1.1.1 Health Boards in Scotland have public health responsibilities to make arrangements for the surveillance, prevention, treatment and control of communicable disease. This public health responsibility covers the entire population of a Health Board, including patients and staff within the health service. These functions are the professional responsibility of the Chief Administrative Medical Officer (Director of Public Health) (CAMO(DPH)) and are normally delegated to a Consultant in Public Health Medicine (Communicable Disease and Environmental Health) (CPHM(CD/EH)).
1.1.2 In discharging these responsibilities Health Boards also provide the basis for securing the co-operation of service deliverers in matters relating to communicable disease prevention and control. Health Boards and other bodies responsible for ensuring the provision of care have a duty to ensure that adequate standards of infection control are met by contracted service deliverers. The adequacy and effectiveness of infection control policies and procedures should form key elements in assessing the quality of care being offered by service deliverers.
1.1.3 Health Boards are responsible to The Scottish Office Department of Health (S0DoH) for the infection control standards and the performance of service deliverers, and must therefore:
a) define management procedures within the Health Board for liaising with
S0DoH on infection control issues, and
b) ensure that care deliverers are made aware of relevant S0DoH objectives,
policies, guidance and priorities related to infection control - and are reminded
of their duty to comply with relevant statutory obligations and departmental
guidance, taking account of the nationally agreed operational policies and standards
set, for example, by the NHS in Scotland Estates Environment Forum.
1. 1.4 In addition to their public health responsibilities, Health Boards, hospitals and other healthcare providers have statutory responsibilities under the Health and Safety at Work Act 1974 and Control of Substances Hazardous to Health (COSHH) Regulations to ensure the health and safety of their employees and others, including visitors and patients, to control and manage the risk of infection (see also 1.4.15.7 (iii) and 5.9.1).
1.1.5 It is worth noting that The House of Lords Select Committee on Science and Technology in their 7th Report2 has indicated that " hospital services should put infection control and basic hygiene where they belong, at the heart of good hospital management and practice, and should redirect resources accordingly; such a policy will pay for itself quite quickly .."
1.2.1 Health Boards require specialist advice on infection control procedures in order to fulfil their responsibilities to S0DoH and set standards for their contracted service deliverers. Provision of such advice is the professional responsibility of the CAMO(DPH), supported by the CPHM(CI)/EH). Advice to a Health Board should incorporate input from a wide range of relevant interests, including the service deliverers.
1.2.2 Options for obtaining the necessary range of multi - disciplinary input should include having a standing Infection Control Advisory Committee, or setting up ad hoe task orientated working groups. Such advisory committees should normally be chaired by the CAMO(DPH) or CPHM(CI)/EH) as deputy. Representation should be broadly based and reflect an appropriate range of input from all care sectors e.g. the commissioning organisation, the delivery services and relevant outside agencies.
1.2.3 In addition to public health medicine, advisory groups should incorporate representation from clinical microbiology, infection control nursing, clinical services (medical and surgical), occupational health, pharmacy, health and safety, support services and GPs.
1.2.4 Efforts must be directed at obtaining objective advice by having relevant staff acting as advisors to Health Boards.
1.2.5 Health Boards should, where possible, appoint in-house staff with specialist infection control expertise to assist in standard setting and service quality monitoring. Staff with training and expertise in Infection Control Nursing would be appropriate for such a role and, where appointed, should have a remit linked to the wider infection control responsibilities of the CAMO(DPH) and CPHM(CI)/EH).
Standards for prevention and control of infection should be incorporated in agreements with service deliverers - and be regularly reviewed. In developing appropriate standards, Health Boards should define the infection control responsibilities of contracted service deliverers, and should include:
a)the need for care deliverers to support Scottish Office
Department of Health (S0DoH) and Health Boards in relation to the surveillance,
investigation, control, and prevention of communicable disease through the
provision of adequate clinical facilities and staff, microbiological resources,
ICTs and OHS;
b) the requirement that care deliverers agree to the exchange of appropriate
clinical and microbiological information among relevant staff, the local CPHM(CI)/EH),
the Scottish Centre for Infection and Environmental Health (SCIEH), and
S0DoH;
c) a statement relating to the roles and responsibilities of management;
d) agreed reporting procedures and lines of accountability between the
care deliverer and Health Board on infection control matters;
e) the role, responsibilities, composition and lines of accountability
of Infection Control services within Health Boards;
f) the need to have appropriate arrangements for the management of outbreaks
within Health Boards, Trusts and primary care settings;
g) the contribution of care deliverer services to infection control in
the wider community, including a requirement to develop contingency plans
for major outbreaks of infection in the community;
h) the financial arrangements with care deliverers to cover the costs associated
with managing outbreaks in both health board settings and the wider community;
i) a standard list of Infection Control Policies and operational standards.
Health Boards should regularly review this list and keep it up to date in
line with evolving statutes and best practice. Care deliverers should institute,
develop and adapt these as necessary;
j procedures for enabling the assessment of compliance with detailed infection
control standards - including any management systems which have been nationally
agreed, to assist in achieving statutory requirements, e.g. relating to sterilisation
and disinfection;
k) the infection control outcome measures to be used in assessing the quality
of deliverers services, including surveillance of specific nosocomial infections;
l) to demonstrate a firm commitment to develop standardised surveillance
of nosocomial infection.
