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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 Strategic Directions – Key Milestones Patient Experience Maintain Operational Service Delivery Assurance Framework Integrated Community Pathways Monitor/Finance/Performance Develop Acute services CQC Fundamental Standards - Regulation: 12 and 15 Infection Control Other (please specify): 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) 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: 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: 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: Chicken pox/shingles (Herpes zoster) Diphtheria Food poisoning Influenza Measles Meningitis Meningococcal septicaemia Mumps 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 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: Acute encephalitis Anthrax Leprosy Leptospirosis Malaria Rabies Relapsing fever Smallpox Tetanus Typhus Yellow Fever Food poisoning Dysentery (amoebic or bacillary) Measles Rubella 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: 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