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National Infection Prevention and Control Manual

National Infection Prevention and Control Manual

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 care settings; (that is, NHSScotland, independent contractors providing NHS services and private providers of care).

This guidance is aligned to the Management of Public Health Incidents: Guidance on the Roles and Responsibilities of NHS led Incident Management Teams (2017)

Built environment incidents/outbreaks

HPS are currently working towards delivery of comprehensive evidence-based guidance which will form Chapter 4 of the National Infection Prevention and Control Manual (NIPCM) on the built environment and decontamination. 

In the interim two Aide-Memoires have been produced to provide best practice recommendations to be implemented in the event of a healthcare water-associated or healthcare ventilation-associated infection incident/outbreak.  These will ensure clinical staff, estates and facilities staff, and Infection Prevention and Control Teams (IPCT) have an understanding of the preventative measures required and the appropriate actions that should be taken.

Prevention and management of healthcare water-associated infection incidents/outbreaks

Prevention and management of healthcare ventilation-associated infection incidents/outbreaks



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.


  • 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.

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:
  • 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.
    • If the HIIAT is assessed as Green and there is no HPS support required then this should be reported as per DL(2019)23. If support is required this should be communicated to HPS. The HIIAT Green reporting protocol, procedure and template is available from the resources section.
    • If the HIIAT is assessed Amber or Red report to HPS. Healthcare Infection Incident 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 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. A draft agenda for the IMT is available.
  • The membership of the IMT will vary depending on the nature of the incident.
  • 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 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.
  • Identify and count all cases and/or persons exposed: This includes the total number of confirmed/probable/possible exposed cases. An incident/outbreak data collection tool is available.
  • 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:
    • Generate hypotheses as to which cross-transmission pathways and clinical procedures may be involved.
    • Determine whether additional case finding and control measures may be necessary.
    • Confirm that all incident control measures are being applied effectively and are sufficient.
  • If staff screening is being considered as part of the investigation DL (2020)1 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.
  • 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.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.