Management Arrangements
1.4.1 The range and type of NHS Trusts in Scotland and the variety of health care services which they provide create difficulty in giving prescriptive advice on the arrangements for infection control services. Certain basic organisational structures can, however, be recommended for the majority of Trusts and should include:
a) a Trust Infection Control Committee (TICC)
b) an Infection Control Team (ICT)
1.4.2 Individual hospitals which, either due to their size, the variety of services provided or the high proportion of patients who are particularly vulnerable to infection, may benefit from additional infection control input and should have a Hospital Infection Control Committee (HICC).
1.4.3 GPs, Dentists, Pharmacists and others will have access to infection control advice from the local CPHM(CI)/EH), Health Board Infection Control Nurse (ICN) (where employed) or the local Trust ICN(s), and a Medical Microbiologist infection control specialist (Infection Control Doctor (ICD)).
1.4.4 Advice on infection control arrangements in the non-NHS facilities e.g. residential or nursing homes, schools and nurseries must be tailored to local circumstances, the nature of the organisation and the type of care provided. Advice should initially be sought from the CPHM(CI)/EH) and/or Health Board ICN (where employed) who will have access to specialist expertise from local Environmental Health Departments, Trust ICTs, SCIEH, the Health and Safety Executive (HSE) and others, as required.
The Chief Executive
1.4.5 Although the provision of an infection control service is largely undertaken by medical and nursing staff with specialist expertise, managerial interest and input at a strategic level is essential. The Chief Executive (CE) of every Trust is responsible for ensuring that effective arrangements for infection control are in place. These arrangements should include an effective infection control programme (with defined objectives and regular review) which is designed to ensure that managerial action to assist that programme is taken when necessary. The objectives set should reflect both the requirements of contracts agreed with the Health Board, and national infection control standards. A programme cannot be implemented effectively without the commitment and support of senior management, heads of clinical directorates and relevant departments.
Trust Infection Control Committee
1.4.6 Every Trust should have a TICC. Whether this Committee should also cover the other hospitals which have contracted for the ICT's services is a matter for local agreement. Some of these hospitals may prefer individually or jointly to establish their own committee. However, as many of the local issues are likely to be of concern to all hospitals in a Trust, a large number of separate HICCs will lead to duplication of effort, and the increased number of resultant meetings would cause unnecessary work for the ICT and CPHM(CI)/EH).
The core membership of the TICC should include:
a) the ICD;
b) medical microbiologist (where the ICD is from another specialty);
c) the ICN(s);
d) the CE (or a senior manager with authority to represent him or her e.g.
the Medical Director);
e) the CPHM(CI)/EH) for the Health Board in which the hospital is situated;
f) a representative of the OHS;
g) an Infectious Diseases Physician, where there is one;
h) senior clinical medical staff representing their colleagues (possibly
those taking a lead role on infection control in particular departments);
i) a representative of the Executive Nurse Director;
j) a representative of the Chief Pharmacist;
k) appropriate representatives from other hospitals covered by the TICC.
1.4.7 It is recommended that the TICC meets at least four times a year. It may co-opt (or invite as necessary) other experts on particular topics, for example a Sterile Supplies Department Manager and/or Estates Manager. The Committee may be chaired by the member of the senior Trust Management or by the ICD. External advice may be sought on an ad hoe basis from a local authority Environmental Health Department and the HSE, as necessary.
1.4.8 Although the ICT carries the prime responsibility for infection control, it cannot effectively carry out its role in isolation, and needs the collaboration and support of other hospital staff. Most of the policies and procedures to be followed in individual clinical departments or support services will relate to infection control requirements and these can only be drawn up by those with particular expertise in the needs and problems of those services. Moreover, they can only be implemented by the staff of those services, not by the ICT itself. It is therefore important that these staff have "ownership" of the policies. A Trust-wide infection control programme, although drawn up by the ICT, will raise particular issues for different specialities and services. The TICC represents the main forum for regular, routine consultation between the ICT and the rest of the hospital, and its endorsement of, and support for the ICT's programme, will be ,essential. Support from the members of the TICC- for the advice provided by the ICT to the CE will be of assistance and, in the rare event that the CE needs to be made aware of some problem relating to the ICT itself, the TICC members should ensure that this is done.
