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.
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.
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.
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.
3.3 COVID-19 Definition of confirmed and suspected case
COVID-19 case definitions are regularly reviewed and can be found in the guidance for secondary care and are defined as:
A laboratory confirmed (detection of SARs-CoV-2 RNA in a clinical specimen) case of COVID-19.
An individual meeting one of the following case criteria taking into account atypical and non-specific presentations in older people with frailty, those with pre-existing conditions and patients who are immunocompromised;
recent onset new continuous cough
loss of/change in sense of taste or smell (anosmia)
Definition for individuals requiring hospital admission:
clinical or radiological evidence of pneumonia
Acute Respiratory Distress Syndrome
influenza-like illness (fever greater than or equal to 37.8֯C and at least one of the following respiratory symptoms, which must be of acute onset – persistent cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing, sneezing)
a loss of, or change in, normal sense of taste or smell (anosmia) in isolation or in combination with any other symptoms
3.4 COVID-19 Notification of positive cases
It is essential that NHS Boards have systems in place to ensure that laboratory confirmed cases of SARS-CoV-2 isolated from patients are reported to Infection Prevention and Control Teams (IPCTs) as promptly as possible to allow any inappropriately placed patients to be identified and isolated.
Reporting systems should also be in place to alert the relevant teams of any positive staff cases. There must be a robust and clear process in place for recording and communication of results to staff members.
The Occupational Health Service (OHS) will be key to this process. Staff who have a positive result may require advice, counselling and support. Staff confidentiality and records of test results must be maintained securely. It is recognised that staff in some organisations such as Scottish Ambulance Service, do not fall under the remit of OHS but will be captured under the test and protect service.
COVID-19 is a notifiable disease and as such, directors of diagnostic laboratories must inform their health board, the common services agency and Public Health Scotland of all COVID-19 isolates. This is a requirement of the Public Health etc (Scotland) Act 2008 and notification of infectious disease or health risk forms are available.
3.4.1 Communicating results
On confirmation of a positive COVID-19 patient isolate, the ward staff should be informed by the reporting laboratory or IPCT if the patient is still an inpatient. There must be agreed processes in place for communicating results and IPC advice out of hours when IPCTs are not available.
IPCTs should agree local notification process for any patients who have been discharged home since the COVID-19 test was undertaken to ensure that the patient is contacted at home and provided with the appropriate self-isolation advice.
There should be processes in place to ensure that IPCTs and OHS share intelligence which may indicate an outbreak is occurring in a specific ward/department.
3.4.2 Communication with other care facilities and NHS boards
Where a confirmed case or an identified contact has been transferred to another care facility (care home, hospice, mental health facility), the facility must be notified as soon as possible to make them aware of the positive COVID-19 result or COVID-19 exposure to ensure that the appropriate control measures can be implemented. There should be a local agreement in place to determine whether clinical teams or IPCTs will notify the facility and HPTs where required. Local agreements should include reporting arrangements out of hours.
If a confirmed case or an identified contact has been transferred to another NHS board,
the receiving NHS board must be notified by the IPCT or clinical team and alert them to the positive COVID-19 status or exposure to ensure the appropriate control measures are implemented as per the Scottish COVID-19 IPC addendum.
Similarly, if a confirmed case has transferred from another board within 48 hours of symptom onset or positive test, the IPCT must inform the NHS board from which the patient transferred to allow risk assessment to be undertaken and contacts to be identified.
Active surveillance should be undertaken by IPCTs to allow outbreaks to be detected at the earliest possible opportunity.
3.5 COVID-19 Outbreak definitions
The definitions below should be applied to determine if a COVID-19 outbreak within a healthcare setting is occurring and determine when it can end. When assessing patient and staff clusters to determine if an outbreak is occurring, a high degree of suspicion should be applied.
3.5.1 Criteria to declare a COVID-19 outbreak in an inpatient setting
Two or more patient or staff cases of COVID-19 within a specific setting where nosocomial infection and ongoing transmission is suspected. For the purposes of this reporting, a high degree of suspicion should be applied and should be completed for any non-COVID-19 ward where there are unexpected cases of suspected or confirmed COVID-19. e.g. any cases that were not confirmed or suspected on admission. No time limit should be applied to determining whether a case is nosocomial e.g. 48 hours.
In High Risk Pathway where two or more staff cases of suspected or confirmed COVID-19 are identified.
