National Infection Prevention and Control Manual · National Infection Prevention and Control Manual Health Protection Scotland (HPS) Version 3.6.April 2017 Page 2 of 80 DOCUMENT

Version: Version 3.6. Date: April 2017 Owner/Author: Infection Control Team

National Infection Prevention and Control Manual


Health Protection Scotland (HPS) Version 3.6.April 2017 Page 2 of 80

DOCUMENT CONTROL SHEET Key Information: Title: National Infection Prevention and Control Manual Date Published/Issued: April 2017 Date Effective From: April 2017 Version/Issue Number: 3.6 Document Type: Policy/Guidance Document status: Consultation draft Owner: Health Protection Scotland (HPS) Approver: Steering (Expert Advisory) Group Contact Name: Infection Control Team

Tel: 0141 300 1175 Email: [email protected]

Version History: This literature review and/or National Infection Prevention and Control Manual will be updated in real time if any significant changes are found in the professional literature or from national guidance. Version Date Summary of changes since previous version 3.6 March 2017 Incorporation of Chapter 3 with comments from Steering

Group Taking out of the word ‘infectious’ from Section 1.9 Waste under Orange Waste

3.5 February 2016 Final changes made from comments from steering group.

3.4 06 December 2016 All references to Healthcare Associated Infection Incident Outbreak Reporting Template removed and replaced with Healthcare Infection Incident Outbreak Reporting Template. Update - Chapter 3 title changed page.30 – Healthcare Infection, Incident, Outbreak and Data Exceedance. Introduction to Chapter 3 page.30 – Healthcare settings changed to health and other care settings Appendix 12 p.54 – Calculate the Impact- scoring now changed to allow 1 moderate to be HIIAT Green • Part 2- Communication bullet point 2 GREEN now reads:

Only inform HPS if support/expert advice is required or there is an accompanying press holding/ release/ pro-active statement.

• Part 2 – Communication bullet point – a HIIORT is not required removed.

Appendix 13 page 56 –

mailto:[email protected]



Red box instruction page 1 changed to – Complete within 24 hours for all HIIAT Red and Amber; for HIIAT Green complete only if accompanied by a press statement (holding, release, proactive) and/or HPS support requested. Red box instruction page 2 changed to – Complete this update section weekly as a minimum or as agreed with IMT and HPS for onward reporting to SGHSCD.

3.2 December 2016 Update to definitions in Chapter 3.

3.1 September 2016 Addition of Chapter 3 – Healthcare Associated Infection Outbreaks and Data Exceedance Update of Appendix 7 Rewording of third bullet in left hand side box to now read. "Disinfect specific items of non-invasive, reusable, communal care equipment if recommended by the manufacturer e.g. 70% isopropyl alcohol on stethoscopes". This is changed from "Disinfectants may be used routinely to decontaminate specific items of non-invasive, reusable, communal care equipment if recommended by the manufacturer e.g 70% isopropyl alcohol on stethoscopes." Replacement of third bullet at the bottom of the middle and right hand side box with an asterisk that reads. *If the item cannot withstand chlorine releasing agents consult the manufacturer's instructions for a suitable alternative to use following or combined with detergent cleaning. This replaces the bullet that read " If the item cannot withstand chlorine releasing agents consult the manufacturer's instructions for a suitable alternative e.g 70% isopropyl alcohol. Section 1.2 – Hand Hygiene Wash hands with non antimicrobial soap if: Inclusion of new bullet point • caring for patients with vomiting or diarrhoeal illnesses;

or Section 2.4 – PPE - RPE Addition of National Minimum Risk Categorisation for HCW fit testing with FFP3

3.0 April 2016 Section 1.2 – Hand hygiene Perform hand hygiene. Step 2 changed to say Before clean/aseptic procedures if abhr can’t be used then liquid antimicrobial soap should be used.



Skin care During work breaks changed to during work. Use an emollient hand cream during work and when off duty. Section 1.4 – PPE Footwear. New bullet says Footwear must be: • Able to either withstand machine washing at 40°C or

disinfection with a chlorine releasing agent. Section 1.5 – Decontamination of patient care equipment Addition of text An equipment decontamination status certificate will be required if any item of equipment is being sent to a third party e.g for inspection, servicing or repair (This text replaces the blank Appendix 8 – Decontamination status certificate) Addition of text Guidance may be required prior to procuring, trialling or lending any reusable non-invasive equipment. (This text replaces the blank Appendix 9 – Procuring, trialling or lending any reusable non-invasive care equipment) Section 1.9 Addition of text Local guidance regarding management of waste at care level may be available. (This text replaces the blank appendix 12 Management of waste at care area level) Section 1.10 Inclusion of new sentence Always dispose of needles and syringes as 1 unit. Appendix 1 Addition of asterisk*Any skin complaints should be referred to local occupational health or GP. Appendix 3 Addition of new sentence. Undertake Appendix 1 prior to starting scrub. Image 4 updated with the words ‘using a rotational method’ Appendix 9 Addition of asterisk to say ‘All NHSScotland settings must use granules or equivalent product e.g spill kits’. Appendix 11 Addition of extra wording in Footnote 4 to read o Induction of sputum (not including chest physiotherapy).



2.5 December 2015 Section 1.4. Update to theatre headwear section to say ’Changed/disposed of between clinical procedures/tasks or if contaminated with blood and/or body fluid’. Glossary: • Addition of Hazard Group 4 • Fluid repellent changed to fluid resistant • Definition of outbreak changed • Surgical face masks definition changed to include IIR

masks. Appendix 3 – Surgical Scrubbing – Inclusion of footnote 1 and 2. Appendix 10 – Management of linen at care area level. Inclusion of Linen bagging and tagging guidance. Appendix 14 – List of infectious agents and/or diseases that require TBPs in addition to SICPs. • Inclusion of ‘until resolution of symptoms’ in the Optimal

patient placement box • Inclusion of ‘e.g respiratory secretions’ in the Surgical

Facemask box. 2.4 May 2015 Inclusion of links In Chapter 2 to posters and aide memoire

for TBPs January 2015 Section 1.7 – inclusion of recommendation that linen

deemed unfit for re-use should be returned to the laundry for disposal. Chapter 2. Transmission Based Precautions the distance for droplet precautions has been changed from “less than 3 feet (1 metre)” to “at least 3 feet (1 metre)”. Addition of section 2.5 Infection Prevention and control during Care of deceased Appendix 14 - Inclusion of Viral Haemorrhagic Fever Addition of Appendix 15 - Key Infections from HSE Guidance “Controlling the risks of infection at work from Human Remains”.

2.3 April 2014 Wider Consultation changes SLWG Appendix 14 and Section 2.4. Update and agreed content.

2.2 October 2013 Insertion of Chapter 2, TBPs and Glossary Add Appendix on Glove changes Add care homes consensus

2.1 January 2013

Amended after Board (ICN Leads) Consensus Meeting 9 January 2013.

2.0 December 2012 Amended after Board (ICN Leads) Consensus Meeting 1 November 2012.



HPS ICT Document Information Grid Description:

This evidence based National Infection Prevention and Control (NIP&C) Manual for Scotland is intended to be used by all those involved in care provision. The manual currently contains information on Standard Infection Control Precautions (SICPs), Chapter 1 and Transmission Based Precautions (TBPs), Chapter 2. It is planned to further develop the content of the manual.

Update/review schedule:

Updated in real time with changes made to practice recommendations as new evidence emerges and/or legislation changes.

Cross reference: http://www.nipcm.hps.scot.nhs.uk/

http://www.nipcm.hps.scot.nhs.uk/



Contents Introduction....................................................................................................................................9

Responsibilities for the content of this manual ........................................................................... 10

Responsibilities for the adoption and implementation of this manual ......................................... 10

Chapter 1: Standard Infection Control Precautions (SICPs) ...................................................... 12 1.1. Patient Placement/Assessment for infection risk ....................................................................... 12 1.2. Hand Hygiene ........................................................................................................................... 13 1.3. Respiratory and Cough Hygiene ............................................................................................... 15 1.4. Personal Protective Equipment (PPE) ....................................................................................... 15 1.5. Safe Management of Care Equipment ...................................................................................... 17 1.6. Safe Management of the Care Environment ............................................................................. 19 1.7. Safe Management of Linen ....................................................................................................... 19 1.8. Safe Management of Blood and Body Fluid Spillages ............................................................... 21 1.9. Safe Disposal of Waste (including sharps) ................................................................................ 21 1.10. Occupational Safety: Prevention and Exposure Management (including sharps) ...................... 23

Chapter 2: Transmission Based Precautions (TBPs) ................................................................ 24 2.1 Patient Placement/Assessment for Infection Risk ..................................................................... 25 2.2 Safe Management of Patient Care Equipment in an Isolation Room/Cohort Area .................... 26 2.3 Safe Management of the Care Environment 5 ........................................................................... 26 2.4 Personal Protective Equipment (PPE): Respiratory Protective Equipment (RPE)...................... 27 2.5 Infection Prevention and Control during care of the deceased .................................................. 29

Chapter 3: Healthcare Infection, Incidents, Outbreaks and Data Exceedance........................... 31 3.1 Definitions of Healthcare Infection Incident, Outbreak and Data Exceedance ........................... 31 3.2 Detection and recognition of a Healthcare Infection incident/outbreak or data exceedance ..... 32

Glossary 34

Appendix 1 – How to hand wash step by step images ............................................................... 45

Appendix 2 – How to handrub step by step images ................................................................... 46

Appendix 3 – Surgical scrubbing: surgical hand preparation technique using antimicrobial soap – step by step images ........................................................................................... 47

Appendix 4 - Surgical rubbing: surgical hand preparation technique using alcohol based hand rub (ABHR) - step by step images ........................................................................ 48

Appendix 5 – Glove use and selection ....................................................................................... 49

Appendix 6 – Putting on and removing PPE .............................................................................. 50

Appendix 7 – Decontamination of reusable non-invasive care equipment ................................. 51

Appendix 8 – Management of linen at care area level ............................................................... 52

Appendix 9 – Management of blood and body fluid spillages .................................................... 53

Appendix 10 – Management of occupational exposure incidents .............................................. 54

Appendix 11 – List of infectious agents and/or diseases that require Transmission Based Precautions (TBPs) in addition to SICPs. ............................................................. 55

Appendix 12 – Key Infections from HSE Guidance “Controlling the risks of infection at work from Human Remains”. ................................................................................................. 64

Appendix 13 – NHSScotland Alert organism/Condition list ........................................................ 65

Appendix 14 –NIPCM Healthcare Infection Incident Assessment Tool (HIIAT) ......................... 69



Appendix 15 – Healthcare Infection, Incident and Outbreak Reporting Template (HIIORT) ...... 71 Appendix 16- Healthcare Associated Infection definitions...........................................................72 Appendix 17- Membership and Terms of reference for IMT........................................................75 Appendix 18- Roles and Responsibilities....................................................................................79



Introduction

The National Infection Prevention and Control Manual was first published on 13 January 2012,

by the Chief Nursing Officer (CNO (2012)1):

http://www.sehd.scot.nhs.uk/cmo/CNO(2012)01.pdf, and updated on 17 May 2012:

http://www.sehd.scot.nhs.uk/cmo/CNO(2012)01update.pdf.

This national manual provides guidance to all those involved in care provision and should be

adopted for infection prevention and control practices and procedures. The national manual is

mandatory for NHS employees and applies to all NHS healthcare settings. In all other care

settings the content of this manual is considered best practice.

The manual aims to:

• Make it easy for care staff to apply effective infection prevention and control precautions.

• Reduce variation and optimise infection prevention and control practices throughout

Scotland.

• Help reduce the risk of Healthcare Associated Infection (HAI).

• Help align practice, monitoring, quality improvement and scrutiny.

The literature reviews that underpin and inform the practical application of the national manual

and highlight implications for research are available at

http://www.nipcm.hps.scot.nhs.uk/resources/literature-reviews/

http://www.sehd.scot.nhs.uk/cmo/CNO(2012)01.pdf

http://www.sehd.scot.nhs.uk/cmo/CNO(2012)01update.pdf

http://www.nipcm.hps.scot.nhs.uk/resources/literature-reviews/



Responsibilities for the content of this manual

HPS must ensure:

• that the content of this manual remains evidence based.

Responsibilities for the adoption and implementation of this manual

Organisations must ensure:

• the adoption and implementation of this manual in accordance with their existing local

governance processes;

• systems and resources are in place to facilitate implementation and compliance monitoring

of infection prevention and control as specified in this manual in all care areas. Compliance

monitoring includes all staff (permanent, agency and where required external contractors);

and

• there is an organisational culture which promotes incident reporting and focuses on

improving systemic failures that encourage safe working practices

Managers of all services must ensure that staff:

• are aware of and have access to this manual;

• have had instruction/education on infection prevention and control through attendance at

events and/or completion of training e.g. via NHS Education for Scotland (NES) and/or

local board/organisation;

• have adequate support and resources available to enable them to implement, monitor

and take corrective action to ensure compliance with this manual;

• with health concerns (including pregnancy) or who have had an occupational exposure

are timeously referred to the relevant agency e.g. General Practitioner, Occupational

Health or if required Accident and Emergency;

• have undergone the required health checks/clearance (including those undertaking

Exposure Prone Procedures (EPPs); and

• include infection prevention and control as an objective in their Personal Development

Plans (or equivalent).

