Select Committee on Science and Technology Minutes of Evidence


APPENDIX 3

PROTOCOL FOR MONITORING OF ADVERSE PATIENT INCIDENTS DUE TO INFECTION

MONITORING OF ADVERSE PATIENT INCIDENTS DUE TO INFECTION

RATIONALE FOR SURVEILLANCE

  Adverse patient incidents arising from infection, including outbreaks of healthcare associated infection may vary considerably in size, extent and impact. It will be entirely appropriate for many minor adverse patient incidents to be managed wholly within the Trust. However, where such incidents have a significant impact on the ability of the Trust to admit and discharge patients or undertake its routine activities, it is imperative that the Regional Directors of Public Health (RDsPH) and the relevant Regional Epidemiologist (RE) are kept fully informed of events in a timely manner.

  The purpose of such reporting is to ensure that:

    —  all the necessary resources are brought to bear without delay in order to effectively control the incident whilst maintaining continuity of services to the local population;

    —  information on incidents is used to assist in determining the adequacy of service provision, including infection control arrangements;

    —  to ensure that lessons learnt are incorporated into revised strategic arrangements for infection control; and

    —  to inform Ministers, Parliament and the public.

DEFINITION OF ADVERSE PATIENT INCIDENT DUE TO INFECTION

  An adverse patient incident arising from infection is defined as any event or circumstance arising during NHS care in which infection results in unintended or unexpected harm to the patient.

  Reportable adverse patient incidents are those:

    —  that result in significant morbidity or mortality; and/or

    —  involve highly virulent organisms; and/or

    —  are readily transmissible; and/or

    —  require control measures that have an impact on the care of other patients, including limitation of access to healthcare services;

AND

    —  involve convening an outbreak control committee (OCC). The decision as to the need to call an OCC will be that of the Hospital Control of Infection Officer (HCIO) and/or the Consultant in Communicable Disease Control (CCDC).

TYPE OF SURVEILLANCE

  Exception reporting

Reporting only when events occur

THRESHOLD FOR REPORTING

  Guidance issued by DH and the NHS National Patient Safety Agency (NPSA) require that adverse events to patients should be graded according to the actual impact on the patients and the potential future risk to patients and the organisation.

  For practical purposes, it is the decision of the HCIO, usually in conjunction with the CCDC, to formally convene an OCC that defines the incident as being of such significance as to require reporting to the RDPH and RE.

  It should be noted that the NPSA should also be informed of adverse events categorised as Red. See Special Aspects below.

ROUTE OF REPORTING

  All incidents meeting the DEFINITION should be reported to RDPH and RE.

  Incidents that are categorised as Red using NPSA criteria should be reported to NPSA.

MINIMUM DATA ELEMENTS

    —  Site identifiers.

    —  Nature of incident.

    —  Causative organism.

    —  Date of onset of first case/of exposure(s).

    —  Number of confirmed and suspected cases.

    —  Wards involved.

    —  Clinical speciality.

    —  Outcomes—ill, recovered, deaths.

ANALYSIS AND PRESENTATION OF DATA

Regional monitoring

  As part of its conduct in managing an incident OCCs are required to produce a final report of the outbreak, normally within 30 days of its conclusion. This report will be sent to the RDPH and RE. Information for monitoring purposes will be provided as an annex to this report in a specified format. Aggregated summary data of incidents will be provided by the RE to the RDPH annually.

National monitoring

  Aggregated summary data of incidents will be provided annually to DH by CDSC.

PRINCIPLE USES OF INFORMATION

    —  To ensure that adequate resources are made available for the control of outbreaks of infection.

    —  To co-ordinate the management of outbreaks involving more than one Trust or PCT.

    —  To ensure that lessons learned from individual outbreaks are incorporated into revised guidelines or infection control.

SPECIAL ASPECTS

Immediate action

  Time is of the essence in the communication of information. The Infection Control Team should notify the Chief Executive, the CCDC and the Director of Public Health (DPH) of the problem at the time the incident is first recognised. The OCC should provide a preliminary report within three working days. The RDPH and the relevant RE should be informed that an adverse incident has occured—especially when more than one Trust/PCT is involved.

  The RDPH will be responsible for ensuring that appropriate dissemination within DH, whilst the RE will ensure appropriate communications within CDSC. Other agencies may also need to be informed viz: The Health and Safety Executive, Department of Food, Environment and Rural Affairs, the Medical Devices Agency.

Patients Potentially at risk

  It will need to be borne in mind that some incidents only become apparent after the event eg HIV or Hepatitis B and C infected health care workers involved in exposure prone procedures. Because public concerns can be raised in such circumstances, it is important that the RDPH and relevant CCDC are notified of the problem at an early stage.

Frequency of reporting

  Reports on the progress of the incident should be provided to the Chief Executive of the Trust and the relevant DPH on a regular and timely basis. The Chair of the OCC will ensure that copies of these reports are sent to the RDPH and RE, usually this will be undertaken by the CCDC.

Final report of outbreak control committee

  OCCs are required to produce a final report on the incident. This report will include:

    —  A description of the incident, including investigations to determine the cause of the incident.

    —  An account of the actions taken to control the problem.

    —  An account of actions taken to minimise the chance of a recurrence of the problem.

Audit

  The RDPH will, in conjunction with Regional Performance Managers, audit these arrangements on a regular basis. A summary of adverse patient events due to infection will form part of the annual report provided by the OCC to the Chief Executive of the Trust.

NPSA categorisation of incidents

  The following guidance is given to illustrate how incidents of infection can be categorised in accordance with NPSA criteria:

  Red Incidents: involving very high risk to patients eg:

    —  death of several patients in the same ward/hospital over the same period of time due to a related infection/organism;

    —  hospital acquired infection involving large numbers of patients involving closure of ITU, one or more wards, or resulting in suspension of clinical activity.

  Orange Incidents: these are high risk incidents involving:

    —  outbreak of infection with alert organisms (eg MRSA, GRE, Clostridium difficile) or other organisms which local surveillance has indicated may be a cause for action. Such outbreaks may be new, or continuing despite appropriate control measures;

    —  the actual or potential transfer of blood-borne viral infections from healthcare workers to patients leading to look back reviews;

    —  failure of decontamination or sterilisation of surgical instruments.

  Yellow Incidents: of moderate severity, including:

    —  localised outbreaks of infection in several beds in one or more wards (not necessarily leading to ward closure);

    —  increase in observed over expected ratio for wound sepsis.


 
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