Note: If there is a single suspected or confirmed case in a patient who was not suspected as having COVID-19 on admission, this should initiate further investigation and risk assessment This single case may constitute a possible cluster or an outbreak depending on the contacts and exposures identified. Where patient has been in a side room with transmission based precautions in place for 48 hours prior to symptom onset, and where all staff were wearing appropriate PPE appropriately, the IPCT may decide that there is no further action needed other than active monitoring for any new unexplained cases associated with the ward.
3.5.2 Criteria to determine that a COVID-19 outbreak in an inpatient setting has ended
No new test-confirmed or suspected cases with illness onset date 14 days following the last new confirmed case (from date of symptom onset or date of positive test if case has remained asymptomatic), within the affected ward or department. The outbreak can be declared closed provided that these criteria are met. Stepdown guidance and further information on isolation periods can be accessed .
3.6 COVID-19 Roles and Responsibilities
NHS Boards should have a COVID-19 outbreak response plan which details the roles and responsibilities of Infection Prevention and Control Teams (IPCTs) ,Health Protection Teams (HPTs) and the occupational health services (OHS) within their board when responding to COVID-19 outbreaks.
3.6.1 Convening an Incident Management Team (IMT)/Problem Assessment Group (PAG)
In a healthcare setting, the CPH(M) or the Infection Prevention and Control Doctor (IPCD) will chair the IMT depending on the circumstances and this should be agreed in advance and documented in the COVID-19 outbreak response plan. The ICD will usually chair the IMT, lead the investigation and management of incidents limited to the healthcare site, where no external agencies are involved and where there are no implications for the wider community. The CPH(M) would normally chair the IMT where there are implications for the wider community.
More information on IMTs and PAGS can be found in the Management of Public Health incidents: guidance on the roles and responsibilities of NHS led Incident Management Teams
An IMT generic COVID-19 agenda and a supporting agenda aide memoire in for use by the chair or wider IMT members to support consistency in discussion points during COVID-19 IMTs across NHS Scotland are available.
3.6.2 Contact tracing responsibilities
The board COVID-19 outbreak response plan should include clarity on the responsible teams for contact tracing and follow up amongst the following groups of individuals:
- Community contacts of an inpatient prior to admission
- Healthcare workers and wider staff groups
Typically, IPCTs will follow up inpatient contacts, OHS will follow up staff contacts and HPTs will follow up any contacts in the exposure period prior to hospital admission and visitors.
3.6.3 Case definition for the incident
A case definition for the purpose of the incident must be agreed by the IMT and should include the following:
- the people involved (patients, staff, visitors);
- the pathogen (SARS-CoV-2);
- the place (the ward and hospital);
- a time period (commencing 48 hours prior to index case symptom onset or positive test if asymptomatic).
Suggested case definitions for COVID-19 as follows;
- Confirmed case (Recorded as confirmed case in reporting tool): PCR positive COVID-19 test in anyone associated with ward ** during a specified time period
- Probable case (Recorded as suspected (symptomatic) case in reporting tool): Anyone on ward ** with symptoms of COVID-19 during a specified time period
- Possible case (Recorded as contacts (asymptomatic) in reporting tool): Anyone who has been exposed to COVID-19 on ward ** during a specified time period but not yet developed symptoms
3.7 COVID-19 Investigations
The extent of the outbreak investigations should be decided by the IMT with an emphasis on active case finding and identifying any factors which have contributed towards the development of the outbreak. Investigations undertaken and subsequent findings should be documented by the IMT.
3.7.1 Epidemiological data/Timelines
A basic epidemiological investigation characterising the outbreak in time, place and person should be undertaken. This process will help identify potential sources and mode of transmission.
3.7.2 Identifying missed opportunities to isolate
Review of patient cases should consider any potential missed opportunities to isolate a patient, a delay in which may have resulted in onward transmission. In particular, consider any missed atypical presentation of COVID-19. Any learning should be widely communicated to all clinical staff in the board.
3.7.3 IPC practice and compliance (including AGPs)
Compliance with IPC practice on the ward should be reviewed to determine any practice which may have contributed towards onward transmission. Previous hand hygiene audits and any audits of staff practice and the environment undertaken should be reviewed to establish any education gaps which are required to be addressed.
Where AGPs are undertaken on the ward, IPCTs should check to ensure staff are wearing the appropriate PPE and the correct fallow times are being observed prior to other patients using the room in which the AGP was undertaken. The IMT may choose to repeat audits as part of the outbreak investigation.
Ensure that staff on the ward are compliant with COVID-19 IPC guidance contained within the Scottish COVID-19 addendum.
Ensure that patients are wearing face masks appropriately as per the Scottish COVID-19 addendum.