Staff providing care must ensure that they:

• understand and apply the principles of infection prevention and control set out in this

manual;

http://www.nes.scot.nhs.uk/education-and-training/by-theme-initiative/healthcare-associated-infections.aspx



• maintain competence, skills and knowledge in infection prevention and control through

attendance at education events and/or completion of training e.g. NHS Education for

Scotland (NES) and/or local board/organisation;

• communicate the infection prevention and control practices to be taken by colleagues,

those being cared for, relatives and visitors without breaching confidentiality;

• have up to date occupational immunisations/health checks/clearance requirements as

appropriate;

• report to line managers and document any deficits in knowledge, resources, equipment

and facilities or incidents that may result in transmission of infection;

• do not provide care while at risk of potentially transmitting infectious agents to others. If

in any doubt they must consult with their line manager, Occupational Health Department,

Infection Prevention and Control Team (IPCT) or Health Protection Team (HPT).

• contact HPT/IPCT if there is a suspected or actual HAI incident/outbreak

Infection Prevention and Control Teams (IPCTs) and Health Protection Teams (HPTs) must:

• engage with staff to develop systems and processes that lead to sustainable and reliable

improvements in relation to the application of infection prevention and control practices;

and

• provide expert advice on the application of infection prevention and control in the care

setting and on individual risk assessments as required.

• have epidemiological/surveillance systems capable of distinguishing patient case(s)

requiring investigations and control.

Disclaimer When an organisation e.g. NHS board or care home uses products or adopts practices that differ from those stated in this National Infection Prevention and Control Manual,

that individual organisation is responsible for ensuring safe systems of work including the completion of a risk assessment.





Chapter 1: Standard Infection Control Precautions (SICPs)

Standard Infection Control Precautions (SICPs), covered in this chapter are to be used by all staff, in all care settings, at all times, for all patients1 whether infection is known to be present

or not to ensure the safety of those being cared for, staff and visitors in the care environment.

SICPs are the basic infection prevention and control measures necessary to reduce the risk of

transmission of infectious agent from both recognised and unrecognised sources of infection.

Sources of (potential) infection include blood and other body fluids secretions or excretions

(excluding sweat), non-intact skin or mucous membranes and any equipment or items in the

care environment that could have become contaminated.

The application of SICPs during care delivery is determined by an assessment of risk to and

from individuals and includes the task, level of interaction and/or the anticipated level of

exposure to blood and/or other body fluids.

To be effective in protecting against infection risks, SICPs must be used continuously by all

staff. SICPs implementation monitoring must also be ongoing to ensure compliance with safe

practices and to demonstrate ongoing commitment to patient, staff and visitor safety.

Further information on using SICPs for Care at Home can be found at

http://www.nes.scot.nhs.uk/education-and-training/by-theme-initiative/healthcare-associated-

infections/training-resources/[email protected].

There are ten elements of SICPs:

1.1. Patient Placement/Assessment for infection risk

Patients must be promptly assessed for infection risk on arrival at the care area (if possible,

prior to accepting a patient from another care area) and should be continuously reviewed

throughout their stay. This assessment should influence placement decisions in accordance

with clinical/care need(s).

Patients who may present a cross-infection risk include those:

• With diarrhoea, vomiting, an unexplained rash, fever or respiratory symptoms.

• Known to have been previously positive with a Multi-drug Resistant Organism (MDRO) e.g

MRSA, CPE.

• Who have been hospitalised outside Scotland in the last 12 months.

1 The use of the word ‘Persons’ can be used instead of ‘Patient’ when using this document in non-healthcare settings.

http://www.nes.scot.nhs.uk/education-and-training/by-theme-initiative/healthcare-associated-infections/training-resources/[email protected]

http://www.nes.scot.nhs.uk/education-and-training/by-theme-initiative/healthcare-associated-infections/training-resources/[email protected]



For assessment of infection risk see http://www.nipcm.hps.scot.nhs.uk/chapter-2-transmission-

based-precautions-tbps/

Further information can be found in the patient placement literature review

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-patient-placement-providing-care-in-the-

most-appropriate-place-in-the-hospital-setting/

1.2. Hand Hygiene

Hand hygiene is considered an important practice in reducing the transmission of infectious

agents which cause HAIs.

Before performing hand hygiene:

• expose forearms;

• remove all hand/wrist jewellery (a single, plain metal finger ring is permitted but should be

removed (or moved up) during hand hygiene);

• ensure finger nails are clean, short and that artificial nails or nail products are not worn;

and

• cover all cuts or abrasions with a waterproof dressing.

To perform hand hygiene: Alcohol Based Hand Rubs (ABHRs) must be available for staff as near to point of care as

possible. Where this is not practical, personal ABHR dispensers should be used.

Perform hand hygiene:

1. before touching a patient;

2. before clean/aseptic procedures. If ABHR cannot be used then antimicrobial liquid

soap should be used;

3. after body fluid exposure risk;

4. after touching a patient; and

5. after touching a patient’s immediate surroundings.

Wash hands with non-antimicrobial liquid soap and water if:

o hands are visibly soiled or dirty;

o caring for patients with vomiting or diarrhoeal illnesses; or

o caring for a patient with a suspected or known gastro-intestinal infection e.g. norovirus

or a spore forming organism such as Clostridium difficile.

In all other circumstances use ABHRs for routine hand hygiene during care.

http://www.nipcm.hps.scot.nhs.uk/chapter-2-transmission-based-precautions-tbps/

http://www.nipcm.hps.scot.nhs.uk/chapter-2-transmission-based-precautions-tbps/

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-patient-placement-providing-care-in-the-most-appropriate-place-in-the-hospital-setting/

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-patient-placement-providing-care-in-the-most-appropriate-place-in-the-hospital-setting/



Hand wipes should not be used by staff in the hospital or care home setting for hand

hygiene unless there is no running water available. Staff may use hand wipes followed by

ABHR and should wash their hands at the first available opportunity.

For how to wash hands see Appendix 1.

For how to hand rub see Appendix 2.

Skin care:

• Dry hands thoroughly after hand washing using disposable paper towels.

• Use an emollient hand cream during work and when off duty.

• Do not use or provide communal tubs of hand cream in the care setting.

Surgical Hand Antisepsis Surgical scrubbing/rubbing: (applies to persons undertaking surgical and some invasive

procedures)

• Perform surgical scrubbing/rubbing before donning sterile theatre garments or at other

times e.g. prior to insertion of vascular access devices.

• Remove all hand/wrist jewellery.

• Nail brushes (if used) must only be used for decontamination of nails. Nail picks can be

used if nails are visibly dirty.

• Use an antimicrobial liquid soap licensed for surgical scrubbing or an ABHR licensed for

surgical rubbing (as specified on the product label).

• ABHR can be used between surgical procedures if licensed for this use.

Follow the technique in Appendix 3 for Surgical Scrubbing.

Follow the technique in Appendix 4 for Surgical Rubbing.

Hand Hygiene posters/leaflets can be found at http://www.washyourhandsofthem.com/home.aspx Further information can be found in the Hand Hygiene literature reviews: • Hand hygiene products

• Hand washing in hospitals settings

• Indications for hand hygiene in the hospital setting

• Skin care

• Surgical hand scrubbing/rubbing in the hospital setting

• Use of alcohol based hand rub in the hospital setting

http://www.washyourhandsofthem.com/home.aspx

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-hand-hygiene-hand-hygiene-products-in-hospital-settings/

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-hand-hygiene-hand-washing-in-the-hospital-setting/

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-hand-hygiene-indications-for-hand-hygiene-in-the-hospital-setting/

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-hand-hygiene-skin-care/

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-hand-hygiene-surgical-hand-scrubbingrubbing-in-the-hospital-setting/

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-hand-hygiene-use-of-alcohol-based-hand-rub-in-the-hospital-setting/



1.3. Respiratory and Cough Hygiene

Respiratory and cough hygiene is designed to minimise the risk of cross-transmission of

respiratory illness (pathogens):

• Cover the nose and mouth with a disposable tissue when sneezing, coughing, wiping and

blowing the nose.

• Dispose of all used tissues promptly into a waste bin.

• Wash hands with non-antimicrobial liquid soap and warm water after coughing, sneezing,

using tissues, or after contact with respiratory secretions or objects contaminated by

these secretions.

• Hand wipes should not be used by staff in the hospital or care home setting for hand

hygiene unless there is no running water available. Staff may use hand wipes

followed by ABHR and should wash their hands at the first available opportunity.

• Keep contaminated hands away from the eyes nose and mouth.

Staff should promote respiratory and cough hygiene helping those (e.g. elderly, children) who

need assistance with this e.g. providing patients with tissues, plastic bags for used tissues and

hand hygiene facilities as necessary.

Further information can be found in the cough etiquette/respiratory hygiene in the hospital

setting literature review.

1.4. Personal Protective Equipment (PPE)

Before undertaking any procedure staff should assess any likely exposure and ensure PPE is

worn that provides adequate protection against the risks associated with the procedure or task

being undertaken.

All PPE should be:

• located close to the point of use;

• stored to prevent contamination in a clean/dry area until required for use (expiry dates

must be adhered to);

• single-use only items unless specified by the manufacturer; and

• disposed of after use into the correct waste stream i.e. healthcare waste or domestic

waste.

Reusable PPE items, e.g. non-disposable goggles/face shields/visors must have a

decontamination schedule with responsibility assigned.

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-cough-etiquetterespiratory-hygiene-in-the-hospital-setting/

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-cough-etiquetterespiratory-hygiene-in-the-hospital-setting/



Gloves must be:

• worn when exposure to blood and/or other body fluids is anticipated/likely;2

• changed immediately after each patient and/or following completion of a procedure or

task;

• changed if a perforation or puncture is suspected; and

• appropriate for use, fit for purpose and well-fitting to avoid excessive sweating and

interference with dexterity.

Double gloving is recommended during some Exposure Prone Procedures (EPPs) e.g.

orthopaedic and gynaecological operations or when attending major trauma incidents.

For appropriate glove use and selection see Appendix 5.

Further information can be found in the Gloves literature review.

Aprons must be:

• worn to protect uniform or clothes when contamination is anticipated/likely e.g. when in

direct care contact with a patient; and

• changed between patients and/or following completion of a procedure or task.

Full body gowns/Fluid repellent coveralls must be:

• worn when there is a risk of extensive splashing of blood and/or other body fluids e.g. in

the operating theatre; and

• changed between patients and immediately after completion of a procedure or task.

Further information can be found in the Aprons/Gowns literature review.

Eye/face protection (including full face visors) must be:

• worn if blood and/or body fluid contamination to the eyes/face is anticipated/likely e.g. by

members of the surgical theatre team and always during Aerosol Generating Procedures.

Regular corrective spectacles are not considered eye protection.

Further information can be found in the eye/face protection literature review.

Fluid resistant Type IIR surgical face masks must be:

2 Scottish National Blood Transfusion Service (SNBTS) adopt practices that differ from those stated in the National Infection Prevention and Control Manual.

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-ppe-gloves/

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-ppe-apronsgowns/

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-ppe-eyeface-protection/



• worn if splashing or spraying of blood, body fluids, secretions or excretions onto the

respiratory mucosa (nose and mouth) is anticipated/likely;

• worn to protect patients from the operator as a source of infection e.g. when performing

an epidural or inserting a Central Vascular Catheter (CVC);

• well fitting and fit for purpose (fully covering the mouth and nose) (manufacturers’

instructions must be adhered to ensure effective fit/protection); and

• removed or changed;

• at the end of a procedure/task;

• if the integrity of the mask is breached, e.g. from moisture build-up after extended use

or from gross contamination with blood or body fluids; and

• in accordance with specific manufacturers’ instructions.

Further information can be found in the surgical face masks literature review.

Footwear must be:

• Able to either withstand machine washing at 40°C or disinfection with a chlorine releasing

agent.

• non-slip, clean and well maintained, and support and cover the entire foot to avoid

contamination with blood or other body fluids or potential injury from sharps; and

• removed before leaving a care area where dedicated footwear is used e.g. theatre.

Further information can be found in the footwear literature review

Headwear must be:

• worn in theatre settings/clean rooms e.g. Central Decontamination Unit (CDU);

• well fitting and completely cover the hair; and

• changed/disposed of between clinical procedures/tasks or if contaminated with blood

and/or body fluids.

For the recommended method of putting on and removing PPE see Appendix 6 Further information can be found in the headwear literature review.

1.5. Safe Management of Care Equipment

Care equipment is easily contaminated with blood, other body fluids, secretions, excretions and

infectious agents. Consequently it is easy to transfer infectious agents from communal care

equipment during care delivery.

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-ppe-surgical-face-masks/

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-ppe-footwear/

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-ppe-headwear/



Care equipment is classified as either:

• Single-use – equipment which is used once on a single patient and then

discarded. Must never be reused even on the same patient. The

packaging carries this symbol.

• Needles and syringes are single use devices. They should never be used for more than

one patient or reused to draw up additional medication.

• Never administer medications from a single-dose vial or intravenous (IV) bag to multiple

patients.

• Single patient use – equipment which can be reused on the same patient.

• Reusable invasive equipment - used once then decontaminated e.g. surgical

instruments.

• Reusable non-invasive equipment (often referred to as communal equipment) - reused

on more than one patient following decontamination between each use e.g. commode,

patient transfer trolley.

Before using any sterile equipment check that:

• the packaging is intact;

• there are no obvious signs of packaging contamination; and

• the expiry date remains valid.

