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«Version: 2 Ratified by: Senior Managers Business Group Date ratified: March 2013 Title of originator/author: Infection Prevention Control and ...»

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Version: 2

Ratified by: Senior Managers Business Group

Date ratified: March 2013

Title of originator/author: Infection Prevention Control and

Decontamination Lead

Title of responsible committee/group: Clinical Governance Group Date issued: March 2013 Review date: February 2016 Relevant Staff Groups: Infection Prevention Control Team This document is available in other formats, including easy read summary versions and other languages upon request. Should you require this please contact the Equality and Diversity Lead on 01278 432000 Surveillance Policy V2 -1- March 2013


Reference Number Version Status Author KA/Mar13/ICSP 2 Final Infection Prevention and Control Lead Policy revised in line with the Trust’s procedural document template.

Amendments Amended to reflect the acquisition of Somerset Community Health and changes to the Trusts governance structure.

Document objectives: This policy aims to ensure that Somerset Partnership NHS Foundation Trust has adequate arrangements in place to mitigate the risk of cross infection and onward transmission of resident organisms. Universal Precautions provide the basic principles for all Infection Prevention and Control guidance, adherence to this policy will provide assurance that Somerset Partnership NHS Foundation Trust staff are provided with the information necessary to implement these principles.

Intended recipients: All clinical staff whatever their grade, role or status, permanent, temporary, full-time, part-time staff including locums, bank staff, volunteers, trainees and students. This Policy will be available to the general public on the Trust Internet Committee/Group Consulted: Infection Prevention and Control Implementation Group Monitoring arrangements and indicators: Infection Prevention and Control Implementation Group Training/resource implications: please refer to section 6 of this policy.

Clinical Governance Group Date: February 2013 Approving body and date Impact Part 1 Date: February 2013 Formal Impact Assessment NO Date: N/A Clinical Audit Standards Senior Managers Business

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CONTRIBUTION LIST Key individuals involved in developing the document Name Designation or Group Karen Anderson Infection Prevention Control and Decontamination Lead Jacqui Cross Senior Infection Prevention and Control Nurse Lisa Stone Senior Infection Prevention and Control Nurse Ruth Diligent Junior Infection Prevention and Control Nurse Rebecca Gordon Acting Service Manager for Podiatry All members Infection Prevention and Control Implementation Group All members Clinical Policy Review Group All members Clinical Governance Andrew Sinclair Equality and Diversity Lead

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1.1 Surveillance is part of the routine infection prevention and control programme.

It helps to identify the risks of infection and reinforces the need for good practices.

1.2 Preventing outbreaks depends on prompt recognition of one or more infections with alert organisms and instituting special control measures to reduce the risk of spread of the organism.

1.3 Collection of accurate data allows comparison with other areas and provides further opportunity to assess the responses to changes in clinical practice.

1.4 Surveillance can be undertaken within healthcare settings.

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1.5 A combination of surveillance systems is usually needed to form an effective surveillance programme that meets local and national needs.

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2.1 Surveillance for infection can be defined as the routine collection of data on infections amongst patients or staff, its analysis and the dissemination of resulting information to those who need to know so that appropriate action can be taken (Hospital Infection Working Group of the Department of Health 1995).

2.2 The main objectives of surveillance for infection are:

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2.3 The surveillance of infection is therefore an essential part of any infection prevention and control strategy and is a requirement of the Code of Practice (2006) and Standards for Better Health (2005).

2.4 In response to this, the Department of Health has established a national mandatory surveillance programme. All NHS Healthcare Trusts are required to return data on specified infections on a routine basis. Results are fed back to Trusts and these are also used as part of the national performance ratings programme (Surveillance of healthcare associated infections 2003).


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3.2 Director of Infection Prevention and Control (DIPC) will:

• Oversee the local control of and the implementation of the Infection Control Surveillance Policy.

3.3 The Infection Prevention and Control Implementation Group will:

• Ensure that the procedures for the surveillance of target organisms are continually reviewed and improved within the Trust and report to the Clinical Governance Group.

3.4 The Infection Prevention and Control Team will:

• Undertake surveillance of target organisms/outbreaks

• Support clinical staff in adhering to policies relating to the containment of target organisms/outbreaks

• Participate in Root Cause Analysis as required

• Participate in Serious Incidents requiring Investigations (SIRI) as required

• Notify internal or external providers/agencies as required

• Provide written reports for review by the Infection Prevention and Control Implementation Group regarding target organisms/outbreaks

3.5 Ward and Team Managers/Hospital Matrons will:

• Ensure infection control precautions are carried out as detailed in all infection prevention and control policies.

• Ensure that staff are aware of the policy and requirements for attending training as identified in the Training Needs Analysis. Managers will ensure that staff have attended all relevant training and have current updates

• Ensure that staff are released to attend relevant Training and for recording attendance at training in local training records. All nonattendance at training will be followed up by managers.

• Ensure individual staff and team’s training needs are met through appraisal and in line with the Training Needs Analysis. Training information should be passed to the Learning and Development Department who will update the electronic staff record.

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3.7 The Learning and Development Department will:

• Enter all data relating to Mandatory and Non-Mandatory training attendance onto the Electronic Staff Record (ESR) system and report non-attendance to Ward and Team Managers.

