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THE WATT GROUP REPORT
SUMMARY OF RECOMMENDATIONS
1. That Trusts should put in place structured audits of hand washing for all groups of staff, including medical, bank, agency and night staff.
2. That the cleaning specification in wards and departments should be set by the senior nurse responsible for the area and each ward/departmental manager in collaboration with the relevant Infection Control Team and Domestic Services Manager. Cleaning against this specification should be subject to rigorous monitoring and action to correct deficiencies. Failure to meet the specification should be subject to formal audit and review within each hospital and be subject to public disclosure.
3. That the ward/departmental manager should have unambiguous responsibility and be held accountable for all aspects of hygiene in their area. They must have commensurate authority, skills and resources (time and money) to discharge this responsibility.
4. That Audit Scotland reports are reviewed carefully by the management of Trusts,andthat appropriate action is taken to respond to them.
5. That the Clinical Standards Board for Scotland ensures that there are reliable mechanisms in place to monitor compliance with its cleaning services standards.
6. That exposure of staff to faeces should be documented through the Incident Reporting Procedure as thoroughly as exposure to any other biological (body) fluids.
7. That specific guidelines and facilities (washing, showering, cleaning uniforms) should be available in every hospital for the decontamination of staff who become grossly contaminated from body fluids (blood, urine, faeces and so on).
8. That every Trust should have a staff uniform policy that ensures that:
(a) all staff uniforms are laundered by, or under the auspices of, the NHS;
(b) the widespread practice of staff travelling to and from work in (potentially contaminated) uniforms ceases; and
(c) adequate staff changing and decontamination facilities are provided.
9. That nursing notes/care plans should clearly reflect the need for enteric precautions in individuals suffering from loose stools /diarrhoea.
10. That nursing documentation should be improved so that key information and advice relating to infection control measures can be communicated to all relevant staff.
11. That clear infection control guidance to all staff on how to nurse a patient with loose stools/diarrhoea should be provided within the infection control manual.
12. That there should be careful consideration nationally on reducing the movement of patients between wards in hospitals so that the likelihood of outbreaks occurring is minimised and when they do occur they are contained within as defined a location as possible.
13. That a scientific meeting be organised at which experience and ideas relating to the specific infection control challenges of old buildings be shared and that following this the SEHD should issue guidance on the upgrading and maintenance of such buildings.
14. That Trusts ensure that levels of basic ward equipment (e.g., hoist slings, commodes) are sufficient to reduce the communal use of such equipment and reduce the risk of cross-contamination due to inadequate decontamination.
15. That Trusts develop policies which clearly identify the accountabilities of nursing and domestic staff in the cleaning of ward furniture and apparatus, including baths, food trolleys and "clinical" equipment and that clearly identify who has overall responsibility.
16. (a) That the Scottish Executive Health Department should reinforce the goodpractice contained within the Scottish Health Facilities Note 30, "InfectionControl in the built environment - design and planning," January 2002.
(b) That the NHS in Scotland develops, as a matter of urgency, standardsrelating to new builds and refurbishment projects incorporating, wherenecessary, the Scottish Health Facilities Note 30 guidance as best practiceand requires Trusts to produce action plans for compliance with Note 30.
17. That control of an outbreak must include restriction of staff movement between wards and departments. When patients require infection control precautions to be implemented the nurses providing the care should, where possible, be the 'named nurse'. This should minimise the number of contacts of both the patient and the nurse. This may have implications for staffing of the ward but this will be temporary and not a high recurring cost.
18. That the Agency/Bank/Locum induction checklist should include explicit mention of Infection Control precautions in place.
19. That all Trusts should put in place assessments of the competencies of nursing staff in Infection Control and ensure that structured training programmes are established and the SEHD should consider with the Nursing Agency proprietors how competencies in Infection Control can be similarly assessed and delivered for Agency nurses. Similar training programmes should be put in place for medical and professions allied to medicine (PAM) staff.
20. That all staff at ward or department level who handle food should receive training in food hygiene commensurate with their duties and in compliance with the Food Safety (General Food Hygiene) Regulations 1995.
21. That appliances used for storing or preparing food (whether in the ward or elsewhere) should be subject to appropriate inspection and the results recorded.
22. (a) That contacts with, and advice given by, any member of the ICT should be documented by both the individuals providing and receiving the advice. Thisis in addition to infection control care plans.
(b) That nursing documentation should be improved so that key instructions relating to infection control measures can be communicated to all relevant staff.
23. (a) That an OCT should always be chaired by someone with competence and authority in health care associated infection. The local Consultant in Public Health Medicine (CPHM) should chair OCTs for major outbreaks (see
Appendix E for definition). This demonstrates that the Team is led by an individual external to the Trust, who has close links with the local NHS Board and with community surveillance. In the case of other hospital outbreaks the CPHM should be consulted regarding chairmanship of the team. In practice, this will usually be the ICD.
(b) That there should be clear role definitions for the members of the OCT, with clear responsibilities documented.
(c) That a clear Outbreak Control Plan should be agreed and implemented.
24. That senior management (Executive Director level) of the Trust should be fully engaged from an early stage in managing outbreaks either as full and active members of the OCT or as a separate support team to the OCT. Senior management support should include a senior communications manager who can ensure that staff, relatives and the public are timeously informed of the outbreak and are given appropriate public health messages.
25. That all OCT reports should provide sufficient details of key factors in the spread of infection to allow proper audit.