Decontamination of reusable non-invasive care equipment must be undertaken:

• between each use;

• after blood and/or body fluid contamination;

• at regular predefined intervals as part of an equipment cleaning protocol; and

• before inspection, servicing or repair.

Adhere to manufacturers’ guidance for use and decontamination of all care equipment.

All reusable non-invasive care equipment must be rinsed and dried following

decontamination then stored clean and dry.

Decontamination protocols should include responsibility for; frequency of; and method of

environmental decontamination.

An equipment decontamination status certificate will be required if any item of equipment is

being sent to a third party e.g for inspection, servicing or repair.



Guidance may be required prior to procuring, trialling or lending any reusable non-invasive

equipment.

For how to decontaminate reusable non-invasive care equipment see Appendix 7.

Further information can be found in the management of patient care equipment literature review.

1.6. Safe Management of the Care Environment It is the responsibility of the person in charge to ensure that the care environment is safe for

practice (this includes environmental cleanliness/maintenance). The person in charge must act if this is deficient.

The care environment must be:

• visibly clean, free from non-essential items and equipment to facilitate effective cleaning;

• well maintained and in a good state of repair; and

• routinely cleaned in accordance with the Health Facilities Scotland (HFS) National

Cleaning Specification:

• A fresh solution of general purpose neutral detergent in warm water is recommended

for routine cleaning. This should be changed when dirty or at 15 minutes intervals or

when changing tasks.

• Routine disinfection of the environment is not recommended. However, 1,000ppm

available chlorine should be used routinely on sanitary fittings.

Staff groups should be aware of their environmental cleaning schedules and clear on their

specific responsibilities. Cleaning protocols should include responsibility for; frequency of; and

method of environmental decontamination.

Further information can be found in the routine cleaning of the environment in hospital setting

literature review.

1.7. Safe Management of Linen Clean linen

• Should be stored in a clean, designated area, preferably an enclosed cupboard.

• If clean linen is not stored in a cupboard then the trolley used for storage must be

designated for this purpose and completely covered with an impervious covering that is

able to withstand decontamination.

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-management-of-patient-care-equipment-in-the-hospital-setting/

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-routine-cleaning-of-the-environment-in-the-hospital-setting/

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-routine-cleaning-of-the-environment-in-the-hospital-setting/



• Clean linen that is deemed unfit for re-use e.g. badly torn, should be returned to the

laundry for disposal.

Linen used during patient transfer

• Any linen used during patient transfer e.g. blankets, should be categorised at the point

of destination.

For all used linen (previously known as soiled linen):

• Ensure a laundry receptacle is available as close as possible to the point of use for

immediate linen deposit.

• Do not:

• rinse, shake or sort linen on removal from beds/trolleys;

• place used linen on the floor or any other surfaces e.g. a locker/table top;

• re-handle used linen once bagged;

• overfill laundry receptacles; or

• place inappropriate items in the laundry receptacle e.g. used equipment/needles.

For all infectious linen (this mainly applies to healthcare linen) i.e. linen that has been used

by a patient who is known or suspected to be infectious and/or linen that is contaminated with

blood and/or other body fluids e.g. faeces:

• Place directly into a water-soluble/alginate bag and secure; then place into a plastic

bag e.g. clear bag and secure before placing in a laundry receptacle. This applies

also to any item(s) heavily soiled and unlikely to be fit for reuse.

• Used and infectious linen bags/receptacles must be tagged (e.g. hospital ward/care

area) and dated.

• Store all used/infectious linen in a designated, safe, lockable area whilst awaiting

uplift. Uplift schedules must be acceptable to the care area and there should be no

build-up of linen receptacles.

Local guidance regarding management of linen may be available.

For how to manage linen at care area level see Appendix 8

Further information can be found in the safe management of linen literature review

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-safe-management-of-linen-in-the-hospital-setting/



1.8. Safe Management of Blood and Body Fluid Spillages Spillages of blood and other body fluids may transmit blood borne viruses. Spillages must be

decontaminated immediately by staff trained to undertake this safely. Responsibilities for the

decontamination of blood and body fluid spillages should be clear within each area/care setting.

For management of blood and body fluid spillages see Appendix 9

Further information can be found in the management of blood and body fluid literature review

1.9. Safe Disposal of Waste (including sharps) Scottish Health Technical Note (SHTN) 3: NHSScotland Waste Management Guidance contains

the regulatory waste management guidance for NHSScotland including waste classification,

segregation, storage, packaging, transport, treatment and disposal. The Health and Safety

(Sharp Instruments in Healthcare) Regulations 2013 outline the regulatory requirements for

employers and contractors in the healthcare sector in relation to the safe disposal of sharps.

Categories of waste:

• Healthcare (including clinical) waste – is produced as a direct result of healthcare

activities e.g. soiled dressings, sharps.

• Special (or hazardous) waste – arises from the delivery of healthcare in both clinical

and non-clinical settings. Special waste includes a range of controlled wastes, defined by

legislation, which contain dangerous or hazardous substances e.g. chemicals,

pharmaceuticals.

• Domestic waste – must be segregated at source into:

• Dry recyclates (glass, paper and plastics, metals, cardboard).

• Residual waste (any other domestic waste that cannot be recycled).

Waste Streams:

• Black – Trivial risk

o Domestic waste or yellow and black stripes (small quantities of hygiene waste).Final disposal to Landfill. Clear/opaque receptacles may also be used for

domestic waste at care area level.

• Orange, Light Blue(laboratory) – Low risk3

3 Not required for boards with an on-site incinerator facility. This applies only to NHS Borders.

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-management-of-blood-and-body-fluid-spillages-in-the-hospital-setting/



o Orange - consists of items which are contaminated or likely to be contaminated with

blood and/or body fluids. Final disposal following heat disinfection is to landfill.

o Light Blue – laboratory/microbiological waste that must be autoclaved before disposal

via the orange stream.

• Yellow– High risk o Waste which poses ethical, highly infectious or contamination risks. This includes

anatomical and human tissue which is recognisable as body parts, medical devices and

sharps waste boxes that have red, purple or blue lids. Disposal is by specialist

incineration.

• Red – Special waste

o Chemical waste.

For care/residential homes waste disposal may differ from the categories described above and

guidance from local contractors will apply. Refer to SEPA guidance

http://www.sepa.org.uk/waste.aspx.

Safe waste disposal at care area level:

Always dispose of waste:

• immediately and as close to the point of use as possible; and

• into the correct segregated colour coded UN 3291 approved waste bag (either

orange/yellow for healthcare waste or black/clear/opaque for domestic) or container

(sharps box).

Liquid waste e.g. blood must be rendered safe by adding a self-setting gel or compound

before placing in a healthcare waste bag.

Waste bags must be no more than 3/4 full or more than 4 kgs in weight; and use a ratchet

tag/or tape (for healthcare waste bags only) using a ‘swan neck’ to close with the point of

origin and date of closure clearly marked on the tape/tag.

Store all waste in a designated, safe, lockable area whilst awaiting uplift. Uplift schedules must

be acceptable to the care area and there should be no build-up of waste receptacles.

Sharps boxes must:

• have a dedicated handle;

• have a temporary closure mechanism, which must be employed when the box is not in use;

• be disposed of when the manufacturers’ fill line is reached; and

http://www.sepa.org.uk/waste.aspx



• be labelled with point of origin and date of closure.

Local guidance regarding management of waste at care level may be available.

Further information can be found in the safe management of waste in the hospital setting

literature review

1.10. Occupational Safety: Prevention and Exposure Management (including sharps) The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 outline the

regulatory requirements for employers and contractors in the healthcare sector in relation to:

arrangements for the safe use and disposal of sharps; provision of information and training to

employees; investigations and actions required in response to work related sharps injuries.

Sharps handling must be assessed, kept to a minimum and eliminated if possible with the use

of approved safety devices. Manufacturers’ instructions for safe use and disposal must be

followed.

Needles must not be re-sheathed. 4

Always dispose of needles and syringes as 1 unit.

A significant occupational exposure is:

• a percutaneous injury e.g. injuries from needles, instruments, bone fragments, or bites

which break the skin; and/or

• exposure of broken skin (abrasions, cuts, eczema, etc); and/or

• exposure of mucous membranes including the eye from splashing of blood or other high

risk body fluids.

There is a potential risk of transmission of a Blood Borne Virus (BBV) from a significant

occupational exposure and staff must understand the actions they should take when a

significant occupational exposure incident takes place.

For the management of an occupational exposure incident see Appendix 10

Further information can be found in the occupational exposure management (including sharps)

literature review

4 Only exception is local anaesthetic administration in dentistry.

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-safe-management-of-waste-in-the-hospital-setting/

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-safe-management-of-waste-in-the-hospital-setting/

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-occupational-exposure-management-including-sharps-1/

http://www.nipcm.hps.scot.nhs.uk/documents/sicp-occupational-exposure-management-including-sharps-1/



Chapter 2: Transmission Based Precautions (TBPs)

SICPs may be insufficient to prevent cross transmission of specific infectious agents. Therefore

additional precautions (TBPs) are required to be used by staff. SICPs must still be applied with

these additional considerations.

TBPs should be applied when caring for:

• patients with symptoms of infection;

• asymptomatic patients who are suspected or incubating an infection; or

• patients colonised with an infectious agent.

TBPs are categorised by the route of transmission of infectious agents (some infectious agents

can be transmitted by more than one route):

• Contact precautions: Used to prevent and control infections that spread via direct contact

with the patient or indirectly from the patient’s immediate care environment (including

care equipment). This is the most common route of cross-infection transmission.

• Droplet precautions: Used to prevent and control infections spread over short distances

(at least 3 feet (1 metre)) via droplets (>5μm) from the respiratory tract of one individual

directly onto a mucosal surface or conjunctivae of another individual. Droplets penetrate

the respiratory system to above the alveolar level.

• Airborne precautions: Used to prevent and control infections spread without necessarily

having close patient contact via aerosols (≤5μm) from the respiratory tract of one

individual directly onto a mucosal surface or conjunctivae of another individual. Aerosols

penetrate the respiratory system to the alveolar level.

Further information on Transmission Based Precautions can be found in the definitions of

Transmission Based Precautions literature reviews.

Posters to display on the doors of patients being cared for under contact, droplet or airborne

precautions are available at:

Contact: http://www.nipcm.hps.scot.nhs.uk/media/1185/contact-poster-2015-05.pdf

Droplet: http://www.nipcm.hps.scot.nhs.uk/media/1186/droplet-poster-2015-05.pdf

Airborne: http://www.nipcm.hps.scot.nhs.uk/media/1184/airborne-poster-2015-05.pdf

A TBP aide memoire can be found at:

http://www.nipcm.hps.scot.nhs.uk/media/1187/tbp-aide-memoire-2015-05.pdf

http://www.nipcm.hps.scot.nhs.uk/resources/literature-reviews/transmission-based-precautions-literature-reviews/

http://www.nipcm.hps.scot.nhs.uk/media/1185/contact-poster-2015-05.pdf

http://www.nipcm.hps.scot.nhs.uk/media/1186/droplet-poster-2015-05.pdf

http://www.nipcm.hps.scot.nhs.uk/media/1184/airborne-poster-2015-05.pdf

http://www.nipcm.hps.scot.nhs.uk/media/1187/tbp-aide-memoire-2015-05.pdf



2.1 Patient Placement/Assessment for Infection Risk The potential for transmission of infection or infectious agents must be assessed at the patient’s

entry to the care area and should be continuously reviewed throughout their stay. The

assessment should influence placement decisions in accordance with clinical /care need(s).

Patients who may present a cross-infection risk include those:

• With diarrhoea, vomiting, an unexplained rash, fever or respiratory symptoms.

• Known to have been previously positive with a Multi-drug Resistant Organism (MDRO)

e.g MRSA, CPE.

• Who have been hospitalised outside Scotland in the last 12 months.

These patients should be prioritised for placement in a suitable area to minimise cross

transmission pending investigation e.g.

• In a single room with a clinical wash hand basin; or

• Cohort area/room with a clinical wash hand basin.

Patients being transferred by ambulance should be transported in accordance with SAS local

guidance.

Isolation within a care home for a known/suspected infection may be necessary to prevent

spread. In most cases this can be achieved in the persons’ bedroom.

The clinical judgement and expertise of the staff involved in a patient’s management and the

Infection Prevention and Control Team (IPCT) or Health Protection Team (HPT) should be

sought particularly for patient placement decisions such as the application of TBPs e.g.

isolation prioritisation when single rooms are in short supply.

For patients with a suspected/known infectious agent Appendix 11 provides details of the

route of transmission, optimal patient placement, duration of isolation and type of precautions

required.

Patient/Staff cohorting If multiple patient cases of the same infection are confirmed or if single rooms are unavailable,

cohorting of patients may be appropriate. Patients should be separated by at least 3 feet (1m) if

cohorted.

Consider assigning a dedicated team of care staff to care for patients in isolation/cohort

rooms/areas as an additional infection control measure (staff cohorting). This can only be



implemented if there are sufficient levels of staff available (so as not to have a negative impact

on non-affected patients’ care).

Duration of isolation/cohort

Patient(s) should remain in isolation/cohort whilst they remain symptomatic and/or are

considered infectious and the door must remain closed.

Before discontinuing isolation; individual patient risk factors should be considered (e.g. there

may be prolonged shedding of certain microorganisms in immunocompromised patients); and

the clinical judgement of those involved in the patient’s management should be sought.

Avoid unnecessary transfer of patients within/between care areas.

