INFECTION PREVENTION AND CONTROL

                           SURVEILLANCE POLICY

VERSION NUMBER              1
REVIEW                      November 2009
APPROVAL HISTORY            Infection Prevention and Control Committee: August 2006
                            Board: November 2006
DISTRIBUTION                PCT-wide
RELATED                     Outbreak Policy
                            D&V Policy
AUTHOR/FURTHER              AUTHOR – Infection Control Dept, RUH
                            PCT contact for queries:
                            Mairi Rider, Matron, St. Martin’s Hospital Tel: 01225 831543
                            Sarah Leggett, Asst Director of Quality & Risk Tel 01225
                            Denise Meyers, Infection Control Advisor Tel: 01225 825450

                            None – new policy

IMPLEMENTATION              Local cascade by managers. Key points for implementation;
PLAN                        •   Ensure all staff are made aware of the contents and
                                requirements of this Policy

                            •   Ensure all new staff are made aware of the requirements
                                of this Policy and local procedures as part of their local

                            •   Ensure you have a system in place to telephone the
                                Infection Control Team to notify them of any healthcare
                                associated infections (see Section 8) and that these are
                                also reported using the PCT’s adverse event reporting

Page - 1 - of 5                                  Infection Control Manual: Surveillance Policy
Issue 1 – November 2006
Review: November 2009
      Section                                             Page
      1.0 Purpose of policy                                 2
      2.0 Definition                                        2
      3.0 Standard                                          2
      4.0 Introduction                                      2
      5.0 Surveillance                                      3
      6.0 Surveillance Objective                            3
      7.0 Roles and Responsibilities                        3
      8.0 Types of Surveillance                             4
               8.1 Surveillance Schemes                     4
               8.2 Alert Organism Surveillance              4
               8.3 Alert Condition Surveillance             5
      9.0 Reporting procedures                              5
      10. References                                        5

      To provide clear guidelines on the responsibilities for infection control surveillance and
      the types of surveillance undertaken.

      Surveillance is a comprehensive method of measuring outcomes associated with
      processes of care, analysis of data and providing information to those who are giving
      clinical treatment and care. Surveillance also forms part of clinical audit and clinical
      governance, which assist in reducing the frequency of adverse events of infection or

      Infection control surveillance is undertaken on alert organisms and conditions as
      determined by local and national trends and agreed by the PCT’s Infection Prevention
      and Control Committee. Mandatory surveillance directed by the Department of Health is
      undertaken and timely feedback given to relevant staff / manager in order that any
      necessary action may be taken.

      One in eleven hospital patients acquire an infection associated with healthcare,
      suggesting about 9% of inpatients have a healthcare associated infection at any one

      The National Audit Office has reported that Trusts incur costs that are, on average, three
      times higher for infected patients than uninfected patients. This is equivalent to an
      additional £3,000 per case. On average, these patients have a hospital stay that is 2.5
      times that of uninfected patients, equivalent to 11 extra days in hospital.

      It has been estimated that 5,000 deaths annually may be directly attributable to
      healthcare associated infections.

      The cost of these infections to the NHS is around £1 Billion each year.

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      Review: November 2009
      In most instances, the outcome of an infection is governed by the patient’s susceptibility.
      The young, old, patients with suppressed immunity and those undergoing invasive
      procedures are particularly at risk. Therefore not all hospital acquired infections are

      Surveillance is required to understand the extent, cost and effects of healthcare
      associated infection. It is the foundation for good infection control practice and improving
      patient care.

      It has been shown that hospitals with an infection control programme that includes
      surveillance and feedback of results to clinicians can reduce infections by 32%

      Surveillance provides useful information for identifying infected patients, determining the
      site of infection and ascertaining factors that contribute to healthcare associated
      infection. This data enables the calculation of the rate of infection, which facilitates the
      monitoring of infection trends with respect to time, place and infection site.

      Surveillance encourages infection control interventions and also contributes to evaluating
      their efficacy. Feedback can also form the basis of education, policy development and
      staffing levels.

      Active surveillance and investigation is the first of seven actions set out by the Chief
      Medical Officer in his report “Winning Ways: Working together to reduce healthcare-
      associated infection in England” issued in December 2003.

      The objects of surveillance are:

          a) The prevention and early detection of outbreaks of infectious diseases in order to          Formatted: Bullets and
             allow timely investigation and control.                                                     Numbering

          b) The determination of infection levels over time in order to identify the need for,          Formatted: Bullets and
             and measure the effectiveness of preventative and control measures.                         Numbering

          c) To comply with Department of Health guidelines and requirements.                            Formatted: Bullets and
          d) To meet the requirements from the National Audit Office Report                              Formatted: Bullets and
          e) To meet the Health Care Commission’s requirements and to maintain the NHS                   Formatted: Bullets and
             Litigation Authority’s Risk Assessment for PCTs’ assessment criteria for Infection          Numbering


          •    The Chief Executive is responsible for ensuring that there are effective                  Formatted: Bullets and
               arrangements for infection control within the PCT.                                        Numbering

          •    The PCT has a Service Level Agreement with the RUH for Infection Control for              Formatted: Bullets and
               the PCT’s provider services. The RUH’s Infection Control Team includes an                 Numbering

               Infection Control Doctor, Infection Control Nurses and an Infection Control Audit
               and Surveillance nurse.

