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THE WATT GROUP REPORT
CONCLUSIONS
The Group recognises that hindsight bestows a wisdom that is difficult to achieve when taking day to day decisions in a hard-pressed service. The Group also recognises the wide array of competing pressures on the time, energy and focus of individual managers and on the resources of an NHS Trust that is subject to scrutiny from a wide range of organisations such as the Health & Safety Executive, the Clinical Standards Board for Scotland and the Scottish Health Advisory Service. Nevertheless, hospital acquired infection (HAI) and its control differs significantly from other issues because:
Infection not only affects an individual but it can, and too frequently does, transmit to others who rightly have an expectation that they will be protected from cross infection;
There is a distinct and immediate public health implication and the public have an expectation that coherent advice to them will be forthcoming; and
Even quite small outbreaks of cross infection will have an impact on health service provision, because more resources will be required and also (and of further concern to the public) there is likely to be temporary closure of services such as wards or whole hospitals.
This Report looks at, and comments on, a range of infection control issues that are pertinent throughout the NHS in Scotland. It also makes recommendations on various ways in which the NHS can help to combat HAI in Scottish hospitals. The major themes running through the Report can be summarised within five key areas and include:
1) A comprehensive implementation of Infection Control standards at ward/departmental level and the necessary resources to achieve this;
2) A properly developed and funded infection control infrastructure;
3) A culture change in hand washing, underpinned by hand washing audits for all staff;
4) Implementation of a suggested Infection Control Outbreak/Episode Risk Matrix to allow consistent responses and communications across Scotland (
Appendix E); and
5) Proper emphasis on all aspects of communications in infection control and in outbreaks, including a culture of openness.
The recommendations in this Report should help to ensure that the NHS in Scotland learns the lessons from the outbreak at the Victoria Infirmary and makes changes to minimise the chances of a similar episode occurring in the future. They should therefore be considered as a coherent whole and implemented as a whole.
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