All patient placement decisions and assessment of infection risk (including isolation

requirements) must be clearly documented in the patient notes.

2.2 Safe Management of Patient Care Equipment in an Isolation Room/Cohort Area 5 • Use single-use items if possible.

• Reusable non-invasive care equipment should be dedicated to the isolation room/cohort

area and decontaminated prior to use on another patient.

• An increased frequency of decontamination should be considered for reusable non-

invasive care equipment when used in isolation/cohort areas.

For how to decontaminate non-invasive reusable equipment see Appendix 7

2.3 Safe Management of the Care Environment 5 Routine environmental decontamination

Patient isolation/cohort rooms/area must be decontaminated at least daily using either:

• a combined detergent/disinfectant solution at a dilution of 1,000 parts per million available

chlorine (ppm available chlorine (av.cl.)); or

• a general purpose neutral detergent in a solution of warm water followed by disinfection

solution of 1,000ppm av.cl.

5 Scottish Ambulance Service (SAS) and Scottish National Blood Transfusion Service adopt practices that differ from those stated in the National Infection Prevention and Control Manual.



Increased frequency of decontamination should be incorporated into the environmental

decontamination schedules for areas where there may be higher environmental contamination

rates e.g.

• toilets/commodes particularly if patients have diarrhoea; and

• “frequently touched” surfaces such as door/toilet handles and locker tops, over bed tables

and bed rails.

Equipment used for environmental decontamination must be either single-use or dedicated to

the affected area then decontaminated following use e.g. mop and bucket.

Terminal decontamination Following patient transfer, discharge, or once the patient is no longer considered infectious:

Remove from the vacated isolation room/cohort area, all:

• healthcare waste and any other disposable items (bagged before removal from the

room);

• bedding/bed screens/curtains and manage as infectious linen (bagged before removal

from the room); and

• reusable non-invasive care equipment (decontaminated in the room prior to removal)

Appendix 7.

The room should be decontaminated using either:

• a combined detergent disinfectant solution at a dilution (1,000ppm av.cl.); or

• a general purpose neutral detergent clean in a solution of warm water followed by

disinfection solution of 1,000ppm av.cl.

The room must be cleaned from the highest to lowest point and from the least to most

contaminated point.

Manufacturers’ guidance and recommended product “contact time” must be followed for all

cleaning/disinfection solutions6.

2.4 Personal Protective Equipment (PPE): Respiratory Protective Equipment (RPE)

PPE must still be used in accordance with SICPs when using Respiratory Protective Equipment.

See Chapter 1.4 for PPE use for SICPs. 6 Scottish Ambulance Service (SAS) and Scottish National Blood Transfusion Service adopt practices that differ from those stated in the National Infection Prevention and Control Manual.

http://www.nipcm.hps.scot.nhs.uk/chapter-1-standard-infection-control-precautions-sicps/#a1080



Where it is not reasonably practicable to prevent exposure to a substance hazardous to health

(as may be the case where healthcare workers are caring for patients with suspected or known

airborne micro-organisms) the hazard must be adequately controlled by applying protection

measures appropriate to the activity and consistent with the assessment of risk.

Respiratory Protective Equipment (RPE) i.e. FFP3 and facial protection, must be considered

when a patient is admitted with a known/suspected infectious agent/disease spread wholly or

partly by the airborne or droplet route and when carrying out aerosol generating procedures

(AGPs) on patients with a known/suspected infectious agent spread wholly or partly by the

airborne or droplet route.

For a list of organisms spread wholly or partly by the airborne (aerosol) or droplet routes see

Appendix 11.

The following risk categorisation is the minimum requirement for staff groups that require FFP3

fit testing. NHS Boards can add to this for example where high risk units are present. This

categorisation is inclusive of out of hours services.

National Minimum Risk Categorisation for fit testing with FFP3

• Level 1 – Preparedness for business as usual Staff in clinical areas most likely to provide care to patients who present at healthcare

facilities with an infectious pathogen spread by the airborne route; and/or undertake

aerosol generating procedures i.e. A&E, ICU, paediatrics, respiratory, infectious diseases,

anaesthesia, theatres, Chest physiotherapists, Special Operations Response Team

(Ambulance), A&E Ambulance Staff, Bronchoscopy Staff, Resuscitation teams.

• Level 2 – Preparedness in the event of emerging threat Staff in clinical setting likely to provide care to patients admitted to hospital in the event of

an emerging threat e.g. Medical receiving, Surgical, Midwifery and Speciality wards, all

other ambulance transport staff.

In the event of an ‘Epidemic/Pandemic’ Local Board Assessment as per their

preparedness plans will apply.

All tight fitting RPE i.e FFP3 respirators must be: • Fit tested on all healthcare staff who may be required to wear a respirator to ensure an

adequate seal/fit according to the manufacturers’ guidance.



• Fit checked (according to the manufacturers’ guidance) every time a respirator is donned

to ensure an adequate seal has been achieved.

• Compatible with other facial protection used i.e. protective eyewear so that this does not

interfere with the seal of the respiratory protection. Regular corrective spectacles are not

considered adequate eye protection.

• Donned and removed in a safe area (e.g. outside the isolation/cohort room/area).

Further information regarding fitting and fit checking of respirators can be found on the Health

and Safety Executive website at: http://www.hse.gov.uk/respiratory-protective-

equipment/basics.htm

Powered respirator hoods are an alternative to tight-fitting FFP3 respirators for example when fit

testing cannot be achieved.

FFP3 respirator or powered respirator hood:

• may be considered for use by visitors if there has been no previous exposure to the

infected person or infectious agent; but

• must never be worn by an infectious patient(s) due to the nature of the respirator filtration

of incoming air not expelled air.

Further information can be found in the Respiratory Protective Equipment (RPE) literature

review and the Personal Protective Equipment (PPE) for Infectious Diseases of High

Consequence (IDHC) literature review.

Frameworks to support the assessing and recording of staff competency in PPE for IDHC are

available in the resources section of the NIPCM.

2.5 Infection Prevention and Control during care of the deceased

The principles of SICPs and TBPs continue to apply whilst deceased individuals remain in

the care environment. This is due to the ongoing risk of infectious transmission via contact

although the risk is usually lower than for living patients.

Washing and/or dressing of the deceased should be avoided if the deceased is known or

suspected to be harbouring invasive streptococcal infection, viral haemorrhagic fevers or

other Group 4 infectious agents, see Appendix 12. Staff should advise relatives of the

precautions following viewing and/or physical contact with the deceased and also when this

should be avoided.

http://www.hse.gov.uk/respiratory-protective-equipment/basics.htm

http://www.hse.gov.uk/respiratory-protective-equipment/basics.htm

http://www.nipcm.hps.scot.nhs.uk/documents/tbp-respiratory-protective-equipment-rpe/

http://www.nipcm.hps.scot.nhs.uk/documents/tbp-respiratory-protective-equipment-rpe/

http://www.nipcm.hps.scot.nhs.uk/documents/literature-review-personal-protective-equipment-ppe-for-infectious-diseases-of-high-consequence-idhc/

http://www.nipcm.hps.scot.nhs.uk/documents/literature-review-personal-protective-equipment-ppe-for-infectious-diseases-of-high-consequence-idhc/

http://www.nipcm.hps.scot.nhs.uk/resources/



Deceased individuals known or suspected to be harbouring a Group 4 infectious agent

should be placed in a sealed double plastic body bag with absorbent material placed

between each bag. The surface of the outer bag should then be disinfected with 1000ppm

av.cl before being placed in a robust sealed coffin.

Post mortem examination should not be performed on a deceased individual known or

suspected to have Group 4 infectious agents, see Appendix 12. Blood sampling can be

undertaken in the mortuary by a competent person to confirm or exclude this diagnosis.

Refer to Section 2.4 for suitable PPE.

http://www.nipcm.hps.scot.nhs.uk/chapter-2-transmission-based-precautions-tbps/#a1091



Chapter 3: Healthcare Infection, Incidents, Outbreaks and Data Exceedance

The purpose of this chapter is to support the early recognition of potential infection incidents

and to guide IPCT/HPTs in the incident management process within healthcare settings; (that

is, the NHS, independent contractors providing NHS services and private providers of

healthcare). This guidance is aligned to the Management of Public Health Incidents: Guidance

on the Roles and Responsibilities of NHS led Incident Management Teams.

3.1 Definitions of Healthcare Infection Incident, Outbreak and Data Exceedance

The terms ‘incident’ and ‘Incident Management Team’ (IMT) are used as generic terms to cover

both incidents and outbreaks.

A healthcare infection incident may be:

An exceptional infection episode

• A single case of any serious illness which has major implications for others (patients,

staff and/or visitors), the organisation or wider public health e.g. infectious diseases of

high consequence such as VHF or XDR-TB. See literature review for Infectious

Diseases of High Consequence (IDHC)

A healthcare associated infection outbreak

• Two or more linked cases with the same infectious agent associated with the same

healthcare setting over a specified time period; or

• A higher than expected number of cases of HAI in a given healthcare area over a

specified time period.

A healthcare infection exposure incident

• Exposure of patients, staff, public to a possible infectious agent as a result of a

healthcare system failure or a near miss e.g. ventilation, water or decontamination

incidents.

A healthcare infection data exceedance

• A greater than expected rate of infection compared with the usual background rate for

that healthcare location

Further information can be found in the literature review Healthcare infection incidents and

outbreaks in Scotland.

http://www.gov.scot/Publications/2013/08/6455




http://www.nipcm.hps.scot.nhs.uk/resources/literature-reviews/healthcare-incidents-and-outbreaks/

http://www.nipcm.hps.scot.nhs.uk/resources/literature-reviews/healthcare-incidents-and-outbreaks/



3.2 Detection and recognition of a Healthcare Infection incident/outbreak or data exceedance

An early and effective response to an actual or potential healthcare incident, outbreak or data

exceedance is crucial. The local Board IPCT and HPT should be aware of and refer to the

national minimum list of alert organisms/conditions. See Appendix 13.

3.2.1 Assessment

Following detection/recognition of an incident a member of IPCT or HPT will:

• Undertake an initial assessment, utilising the Healthcare Infection Incident Assessment Tool

(HIIAT) - Appendix 14, gather epidemiological data and clinical assessment information on the

patients condition as per section 1.1 http://www.nipcm.hps.scot.nhs.uk/chapter-1-standard-

infection-control-precautions-sicps/#a1068 and 2.1 http://www.nipcm.hps.scot.nhs.uk/chapter-

2-transmission-based-precautions-tbps/#a1088

• Based on this initial assessment the IPCT/HPT may choose to convene a Problem

Assessment Group (PAG) to further assess and determine if an IMT is required.

o If the HIIAT is assessed as Green and there is no HPS support required then this

should be reported as per DL(2015)19 http://www.sehd.scot.nhs.uk/dl/DL(2015)19.pdf

If support is required this should be communicated to HPS.

o If the HIIAT is assessed Amber or Red report to HPS. Healthcare Incident Infection

and Outbreak Reporting Template (HIIORT) - Appendix 15 should be completed.

3.2.2 Investigation

The IPCT/HPT will establish an IMT if required.

• In the NHS hospital setting the ICD or Head of Infection Prevention and Control will usually

chair the IMT and lead the investigation of healthcare incidents. Where there are

implications for the wider community e.g. TB or measles, or rare events such as CJD or a

Hepatitis B/HIV look back, or where there is an actual or potential conflict of interest with the

hospital service, the CPHM may chair the IMT.

• The membership of the IMT will vary depending on the nature of the incident. A draft IMT

agenda is available in the resources section of the NIPCM website.

• A case definition for the purpose of the incident will be agreed. A case definition should

include the following: the people involved (e.g. patients, staff); the

symptoms/pathogen/infection (e.g. with Group A Streptococci); the place (e.g. care area(s)

involved); and a limit of time (e.g. between January and March year/date). The case





http://www.hps.scot.nhs.uk/haiic/haicompendium.aspx

http://www.sehd.scot.nhs.uk/dl/DL%282015%2919.pdf

http://www.nipcm.scot.nhs.uk/resources/



definition(s) should be regularly reviewed and refined (if required) throughout the incident

investigation as more information becomes available.

• The investigation of the incident should include: an ongoing epidemiological investigation;

the nature and characteristics of the incident e.g. a microbiological investigation; and how

cases were exposed to the infective agent or other hazard to inform control measures.

• Identify any change(s) in the system: staffing, procedures/processing, equipment, suppliers.

A step-by-step review of procedure(s). A generic outbreak checklist is available in the

resources section of the NIPCM website.

• Identify and count all cases and/or persons exposed: This includes the total number of

confirmed/probable/possible exposed cases. A data collection tool is available in the

resources section of the NIPCM website.

• The IMT should receive and discuss all information gathered and epidemiological outputs

e.g. an epidemiological (epi) curve, a timeline and a ward map to:

o generate hypotheses as to which cross-transmission pathways and clinical

procedures may be involved.

o Determine whether additional case finding and control measures may be necessary.

o Confirm that all incident control measures are being applied effectively and are

sufficient.

• If staff screening is being considered as part of the investigation HDL (2006) 31

www.show.scot.nhs.uk/sehd/mels/HDL2006_31.pdf must be followed.

• HAI deaths, which pose an acute and serious public health risk, must be reported to the

Procurator Fiscal, refer to (SGHD/CMO(2014)27)

http://www.sehd.scot.nhs.uk/CMO/CMO(2014)27.pdf

• If no new cases arise and any remaining cases are considered to no longer pose a risk,

the IMT should agree on actions prior to resumption of normal service.

