Infection Prevention and Control (IPC) Practice Guidance Note

Infection Prevention and Control (IPC) Practice Guidance Note

Reporting and Notification of Infectious Diseases – V04

Date issued
Issue 1 – Mar 2017 / Planned review
March 2020 / IPC-PGN 05
Part of NTW(C)23 – Infection, Prevention and Control Policy
Author/Designation / Carole Rutter, Infection Control Matron
Responsible Officer / Designation / Anne Moore - Director of Infection, Prevention and Control
Issue Notes
This guidance replaces all similar guidance issued by the former organisations.
KEY POINTS
·  All episodes of infectious disease occurring within Northumberland, Tyne and Wear NHS Foundation Trust (the Trust) must be reported to the Infection, Prevention and Control Team (IPCT) and through the Trust’s local web-based reporting mechanisms
·  Notification is a means of identifying and preventing the spread of infectious diseases
·  Serious and significant episodes must be reported as Serious and Untoward Incidents
·  There is a legal requirement to report some diseases that may present significant risk to human health to Public Health England under the Health Protection Notification Regulations 2010
Section / Content / Page No:
1 / Introduction / 1
2 / Reporting infectious diseases under the Trust's NTW(O)05 policy and procedure for reporting accidents and incidents / 1
3 / Reporting of infectious diseases under the Trust's NTW(O)05 - Incident Policy / 2
4 / Diseases that must be notified under law or regulation / 3
5 / The role of the Infection Prevention and Control Team / 3
6 / Reporting back to clinicians and managers / 4
Appendices, listed within practice guidance note
Appendix 1 / Reportable Diseases
Appendix 2 / Notifiable Diseases
Appendix 3 / Registered Medical Practitioner Notification Form Template
Appendix 4 / Contact Details for IPC

Northumberland, Tyne and Wear NHS Foundation Trust

IPC-PGN-05 – Reporting and notifying infectious diseases – V04 – Apr 17

Part of NTW(C)23 – Infection, Prevention and Control

1  Introduction

1.1 In order to inform the Infection Prevention and Control (IPC) function of Northumberland, Tyne and Wear NHS Foundation Trust (the Trust/NTW), it is necessary to maintain a good information system that collects timely data on the occurrence of infectious diseases across the organisation.

1.2 The National Patient Safety Agency (NPSA) has published a document "NPSA Seven Steps to Patient Safety", which concludes that, in respect of reporting –

"Research has shown that the more incidents are reported, the more information is available about what is going wrong, and the more action can be taken to make healthcare safer. That is why it is important that all staff, both clinical and non-clinical, have the confidence and knowledge to report all patient safety incidents. Analysis at a national level will enable service-wide action where patterns, clusters or trends reveal the scope to reduce risk or prevent recurrence for future patients."

1.1.  This Trust will use a number of methods to collect and analyse data on the occurrence of infectious diseases, and feedback this data to clinicians and managers on a regular basis.

2 Reporting of infectious diseases under the Trust's policy and procedure for reporting accidents and incidents

2.1 The following are examples of cases of infectious disease that should be reported using the Trust’s local reporting systems under the Trust's policy NTW(O)05 – Incidents (including reporting accidents and incidents). The list is not exclusive and all suspected or confirmed infectious incidents should be discussed with the Infection, Prevention and Control Team (IPCT)/Matron and the Trust's Patient Safety Manager informed.

2.2 A doctor who knows or suspects that a patient is suffering from one of the infectious diseases listed in Appendix 1 or Appendix 2 should notify the IPCT/Matron immediately. Notification should not be dependant upon laboratory confirmation but made at the time of clinical diagnosis.

2.3 Conditions and organisms that may give rise to hospital outbreaks or may have significant implications in terms of infection prevention.

2.4 All cases of infectious disease which appear to have been acquired in hospital, including food borne illness, cases of infectious gastroenteritis and other health care associated infections.

2.5 All cases of infectious disease where there is evidence of/or likely to be ongoing transmission.

2.6 Those diseases listed in Appendix 1 - Reportable Diseases

2.7 All cases of infectious diseases notifiable to Public Health England under Law or Regulation (also to Corporate Services - see section later in this practice guidance note (PGN) and Appendix 2 - Notifiable Disease)

2.8 Any other disease caused by a particular infectious agent where the Director of Infection, Prevention and Control (DIPC) has decided that cases of that disease should be reported for a temporary or permanent period of time

2.9 There may be circumstances when it is also appropriate to report certain cases via web-based reporting ; See the Trust's policy, NTW(O)05 – Incidents (including Serious and Untoward Incidents).