3.7.4 Review of visiting
When investigating an outbreak of COVID-19, ascertain from ward staff if there has been any non-compliance with visiting rules for example, visitors presenting symptomatic, declining to wear face coverings or non compliance with physical distancing. Consider what, if any, measures need to be introduced to mitigate any risks identified.
3.7.5 Testing during an outbreak
Proactive case finding should be supported through selected testing of any suspected symptomatic cases and when indicated, asymptomatic testing as determined by the IMT. The highest level of benefit in terms of reducing transmission will be from identifying those most likely to have been infected. The highest level of benefit in terms of reducing harm will be from detecting asymptomatic positive cases who may transmit the infection.
Patients: All patients symptomatic of COVID-19 should be tested.
Staff: All staff who are symptomatic of COVID-19 must be tested and excluded from work. Follow COVID-19: Management of exposed healthcare workers and patients in hospital settings.
3.7.6 Whole Genome Sequencing
Public Health Scotland now offer a sequencing service to expedite outbreak investigations and address important clinical and epidemiological questions.
3.7.7 Contact tracing
This is a 2 step process involving identification of contacts and then risk assessing which contacts will require self-isolation.
Anyone who has been in the same room/area with the confirmed case in the 48 hours prior to symptom onset (or 48 hours prior to positive test if asymptomatic) until the point when the confirmed case was appropriately isolated/cohorted/discharged should be considered as a potential healthcare setting contact.
The case definitions below should be applied to determine who is a potential contact requiring self-isolation and should take account of all staff, patients and visitors. IPCTs should then consider any mitigating factors which will exclude staff being identified as a contact and avoid the need for these staff having to be excluded from work.
Case definitions for contacts
A contact is defined as a person who, in the period 48 hours prior to and 10 days after the confirmed case’s symptom onset, or date a positive test was taken if asymptomatic and had at least one of the exposures listed below.
- Those that are living in the same household as a case for example those that live and sleep in the same home, or in shared accommodation such as university accommodation that share a kitchen or bathroom.
- Those that do not live with the case but have contact within the household setting.
- Those that have spent a significant time in the home (cumulatively equivalent to an overnight stay and without social distancing e.g. 8 hours or more) with a case during the infectious period.
- Sexual contacts who do not usually live with the case.
- Cleaners (without protective equipment) of household settings during the infectious period, even if the case was not present at the time.
- Face to face contact with a case within 1 metre for any length of time, including: being coughed on.
- Having a face-to-face conversation.
- Having skin-to-skin physical contact.
- Any contact within 1 metre for one minute or longer without face-to-face contact.
- A person who has travelled in a small vehicle with someone who has tested positive for coronavirus (COVID-19); or in a large vehicle near someone who has tested positive for coronavirus (COVID-19).
- A person who has been between 1 and 2 metres of someone who has tested positive for coronavirus (COVID-19) for more than 15 minutes, cumulatively, during the period defined above.
Contact tracing patients
Typically, any patients in the same bed bay as a confirmed case should be considered household contacts. For larger open bedded areas such as ITUs or nightingale wards the proximity contact definition may be used however, as a minimum this should include patients on either side of the confirmed case and an assessment of the whole area/ward must take account of the patient group and circumstances surrounding potential exposures such as:
- Whether or not all the patients were bed bound (e.g in an ITU area).
- Whether or not the confirmed case had an AGP performed during the exposure period.
- The patient population and patients who may mobilise between bed spaces including the confirmed case.
- Any reported suspected COVID-19 symptomatic cases in other parts of the ward or department.
- Ventilation; is the area poorly ventilated? i.e only natural ventilation and windows have been closed?
Depending on the findings of the considerations above and any other potential contributing transmission risks, the IMT may decide that all the patients and staff in the large open bedded area should be considered contacts.
For cases who have been in a single side room for the exposure period, only staff, patients and visitors who have entered the room of the confirmed case should be considered potential contacts. If the confirmed case has entered the room of any other patients or shared communal spaces with others, these should also be considered as potential contacts.
IMTs must also consider any patient transfers to other areas of the hospital within the exposure period e.g radiology, shops, other wards and consider any potential contacts in these areas.
Contact tracing staff
The flow chart in appendix 1 should be used to assess staff contacts in the healthcare setting and assumes that staff who have worn PPE have had training in its use and that the PPE worn at the time of contact met technical and quality standards.