Once the incident is over the IMT/NHS Board should evaluate and report on the

effectiveness and efficiency of incident management using the Hot Debrief Tool which is

available in the resources section of the NIPCM website. This is not a mandatory

requirement but for the purpose of sharing lessons learned across Scotland.

The IMT Chair, in discussion with the IMT, should determine whether further reporting on

the incident and the incident management is required i.e. SBAR Report and full IMT report

template are available in the resources section of the NIPCM website.



http://www.sehd.scot.nhs.uk/mels/HDL2006_31.pdf

http://www.show.scot.nhs.uk/sehd/mels/HDL2006_31.pdf

http://www.sehd.scot.nhs.uk/CMO/CMO(2014)27.pdf





Glossary

Abrasion – A graze. A minor wound in which the surface of the skin or a mucous membrane

has been worn away by rubbing or scraping.

Aerosols – See Airborne Particles.

Aerosol Generating Procedures (AGPs) – Certain medical and patient care activities that can

result in the release of airborne particles (aerosols). AGPs can create a risk of airborne

transmission of infections that are usually only spread by droplet transmission. See Appendix

11, footnote 3 for further information.

Airborne particles (aerosols) – Very small particles that may contain infectious agents. They

can remain in the air for long periods of time and can be carried over long distances by air

currents. Airborne particles can be released when a person coughs or sneezes, and during

aerosol generating procedures (AGPs).

Airborne (aerosol) transmission – The spread of infection from one person to another by

airborne particles (aerosols) containing infectious agents.

Alcohol based hand rub (ABHR) – A gel, foam or liquid containing alcohol that is rubbed into

the hands as an alternative to washing hands with soap and water.

Alert organism – An organism that is identified as being potentially significant for infection

prevention and control practices. Examples of alert organisms include Meticillin Resistant

Staphylococcus aureus (MRSA), Clostridium difficile (C.diff) and Group A Streptococcus. See

Appendix 11 – List of infectious agents and/or diseases that require Transmission Based

Precautions (TBPs) in addition to SICPs.

Alveolar – Refers to the alveoli which are the small air sacs in the lungs. Alveoli are located at

the ends of the air passageways in the lungs, and are the site at which gas exchange takes

place. Antimicrobial – An agent that kills microorganisms, or prevents them from growing. Antibiotics

and disinfectants are antimicrobial agents.



Antimicrobial hand wipes – Hand wipes that are moistened with an antimicrobial

solution/agent at a concentration sufficient to inactivate microorganisms and/or temporarily

suppress their growth.

Aseptic technique – A healthcare procedure designed to minimise the risks of exposing the

person being cared for to pathogenic micro-organisms during simple (e.g dressing wounds) and

complex care procedures (e.g. surgical procedures). Asymptomatic – Not showing any symptoms of disease but where an infection may be

present.

Autoclave – Machine used for sterilising re-usable equipment using superheated steam under

pressure.

Body fluids – Fluid produced by the body such as urine, faeces, vomit or diarrhoea.

Blood Borne Viruses (BBV) – Viruses carried or transmitted by blood, for example Hepatitis B,

Hepatitis C and HIV.

Carbapenemase Producing Enterobacteriaceae (CPE) - A group of bacteria that have

become extremely resistant to antibiotics including those called carbapenems.

Care areas/environment – Any place where care is carried out. This includes hospital wards,

treatment rooms, care homes and care at home.

Care staff – Any person who cares for patients, including healthcare support workers and

nurses.

Central Decontamination Unit (CDU) – A large, centralised facility for the decontamination

and re-processing of re-usable medical equipment e.g. surgical instruments.

Central Vascular Catheter (CVC) – An intravenous catheter that is inserted directly into a large

vein in the neck, chest or groin to allow intravenous drugs and fluids to be given and to allow

blood monitoring.



Chlorine – A chemical that is used for disinfecting, fumigating and bleaching.

Cleaning – The removal of any dirt, blood, sickness, etc by use of an appropriate cleaning

agent such as detergent.

Clinical setting – Any area where a patient is observed or treatment is carried out such as a

treatment room or hospital ward.

Clinical wash hand basin – A sink designated for hand washing in clinical areas. Clostridium difficile (C.diff) – An infectious agent (bacterium) that can cause mild to severe

diarrhoea which in some cases can lead to gastro-intestinal complications and death.

Cohorting – Placing a group of two or more patients (a cohort) with the same confirmed

infection in the same room or area.

Cohort area – A bay or ward in which two or more patients (cohort) with the same confirmed

infection are placed. A cohort area should be physically separate from other patients. Cohort nursing – A dedicated team of healthcare staff who care for a cohort of patients, and do

not care for any other patients.

Colonisation – The presence of bacteria on a body surface (such as the skin, mouth, intestines

or airway) that does not cause disease in the person or signs of infection.

Conjunctivae – Mucous membranes that cover the front of the eyes and the inside of the

eyelids.

Contact transmission – The spread of infectious agents from one person to another by

contact. When spread occurs through skin-to-skin contact, this is called direct contact

transmission. When spread occurs via a contaminated object, this is called indirect contact

transmission.

Contaminated – Dirty, soiled or stained.



Cross-infection/Cross-transmission – Spread of infection from one person to another.

Decontamination – Removing, or killing pathogens on an item or surface to make it safe for

handling, re-use or disposal by cleaning, disinfection and/or sterilisation.

Detergent – A chemical cleansing agent that can dissolve oils and remove dirt.

Diarrhoea – 3 or more loose or liquid bowel movements in 24 hours or more often than is

normal for the individual.

Direct contact transmission – Spread of infectious agents from one person to another by

direct skin-to-skin contact.

Disinfectant – A chemical used to remove infectious agents from objects and surfaces.

Disinfection – A process, for example using a chemical disinfectant, to reduce the number of

infectious agents from an object or surface to a level that means they are not harmful to your

health.

Domestic waste – Waste produced in the care setting that is similar to waste produced in the

home.

Droplet – A small drop of moisture, larger than airborne particle, that may contain infectious

agents. Droplets can be released when a person talks, coughs or sneezes, and during some

medical or patient care procedures such as open suctioning and cough induction by chest

physiotherapy. It is thought that droplets can travel around 1 metre (3 feet). Droplet transmission – The spread of infection from one person to another by droplets

containing infectious agents. Emollient – An agent used to soothe the skin and make it soft and supple.

En-suite – A room containing a sink and toilet and sometimes a shower/wetroom or bath.



Excretions – Waste products produced by the body such as urine and faeces (bowel

movements).

Exposure – The condition of being exposed to something that may have a harmful effect such

as an infectious agent.

Exposure Prone Procedures (EPPs) – Certain medical and patient care procedures where

there is a risk that injury to the healthcare worker may result in exposure of the patient’s open

tissues to the healthcare worker’s blood e.g the healthcare worker’s gloved hands are in

contact with sharp instruments, needle tips or sharp tissues inside a patient’s body.

Fit testing – a method of checking that a tight-fitting facepiece respirator fits the wearer and

seals adequately to their face. This process helps identify unsuitable facepieces that should not

be used

FFP3 – Respiratory protection that is worn over the nose and mouth designed to protect the

wearer from inhaling hazardous substances, including airborne particles (aerosols). FFP stands

for filtering facepiece. There are three categories of FFP respirator: FFP1, FFP2 and FFP3. An

FFP3 respirator or hood provides the highest level of protection, and is the only category of

respirator legislated for use in UK healthcare settings.

Fluid resistant – A term applied to fabrics that resist liquid penetration, often used

interchangeably with ‘fluid-repellent’ when describing the properties of protective clothing or

equipment.

GP – General practitioner (your family doctor).

Group 4 Infections - Definition taken from the HSE Approved list of biological agents

www.hse.gov.uk/pubns/misc208.pdf

Group 4 infections cause severe human disease and is a serious hazard to employees; it is

likely to spread to the community and there is usually no effective prophylaxis or treatment

available.

http://www.hse.gov.uk/pubns/misc208.pdf



Hand Hygiene – The process of cleaning your hands by using either alcohol based hand rub or

liquid soap and water.

Health Protection Team (HPT) – A team of healthcare professionals whose role it is to protect

the health of the local population and limit the risk of them becoming exposed to infection and

environmental dangers. Every NHS board has a HPT.

Healthcare Associated Infection (HAI) – Infections that occur as a result of medical care, or

treatment, in any healthcare setting.

Healthcare Waste – Waste produced as a result of healthcare activities for example soiled

dressings, sharps.

Hygiene Waste – Waste that is produced from personal care. In care settings this includes

feminine hygiene products, incontinence products and nappies, catheter and stoma bags.

Hygiene waste may cause offence due to the presence of recognisable healthcare waste items

or body fluids. It is usually assumed that hygiene waste is not hazardous or infectious.

Hypochlorite – A chlorine-based disinfectant such as bleach.

Immunisation – To provide immunity to a disease by giving a vaccination.

Immunocompromised patient/individual – Any person whose immune response is reduced

or deficient, usually because they have a disease or are undergoing treatment. People who are

immunocompromised are more vulnerable to infection.

Impervious – Cannot be penetrated by liquid.

Indirect contact transmission – The spread of infectious agents from one person to another

via a contaminated object. Infection – Invasion of the body by a harmful organism or infectious agent such as a virus,

parasite or bacterium.



Infectious agent – Any organism, such as a virus, parasite, or bacterium, that is capable of

invading body tissues, multiplying, and causing disease.

Invasive device – A device which penetrates the body, either through a body cavity or through

the surface of the body. Central Venous Catheters (central line), Peripheral Arterial Lines and

Urinary Catheters are examples of invasive devices.

Infectious Diseases of High Consequence (IDHC) – An infectious disease of high

consequence (IDHC) typically causes severe symptoms requiring a high level of care and a

high case-fatality rate, there may not be effective prophylaxis or treatment. IDHC are

transmissible from human to human (contagious) and capable of causing large-scale epidemics

or pandemics.

Incident Management Team (IMT): A multidisciplinary group with responsibility for

investigating and managing the incident.

Invasive procedure – A medical/healthcare procedure that penetrates or breaks the skin or

enters a body cavity.

Isolation – Physically separating patients to prevent the spread of infection.

Isolation suite/room – An isolation suite comprises a single-bed room, en-suite facilities and a

ventilated entry lobby.

Microorganism (microbe) – Any living thing (organism) that is too small to be seen by the

naked eye. Bacteria, viruses and some parasites are microorganisms.

Mode of transmission – The way that microorganisms spread from one person to another. The

main modes or routes of transmission are airborne (aerosol) transmission, droplet transmission

and contact transmission.

MRSA – Strains of the infectious agent (bacterium) Staphylococcus aureus that are resistant to

many of the antibiotics commonly used to treat infections.

http://en.wikipedia.org/wiki/Microorganism



Mucous membranes/mucosa – The surfaces lining the cavities of the body that are exposed

to the environment such as the lining of the mouth and nose.

Needle safety device – Any device designed to reduce the risk of injury from needles. This

may include needle-free devices or mechanisms on a needle, such as an automated

resheathing device, that cover the needle immediately after use.

Nitrile – A synthetic rubber material used to make non-latex gloves.

Non-sterile procedure – Care procedure that does not need to be undertaken in conditions

that are free from bacteria or other microorganisms.

Occupational exposure – Exposure of healthcare workers or care staff to blood or body fluids

in the course of their work.

Organism – Any living thing that can grow and reproduce, such as a plant, animal, fungus or

bacterium.

Outbreak – When two or more people have the same infection, or more people than expected

have the same infection. The cases will be linked by a place and time period.

Pathogen – Any disease-producing infectious agent.

Percutaneous injury – An injury caused by a sharp instrument or object such as a needle or

scalpel, cutting or puncturing the skin.

Personal Protective Equipment (PPE) – Equipment a person wears to protect themselves

from risks to their health or safety, including exposure to infections e.g. disposable gloves and

disposable aprons.

Problem Assessment Group (PAG) - A group that is convened by IPCT/HPT to determine and

assess if further action relating to a Healthcare Incident/Outbreak/Data Exceedance is required

i.e IMT. The outcome may be:

• HIIAT Green – continue to monitor

• HIIAT Amber/Red – IMT required.



Pyrexia – Fever. Rise in body temperature above the normal level >37.2°.

Respiratory droplets – A small droplet, such as a particle of moisture released from the mouth

during coughing, sneezing, or speaking.

Respiratory Protective Equipment (RPE) – There are two main types of RPE: respirators and

breathing apparatus.

• Respirators are devices worn over the nose and mouth or head and are designed to

filter the air breathed in to protect the wearer from inhaling hazardous substances,

including airborne particles (aerosols).

• Breathing apparatus provides a supply of breathing quality air from an external source

such as a cylinder or an air compressor. The most commonly used item of RPE in

healthcare settings is an FFP3 respirator.

Re-sheath – To put a needle or other sharp object back into its plastic sheath.

Sanitary fittings – Pieces of furniture that are in a bathroom, such as a toilet, bath etc.

Secretions – Any body fluid that is produced by a cell or gland such as saliva or mucous.

Segregated – Physically separating or isolating from other people.

Sharps – Sharp instruments used in healthcare settings such as needles, lancets and scalpels.

Sharps injury – See percutaneous injury.

Spore – A form that some types of bacteria take under certain environmental conditions.

Spores can survive for long periods of time and are very resistant to heat, drying and chemicals.