2.10 Reporting applies to members of staff and visitors to Trust premises, as well as to service users.

2.11 For single cases affected by one of the circumstances listed above in either patients, visitors or staff a separate report should be completed. In cases of an outbreak affecting 2 or more people individual reporting may not be necessary.

2.12 The responsibility for reporting the incident lies with the senior member of staff in charge of the clinical or non-clinical area when the incident is reported. It is not the responsibility of the IPCT/Matron to report the incident although they will offer advice and assistance in their completion.

3 Reporting of infectious diseases under the Trust's Incident Policy (NTW(O)05)

3.1 A serious and untoward incident is defined as:

3.2 An accident or incident (including near misses) when a patient, member of staff or a member of the public suffers injury or unexpected death, or the risk of death or injury, either in hospital or on other health service premises where health care is provided or

3.3 Where actions of health services are likely to cause significant public concern.

3.4 The following are examples of cases of infectious disease that must be reported under the Trust's NTW(O)05 Incident policy, in addition to routine reporting as in Section 2. The list is not exclusive and all cases of infectious illness should be discussed with the IPC T/Matron.

3.5 All cases of infectious disease where a service user or member of staff dies, nearly dies, or suffers significant harm or injury

3.6 All cases of diseases notifiable to Public Health England under Law or Regulation (see Appendix 2 - Notifiable Diseases)

3.7 All cases of infectious disease where there may be significant Public Health implications, for example an infectious agent associated with high mortality or infectivity, or spread into the community. This would include, for example, tuberculosis and serious cases of food borne illness.

3.8 All cases of infectious disease where significant disruption to the services provided by the Trust might be involved, for example the closure of a number of wards or an entire service.

3.9 Any circumstance where there may be interest from the media.

3.10 Any circumstance where there is a possibility that an infective agent has been released or used with the intention of causing harm.

4 Diseases that must be notified under law or regulation.

4.1 A large number of infectious diseases must be notified to the local North East Public Health England Centre [PHE] Health Protection Team under the Public Health (Control of Disease) Act 1984 and the Health Protection (notification) Regulations 2010. These diseases are listed in Appendix 2 at the end of this Practice Guidance Note.

4.2 The list contains a number of common infections seen in hospital and community settings and the requirement to report these is often overlooked.

4.3 It is the legal responsibility of the doctor making the diagnosis to ensure that cases of these diseases are reported to the local North East PHE Health Protection Team and this responsibility cannot be delegated to or assumed by any other person.

4.4 The IPCT/Matron must be informed of all cases of notifiable diseases diagnosed on Trust premises.

5 The role of the Infection Prevention and Control (IPC) Team

5.1 The IPC Team will fulfil the following functions in respect of the reporting and notification of infectious disease –

·  Act as a resource and support to all clinical and non clinical staff

·  To work with the Trust's Patient Safety Manager to ensure an up to date knowledge of the occurrence of infectious diseases across the organisation

·  To alert staff to the requirement to report or notify cases of infectious diseases as appropriate

·  To offer advice and assistance to staff in completion of web-based reporting forms and notification of diseases to the local North East PHE Health Protection Team

·  To undertake "look back" exercises as appropriate

·  To undertake occasional longitudinal or cross-sectional surveys

·  To assist with the production of the Annual Report of the Director of Infection, Prevention and Control

5.2 The IPCT/Matron will also be available to provide clinical advice on individual cases or clusters of infection, and to act proactively if they become aware of the occurrence of unusual patterns or frequency of infection in the Trust.

6 Reporting back to clinicians and managers

6.1 Regular reports on incidents reported will be provided through the routine SAFEGUARD reporting mechanisms. These reports are available on request by clinical staff and managers and are reviewed by the Infection Prevention and Control Committee, Quality Performance Committee and Trust Board (through exception reporting) on a regular basis. These reports give the most up to date information on the position of infection prevention and control within the Trust.

6.2 Incidents reported under the serious and untoward incident policy may be subject to further formal investigation. The Patient Safety Committee reviews recommendations arising from these investigations monthly.

