Download Surveillance and Reporting of Infectious Disease, Healthcare

Surveillance and Reporting Policy for Infectious Disease,
Healthcare Associated Infection and
Antibiotic Resistant Organisms
Post holder responsible for Policy
Judy Potter, Lead Nurse for Infection
Prevention & Control
Author of Policy
Judy Potter, Lead Nurse for Infection
Prevention & Control
Division/ Department responsible for Policy
Specialist Services, Infection Prevention &
Control
Contact details
x2355
Date of original document
January 2007
Impact Assessment performed
Yes/ No
Ratifying body and date ratified
Infection Control & Decontamination
Assurance Group: 24th January 2017
Review date (and frequency of further
reviews)
July 2021 (every 5 years)
Expiry date
January 2022
Date document becomes live
21 February 2017
Please specify standard/criterion numbers and tick  other boxes as appropriate
Monitoring Information
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Maintain Operational Service
Delivery
Assurance Framework
Integrated Community Pathways
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CQC Fundamental Standards - Regulation: 12 and 15
Infection Control

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Note: This document has been assessed for any equality, diversity or human rights implications
Controlled document
This document has been created following the Royal Devon and Exeter NHS Foundation Trust Development,
Ratification & Management of Procedural Documents Policy. It should not be altered in any way without the
express permission of the author or their representative.
Surveillance and Reporting Policy for Infectious Disease, Healthcare Associated Infection and
Antibiotic Resistant Organisms
th
Ratified by: Infection Control & Decontamination Assurance Group: 24 January 2017
Review date: July 2021
Page 1 of 16
Full History
Version
1.0
2.0
3.0
4.0
5.0
6.0
Date
January
2007
July 2007
August 2009
Oct 2011
January
2014
Oct 2016
Status: Final
Author (Title not
name)
Lead Nurse
Reason
Lead Nurse
Lead Nurse
Routine revision
Routine revision
Lead Nurse
Lead Nurse
Routine revision
Routine revision
Lead Nurse
Routine revision harmonised with
community services requirements
Associated Trust Policies/ Procedural
documents:
Incident Reporting, Analysing, Investigating &
Learning Policy
Health and Safety Policy
MRSA Policy
Clostridium difficile Infection Policy
Infection Prevention & Control Policy
Multi Drug Resistant Organism Policy
Key Words
Surveillance; notifiable disease notification
In consultation with and date:
Infection Control Operational Group: 14th November 2016
Community Professional Leads, Senior Nurses and Matrons: 19th December 2016
Infection Control & Decontamination Assurance Group: 24th January 2017
Policy Expert Panel (PEP): 1st February 2017
Contact for Review:
Lead Nurse, Infection Prevention & Control
Executive Lead Signature:
(Only applicable for Strategies & Policies)
Medical Director
Surveillance and Reporting Policy for Infectious Disease, Healthcare Associated Infection and
Antibiotic Resistant Organisms
th
Ratified by: Infection Control & Decontamination Assurance Group: 24 January 2017
Review date: July 2021
Page 2 of 16
CONTENTS
1.
INTRODUCTION.............................................................................................. 4
2.
PURPOSE ....................................................................................................... 4
3.
DEFINITIONS .................................................................................................. 4
4.
DUTIES AND RESPONSIBILITIES OF STAFF ............................................... 4
5.
ALERT ORGANISM AND CONDITION SURVEILLANCE ............................... 6
6.
VOLUNTARY TARGETED SURVEILLANCE .................................................. 9
7.
MANDATORY SURVEILLANCE ..................................................................... 9
8.
SERIOUS INCIDENTS REQUIRING INVESTIGATION ................................. 10
9.
PATIENT AND PUBLIC INFORMATION ....................................................... 10
10.
ARCHIVING ARRANGEMENTS .................................................................... 11
11.
PROCESS FOR MONITORING COMPLIANCE WITH AND EFFECTIVENESS
OF THE POLICY............................................................................................ 11
12.
REFERENCES............................................................................................... 12
APPENDIX 1: COMMUNICATION PLAN.................................................................. 13
APPENDIX 2: EQUALITY IMPACT ASSESSMENT TOOL....................................... 14
Surveillance and Reporting Policy for Infectious Disease, Healthcare Associated Infection and
Antibiotic Resistant Organisms
th
Ratified by: Infection Control & Decontamination Assurance Group: 24 January 2017
Review date: July 2021
Page 3 of 16
1.
INTRODUCTION
1.1
Surveillance is an essential component of infection prevention and control
(Department of Health/Public Health Laboratory Service, 1995). High quality
information on infectious diseases, healthcare associated infection and
antimicrobial resistant organisms is essential for monitoring progress,
investigating underlying causes and applying prevention and control
measures (DH, 2003a).
1.2
Surveillance will be undertaken as part of a national surveillance scheme or
may involve the use of a locally defined protocol. Some national surveillance
schemes are mandatory, others are voluntary.
1.3
All surveillance systems have four key components (DH/PHLS, 1995)


