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THE WATT GROUP REPORT
CHAPTER 5 MANAGEMENT OF THE OUTBREAK
Initial Response
The cases occurred over a festive holiday period and initial actions were undertaken by the Infection Control Doctor (ICD). However, it was not clear to the Review Group that these actions/instructions had been properly documented at ward level or carried out.
Recommendation
22. (a) That contacts with, and advice given by, any member of the ICT should bedocumented 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 instructionsrelating to infection control measures can be communicated to all relevantstaff.
Infection Control Doctor
The Group considered that while the individual performed well as Infection Control Doctor (ICD) during the outbreak, the role and accountability of the ICD in the Victoria Infirmary was poorly defined and no clear sessional commitments for this role were agreed or documented.
Outbreak Control Team (OCT)
Although three cases of salmonella infection had been identified in patients from the same ward by 3
rd January 2002, an outbreak was not declared and the OCT was not established until 8
th January 2002. Thereafter the OCT met regularly, but attendances were inconsistent, roles and responsibilities were not clearly defined and the OCT was chaired by three different individuals. To some extent this reflected the impact of media coverage and of the developing SRSV outbreak. Nevertheless there was a lack of clarity about who was responsible for the overall management of the
Salmonella outbreak. The line of executive actions (taking decisions, committing resources, ensuring that actions were carried out) was also unclear. It appeared that management at Executive Director level within the Greater Glasgow NHS system were not fully engaged until late in the outbreak.
The Group believes that Infection Control needs to command a much higher order in the priorities of senior managers.
Recommendations
23. (a) 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 NHSBoard 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. [
See Chapter 6]
OCT Report
The report was well written and provided a clear account of the epidemiological, microbiological and environmental investigations and conclusions, as well as succinctly describing the management of the outbreak. It was in a format suitable for public dissemination. However, the Report did not document the fundamental aspects of the likely spread of infection, nor give details of key infection control issues relevant to the outbreak (e.g., hand washing, cleanliness, decontamination). As there was no "lessons learnt" section in the Report, this could prevent proper audit of remedial actions and lead to a belief amongst staff that there were few, if any, lessons to be learnt. There was some evidence of this belief from our interviews.
Recommendations
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
15 (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."
Staff Screening
The OCT changed its policy on staff screening in the middle of the outbreak, due to the further development of new cases, from one of no screening to one of screening of relevant staff. When screening commenced, it was on a voluntary basis and it was clear that a significant proportion of staff did not submit samples.
The Group was aware of the confusion surrounding guidelines on staff screening (and of the benefits of hindsight) but considered that earlier screening of staff might have defined the extent of the outbreak more clearly.
Recommendations
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.
Major Outbreak Plan
At no point was the outbreak managed as a major or critical incident. There was little clarity about which guidance was followed by the OCT; initially local guidelines were followed and only very late in the outbreak did Greater Glasgow NHS Board guidelines come to the fore. The Review Team also heard evidence that although the NHS Board's Infection Control Guidelines (including an Outbreak Control Plan) were available, some Trusts in Greater Glasgow had developed their own guidelines without reference to those of the Board.
This issue is covered in more detail in
Chapter 6 and our recommendations are set out there.
Infection Control Nurse (ICN) Support
Although we recognise that the Trust subsequently increased the number of ICNs to 4 WTEs, shared between the two major sites (Southern General Hospital and Victoria Infirmary) there was insufficient ICN support in the period leading up to the outbreak. The fact that there was only one WTE in post at the Trust at the time of the outbreak did not allow for delivery of a comprehensive, fully integrated, infection control service and proper monitoring of compliance with infection control guidelines.
Telephone guidance was available from 4
th January 2002, and in person from 8
th January 2002, but the Group found evidence that Infection Control advice was not properly documented in the nursing notes. The Group found no evidence of guidelines relating to the management of patients admitted with diarrhoea and vomiting.
The Group was concerned that, although ICN support has been increased since the outbreak, there was still no clarity about which individual was designated to provide ICN leadership and no clear evidence of plans for the future development of the service.
The Group believes that the present 9.00am to 5.00pm, 5 days a week, ICN service (with no telephone cover or public holiday cover) that exists in Scottish hospitals is inadequate to provide a comprehensive infection control nursing service.
This is addressed in detail in Chapter 6.
Microbiological Support
The microbiology laboratory provided good support during the outbreak. However, it is unfortunate that the possible role of patient F in the outbreak was not considered until 8
th January 2002 when delayed phage typing results from the Reference Laboratory became available, although a faecal sample was taken from the patient on 23
rd December 2001.
The amount of clinical information given on several of the request forms was inadequate or absent; mention of changes in bowel habit might have alerted laboratory staff to the need for more extensive testing.
Inadequate clinical information on laboratory request forms is a common problem. Medical and nursing staff must be aware of the need for relevant and up-to-date clinical information.
Recommendation
29. That Trusts take measures to improve the quality of clinical information on laboratory request forms.
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