostridium difficile. Symptoms include diarrhoea Web based computer database for recording HCAI episodes of bacteraemia and Clostridium difficile. The database is managed by Public Health England (PHE) Infection acquired by a patient as a result of contact with a healthcare provider Includes all devices that break through the skin Microbiological organisms resistant to common antimicrobials Diseases notifiable to local authority proper officers under the Health Protection (Notification) Regulations 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) is a formal investigation following an incident using a specific format ending in action plan 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 of Infection and Data Collection Page 3 of 10 Version 1.0 December 2015

4 Surveillance - Laboratory Surveillance - Mandatory Surveillance - Targeted Surveillance - Voluntary 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) Some surveillance is mandatory MRSA bacteraemia and Clostridium difficile positive data are used by the DH and Monitor 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 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 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 2. Collation of data 3. Analysis and interpretation 4. Timely dissemination of information 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. 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 Surveillance of Infection and Data Collection Page 4 of 10 Version 1.0 December 2015

5 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 Reporting Incidents of Infection to Public Health England or the Local Authority Standard Operating Procedure Appendix 3 explains the surveillance processes used within the Trust. Additional Information/ Associated Documents Infection Prevention and Control Assurance Policy Recognition and Management of Outbreaks (Standard Operating Procedure) Reporting incidents of infection to PHE or the Local Authority (Standard Operating Procedure) Surveillance and data collection (including reporting Healthcare Associated Infections (HCAI) to Public Health England) (Standard Operating Procedure) HCAI data capture system and protocol - Available at: - Accessed 10/2015 Norovirus web based reporting Available at: - Accessed 10/2015 Dept. of Health (2003) Winning ways. Working together to reduce Healthcare Associated Infection in England. Report from the Chief Medical officer. London. DH. Available at: tatistics/publications/publicationspolicyandguidance/dh_ Accessed 10/2015 Guidance on reporting and monitoring arrangements and post infection review process for MRSA bloodstream infections from April 2014 (v2) available at - Accessed 10/2015 C. difficile infection: inclusion criteria for reporting to the surveillance system January 2014 available at: - Accessed E.coli bacteraemia mandatory reporting - Accessed 10/2015 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 Surveillance of Infection and Data Collection Page 5 of 10 Version 1.0 December 2015

6 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 Surveillance of Infection and Data Collection Page 6 of 10 Version 1.0 December 2015

7 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 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 Alert Conditions 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 Surveillance of Infection and Data Collection Page 7 of 10 Version 1.0 December 2015

8 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, Elgar House, Green Street, Kidderminster, DY10 1JF Phone: option 2, option 3 (Out of hours for health professionals only: please phone ) Notification Form: 0/Notifiable_disease_form.pdf Surveillance of Infection and Data Collection Page 8 of 10 Version 1.0 December 2015

9 Appendix 3 Weekly Surveillance Alert Organisms/ Alert Conditions Undertaken by Clinical Teams and IPC Team In-Patient Units Infection Prevention and Control Team 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 Clinical teams 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: /?task=doc_download&gid=1757 ) 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 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 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 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 Surveillance of Infection and Data Collection Page 9 of 10 Version 1.0 December 2015

10 Standard Operating Procedure Details Unique Identifier for this SOP is State if SOP is New or Revised BCPFT-COI-POL New Policy Category Executive Director whose portfolio this SOP comes under Policy Lead/Author Job titles only Committee/Group Responsible for Approval of this SOP Month/year consultation process completed Control of Infection Executive Director of Nursing, AHPs and Governance Infection Prevention and Control Team Infection Prevention and Control Committee November 2015 Month/year SOP was approved December 2015 Next review due December 2018 Disclosure Status B can be disclosed to patients and the public Review and Amendment History Version Date Description of Change 1.0 Dec 2015 New Procedure established to supplement Infection Control Assurance Policy Surveillance of Infection and Data Collection Page 10 of 10 Version 1.0 December 2015