Sterile – Free from live bacteria or other microorganisms.

Sterile procedure – Care procedure that is undertaken in conditions that are free from bacteria

or other microorganisms.

http://dictionary.cambridge.org/search/british/direct/?q=furniture

http://dictionary.cambridge.org/search/british/direct/?q=bathroom

http://dictionary.cambridge.org/search/british/direct/?q=toilet

http://dictionary.cambridge.org/search/british/direct/?q=bath

http://dictionary.cambridge.org/search/british/direct/?q=etc



Sterilisation – The procedure of making some object free of all germs, live bacteria or other

microorganisms (usually by heat or chemical means).

Surgical face mask – A disposable fluid repellent mask worn over the nose and mouth to

protect the mucous membranes of the wearer’s nose and mouth from splashes and infectious

droplets and also to protect patients. When recommended for infection control purposes a

‘surgical face mask’ typically denotes a fluid-resistant (Type IIR) surgical mask.

Swan-neck – Way of closing bag by tying in a loop and securing with a zip tie to make a

handle.

Terminal decontamination – Cleaning/decontamination of an area or room following

transfer/discharge of patient or when they are no longer considered infectious to ensure the

area safe for the next patient or for the person to go back into their room in a care home setting.

Vascular access devices – Any medical instrument used to access a patient’s veins or arteries

such as a Central Venous Catheter or peripheral vascular catheter.



Appendices

Appendix 1 – How to hand wash step by step images

Appendix 2 – How to hand rub step by step images

Appendix 3 – Surgical Scrubbing: surgical hand preparation technique using antimicrobial soap – step by step images

Appendix 4 – Surgical rubbing: surgical hand preparation technique using alcohol based hand rub (ABHR) – step by step images

Appendix 5 – Glove use and selection

Appendix 6 – Putting on and removing PPE

Appendix 7 – Decontamination of reusable non-invasive patient care equipment

Appendix 8 – Management of linen at care level

Appendix 9 – Management of blood and body fluid spillages

Appendix 10 – Management of occupational exposure incidents

Appendix 11 – List of infectious agents and/or diseases that require Transmission Based Precautions in addition to SICPs.

Appendix 12 – Key Infections from HSE Guidance “Controlling the risks of infection at work from Human Remains.

Appendix 13 – NHS Scotland Alert Organism/Condition list

Appendix 14 – NIPCM Healthcare Infection Incident Assessment Tool (HIIAT)

Appendix 15 – Healthcare Infection Incident and Outbreak Reporting Template (HIIORT) Appendix 16- Healthcare Associated Infection definitions Appendix 17- Membership and Terms of reference for IMT Appendix 18- Roles and Responsibilities



Appendix 1 – How to hand wash step by step images



Appendix 2 – How to handrub step by step images



Appendix 3 – Surgical scrubbing: surgical hand preparation technique using antimicrobial soap – step by step images



Appendix 4 - Surgical rubbing: surgical hand preparation technique using alcohol based hand rub (ABHR) - step by step images



Appendix 5 – Glove use and selection

*sterile gloves are not required e.g for insertion of a PVC or obtaining blood cultures or when a safety device/technique is used

No gloves required

Is this a non-sterile procedure with a

risk of blood or body fluid contamination?

Yes

Is this a sterile or invasive *procedure

e.g insertion of CVC?

No

Sterile latex/nitrile or neoprene gloves

Non sterile gloves latex/nitrile or neoprene or vinyl gloves

Patient contact or procedure/task

Is this a surgical procedure? Sterile latex/nitrile or

neoprene surgical gloves

Yes

Yes

Non sterile latex/nitrile or neoprene gloves

Yes

No

No

Is the procedure equipment or environmental

cleaning?

No

No



Appendix 6 – Putting on and removing PPE



Appendix 7 – Decontamination of reusable non-invasive care equipment

An example A-Z template to promote consistency of practice for decontamination of re-usable communal equipment in NHSScotland can be found at http://www.hps.scot.nhs.uk/haiic/decontamination/publicationsdetail.aspx?id=57669

http://www.hps.scot.nhs.uk/haiic/decontamination/publicationsdetail.aspx?id=57669



Appendix 8 – Management of linen at care area level



Appendix 9 – Management of blood and body fluid spillages



Appendix 10 – Management of occupational exposure incidents

Occupational exposure incident

Is skin/tissue affected?

• Encourage the area to bleed • Do not suck the damaged skin

or tissue • Wash/irrigate with warm running

water and non-antimicrobial soap

• If running water is unavailable use pre-packed solutions e.g. sterile water/saline for irrigation

Are eyes/mouth affected?

• Rinse/irrigate copiously with water • Use eye/mouth washout kits if available • If contact lenses are worn, remove then irrigate

Perform first aid to the exposed area immediately

Yes

No

Yes

• Report/document the incident as per local procedures and ensure that any corrective actions or interventions are undertaken

• Ensure that the item that caused the injury is disposed of safely

Infection prevention and control/Occupational Health or Health Protection Teams Name: ……………………………………….. Designation: ………………………………… Contact Number…………………………….. Exposure incident reporting Name: ……………………………………….. Designation: …………………………………


Health Protection Scotland (HPS) Version 3.6. April 2017 Page 55 of 80

Appendix 11 – List of infectious agents and/or diseases that require Transmission Based Precautions (TBPs) in addition to SICPs.

The following table outlines:

1. Main route of transmission for a number of infectious agents/diseases; 2. Optimal patient placement whilst the patient is considered infectious; and 3. The appropriate RPE to minimise risk of infection to staff, patients and visitors. Clinical decisions made by staff regarding use/non-use of

RPE will depend on a risk assessment which should include e.g. the risk of infection acquisition and the severity of the illness caused. The clinical judgement and expertise of the Infection Prevention and Control Team or the Health Protection Team should be sought for novel, unusual or an increase in cases of known or suspected infectious agents in any care setting.

Pathogen Disease

Main route of transmission

Notifiable4

Optimal placement whilst patient is considered

infectious and until resolution of symptoms

Respiratory and facial protection (RPE) for healthcare workers

whilst patient is considered infectious

Single en-suite room

Isolation room

Surgical Facemask (If there is a risk of

splashing or spraying of blood/body fluids e.g

respiratory secretions, from patient contact or

procedure)

FFP3 respirator or Hood for AGPs

Adenovirus1

Upper +/- lower respiratory tract

infection

Droplet No

Conjunctivitis Contact No

Aspergillus spp.6 Invasive Pulmonary Aspergillosis Contact/Airborne No

Bacillus spp.

Gastroenteritis, sepsis, pneumonia,

endocarditis, central nervous system (CNS) and ocular infections

Contact/Airborne

Yes. Bacillus anthracis and

Bacillus cereus only



Pathogen Disease


Notifiable4






Isolation room




procedure)


Bordetella pertussis Pertussis/Whooping Cough Droplet

Chlamydia pneumoniae Pneumonia Droplet

Clostridium difficile Clostridium difficile infection (CDI) Contact

Coronavirus 1, 5

Acute respiratory syndrome (Non-

SARSCoV) Droplet

Corynebacterium

diphtheriae

Diphtheria – Cutaneous Contact

Corynebacterium ulcerans

Diphtheria – Pharyngeal toxigenic strains Droplet

Gastrointestinal infections e.g salmonella Contact

(some GI



Pathogen Disease


Notifiable4






Isolation room




procedure)


Infections are notifiable. Refer to

guidance)

Haemophilus influenzae type b

Epiglottitis Droplet

and until patient has received 24 hours of

appropriate antibiotics

Meningitis Droplet

Herpes zoster (varicella-zoster) 2

Shingles (vesicle fluid) Contact

If lesions cannot be covered

Shingles (lesions in the

respiratory tract) Droplet/airborne

Influenza virus (Endemic strains)5

Influenza Droplet



Pathogen Disease


Notifiable4






Isolation room




procedure)


Measles virus2

Measles (rubeola) Droplet/airborne

Mumps virus2

Mumps

(infectious parotitis) Droplet

Mycobacterium tuberculosis

Extrapulmonary Tuberculosis Contact

Pulmonary or laryngeal disease Tuberculosis

Airborne

• Until patient has received 14 days of appropriate antibiotics

• If the patient has MDR or XDR TB

and always if the patient

has MDR or XDR TB

Mycoplasma pneumoniae Pneumonia Droplet



Pathogen Disease


Notifiable4






Isolation room




procedure)


Neisseria meningitides

Meningitis – meningococcal (Or

presentation of clinical meningitis of unknown

origin)

Droplet

and until patient has received 24 hours of

appropriate antibiotics

Norovirus Contact/Droplet

Parainfluenza virus1

) Upper +/- lower respiratory tract

infection Droplet

Parvovirus B19 – (Erythema infectiosum – Erythrovirus

B19)

Slapped cheek syndrome Droplet

Not required if the rash+/- arthralgia has

developed

Not required if the rash+/- arthralgia has developed

Pneumocystis jirovecii6 Pneumonia Contact/Airborne



Pathogen Disease


Notifiable4






Isolation room




procedure)


Respiratory syncytial virus (RSV)1

Upper +/- lower respiratory tract

infection Droplet

Rhinovirus1 Upper +/- lower respiratory tract

infection Droplet

Rotavirus Gastroenteritis Droplet / contact

Rubella virus2

German Measles Droplet

Staphylococcus aureus (Enterotoxigenic) Scalded skin syndrome Contact

If lesions cannot be covered

Methicillin resistant Staphylococcus aureus

(MRSA) Infection Contact



Pathogen Disease


Notifiable4






Isolation room




procedure)


Colonisation (either swab positive or positive

as per clinical risk assessment criteria)

Streptococcus pyogenes (Group A Strep)

Respiratory Droplet

Bacteraemia, meningitis, wound i.e. blood, cerebrospinal

fluid or other normally sterile site

Contact

Streptococcus pneumoniae

Pneumonia Meningitis Droplet

Bacteraemia, meningitis, wound i.e. blood, cerebrospinal

fluid or other normally sterile site

Contact

(presence in the wound is not notifiable)

Varicella virus2 Chickenpox Droplet/airborne

http://www.hps.scot.nhs.uk/haiic/sshaip/mrsascreeningpathfinderprofessionals.aspx

http://www.hps.scot.nhs.uk/haiic/sshaip/mrsascreeningpathfinderprofessionals.aspx



Pathogen Disease


Notifiable4






Isolation room




procedure)


Viral Haemorrhagic Fever (VHF) See http://www.hps.scot.nhs.uk/travel/viralhaemorrhagicfever.aspx?subjectid=00C

Footnote 1 In routine clinical practice healthcare workers do not commonly wear masks when dealing with patients presenting with the “common cold” or “influenza – like illness”. However, in a patient with undiagnosed respiratory illness where coughing and sneezing are significant features, or in the context of known widespread respiratory virus activity in the community or a suspected or confirmed outbreak of a respiratory illness in a closed or semi-closed setting, the need for appropriate respiratory and facial protection to be worn should be considered. Footnote 2 In relation to childhood illnesses and use of masks, no vaccine offers 100% protection and a small proportion of individuals acquire/become infected despite vaccination. PPE i.e. facial/respiratory protection should be used as a means of protecting from the risks that remain. For those staff who are unaware of their IgG immunity or vaccination history a FFP3 respirator must be worn at all times during contact with the patient. Footnote 3 Aerosol Generating Procedures (AGPs) can produce droplets <5 microns in size which may cause infection if they are inhaled. These small droplets, containing pathogens, can remain in the air, travel over a distance and still be infectious. AGPs procedures should only be carried out when essential. Where possible, these procedures should be carried out in well-ventilated single rooms with the doors shut. Only those healthcare workers who are needed to undertake the procedure should be present. Aerosol Generating Procedures (AGPs) are defined as: o Intubation, extubation and related procedures, for example manual ventilation and open suctioning. o Cardiopulmonary resuscitation. o Bronchoscopy. o Surgery and post mortem procedures in which high-speed devices are used. o Some Dental procedures (e.g drilling)

http://www.hps.scot.nhs.uk/travel/viralhaemorrhagicfever.aspx?subjectid=00C



o Non Invasive Ventilation (NIV) e.g. Bilevel Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP). o High Frequency Oscillatory Ventilation (HFOV). o Induction of sputum (not including chest physiotherapy). Footnote 4 A list of notifiable diseases and organisms can be found in the Public Health etc. (Scotland) Act 2008. Schedule 1 http://www.legislation.gov.uk/asp/2008/5/contents Footnote 5 Additional guidance should be followed for known/suspected cases of novel influenza viruses, including avian influenza, MERS CoV. Footnote 6 Aspergillus spp and Pneumocystis jirovecii typically cause infection in severely immunocompromised hosts, under some circumstances (e.g during an outbreak) it may be recommended for such patients to wear a fluid-resistant surgical face mask. These organisms do not pose a risk to immunocompetent staff, therefore fluid-resistant surgical face masks will only be required as per SICPs. For more information refer to the ‘Staff Information Leaflets’ for these organisms.

http://www.legislation.gov.uk/asp/2008/5/contents



Appendix 12 – Key Infections from HSE Guidance “Controlling the risks of infection at work from Human Remains”.

Infection Causative agent Is a body bag needed?

Can the body be viewed?

Can hygienic preparation* be carried out?

Can embalming be carried out?