Contact tracing visitors
It is essential that ward staff keep comprehensive lists of all visitors who have come into the ward. These lists should be provided to Test and Protect teams when an outbreak is recognised to enable contact tracing of visitor contacts. Teams should take into account the PPE worn by visitors when considering them as possible contacts requiring self-isolation. Details of visitor PPE can be found within the Scottish COVID-19 addendum .
It should be noted that whilst visitors may have worn PPE as advised by staff, they are not trained in donning and doffing and therefore there remains a higher risk of exposure.
3.7.8 Ventilation considerations
Learning from the COVID-19 pandemic to date has highlighted the risk of COVID-19 transmission associated with closed environments that have poor ventilation. It is important to consider best practice on ventilation and FAQs developed specifically in response to the COVID-19 pandemic. The impact of the ventilation and any contribution it may have had to the onward transmission of COVID-19 should be noted for future learning and wherever possible mitigated.
The following should be considered when deciding if the ventilation may have been a contributing factor in the outbreak;
- Is the planned preventative maintenance (PPM) programme up to date?
- When was the last PPM check performed?
- Is ventilation system functioning within normal set parameters?
- Are ventilation grilles, AHU, ductwork etc clean and free from dust/debris?
- Is cleaning schedule for the above up to date?
- Does the ventilation system meet current specification?
3.7.9 Bed spacing
Bed spacing in the affected ward should be reviewed to ensure that it is adequate to prevent onward transmission of Healthcare Associated Infections (HAIs) and to ensure that mitigation measures implemented to support physical distancing are adequate. See section 5.12.1 of COVID-19 addendum.
3.7.10 Review of physical distancing
Physical distancing amongst patients and staff should be reviewed by the IMT.
Non-compliance with physical distancing by staff, particularly during breaks, when car sharing and outside of work, has been regularly reported as a factor in the development of outbreaks in the healthcare setting. Review of staff meeting rooms, changing rooms, break facilities, and other non clinical meeting areas are important to detect and control transmission between staff.
Patients must be reminded of the importance of physical distancing and refraining from entering the bed space/zone of other patients.
Organisations should ensure there are engineering and administrative measures in place wherever possible to support physical distancing such as floor markings, physical barriers, staggered tea breaks and promotional signage.
3.7.11 COVID-19 messaging
IMT should consider if the COVID-19 messaging in the ward for both staff, patients and visitors is adequate. COVID-19 messaging should be in place to promote;
- Physical distancing
- Hand hygiene
- Appropriate use of face masks and face coverings
- Awareness of COVID19 symptoms & requirement for patients/staff/visitors to report symptoms to staff
- No visiting if symptomatic
- Staff testing
Every opportunity to promote this messaging should be considered.
3.8 COVID-19 Formulate hypothesis
A hypothesis or hypotheses should be generated at the first IMT. The hypothesis should address the potential source and mode of transmission. The hypothesis should be re-visited at every IMT and consideration given as to whether it remains to be the most probable cause of the outbreak.
3.9 COVID-19 Control Measures
Control measures should be implemented immediately to prevent onward transmission of COVID-19. These must include:
3.9.1 Patient placement
- The PAG/IMT must agree the most appropriate placement for the suspected/confirmed cases and any contacts that are identified.
- Ideally, those who are confirmed cases of COVID-19 should be transferred to the High Risk (Red) Pathway as soon as possible.
- Cohort areas may be established where required and may consist of the following;
- Confirmed positive COVID-19
- Asymptomatic contacts of COVID-19
- Suspected cases (symptomatic) should be isolated on the ward and tested for COVID-19 as soon as possible. Symptomatic patients should not be cohorted together. The cohorting of symptomatic patients’ risks transmission of other respiratory viruses whilst the causative pathogen remains unknown.
- Doors to isolation rooms and cohorts should be closed and signage clear.
- Patient placement is regularly reviewed and documented in patient case notes.
- Restrict transfers to any other ward or department unless essential.
- Depending on the degree of exposure to the index case/s, the number of patients exposed, type of department in which the outbreak has occurred, the clinical needs of the patients and where staffing allows, it may be necessary to leave the contacts in the low or medium risk COVID-19 pathway and apply cohort nursing – a local risk assessment should be undertaken by the IMT and take account of whether the ward will remain open or closed.
Any asymptomatic contacts should be isolated or remain cohorted together until the 14 day isolation period has elapsed.
During the isolation period, contacts must be managed in the same manner as a confirmed case on the High risk pathway.
- If a contact develops symptoms during the 14 day isolation period, testing should be performed as soon as possible. If a contact tests positive for COVID-19 they should be transferred to the High Risk (Red) pathway as soon as possible to complete their isolation period which should be reset to commence from the day of symptom onset.