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
Data collection using standard case definitions
Collation of data
Analysis and interpretation
Timely dissemination of information
1.4
Failure to comply with this policy could result in disciplinary action.
2.
PURPOSE
2.1
The purpose of this policy is to provide a framework to:





Monitor the incidence of infection
Provide early warning and investigation of problems and subsequent
planning and intervention to control
Monitor trends, including the detection of outbreaks
Examine the impact of interventions
Ensure compliance with mandatory surveillance systems
3.
DEFINITIONS
3.1
All definitions are provided within sections 5-8 below.
4.
DUTIES AND RESPONSIBILITIES OF STAFF
4.1
Board of Directors
The Board of Directors, through the Chief Executive and the Medical Director,
will delegate to the Joint Directors of Infection Prevention and Control
responsibility for ensuring that there is a surveillance system and processes
in place for the surveillance of infection that meet local and national
requirements:
4.2
Chief Executive
The Chief Executive is responsible for ensuring that the mandatory
surveillance data entered on the Public Health England health care
associated infection data capture system is ‘signed off’ by the 15th of each
month.
Surveillance and Reporting Policy for Infectious Disease, Healthcare Associated Infection and
Antibiotic Resistant Organisms
th
Ratified by: Infection Control & Decontamination Assurance Group: 24 January 2017
Review date: July 2021
Page 4 of 16
4.3
Joint Directors for Infection Prevention and Control (DsIPC)
The Joint DsIPC are responsible for:


4.4
Divisional Directors, Associate Medical Directors and Assistant
Directors of Nursing
Each divisional management team is responsible for:



4.5
Providing assurance to the Board of Directors that adequate systems
and processes are in place
Publishing key elements of surveillance activities in their annual report
Using the outcome data from surveillance activities to inform action
plans for improvement
Ensuring that investigations into cases of C.difficile infection and other
significant infections, as advised by the Infection Prevention and Control
Team, are undertaken using principles of root cause analysis, action
plans formulated and learning shared
Monitoring any action plans through the Divisional Governance Group
and ICDAG
Infection Prevention and Control Team (IPCT) is responsible for:

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Coordinating surveillance activities
Producing timely feedback of surveillance data to wards/units and
divisions.
Ensuring that patients with first time isolates of key alert organisms and
conditions have an Infection Control (IC) alert placed on the Royal
Devon & Exeter NHS Foundation Trust’s (hereafter referred to as “the
Trust”) Patient Information System (PAS), on the IT system for the ‘out of
hours’ GP service in Devon.
Producing surveillance reports to relevant committees and groups and
for the Board of Directors
Ensuring that data required as part of the mandatory surveillance
programme is reported on the Public Health England (PHE) web based
health care associated infection data capture system
Ensuring that investigations into cases of C.difficile infection are
undertaken using principles of root cause analysis, and action plans are
shared with relevant directorates
Co-ordinating post infection reviews following Trust apportioned MRSA
bacteraemia.
Supporting the investigation of, and learning from cases of C.difficile
infection
Supporting the investigation of, and learning from other types of health
care associated infection as relevant
Investigating suspected incidents of cross infection and outbreaks.
Surveillance and Reporting Policy for Infectious Disease, Healthcare Associated Infection and
Antibiotic Resistant Organisms
th
Ratified by: Infection Control & Decontamination Assurance Group: 24 January 2017
Review date: July 2021
Page 5 of 16
4.6
Microbiology Department
The microbiology laboratory are responsible for:


4.7
Matrons and Other Registered Nurses are responsible for:
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
4.8
Ensuring that relevant patients are screened for MRSA on admission or
pre admission.
Ensuring that relevant patients are screened for CPE carriage on
admission or pre admission.
Ensuring that other specimens are obtained in a timely fashion
Ensuring that arrangements are in place to check for an IC alert on
PAS/Whiteboard to identify patients with a history of an alert organism or
condition.
Ensuring the infection control risk assessment is completed on
admission.
Engaging in the investigation of infection incidents and learning from root
cause analysis events.
Ensuring that alert organisms and conditions are communicated if
patients are transferred between the acute trust and community teams
who may not have access to infection control flags.
Consultant and Other Medical Staff including GPs
Consultants and other medical staff are responsible for:




4.9
Ensuring that appropriate tests are available to support surveillance
activities
Ensuring that results are communicated promptly to clinical teams and
the infection prevention and control team.
Considering surveillance reports pertinent to their specialty
Engaging in improvement work if surveillance data suggests that
improvement is appropriate
Engaging in the investigation of infection incidents and learning from root
cause analysis events.
Reporting notifiable diseases to the ‘Proper Officer’ (refer 5.5.1)
Infection Control and Decontamination Assurance Group (ICDAG)
ICDAG is responsible for:





Ratifying this policy
Approving any actions that may be required for practice improvement
based on the recommendations of significant investigations
Escalating issues and concerns to the Safety and Risk Committee
Using surveillance data to identify areas for improvement
Recommending to the clinical divisional management teams
improvement programmes to rectify any practice concerns
5.
ALERT ORGANISM AND CONDITION SURVEILLANCE
5.1
Alert organisms and alert conditions are those that may give rise to
outbreaks.
Surveillance and Reporting Policy for Infectious Disease, Healthcare Associated Infection and
Antibiotic Resistant Organisms
th
Ratified by: Infection Control & Decontamination Assurance Group: 24 January 2017
Review date: July 2021
Page 6 of 16
5.2
Alert Organisms
5.2.1
Alert organisms are identified in the microbiology laboratory and include
organisms such as MRSA and other antibiotic resistant organisms e.g.
Vancomycin Resistant Enterococci and Extended Spectrum Betalactamases
(ESBLs), Carbapenemase Producing Enterobacteriaceae, Clostridium
difficile, Streptococcus pyogenes, Norovirus and Respiratory Syncytial Virus
(RSV). The Medical Microbiologist is responsible for informing clinical teams
when a new clinical isolate (i.e. not screening specimens) of an alert
organism has been identified.
5.2.2
Advice on the control measures, if needed, will usually be provided by the
IPCT, who will also investigate clusters of cases.
5.3
Using Alert Organism Surveillance to Monitor Performance
5.3.1
MRSA and C.difficile pose particular challenges in acute hospital settings.
Therefore, acute wards/units at the Trust will receive feedback from the IPCT
on the number of new cases per month as part of the Ward to Board Report.
This will enable wards and units to determine the impact, or not, of prevention
and control strategies.
5.3.2
Where appropriate, trends in MRSA and C.difficile acquisition will be reviewed
at Divisional (or Cluster) Governance Group meetings. In addition, the
Directors of Infection Prevention and Control make quarterly reports of
Trustwide data to ICDAG, which in turn reports to the Safety and Risk
Committee.
5.4
Infection Control Flag
Some patients will become long term carriers of alert organisms e.g. MRSA
and other antibiotic resistant organisms. These patients will have an infection
control (IC) alert put onto PAS by the IPCT. In addition, for in-patients at the
Trust, the alert will be displayed automatically on the electronic white board.
It is the responsibility of the clinical staff to contact the IPCT for details about
the type of alert organism a ‘flagged’ patient may be carrying. N.b.
community teams may not have access to PAS or whiteboard so any relevant
information will need to be communicated at the time of referral.
5.5
Alert Conditions
5.5.1
Alert conditions are identified through clinical diagnosis, not laboratory tests,
and therefore staff in clinical areas must inform the IPCT of any suspected
occurrence of these conditions at the earliest opportunity. Alert conditions
include:
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Chicken pox/shingles (Herpes zoster)
Diphtheria
Food poisoning
Influenza
Measles
Meningitis
Meningococcal septicaemia
Mumps
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Rubella
Scabies
Scarlet fever
Severe soft tissue infections
Suspected infective diarrhoea
and/or vomiting
Suspected legionellosis
Tuberculosis
Typhoid/Paratyphoid
Surveillance and Reporting Policy for Infectious Disease, Healthcare Associated Infection and
Antibiotic Resistant Organisms
th
Ratified by: Infection Control & Decontamination Assurance Group: 24 January 2017
Review date: July 2021
Page 7 of 16