26. That recommendation 10.22(a) and 10.22(b) of the Pennington Group Report (page 37) be extended to cover all outbreaks:
(a) "On completion of investigations, it should be the responsibility of the CPHM to provide SCIEH with a minimum data set (in the form of a standard proforma) "
(b) "For large (or otherwise significant) outbreaks a full written report should be completed and consideration given to its publication. Copies of written reports should be forwarded to SCIEH."
27. That an expert group be set up to give clear Scottish guidance on the role of staff screening in outbreaks of infection, so that such guidance can be used by OCTs in the future.
28. That in the case of an outbreak where non-invasive screening of relevant staff is deemed appropriate, Trusts should place a duty on all such staff to comply.
29. That Trusts take measures to improve the quality of clinical information on laboratory request forms.
30. That a classification system for infection outbreaks/episodes be drawn up and used by all key players as "common currency" in deciding the actions and communications required in a given infection incident (A framework (Infection Control Risk Matrix) is set out in detail in
Appendix E)
and that clear policies are developed, using this system, which identify all the key individuals involved in communications about outbreaks of different severity.
31. That in any outbreak that is considered at any stage to be foodborne, the Scottish Executive is informed in addition
to the Food Standards Agency.
32. That Trusts and Boards ensure that there are sufficient resources to appoint adequate levels of communication professionals, but
that "Press Office to Press Office" communication is additional to, not a substitute for, professional communication.
33. (a) That the Chief Executive of a Trust or Health Board (depending on whether the outbreak is primarily in the hospital or community respectively) should assume the unambiguous responsibility for ensuring effective internal and external communications, including the media, appropriate Government Departments and Agencies.
(b) That within the SEHD consideration should be given to the nomination of an issue manager as soon as a serious outbreak occurs and irrespective of the route through which notification has come. Clear guidelines should also be in place on which Division/Unit within the SEHD should be responsible for actions and briefing associated with an outbreak.
34. That resources are in place to ensure that each Trust has a designated and trained ICD, who will normally lead the Trust ICT. This will usually, but not invariably, be a consultant microbiologist who will have designated sessions and a clearly defined job description for this component of their work. In the case of Trusts without laboratory facilities (e.g., Primary Care Trusts) they should formalise arrangements with a suitably trained and appropriately resourced individual.
35. That resources are in place to ensure that each Trust has sufficient ICN establishment to:
(a) have daily contact with wards or other health care premises;
(b) visit each facility at least weekly;
(c) provide advice to ward and departmental nursing staff on the nursing care of patients who are at risk of , or who have, infection;
(d) be responsible for a systematic competency programme in infection control for all health care workers at their place of work (including medical, agency and bank staff);
(e) undertake systematic hand washing audits, including audits involving night and weekend health care workers; and
(f) provide an on-call service to advise on infection control matters on a 24-hour basis.
36. That there should be a lead Infection Control Nurse (ICN) in each Trust.
37. That infection control champions at ward level can complement, but not replace, the roles of the Infection Control Team. They should not be used as substitutes for ICNs but:
(a) They should assist in the delivery of a comprehensive infection control service and be integral members of an enlarged Infection Control Team; and
(b) Have clearly defined roles, dedicated time for infection control duties and be appropriately trained and supervised. The extra responsibilities and training should attract enhancement of salaries.
38. That each Health Board should have an appropriately constituted Standing Infection Control Team (ICT) which:
(a) takes the lead in strategic aspects of infection control in their area;
(b) formulates and agrees infection control policies;
(c) co-ordinates the management of all outbreaks where the Major Outbreak Plan is invoked;
(d) has a designated leader;
(e) links effectively with Risk Management Committees and Clinical Governance Committees; and
(f) provides assistance and advice to Trust ICTs when requested and/or when appropriate.
39. That large Trusts should have an appropriately constituted Standing Infection Control Team (ICT) which:
(a) prevents and manages healthcare associated infection within their Trust;
(b) implements agreed Board and Trust policies in infection control;
(c) has a designated leader;
(d) links effectively with Risk Management Committees and Clinical Governance Committees; and
(e) liaises closely with, co-operates with, and provides membership for the Health Board ICT.
40. That CPHMs (CD/EH) should be trained in the management of HAI and play a more prominent role in HAI surveillance and hospital outbreak management. They should normally lead all infection outbreaks within their Board where the Board's Major Outbreak Plan is invoked.
41. That each Health Board holds regular (possibly every 2 years) simulated outbreak exercises, with adequate debriefing afterward, and that documentation of such exercises be provided to the Clinical Standards Board at the time of their inspections.
42. (a) That all relevant parts of the NHS operate to a consistent set of criteria that is linked to a risk management classification that describes infection outbreaks/episodes.
(b) That the level of outbreak/episode risk category determines both the level of action(s) required and the level of communications.
43. That Trusts link infection control to risk management structures as a matter of urgency.
44. That at both local and Scottish Executive level more strenuous efforts are made to tap the potential of the media to improve the public understanding of infection control issues. This will require a more open relationship to be developed between the NHS and the media based on mutual trust. There should be presumption of early disclosure to the public and the media of outbreaks of infection.
45. That internal communications within and between the Scottish Executive and NHS organisations are improved and clarified so as to reflect the openness culture and this is emulated in communications with relevant agencies (e.g., The Food Standards Agency, Scottish Water, Scottish Environmental Protection Agency (SEPA).
46. (a) That NHS Scotland should adopt a programme budgeting approach to Infection Control and that each Trust and each Board be required to provide details of the resources devoted to Infection Control.
(b) That such details are supplied as part of the documentation provided to the Clinical Standards Board for Scotland at the time of individual Trust reviews.
47. That the Scottish Executive should convene a Working Group to develop methods of tracking and calculating the costs of HAI and its control in Scotland.
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