- All efforts should be made to dedicate staff to the management of the cohort and ideally those staff must not then go between the case and contacts and all other unaffected patients on the ward. These staff cohorts should be maintained wherever possible for the duration of the isolation period.
3.9.2 Hand hygiene
- Reinforce hand hygiene techniques and opportunities to all staff groups and ensure hand hygiene signage is in place
- Adequate supplies of ABHR and plain liquid soap is available.
- Ensure patients are supported with hand hygiene where required and symptomatic patients are provided with disposable tissues and waste bag for disposal.
3.9.3 Personal Protective Equipment
- Reinforce appropriate PPE use as per COVID-19 IPC addendum (general use and AGP) to all staff groups
- Ensure adequate PPE supplies are available
3.9.4 Safe Management of care Equipment
- All non essential items of equipment and any clutter removed from ward to aid cleaning.
- Dedicated equipment for the affected areas where possible. Ensure equipment is cleaned as per appendix 7 of NIPCM.
3.9.5 Safe Management of Care Environment
- As a minimum, twice daily cleaning with chlorine based detergent is in place throughout the ward paying close attention to touch surfaces
- Terminal clean is undertaken following a patient transfer, discharge, once the patient is no longer considered infectious and prior to ward reopening.
3.9.6 Waste and Linen
- Waste associated with the affected area is disposed of as category B waste and in line with COVID-19 addendum.
- All linen used by patients in the affected area should be managed as infectious linen in line with COVID-19 addendum.
- When a bed is vacated and the linen removed, new linen should not be put in place until the ward or bed bay has been terminally cleaned and is ready to re-open to admissions and transfers.
- Ward staff provided with regular updates and support regarding outbreak management.
- The number of staff entering the ward should be restricted as far as possible. The number of staff on wards rounds should be reduced to essential staff only. Non-essential patient assessments by staff external to the ward should be postponed until the outbreak is closed.
- Staff should be cohorted to the symptomatic patients and any contacts and avoid caring for other unaffected patients on the ward wherever possible.
- Regular symptom vigilance must be in place at all times especially during outbreaks and arrangements made for staff to leave the ward if symptoms develop during a shift.
3.9.8 Management of staff exposed to a case
- IMTs should refer to the COVID-19: Management of HCW and exposed patients or residents in health and social care settings when managing staff identified as contacts.
- Staff members who have a positive test must inform their line manager and arrangements should be made for them to stop work immediately and return home, avoiding the use of public transport. Local arrangements for transport of infected patients should be followed.
- NHS Boards should have arrangements in place to backfill staff who test positive.
- The staff member who tests positive will need to self-isolate for a period of 10 days, and their households also need to isolate for a period of 10 days as described by NHS Inform in Coronavirus (COVID-19): Guidance for households with possible coronavirus infection.
- In addition, staff who test positive will be contacted by the contact tracing team as part of the Test and Protect programme.
- More information can be found in the healthcare worker testing guidance on the Scottish Government website.
3.9.9 Closure of the ward/unit
- There should be a low threshold for ward closure.
- If cases have limited patient contacts which can all be isolated or cohorted in a closed bed bay, the IMT may decide that it is appropriate to keep the ward open taking account of bed availability and any specialist services provided in the affected ward. This must be reviewed regularly (at least twice daily) and where there is any other symptom onset identified in staff, patients or visitors outside of the affected bay, the ward should be closed to admissions and transfers.
- Where all contacts and subsequent cases are unable to be cohorted, isolated or transferred to the high risk pathway, the ward should be closed to admissions and transfers wherever possible.
3.9.10 Other control measures which may be considered by the IMT
- Visiting restrictions
- Education sessions for staff if knowledge gaps identified
- Wider screening of patients and staff during the outbreak period
3.9.11 Conversion of outbreak ward to high risk pathway
Where bed capacity in the board is extremely limited, the board may consider converting the outbreak ward into a high risk pathway ward to allow confirmed COVID-19 cases to be transferred/admitted to the area and utilise bed capacity within the ward. This is an operational decision which must be carefully considered, documented and undertaken as a last resort. The following must apply;
- If there are contacts on the ward who remain asymptomatic and do not have a confirmed COVID-19 positive test, these may be moved to other wards for the conversion to take place. However, these contacts must be placed in single side rooms on transfer and must be managed as a high risk patient until the 14 day isolation period is complete
- There must be no patients remaining on the outbreak ward who have not yet tested positive for COVID-19 – all patients on the ward must be confirmed COVID-19 before the conversion takes place.