          •    Infection Control advice is provided on a 24 hour basis from the RUH for the PCT          Formatted: Bullets and
               provider services.                                                                        Numbering

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      Review: November 2009
          •    The Infection Control Annual programme includes a section on surveillance, which              Formatted: Bullets and
               is supported by the PCT’s Infection Prevention and Control Committee.                         Numbering

          •    The RUH’s Infection Control Team reports surveillance data to the PCT’s Infection             Formatted: Bullets and
               Prevention and Control Committee on a regular basis. The Infection Control                    Numbering

               annual report, which includes surveillance reports, is provided to the PCT Board.

          •    The RUH’s Infection Control Team report adverse incidents e.g. outbreaks.                     Formatted: Bullets and

          •    The RUH’s Infection Control Team will inform the Health Protection Agency of                  Formatted: Bullets and
               serious outbreaks of infection on the PCT’s in-patient wards.                                 Numbering

          •    The PCT monitors, reports and audits alert organisms and conditions that meet                 Formatted: Bullets and
               regional and national requirements.                                                           Numbering


8.1   Surveillance Schemes

      This PCT will participate in all DoH mandatory surveillance schemes for healthcare
      associated infections.

          •    Staphylococcus aureus bacteraemia (which includes all clinically significant MRSA             Formatted: Bullets and
               bacteraemias).                                                                                Numbering

          •    Glycopeptide resistant enterococci bacteraemia.                                               Formatted: Bullets and

          •    Reporting of serious untoward incidents associated with infection.                            Formatted: Bullets and

          •    Clostridium difficile associated diarrhoea.                                                   Formatted: Bullets and

      All clinical areas must put a system in place to telephone the Infection Control
      Team to notify them of all healthcare associated infections (HCAI) and to report the
      HCAI using the PCT’s adverse event form.

8.2   Alert Organism Surveillance

      The Microbiology Department at the RUH advises the RUH Infection Control Team of
      significant alert organisms that are likely to cause outbreaks of infection and /or are multi
      –drug resistant. This list currently includes

                                                                                                             Formatted: Bullets and
          •    Methicillin resistant staphylococcus aureus (MRSA) bacteraemia                                Numbering

          •    Glycopeptide resistant enterococci (GRE )
          •    Group A beta haemolytic streptococci
          •    Penicillin resistant Streptococcus pneumoniae
          •    Multi resistant coliforms – e. coli, acinetobacter, enterobacter cloacea,
               stenotrophomonas multophilia, extended spectrum beta lactamase (ESBL)
          •    Tuberculosis

      Page - 4 - of 5                                        Infection Control Manual: Surveillance Policy
      Issue 1 – November 2006
      Review: November 2009
8.3    Alert Condition Surveillance

       Clinical ward staff, the Consultant Microbiologists and microbiology staff have a
       responsibility to report particular clinical conditions to the Infection Control Team that are
       likely to cause outbreak of infections and / or are notifiable diseases. These measures will
       prevent the development of an outbreak of infection by the implementation of effective
       infection control measures. Currently this list includes

                                                                                                           Formatted: Bullets and
           •    Chicken pox / Shingles                                                                     Numbering

           •    Mycobacterium Tuberculosis ( TB )
           •    Scabies
           •    Meningococcal Meningitis
           •    Creutzfeldt jakob Disease ( CJD )
           •    Mumps and Measles
           •    Influenza
           •    2 or more cases of vomiting and diarrhoea in the same geographical area within a           Formatted: Bullets and
                48 hour period, i.e. outbreak
           •    Two or more cases of surgical site infection with the same causative micro-
                organism isolated at any one time.
           •    Where there is a confirmed or a high suspicion of a communicable disease.


       Summaries of all mandatory surveillance data will be reported at the PCT’s Infection
       Prevention and Control Committee meetings and the Infection Control Annual Report.

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

       2. National Audit Office (2000) The Management and control of Hospital Acquired
          Infection in NHS Acute Trusts in England. HC 230 session 1999-2000. London.
          Stationary Office.

       3. Department of Health (2002) Getting Ahead of the Curve, a strategy for combating
          infectious diseases (including other aspects of health protection). A report by the
          Chief Medical Officer. London

       4. Plowman R, Craven N, Griffin M et al. (2000). The socio-economic burden of hospital
          acquired infection. PHLS, London.

       Page - 5 - of 5                                     Infection Control Manual: Surveillance Policy
       Issue 1 – November 2006
       Review: November 2009

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