Intestinal infections: Transmitted by hand-to-mouth contact with faecal material or faecally contaminated objects Dysentery (bacillary) Bacterium – Shigella

dysenteriae Advised Yes Yes Yes

Hepatitis A Hepatitis A virus No Yes Yes Yes Typhoid/ paratyphoid fever

Bacterium – Salmonella typhi/ paratyphi

Advised Yes Yes Yes

Blood-borne infections: Transmitted by contact with blood (and other body fluids which may be contaminated with blood) via a skin-penetrating injury or via broken skin. Through splashes of blood (and other body fluids which may be contaminated with blood) to eyes, nose and mouth HIV Human

immunodeficiency virus

Yes Yes Yes No

Hepatitis B and C Hepatitis B and C viruses

Yes Yes Yes No

Respiratory infections: Transmitted by breathing in infectious respiratory discharges Tuberculosis Bacterium –

Mycobacterium tuberculosis

Advised Yes Yes Yes

Meningococcal meningitis (with or without septicaemia)

Bacteria – Neisseria meningitidis

No Yes Yes Yes

Non-meningococcal meningitis

Various bacteria including Haemophilus influenza and also viruses

No Yes Yes Yes

Diphtheria Bacteria – Corynebacterium diphtheria

Advised Yes Yes Yes

Contact: Transmitted by direct skin contact or contact with contaminated objects Invasive Streptococcal infection

Bacterium – Streptococcus pyogenes (Group A)

Yes Yes No No

MRSA Bacterium – methicillin-resistant Staphylococcus aureus

No Yes Yes Yes

Other infections Viral haemorrhagic fevers (transmitted by contact with blood)

Various viruses, eg Lassa fever virus, Ebola virus

Yes No No No

Transmissible spongiform encephalopathies (transmitted by puncture wounds, ‘sharps’ injuries or contamination of broken skin, by splashing of the mucous membranes)

Various prions, eg Creutzfeldt Jacob [sic] disease/variant CJD

Yes Yes Yes No

*“Hygienic preparation” refers to the washing and/or dressing of the deceased.



Appendix 13 – NHSScotland Alert organism/Condition list

Tables 1 to 5 outline a nationally agreed minimum list of alert organisms/conditions. The

purpose of this list is to alert NHS Board Infection Prevention and Control Teams (IPCT) and

Health Protection Teams (HPTs (if out-with the healthcare environment)) of the occurrence of

these organisms/conditions, which may require further investigation. Unless otherwise stated,

one case would require an IPCT or HPT review to advise SICPs and TBPs have been followed

and continue to be applied. Typically, two or more linked cases should trigger further

investigations into a possible outbreak.

This list is not exhaustive and specialist units e.g. those managing patients with Cystic Fibrosis

will also be guided by local policy regarding other alert organisms not included within these lists.

The responsibilities for managing and investigating these organisms/conditions are outlined in

Chapter 3 of the NIPCM for health and care settings and within The Management of Public

Health Incidents (MPHI) Guidance for all other settings.

In addition, Table 6 outlines resistant bacteria, the identification of which should act as an alert

to Microbiology Teams, IPCTs and Antimicrobial Management Teams (AMT).

Table 1: Bacteria

Bacteria Locations Bacillus anthracis All care settings

Bordetella pertussis All care settings Clostridium difficile All care settings

Corynebacterium diphtheria/ulcerans All care settings Legionella spp. All care settings

Mycobacterium tuberculosis complex All care settings Neisseria meningitidis All care settings

Staphylococcus aureus All care settings Staphylococcus aureus – PVL All care settings

Streptococcus pyogenes All care settings GI bacteria:

Campylobacter spp, Escherichia coli (toxin producing strains e.g. E.

coli O157) Salmonella spp,

Shigella spp.

All care settings

Environmental bacteria: Pseudomonas aeruginosa,

Acinetobacter spp, Stenotrophomonas maltophilia,

Serratia marcescens List is not exhaustive. Consider clinical

likelihood of infection due to these opportunistic pathogens, particularly in

High risk units e.g. ICU/PICU/NICU, oncology/haematology





patients at high risk of infection.

Resistant bacteria Extended-spectrum beta-lactamase (ESBL)

producers Vancomycin-resistant Enterococci (VRE)

Carbapenem-resistant Enterobacteriaceae (CRE)

Mulit-drug resistant (MDR) or extensively drug resistant (XDR) M tuberculosis complex

All clinical/care settings

Table 2: Viruses

Virus Locations BBV (HBV, HCV and HIV) All clinical/care settings

Hepatitis A All clinical/care settings GI viruses: Adenovirus Norovirus , Rotavirus,


Respiratory viruses: Adenovirus

Parainfluenza, RSV

High risk units e.g. ICU/PICU/NICU, oncology/haematology

Respiratory viruses cont. Influenza

Novel coronavirus (MERS/SARS)


Varicella zoster virus (chickenpox) All clinical/care settings Parvovirus B19 (In high risk units) All clinical/care settings

Measles, Mumps, Rubella


Table 3: Fungi

Fungi Locations Aspergillus spp. High risk units e.g. ICU/PICU/NICU,

oncology/haematology

Pneumocystis jirovecii High risk units e.g. ICU/PICU/NICU, oncology/haematology, renal unit.

Candida auris

Single case of invasive infection or isolates from superficial sites from patients in high risk

units or those transferred from an affected hospital (UK or abroad)




Table 4: Parasites

Parasite Locations GI parasites:

Cryptosporidium spp Giardia lamblia


Table 5: Alert conditions

Condition Locations Acute flaccid myelitis or paralysis with

infectious aetiology e.g. EVD68 All clinical/care settings

Potentially infectious diarrhoea/vomiting All clinical/care settings Necrotising fasciitis All clinical/care settings

Necrotising pneumonia (suggesting possible PVL S. aureus infection)


Scabies In-patient/care and day care settings Shingles All clinical/care settings

Transmissible Spongiform Encephalopathy (TSE) e.g. CJD


Viral Haemorrhagic Fever (VHF) All clinical/care settings

Table 6: Resistant bacteria (exceptional phenotypes) - (amended version based on ‘EUCAST Expert rules and intrinsic resistance, 2016’) This list has been produced in conjunction with the Scottish Microbiology and Virology Network

(SMVN). Not all drug-bug combinations are routinely tested, but the complete list of drugs from

the EUCAST guidance is included below for reference. Any exceptional organism/antibiotic

combinations may indicate laboratory processing errors, and where reported should be checked

first to ensure accuracy. If confirmed, local IPCT or HPT as appropriate need to be made aware

to ensure appropriate actions are put in place.

A single isolate from a healthcare associated case would constitute an ‘alert’.

Organisms Exceptional phenotypes Exceptional resistance phenotypes of Gram-negative bacteria Any Enterobacteriaceae Resistant to colistin1 (except Proteae and Serratia

marcescens), Resistant to meropenem and/or imipenem (except Proteae – Proteus spp, Providencia spp and Morganella spp)

Salmonella typhi Resistant to fluoroquinolones and/or carbapenems Pseudomonas aeruginosa and Acinetobacter spp.

Resistant to colistin

Acinetobacter baumannii Resistant to any carbapenem Haemophilus influenzae Resistant to any third-generation cephalosporin,

carbapenems, fluoroquinolones Moraxella catarrhalis Resistant to any third-generation cephalosporin and/or

fluoroquinolones Neisseria meningitidis Resistant to any third-generation cephalosporins and/or

fluoroquinolones



Neisseria gonorrhoeae Resistant to spectinomycin and / or azithromycin and/or third-generation cephalosporins

Exceptional resistance phenotypes of Gram-positive bacteria Staphylococcus aureus Resistant to vancomycin, teicoplanin, televancin,

dalbavancin, oritavancin, daptomycin, linezolid, tedizolid, quinupristin-dalfopristin and/or tigecycline, ceftaroline or ceftobiprole.

Coagulase-negative staphylococci Resistant to vancomycin, telavancin, dalbavancin, oritavancin, daptomycin, linezolid, tedizolid, quinupristin-dalfopristin and/or tigecycline.

Corynebacterium spp. Resistant to vancomycin, teicoplanin, telavancin, dalbavancin, oritavancin, daptomycin, linezolid, quinupristin-dalfopristin and/or tigecycline

Streptococcus pneumoniae Resistant to carbapenems, vancomycin, teicoplanin, telavancin, dalbavancin, oritavancin, daptomycin, linezolid, tedizolid, quinupristin-dalfopristin, tigecycline and/or rifampicin. High level penicillin resistance.

Group A, B, C and G β-haemolytic streptococci

Resistant to penicillin, cephalosporins, vancomycin, teicoplanin, telavancin, dalbavancin, oritavancin, daptomycin, linezolid, tedizolid, quinupristin-dalfopristin and/or tigecycline.

Enterococcus spp. Resistant to daptomycin, linezolid, tedizolid and/or tigecycline

Exceptional resistance phenotypes of anaerobes Bacteroides spp. Resistant to metronidizole Clostridium difficile Resistant to metronidizole, vancomycin, fidaxomicin

(1) Current difficulties regarding testing methodologies, awaiting clarification



Appendix 14 –NIPCM Healthcare Infection Incident Assessment Tool (HIIAT)

The Healthcare Infection Incident Assessment Tool (HIIAT) should be used by the Infection Prevention and Control Team (IPCT) or Health Protection Team (HPT) to assess every healthcare infection incident i.e. all outbreaks and incidents (including decontamination incidents or near misses) in any healthcare setting (that is, the NHS, independent contractors providing NHS services and private providers of healthcare). The HIIAT has two parts/functions:

Part 1: Assesses impact of a healthcare infection incident/outbreak on patients, services and public health.

The HIIAT should:

• Be utilised to assess the initial impact and monitor any ongoing impact (escalating and de-escalating the incident/outbreak until declared closed).

• Remain assessed ‘Amber’ or ‘Red’ only whilst there is ongoing risk of exposure, new cases, or until all exposed cases have been informed.

An individual member of the IPCT or HPT may undertake the initial assessment. If a PAG/IMT is established then further assessments will be led by the chair of the PAG/IMT. Part 1: Assessment

Severity of illness Impact on services

Risk of transmission

Public Anxiety

Minor

Patients require only minor clinical interventional support as a consequence of the incident.

There is no associated mortality as a direct result of this incident.

No or minor impact on services.

Minor implications for Public Health.

Minor risk or no evidence of cross transmission or on-going exposure

No or minor public anxiety is anticipated.

No, or minimal, media interest: no press statement.

Moderate

Patients require moderate clinical interventional support as a consequence of the incident.

There is no associated mortality as a direct result of this incident.

Moderate impact on services e.g. multiple wards closed or ITU closed as a consequence of the control measures

Moderate implications for Public Health.

Moderate risk or evidence of cross transmission or on-going exposure

Moderate public anxiety is anticipated.

Media interest expected: prepare press statement

Major

Patients require major clinical interventional support as a consequence of the incident and/or Severe/life threatening /rare

Major impact on services e.g. hospital closure(s) for any period of time as a consequence of the control measures

Major implications to Public Health or Significant risk of cross transmission, of a severe/life threatening /rare

Major public anxiety anticipated.

Significant media interest: prepare press statement



infection and/or there is associated mortality*

infection or significant on-going exposure

Calculate the Impact: All Minor = GREEN; 3 minor and 1 Moderate = GREEN; No major and 2-4 Moderate = AMBER; Any Major = RED.

Part 2: Supports a single channel of infection incident/outbreak assessment and information reporting both internally within a NHS Board area and externally to Health Protection Scotland (HPS) and Scottish Government Health and Social Care Department (SGHSCD).

Part 2: Communication

GREEN AMBER RED

Complete mandatory HIIAT Green reporting template and attach any prepared press statements. http://www.documents.hps.scot.nhs.uk/hai/infection-control/publications/template-hiiat-green.xlsx

A HIIORT is only required when HPS support is requested.

Follow local governance procedures for assessing and reporting.

Report to HPS and complete HIIORT within 24 hours for onward reporting to SGHSCD. NHS board will be cited.

Press statement (holding or release) must be prepared and sent to HPS

Request HPS support as required.


Review and report HIIAT assessment as agreed between IMT and HPS (at least weekly)

The HIIAT should remain Amber only whilst there is ongoing risk of exposure to new cases or until all exposed cases have been informed

Report to HPS and complete HIIORT within 24 hours for onward reporting to SGHSCD. NHS board will be cited.

Press statement (holding or release) must be prepared and sent to HPS.

Request HPS support as required.


Review and report HIIAT daily or as agreed between HPS and IMT (a minimum of weekly).

The HIIAT should remain Red only whilst there is significant ongoing risk of exposure to new cases or until all exposed cases have been informed.

The final decision to release a press statement irrespective of HIIAT assessment (colour) is the responsibility of the IMT chair.

* Only HAI deaths which pose an acute and serious public health risk must be reported to the Procurator Fiscal (SGHD/CMO(2014)27).