- The incident must remain open on the boards reporting dashboard to ensure all contacts are monitored regardless of where they are placed until the ‘ending an outbreak’ criteria is met.
In choosing to convert the outbreak ward to a high risk pathway ward, IMTs alongside hospital management must weigh up the risk associated with transferring contacts to other wards and the demand for patient beds to accommodate emergency admissions.
3.10 COVID-19 Communications
- Internal outbreak communication plans should be agreed for each NHS board and this should include senior managers within the board, department leads for visiting staff such as clinical teams, phlebotomists, pharmacists, physiotherapists, all support staff, including porters, cleaners, volunteers.
- Regular updates should be reported to ARHAI in line with section 3.11.
- COVID-19 test results should be documented in individual case notes including any IPC advice issued.
- Where guidance can not be followed, this should be risk assessed and documented by the clinical team or IMT.
- Media statements should be prepared by the IMT ready for release should it be required.
- Patients and carers where applicable should be kept informed of all screening investigations and provided with information leaflets where available or advice provided from NHS Inform.
3.11 COVID-19 Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) reporting requirements
Reporting should be led by the IPCT. Reporting of COVID-19 can be split into the following:
- No contacts or exposures identified.
- A single case of unexpected COVID-19 in a patient where COVID-19 was not suspected on admission should be reported to ARHAI Group using the Healthcare Infection Incidents, Outbreaks and Data Exceedance Reporting Tool.
- If no other linked cases are identified, then the incident can be closed after the 14 day follow up. They are not required to be HIIAT assessed.
- Single case with contacts identified.
- A possible cluster of COVID-19 should also be reported to ARHAI using the Healthcare Infection Incidents, Outbreaks and Data Exceedance Reporting Tool.
- They are not required to be HIIAT assessed.
Cluster (possible COVID-19 outbreak as defined in section 3.5)
- A cluster should be assessed using the Healthcare Infection Incident Assessment Tool (HIIAT) as per Appendix 14 of the NIPCM.
- All confirmed clusters/possible outbreaks, must be reported to ARHAI.
- A Healthcare Infection Incidents, Outbreaks and Data Exceedance Reporting Too (HIIORT). should be completed for any HIIAT score of Red or Amber and for any HIIAT Green incident where support from ARHAI Scotland is required/requested.
- HIIORTs must be submitted using the Healthcare Infection Incidents, Outbreaks and Data Exceedance Reporting Tool. The protocol for completion of the tool will be available here soon
- The data submitted above is reported through ARHAI to the Scottish Government Healthcare Associated Infection Policy Unit and it is essential that all fields within the tools are completed to enable reporting requirements to be met.
- Any media statements prepared by the IMT in response to the incident should be shared with ARHAI.
3.12 COVID-19 Learning from the outbreak
As the COVID-19 pandemic continues, it is essential that NHS Boards record and disseminate learning from outbreaks internally and with ARHAI for sharing nationally.
An evaluation of the effectiveness and efficiency of outbreak investigations and control measures will help inform the future management of COVID-19 patients and any COVID-19 outbreaks.
3.13 COVID-19 Outbreak Resources
- Outbreak checklist
- Outbreak data collection tool
- IMT generic COVID-19 Agenda
- IMT generic COVID-19 Agenda Aide-memoire
COVID-19 Appendix 1 - Assessing staff contacts in Acute Settings
This appendix should be used by Health Protection Teams (HPTs), Occupational Health Services (OHS) and Infection Preventon and Control Teams (IPCTs) aiming to apply some consistency in approach to assessment of staff contacts within healthcare and state health and care settings.
- 3.1 Definitions of Healthcare Infection Incident, Outbreak and Data Exceedance
- 3.2 Detection and recognition of a Healthcare Infection incident/outbreak or data exceedance
- 3.3 COVID-19 Definition of confirmed and suspected case
- 3.4 COVID-19 Notification of positive cases
- 3.5 COVID-19 Outbreak definitions
- 3.6 COVID-19 Roles and Responsibilities
- 3.7 COVID-19 Investigations
- 3.8 COVID-19 Formulate hypothesis
- 3.9 COVID-19 Control Measures
- 3.10 COVID-19 Communications
- 3.11 COVID-19 Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) reporting requirements
- 3.12 COVID-19 Learning from the outbreak
- 3.13 COVID-19 Outbreak Resources
- COVID-19 Appendix 1 - Assessing staff contacts in Acute Settings