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Ophthalmia neonatorum
Other childhood exanthemata
Plague
Poliomyelitis
Pyrexia of unknown origin with history of
foreign travel
Viral haemorrhagic fevers
Viral hepatitis
Whooping cough
5.5
Notifiable Diseases
5.5.1
Some ‘alert’ conditions are ‘Notifiable diseases’ (see list below). This a legal
term denoting diseases that must, by law, be reported to the ‘proper officer’
i.e. the Consultant for Communicable Disease Control (CCDC), who is based
in the Devon, Cornwall and Somerset Health Protection Team.
Downloadable notification forms can be found on the Trust intranet.
5.5.2
It is the responsibility of the physician in charge of each case to make the
notification. It is also the responsibility of the Microbiology Laboratory to
notify the Proper Officer when “Notifiable Diseases” that are identified through
a laboratory investigation.
5.5.3
Diseases that are notifiable are:
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Acute encephalitis
Anthrax
Leprosy
Leptospirosis
Malaria
Rabies
Relapsing fever
Smallpox
Tetanus
Typhus
Yellow Fever
Food poisoning
Dysentery (amoebic or bacillary)
Measles
Rubella
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Meningococcal septicaemia
Viral hepatitis
Ophthalmia neonatorum
Paratyphoid fever
Scarlet fever
Meningitis
Typhoid fever
Diphtheria
Poliomyelitis
Viral haemorrhagic fevers
Cholera
Plague
Tuberculosis
Mumps
Whooping cough
5.6
RIDDOR Reporting
5.6.1
Any infection reliably attributable to the performance of the work of an
employee within the Trust is reportable to the Health and Safety Executive
under the Reporting of Injuries, Diseases and Dangerous Occurrences
Regulations 1995 (RIDDOR). Reporting is normally undertaken by the Safety
& Risk Department on the advice of the Occupational Health Service.
5.6.2
In addition, certain exposures to micro-organisms may also be reportable as
dangerous occurrences e.g. exposure to HIV or Hepatitis B/C as a result of
an inoculation injury. Once again reporting is undertaken by the Safety &
Risk Department.
Surveillance and Reporting Policy for Infectious Disease, Healthcare Associated Infection and
Antibiotic Resistant Organisms
th
Ratified by: Infection Control & Decontamination Assurance Group: 24 January 2017
Review date: July 2021
Page 8 of 16
6.
VOLUNTARY TARGETED SURVEILLANCE
6.1
Venous Access Device Associated Bacteraemia Surveillance
The IPCT will undertake continuous laboratory based ward liaison
surveillance of all positive blood culture isolates at the Trust. Bacteraemias
associated with venous access devices will be investigated and reported on in
the form of a written report to the ICDAG to target appropriate prevention and
control strategies if indicated.
6.2
Other Voluntary Targeted Surveillance
The need for intermittent targeted surveillance of other types of infection or
sub groups of patients will be determined in response to local need and will
be detailed in the annual infection control programme.
7.
MANDATORY SURVEILLANCE
7.1
Mandatory Surveillance of Healthcare-associated Infection
The Trust complies with mandatory surveillance of healthcare-associated
Infection in accordance with the requests made by the Department of Health.
7.2
Laboratory Based Surveillance