The full manual is available at www.nipcm.hps.scot.nhs.uk/

http://www.documents.hps.scot.nhs.uk/hai/infection-control/publications/template-hiiat-green.xlsx




http://www.nipcm.hps.scot.nhs.uk/



Appendix 15 – Healthcare Infection, Incident and Outbreak Reporting Template (HIIORT)

Section 1 :Contact Details NHS Board/Care organisation Date and time of reporting Person Reporting and designation Telephone number and email Section 2: Infection Incident/outbreak Details Care facility/hospital Clinical area/ward and speciality Total number of beds Total number of beds occupied Section 3: Initial assessment Type: Incident/outbreak/ data exceedance e.g. Gastrointestinal, decontamination failure

Infectious agent known or suspected Case definition

Date of first case (if applicable)

Total number of confirmed patient cases

Total number of probable patient cases

Total number of possible patient cases:

Total number of staff cases:

Number of patients giving clinical cause for concern as a consequence of this incident/outbreak

Number of deaths as a consequence of this incident/outbreak Was the infectious agent cited as a cause of death on a death certificate* (if yes, state which part of the certificate)

Additional information: e.g. closure of care area, control measures Section 4: Healthcare Infection Incident Assessment Tool (HIIAT) (link to tool) Severity of illness Minor/Moderate/Major Impact on services Minor/Moderate/Major Risk of transmission Minor/Moderate/Major Public anxiety Minor/Moderate/Major HIIAT Assessment Red Amber Green Section 5: Organisational Arrangements PAG/IMT meeting held Y /N/ NA Date: Chair: Next planned IMT Y /N/ NA Date: Press statement (send with HIIORT or provide date for receipt)

Holding, Release Date:

HPS support requested Y/N Date.................................... Other information: e.g. decisions from IMT

Complete within 24 hours for all HIIAT Red and Amber; for HIIAT Green complete only if HPS Support requested.

Complete this update section weekly as a minimum or as agreed with IMT and HPS for onward reporting to SGHSCD.



Section 6: Update On this date: Cumulative total of confirmed patient cases

Cumulative total of probable patient cases

Cumulative total of possible patient cases

Cumulative total of staff cases

Total number of symptomatic patients today

Number of patients giving cause for concern

Total number of deaths as a consequence of the incident since last HIIORT report

`1234Is the ward/services closed

Is a service restricted HIIAT assessment Organisation update Comments (including changes to any control measures, case definition or death) certification information) Date:

Date:

Date:

Date:

Date:

ONCE COMPLETED, EMAIL TO: [email protected]

mailto:[email protected]



Appendix 16- Healthcare Associated Infection definitions Cases that have been categorised as Healthcare associated infection (HCAI) outside hospitals and hospital acquired infection (HAI) will be grouped together and standardised by total occupied bed days (using up to date ISDSI data). The resulting incidence rate will be referred to as “healthcare associated infection incidence”. The Scottish healthcare associated

An outbreak would be defined as a situation where:

• there are two or more linked cases of the same illness or infection with the same organism, or,

• where the number of cases of an illness exceeds the expected number and the cases or source is thought to be an HAI.

An incident would be defined as a single case of serious illness with major public health and/or infection control implications.

A Situational Assessment Group (SAG) should be convened by the Head of Infection Prevention and Control or nominated deputy and ICD on reporting of a potential issue requiring management. The SAG will “fact find” and assess the potential issue; gather patient information, demographics and relevant timelines. The SAG will decide on whether there is need to escalate to an IMT.

An Outbreak Control Team (OCT) should be convened in the event of 2 or more wards in one acute hospital being closed in full to admissions. The OCT would be chaired by the Head of Infection Prevention and Control or the Infection Control Doctor. • An Incident Management Team (IMT) should be convened if there is a significant issue that

requires multidisciplinary or multi agency support • the number of cases causes undue pressure on existing services • large volume of public enquiries, or • increased political or media interest



Appendix 17- Membership and TOR of IMT

Incident Management Team (IMT) Terms of Reference

Authors:

Responsible Lead Executive Director: Irene Barkby

Endorsing Body: NHS Lanarkshire Infection Control Committee Governance or Assurance Committee NHS Lanarkshire Infection Control Committee

Accountable to Healthcare Quality Assurance and Improvement Committee (HQAIC).

Reports to NHS Lanarkshire Infection Control Committee

Implementation Date:

Version Number: 1

Review Date:

Responsible Person(s) Emer Shepherd

CHANGE RECORD Date Author(s) Change Version

No.



1. INTRODUCTION This document outlines the terms of reference for an NHS Lanarkshire (NHSL) Incident Management Team (IMT). 2. Purpose

The remit of the IMT is to ensure that the following actions are completed as appropriate provide assurance that NHSL. • Agree a case definition at first meeting • Review existing case information and definitions and advise on further investigation or

information gathering or case finding at each meeting • Review the existing control measures advised and advise if any additional steps are required • advise clinicians on additional microbiological sampling required • advise and coordinate further environmental investigation e.g. sampling water systems • agree and coordinate appropriate action to be undertaken by each discipline or agency

involved in the investigation, management and control of the outbreak or incident • advise and coordinate further environmental investigation e.g. sampling water and systems • ensure effective liaison and communication between all appropriate agencies • agree information and advice for the general public, relevant professional groups and other

as required • agree and coordinate arrangements for media briefing and liaison • review the efficacy and progress with actions advised (minimum daily), and • advise when the outbreak/incident is over The IMT can request additional expert advice and input into the outbreak/incident in line with the National Support Framework. 3. CHAIRPERSON

• The Lead Infection Prevention and Control Doctor or the Head of Infection Prevention and

Control will chair the IMT meetings with referral to a Consultant for Public Health Medicine as appropriate will normally chair meetings. In their absence, the Co-chair or other nominated person will be the Head of Infection Prevention and Control.

• The Generic IMT Agenda will be utilised for each meeting, although may be subject to change due to the nature of the incident. This will be at the discretion of the Chair.

• The Chair of the Incident Management Team is responsible for ensuring completion of the Hospital Incident Assessment Tool (HIIAT) and relevant communication via the HAI-Outbreak Reporting Template. The Chair is also responsible for providing written updates to corporate management and relevant stakeholders following each IMT meeting.

4. SECRETARIAL SUPPORT

Secretarial support will be provided by the Infection Prevention and Control Department to the IMT. The secretary tasked with providing support will ensure that as far as practicable: • Full minutes will be taken at all meetings, and action logs produced. Individual members

should keep accurate personal and professional records of all activities relating to the outbreak or incident, including records of information received, conversations and

• • meetings attended. All notes and records pertaining to an incident or outbreak have the

http://www.hps.scot.nhs.uk/resourcedocument.aspx?id=4377



potential to be subject to legal scrutiny in the event of litigation or enquiry. • Admin will ensure all group members are provided with copies of the HIIAT assessment

tool for scoring during the meeting. 5. MEMBERSHIP The Core membership of the IMT will be: • Infection Control Doctor • Head of IPC • Senior Nurse-IPC • IPC Clinical Nurse Specialists • Consultant Microbiologist • Consultants in charge of case(s) • Senior nurse for the specialty/hospital • General Manager/Senior Hospital Manager • Bed Manager • Antimicrobial Pharmacist • Domestic Services Manager • Facilities/Hotel services Manager • SALUS Occupational Health & Safety • Communications Manager • Administrative support Other members may include (but is not restricted to):

• Consultant in Public Health Medicine • Health Protection Nurse • Infectious Diseases Consultant • Other Clinicians • Medical Director/Nurse Director • Environmental Health Officer or other Local Authority representation • Health Protection Scotland (HPS)representation • Food Standards Agency (FSA) representation • Health & Safety Executive (HSE) representation • Hospital catering manager • Senior pharmacist • Procurement Manager • AHP representative 6. QUORUM Meetings of the IMT will be quorate when at least six members are present, at least one of whom must be: • Chair or Co-Chair of IMT • Representation from all services involved other services. Where no quorum of membership is present, the meeting may proceed at the discretion of the Chair (or Vice-Chair or other nominated person in the absence of the Chair), but all decisions



taken will be subject to future ratification by a meeting of the group where a quorum is present. The decision making process will be based on the principles of partnership working and wherever possible decisions will be reached by consensus. DEPUTISING ARRANGEMENTS Where a member of the group is unable to attend they may nominate a deputy to attend the meeting on their behalf, with the agreement of the Chair. The principal Group member will be responsible for passing papers to and briefing their delegated representative. Members are expected to offer apologies for non-attendance in advance of a scheduled meeting directly to the Secretary. DECISIONS AND RESOLUTIONS The Group may make decisions and resolutions within its ‘Terms of Reference’ and the Scheme of Delegation established by NHS Lanarkshire. 7. AGENDA FOR IMT MEETINGS At each meeting the following business shall be discussed:

1. Introduction (Reminder of confidentiality and need for accurate records) 2. Declarations of conflicts or vested interests.

3. Minute of last meeting (if applicable) including review of actions agreed at previous

Meeting

4. Incident/Outbreak Resume/Update

• General situation statement • Patient report • Microbiology/Toxicology report • Environmental Health report • Other relevant reports

5. Risk Assessment

• Need to escalate • Inform other authorities – Procurator Fiscal

6. Risk Management/Control Measures 7. Hospital Infection Incident Assessment Tool

• Patients • General • Public Health • Staff

8. Care of Patients - Hospital and Community

• Further Investigation • Epidemiological • Environmental



• Toxicological 9. Risk Communication

• Advice to public (letters, printed materials, media, social networking, websites, helplines etc)

• Advice to professionals (GPs, clinical staff, other NHS Boards, partners) • Media (print, radio, TV, websites, social networking sites)

10. Obtain contact details of all key personnel within and out with hours 11. Action list with timescale and allocated responsibility 12. Date and time of next meeting



Appendix 18 Roles and Responsibilities

Who Roles & Responsibilities

Corporate Management Team

• To provide a managed system in relation to infection prevention & control across NHS Lanarkshire

• To cooperate with partner agencies (e.g. Local Authority) to protect the local population from hazards to health by preventing, controlling or reducing exposure to these.

• To take steps to limit damage to health when such exposures occur.

Hospital Management Teams

• Promote compliance with infection prevention & control policy • Support the Infection Prevention & Control Team (IPCT) in managing

outbreaks or incidents • Support the Incident Management Team (IMT) or Outbreak Control Team

(OCT) by ensuring all necessary resources as identified by the IMT/OCT are available.

Infection Prevention & Control Team

• To provide specialist advice, assessment and advice on infection prevention and control policy and practice

• Maintain effective surveillance systems to detect and investigate outbreaks • Collate and maintain details of all patients involved • Investigate all reports of possible hospital and other HAI outbreaks • Ensure that a HIIAT assessment is documented for all outbreaks • Take all necessary actions to identify the cause of an outbreak and bring

the outbreak to a close • Provide evidence of Audits as appropriate during Outbreaks/Incidents • Provide a plan of action to manage situations and prevent recurrence • Communicate with all internal and external stakeholders NHS Lanarkshire

as specified within the NHS Lanarkshire communications plan. • Prepare Communications statement at each meeting. • Conduct debrief following incident to identify learning points and or

implement action plan.

Microbiology/ Laboratory staff

• To provide laboratory testing, clinical support and interpretation of results for clinical staff and the IPCT and IMT

• To prioritise and process outbreak samples on the advice of the IPCT • To liaise with appropriate reference laboratories to coordinate additional

specimen investigation

Health Protection Team

• To protect public health by monitoring disease, recommending preventive measures, and investigating and controlling incidents and outbreaks of communicable disease and other environmental hazards within the NHS Lanarkshire Health Board area.

• To support and advise the IPCT or IMT as required. • Attend OCT or IMT as requested by the Chair



Who Roles & Responsibilities

Senior Charge Nurse (Ward Manager)

• To provide clinical and managerial leadership within the clinical area & act as role models in relation to infection prevention and control.

• To ensure implementation and ongoing compliance with Standard Infection Control Precautions (SICPs) and Transmission Based Precautions (TBP) and take appropriate action to address any area of non compliance

• To report any difficulty in accessing or providing sufficient resource to achieve this.

• Recognise and report to the IPCT any incidences of clinical conditions where the signs/symptoms are suggestive of an outbreak, Work with the IPCT in completing the daily assessments.

• Attendance at PAG/OCT and/or IMT as appropriate

Antimicrobial Pharmacists

• Site Antimicrobial Pharmacists available as required, to investigate appropriateness of antibiotic use for affected patients and give steer on utilisation in general in affected clinical area/site

Health Care Workers (HCWs)

• To implement infection & prevention policies in the planning and delivery of patient care

• To report to the Nurse in Charge and/or IPCT any concerns or suspected outbreaks without delay. Follow the advice & recommendations made by the IPCT/IMT

Clinicians • To provide clinical care in line with local/national guidance, including observations, specialist referrals and antibiotic therapy with infection prevention and control policies

• To act as role models in relation to infection prevention and control • Report to hospital management any difficult in accessing or providing

sufficient resource to achieve this • Report any incidences of clinical conditions where the

signs/symptoms are suggestive of an outbreak to the IPCT • Attendance at PAG/OCT and/or IMT as appropriate

PSSD • To provide support services including domestic services to NH Lanarkshire to maintain the cleanliness and safety of premises in line with local/national policy.

• Attendance at PAG/OCT and/or IMT as appropriate

SALUS occupational health & safety

• To provide specialist advice and support to clinical teams and the IPCT in relation to staff health and other matters of health & safety

• To support and advise the OCT /IMT as required • Attendance at PAG/OCT and/or IMT as appropriate

Communications Department

• To lead on the development and dissemination of media statements and other key information to NHS Lanarkshire and external agencies

• To take the lead on public communication • Assist the OCT / IMT by preparing written and printed information

materials e.g. posters, leaflets • Attendance at PAG/OCT and/or IMT as appropriate

Bed Managers • Attendance at PAG/OCT and/or IMT as appropriate

Documents

National Infection Prevention and Control Manual · National Infection Prevention and Control Manual Health Protection Scotland (HPS) Version 3.6.April 2017 Page 2 of 80 DOCUMENT