6.3 The Annual Report of the Director of Infection Prevention and Control will include a summary of the occurrence of infectious diseases in the Trust. The Report is formally reviewed by the Trust Board annually and published for public viewing thereafter.

6.4 Exceptional incidents are reported back to the Trust Board, Quality and Performance Committee and Patient Safety Committee as and when necessary.

6.5 Urgent information and updates to Practice Guidance Notes is made available on the Trust Intranet.

Appendix 1

Notifiable/Reportable Diseases

Infectious diseases that must be reported to the Trust's Patient Safety Manager via web-based reporting forms

·  All cases of these diseases must be reported to the IPCT and the Patient Safety Manager under the Trust's policy and procedure for reporting accidents and incidents – (NTW(O))05 Incident Policy including serious untoward incidents)

List of notifiable organisms (causative agents):

The Causative agents identified below are notifiable to PHE under the Health Protection (Notification) Regulations 2010:

·  Bacillus anthracis

·  Bacillus cereus (only if associated with food poisoning)

·  Bordetella pertussis

·  Borrelia spp

·  Brucella spp

·  Burkholderia mallei

·  Burkholderia pseudomallei

·  Campylobacter spp

·  Chikungunya virus

·  Chlamydophila psittaci

·  Clostridium botulinum

·  Clostridium perfringens (only if associated with food poisoning)

·  Clostridium tetani

·  Corynebacterium diphtheriae

·  Corynebacterium ulcerans

·  Coxiella burnetii

·  Crimean-Congo haemorrhagic fever virus

·  Cryptosporidium spp

·  Dengue virus

·  Ebola virus

·  Entamoeba histolytica

·  Francisella tularensis

·  Giardia lamblia

·  Guanarito virus

·  Haemophilus influenzae (invasive)

·  Hanta virus

·  Hepatitis A, B, C, delta, and E viruses

·  Influenza virus

·  Junin virus

·  Kyasanur Forest disease virus

·  Lassa virus

·  Legionella spp

·  Leptospira interrogans

·  Listeria monocytogenes

·  Machupo virus

·  Marburg virus

·  Measles virus

·  Mumps virus

·  Mycobacterium tuberculosis complex

·  Neisseria meningitidis

·  Omsk haemorrhagic fever virus

·  Plasmodium falciparum, vivax, ovale, malariae, knowlesi

·  Polio virus (wild or vaccine types)

·  Rabies virus (classical rabies and rabies-related lyssaviruses)

·  Rickettsia spp

·  Rift Valley fever virus

·  Rubella virus

·  Sabia virus

·  Salmonella spp

·  SARS coronavirus

·  Shigella spp

·  Streptococcus pneumoniae (invasive)

·  Streptococcus pyogenes (invasive)

·  Varicella zoster virus

·  Variola virus

·  Verocytotoxigenic Escherichia coli (including E.coli O157)

·  Vibrio cholerae

·  West Nile Virus

·  Yellow fever virus

·  Yersinia pestis

Appendix 2

In addition to the causative organisms in Appendix 1, the following list of diseases are notifiable to local authority proper officers under the Health Protection (Notification) Regulations 2010:

·  Acute encephalitis

·  Acute infectious hepatitis

·  Acute poliomyelitis

·  Acute meningitis

·  Anthrax

·  Botulism

·  Brucellosis

·  Cholera

·  Diphtheria

·  Enteric Fever (Typhoid and Parathyphoid)

·  Food Poisoning

·  Haemolytic Uraemic syndrome (HUS)

·  Infectious bloody diarrhoea

·  Invasive Group A Streptococcal Infection

·  Legionnaires disease

·  Leprosy

·  Malaria

·  Measles

·  Meningococcal septicaemia

·  Mumps

·  Plague

·  Rabies

·  Rubella

·  Severe Acute Respiratory Syndrome (SARS)

·  Scarlet fever

·  Small Pox

·  Tetanus

·  Tuberculosis

·  Typhus

·  Viral haemorrhagic fever

·  Whooping cough

·  Yellow fever

These and other diseases that may present significantrisk to human health may be reported under other significant disease category

·  It is the legal responsibility of the clinician making the diagnosis to ensure that these diseases are reported to the local PHE Health Protection Team. The reporting clinician should complete Appendix 3

·  Cases of these diseases must also be reported to the IPC Team and under the Trust's Incident Policy NTW(O)05