Under current requirements, the RD&E reports all of the following, regardless
of the source of the specimen, to the Communicable Disease Surveillance
Centre of the Public Health England:
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Staphylococcal bacteraemia (Meticillin resistant and Meticillin sensitive)
E. coli bacteraemia
Toxigenic Clostridium difficile positive results from patients over the age
of 2,
Bacteraemia caused by Glycopeptide-resistant Enterococci
7.3
Mandatory healthcare associated infection data capture system –
MRSA, MSSA and E.coli Bacteraemia and Clostridium difficile infection
7.3.1
All are reported via the web based data capture system. MRSA bacteraemia
and toxigenic Clostridium difficile positive data are used by the DH and
Monitor as infection control performance indicators.. An enhanced data set
for S. aureus bacteraemia was introduced in 2005 (DH, 2003b) and for
Clostridium difficile infection in 2008 (DH 2008). The IPCT are responsible for
collecting and reporting the additional data via a dedicated secure website.
The Chief Exective ensures that the data entered on the site is ‘signed off’ by
the 15th of each month.
7.4
Formal Investigation using principles of Root Cause Analysis (RCA)
7.4.1
Each Trust is required to undertake an investigation based on the principles
of root cause analysis of each MRSA bacteraemia (this is known as post
infection review) and toxigenic Clostridium difficile where it is cited as cause
of death on Part 1 of the death certificate or results in colectomy.
Surveillance and Reporting Policy for Infectious Disease, Healthcare Associated Infection and
Antibiotic Resistant Organisms
th
Ratified by: Infection Control & Decontamination Assurance Group: 24 January 2017
Review date: July 2021
Page 9 of 16
7.4.2
The IPCT will determine the extent of investigation into other infections or
infection control incidents but this will usually include all Trust apportioned
C.difficile infections.
7.4.3
These investigations will be undertaken as soon as possible after
identification of the incident preferably within 7 days and will involve, as a
minimum, medical and nursing representatives from the team/ward
responsible for the care of the patient, a microbiologist and an ICN.
7.5
Orthopaedic Surgical Site Infection Surveillance
7.5.1
Targeted surveillance of orthopaedic implant surgery is also a mandatory
requirement. Data collection must be undertaken in the clinical setting for a
minimum of three months every year and reported via the Public Health
Engalnd surgical site infection surveillance service. At the Trust this is
undertaken continuously for hip and knee replacements. In addition,
continous surveillance of spinal surgery is undertaken.
8.
SERIOUS INCIDENTS REQUIRING INVESTIGATION
8.1
Serious incidents requiring investigation associated with infection must be
reported via the normal reporting system in accordance with the Reporting,
Analysing, Investigating and Learning Policy & Procedure.
8.2
In addition the IPCT will inform the Regional Epidemiologist and the CCDC.
8.3
The DH (2003b) define serious incident associated with infection as those
that “produce, or have the potential to produce, unwanted effects involving the
safety of patients, staff or others”. Reportable incidents are those that:




8.4
result in signifance 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
A serious incident includes:




Outbreaks
Deaths associated with Clostridium difficile infection where CDI features
on Part 1 of the death certificate
Infected healthcare worker or patient incidents requiring a lookback
exercise e.g. TB, vCJD, blood borne viral infections
Significant breakdown of infection control procedures, such as the use of
invasive instruments released from a failed sterilisation cycle or the use
of contaminated blood products.
9.
PATIENT AND PUBLIC INFORMATION
9.1
This policy will be made available to the public on the Trust website
9.2
The website also provides a link to the DIPC annual report which includes
results of surveillance activities.
Surveillance and Reporting Policy for Infectious Disease, Healthcare Associated Infection and
Antibiotic Resistant Organisms
th
Ratified by: Infection Control & Decontamination Assurance Group: 24 January 2017
Review date: July 2021
Page 10 of 16
10.
ARCHIVING ARRANGEMENTS
The original of this policy will remain with the author, Lead Nurse/Director for
Infection Prevention and Control. An electronic copy will be maintained on
the Trust intranet, (A-Z) P – Policies (Trust-wide) – S - Surveillance. Archived
copies will be stored on the Trust’s “archived policies” shared drive, and will
be held indefinitely. A paper copy (where one exists) will be retained for 10
years.
11.
PROCESS FOR MONITORING COMPLIANCE WITH AND
EFFECTIVENESS OF THE POLICY
11.1
In order to monitor compliance with this policy, the auditable standards will
be monitored as follows:
No
Minimum Requirements
Evidenced by
1.
Surveillance outcome data will be included
Annual Report
in the Joint DsIPC’s annual report
2.
Data required as part of the DH mandatory
surveillance will be entered onto the Public
Reports on PHE website
Health England ( PHE) web based HCAI
data capture system
3.
Surveillance outome data will be reviewed at
appropriate groups and committees
ICOG minutes
ICDAG minutes
Divisional Governance Group minutes
Integrated Performance Reports to
the Board
11.2
Frequency
In each financial year, the Lead Nurse/Director of Infection Prevention and
Control (DIPC) will ensure that results of the auditable standards are included
in the annual report of the Joint Directors of Infection Prevention and Control
which is presented to the Board of Directors.
11.3
Undertaken by
Lead Nurse/Joint DIPC
11.4
Dissemination of Results
Results from reporting will be discussed through Divisional Governance
Group meetings and escalated to the ICDAG if compliance with the minimum
standards is not achieved.
11.5
Recommendations/ Action Plans
Implementation of the recommendations and action plans will be monitored
by the Infection Control and Decontamination Assurance Group, which meets
quarterly.
11.6
Any barriers to implementation will be risk-assessed and added to the risk
register.
Surveillance and Reporting Policy for Infectious Disease, Healthcare Associated Infection and
Antibiotic Resistant Organisms
th
Ratified by: Infection Control & Decontamination Assurance Group: 24 January 2017
Review date: July 2021
Page 11 of 16
11.7
Any changes in practice needed will be highlighted to Trust staff via the
Governance Managers’ cascade system.
12.
REFERENCES
Dept of Health/PHLS (1995) Hospital Infection Control. Guidance on the
control of infection in hospitals. London. DH. (URL not available)
Dept of Health (2003a) Winning ways. Working together to reduce Healthcare
Associated Infection in England. Report from the Chief Medical officer.
London. DH. Available at
http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.go
v.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitala
sset/dh_4064689.pdf
Accessed 20/08/16
Dept of Health (2003b) Surveillance of healthcare associated infections
PL CMO (2003)4. London. DH. Available at:
http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.go
v.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitala
sset/dh_4013410.pdf
Accessed 20/08/2016
Dept of Health (2008) Changes to the mandatory healthcare associated
infection surveillance system for Clostridium difficile infection (CDI) from 1
January 2008 PL CMO(2008)1
http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.go
v.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_08
2109.pdf
Accessed 24/08/16
NHS England (2014) Guidance on the reporting and monitoring arrangements
and post infection review process for MRSA bloodstream infections from April
2014.
https://www.england.nhs.uk/patientsafety/wpcontent/uploads/sites/32/2014/02/post-inf-guidance2.pdf Accessed 24/8/16.
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations
1995 (RIDDOR) (SI 1995/3163). London: Stationary Office. Available at:
http://www.legislation.gov.uk/uksi/1995/3163/contents/made
Surveillance and Reporting Policy for Infectious Disease, Healthcare Associated Infection and
Antibiotic Resistant Organisms
th
Ratified by: Infection Control & Decontamination Assurance Group: 24 January 2017
Review date: July 2021
Page 12 of 16
APPENDIX 1: COMMUNICATION PLAN
COMMUNICATION PLAN
The following action plan will be enacted once the document has gone live.
Staff groups that need to have
knowledge of the strategy/policy
Registered Nurses
Medical staff
Microbiology laboratory staff
Medical Microbiologists
Infection Control Team
Divisional Management Teams
The key changes if a revised
policy/strategy
Routine update of references, hyperlinks,
structure.
The key objectives
The purpose of this policy is to provide a
framework to:





Monitor the incidence of infection
Provide early warning and
investigation of problems and
subsequent planning and
intervention to control
Monitor trends, including the
detection of outbreaks
Examine the impact of interventions
Ensure compliance with mandatory
surveillance systems
How new staff will be made aware of
the policy and manager action
Induction and through routine work of the
Infection Control Team.
Specific Issues to be raised with staff
N/A
Training available to staff
Annual updates
Any other requirements
N/A
Issues following Equality Impact
Assessment (if any)
No negative impacts
Location of hard / electronic copy of
the document etc.
Electronic copy available on Hub. Electronic
copy saved onto infection control team shared
drive and hard copy available in the Infection
Control Department.
Hard copy also available in the Site Management
Office.
Surveillance and Reporting Policy for Infectious Disease, Healthcare Associated Infection and
Antibiotic Resistant Organisms
th
Ratified by: Infection Control & Decontamination Assurance Group: 24 January 2017
Review date: July 2021
Page 13 of 16
APPENDIX 2: EQUALITY IMPACT ASSESSMENT TOOL
Name of document
Surveillance and Reporting Policy for
infectious disease, healthcare associated
infection and antibiotic reistant organisms
Division/Directorate and service area
Specialist Services, Infection Control
Name, job title and contact details of
person completing the assessment
Judy Potter
Lead Nurse/Joint Director for Infection
Prevention and Control
Date completed:
02/11/2016
The purpose of this tool is to:



1.
identify the equality issues related to a policy, procedure or strategy
summarise the work done during the development of the document to reduce
negative impacts or to maximise benefit
highlight unresolved issues with the policy/procedure/strategy which cannot be
removed but which will be monitored, and set out how this will be done.
What is the main purpose of this document?
The purpose of this policy to provide a framework to:
2.

Monitor the incidence of infection

Provide early warning and investigation of problems and subsequent
planning and intervention to control

Monitor trends, including the detection of outbreaks

Examine the impact of interventions

Ensure compliance with mandatory surveillance systems
Who does it mainly affect? (Please insert an “x” as appropriate:)
Carers ☐
3.
Staff X Patients X
Other (please specify)
Who might the policy have a ‘differential’ effect on, considering the
“protected characteristics” below? (By differential we mean, for example
that a policy may have a noticeably more positive or negative impact on a
particular group e.g. it may be more beneficial for women than for men)
Please insert an “x” in the appropriate box (x)
Surveillance and Reporting Policy for Infectious Disease, Healthcare Associated Infection and
Antibiotic Resistant Organisms
th
Ratified by: Infection Control & Decontamination Assurance Group: 24 January 2017
Review date: July 2021
Page 14 of 16
Protected characteristic
Relevant
Not relevant
Age
☐
X
Disability
☐
X
Sex - including: Transgender,
and Pregnancy / Maternity
☐
X
Race
☐
X
Religion / belief
☐
X
Sexual orientation – including:
Marriage / Civil Partnership
☐
X
4.
Apart from those with protected characteristics, which other groups in
society might this document be particularly relevant to… (e.g. those
affected by homelessness, bariatric patients, end of life patients, those with
carers etc.)?
N/A
X
5.
Do you think the document meets our human rights obligations?
6.
Looking back at questions 3, 4 and 5, can you summarise what has
been done during the production of this document and your
consultation process to support our equality / human rights / inclusion
commitments?
The content of this policy is not new but now makes specific reference to
community services Previous discussions with the Equality and Diversity Manager
did not identified any issues relating to equality, diversity and inclusion
commitments. The policy has been circulated to all members of the Infection
Control Team which includes Specialist Nurses and Medical Microbiologists for
consultation, including those working in the community setting, and has been
considered by the Infection Control Operational Group, which includes widespread
representation from clinical, managerial and support staff, and the professional
leads in the community services division.
Surveillance and Reporting Policy for Infectious Disease, Healthcare Associated Infection and
Antibiotic Resistant Organisms
th
Ratified by: Infection Control & Decontamination Assurance Group: 24 January 2017
Review date: July 2021
Page 15 of 16
7.
If you have noted any ‘missed opportunities’, or perhaps noted that
there remains some concern about a potentially negative impact please note
this below and how this will be monitored/addressed.
“Protected
characteristic”:
N/A
Issue:
How is this going to be
monitored/ addressed
in the future:
Group that will be
responsible for
ensuring this carried
out:
Surveillance and Reporting Policy for Infectious Disease, Healthcare Associated Infection and
Antibiotic Resistant Organisms
th
Ratified by: Infection Control & Decontamination Assurance Group: 24 January 2017
Review date: July 2021
Page 16 of 16