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4.1 Mandatory Surveillance - This national scheme is based upon clinically significant positive laboratory results. This scheme collates information relating to all the following identified organisms.

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Participation is mandatory for all healthcare providers.

4.2 Alert Organism Surveillance - This method is used widely across the UK to detect and prevent outbreaks of infections. It is based upon routine monitoring of all laboratory results by microbiology staff. Any micro organisms identified that are on current alert organism or alert conditions lists are then notified to the Partnership Trust Infection Prevention and Control Team.

This will be done through the ICNET database within Somerset Partnership NHS Foundation Trust and Acute NHS Trusts.

Results will be reviewed and acted upon by the Infection Prevention and Control Team who will regularly feedback to all clinical areas via agreed channels.

Alert organism surveillance is performed continuously.

4.3 Laboratory Based Hospital Wide Surveillance - This involves the microbiological review of laboratory results by Taunton and Somerset NHS Foundation Trust Microbiology Department, and the identification of trends in infections throughout the healthcare provider service areas.

Laboratory based hospital wide surveillance is performed continuously for all Acute Trusts and Somerset Partnership NHS Foundation Trust.

4.4 Targeted Surveillance - A specific group of patients, clinical area or procedure is targeted for surveillance. This may be performed over a period of time (an incidence survey) as a single survey (prevalence study) or as a series of prevalence studies.

Targeted surveillance is performed as part of the annual infection prevention and control programme.

In addition other targeted surveillance may be used to monitor trends in infections or following changes in clinical practice/policy guidance.

Surveillance in the wider community following discharge from hospital may be an increasing area within target surveillance especially with regard to surgical site wound surveillance.

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5.1 Outcomes of all surveillance will be reported by the Infection Prevention and Control Team to the Infection Prevention and Control Implementation group.

The results will be further disseminated to relevant clinical areas via an agreed mechanism.

5.2 Results for mandatory surveillance will also be formally reported to the Trust Board and will be detailed in the Somerset Partnership NHS Foundation Trust Infection Control Annual Report.

5.3 Results of surveillance will be linked with infection control audit reports where appropriate. The Infection Prevention and Control Team will work in collaboration with clinical staff to identify areas for practice improvement.


6.1 The Trust will work towards all staff being appropriately trained in line with the organisation’s Staff Mandatory Training Matrix (training needs analysis). All training documents referred to in this policy are accessible to staff within the Learning and Development Section of the Trust Intranet.


All relevant persons are required to comply with the document and must demonstrate sensitivity and competence in relation to the nine protected characteristics as defined by the Equality Act 2010. If you, or any other groups, believe you are disadvantaged by anything contained in this document please contact the Document Lead (author) who will then actively respond to the enquiry.


8.1 Overall monitoring will be by the Clinical Governance Group who will be provided with a quarterly report from the Infection Control Group. The Infection Prevention and Control Implementation Group will monitor incident reporting, serious incidents requiring investigations/root cause analysis reports related to infection control surveillance.

8.2 The Infection Prevention and Control Implementation Group will identify good practice, any shortfalls, action points and lessons learnt. This Group will be responsible for ensuring improvements, where necessary, are implemented and will escalate any areas of concern to the Clinical Governance Group within the next quarter report.

8.3 Lessons Learnt will be forwarded to the Clinical Effectiveness Team who will raise awareness through the monthly SPICE newsletter with a hyperlink to supporting documents where appropriate. SPICE newsletter is a monthly newsletter emailed to all staff.

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9.1 The Trust is committed to the NHS Protect Counter Fraud Policy – to reduce fraud in the NHS to a minimum, keep it at that level and put funds stolen by fraud back into patient care. Therefore, consideration has been given to the inclusion of guidance with regard to the potential for fraud and corruption to occur and what action should be taken in such circumstances during the development of this procedural document.



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Relevant National Requirements CMO Letter (PLCM02003/4) Surveillance of healthcare associated infections 9 June 2003 Department of Health (2008) Changes to the mandatory healthcare associated infection surveillance system for Clostridium difficile infection (CDI) from 1 January 2008 Professional Letter from the Chief Medical Officer and the Chief Nursing Officer.

Department of Health (2005) Mandatory surveillance of Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemias. Professional Letter from the Chief Medical Officer and the Chief Nursing Officer. London.


11.1 References Department of Health (2003) Winning Ways. Working together to reduce Healthcare Associated Infection in England. Report from the Chief Medical Officer. London.

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Hospital Infection Control, Guidance on the Control of Infection in Hospitals, PHLS: 1995 (Cooke Report) Department of Health (2008) The Health and Social Care Act 2008, Code of Practice for health and social care on the prevention and control of infections and related guidance (revised 2011).

11.2 Cross reference to other procedural documents

• Clostridium Difficille Policy

• Glycopeptides Resistant Enterococcus (GRE) Policy

• Hand Hygiene Policy

• Health and Safety policy

• Healthcare (Clinical) Waste Policy

• Infection Control Standard Precautions Policy

• Meticillin Resistant Staphylococcus Aureus (MRSA) Policy

• Outbreak of Infection – Policy for management and Control

• Risk management Policy and Procedure

• Risk Management Strategy

• Serious Incidents Requiring Investigations Policy

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