1.4.9 The functions of the Committee are to:
a) liaise with the relevant Health Board Infection Control Advisory Committee
(HBICAQ;
b) monitor compliance with infection control standards as specified by the
HealthBoard;
C) advise the management of those delivering care on all matters related
to infection control;
d) advise and support the ICT;
e) consider reports on infections and infection control problems and draw
the attention of the CE (either through the ICT or directly) to any serious
problems or potential hazards relating to infection control;
f) discuss and endorse a plan for the management of outbreaks in the hospital
- and monitor its implementation; this will need to be developed in line with
the Health Board's outbreak or emergency plans;
g) provide a core of personnel to form an Outbreak Control Team (OCT);
h) discuss and endorse the annual infection prevention and control programme,
including plans for surveillance. This should be submitted for approval to the
CE, who should review the progress and outcomes of the programme, and assist
in its implementation.
i) advise on the most effective use of resources available for implementation
of the programme and for contingency requirements e.g. involvement in hospital
management of patients emanating from a community outbreak;
j) prepare and approve infection control policies before their submission
to the CE for approval, and review their implementation. Written policies, procedures
and guidelines for the prevention and control of infection should be produced
and regularly reviewed by the TICC. Subjects may include antibiotic usage, cleaning
and disinfection procedures, clinical and nursing practices - including those
in operating theatres and other specialist departments. Operational policies
may include laundry, purchase of new equipment, new building or the upgrading
of existing buildings. In many cases these are provided by the clinical and
other directorate teams involved in consultation with the ICT, or by other Committees,
such as the Drugs and Therapeutics Committee on which the ICT should be represented;
k) promote and facilitate the education of all grades of Trust staff in infection
control procedures;
encourage communication among the different disciplines involved. The minutes
of the TICC meetings should be widely circulated and made accessible to senior
medical and nursing staff and appropriate committees.
The Infection Control Team
1.4.10 Every Trust should have an ICT which reports to the CE and has the primary responsibility for all aspects of infection prevention and control within the Trust. Whether or not the team is based in the Trust depends on whether staff with the appropriate expertise are employed by it. In practice this normally depends upon the organisation of local microbiology services, as the ICD is almost always a Consultant Medical Microbiologist (CMM) (see 1.4.20). It is desirable (although not essential) for the ICD and ICN(s) to work from the same premises. Trusts which do not employ an ICD or ICNs should make appropriate service level arrangements for these services, normally with that of a neighbouring Trust. The ICT should be resourced to meet its obligations in the Trust in which it is based and to fulfil its contractual obligations to others; the CEs of "base Trusts" should therefore review their needs with regard to the sessional commitment of the ICD, the number of ICNs and cleric al/support staff and facilities.
The members of the Infection Control Team are:
1.4.11 A member of senior management (normally the Medical Director) to act for the CE should be appointed and liaise closely with the ICT. He/she need not necessarily be a member of the team, but should have authority to take decisions on the CE's behalf. There should be suitable arrangements to cover managerial input if emergencies arise outside office hours. It is useful, from time to time, to test lines of communications in this setting.
1.4.12 The ICD and ICNs need to liaise frequently, preferably daily.
1.4.13 The role of the ICT is to implement the annual programme and develop policies - and to make decisions (on a 24 hour basis) about the prevention and control of infection, providing advice to all grades of staff on the management of infected patients and infection control problems.
1.4.14 The functions of the ICT include:
a) the identification, investigation and control of outbreaks - in collaboration
with the CPHM(CI)/EH) and an outbreak control group, as appropriate;
b) education of all Trust staff in infection prevention and control procedures;
C) preparation of policy documents - in liaison with other relevant staff;
d) formulation of an annual programme of work, including surveillance of
infection, in collaboration with the Health Board;
e) implementation of this programme (in liaison with other Trust staff),
and provision of progress reports to the CE on important incidents, lessons
learned, and surveillance or audit results. These reports should be discussed
at each TICC meeting before they are sent to the CE;
f) provision of an annual report to the CE (following discussion by the TICC
on the results of the programme) indicating achievements and drawing attention
to matters of concern;
g) liaison with the OHS on relevant staff and patient health issues;
h) liaison with clinical teams on the development of standards, audit and
research.
1.4.15 The programme, not all of which need be undertaken by the ICT itself but in which the ICT should be involved, must provide for the drafting and review of policies, staff education, surveillance of infection, monitoring of hospital hygiene and catering, and other relevant matters. It should ensure the most effective use of resources.
1.4.15.1 Policies
(i) Written policies, procedures and guidelines for the prevention and control of infection should be produced, and regularly reviewed, by the ICT in conjunction with the TICC. Policies prepared by the HBICAC may require local adaptation. Where appropriate, policies should be prepared in conjunction with the CPHM(CI)/EH).
(ii) An audit cycle should be instituted and other mechanisms established to evaluate the effectiveness and implementation of policies and procedures.
1.4.15.2 Staff Education
(i) An education programme for all employees and students should be provided.
Information should be readily available to them on the measures to prevent and
control infection.
(ii) Advice should be provided to staff on appropriate precautions to be
observed in managing patients with infection (including carriers of potential
pathogens) and to correct hazardous or ineffective procedures.
(iii) Advice should be provided, in collaboration with the OHS, on agreed
measures to avoid the transmission of infection between staff and patients and
vice versa.
1.4.15.3 Surveillance of Infection
(i) Surveillance of HAI should be carried out to detect
outbreaks, to produce information on trends in sporadic infections, to inform
decisions on and evaluations of changes in clinical practice, and to assist
in the targeting of preventive efforts.
(ii) A hazard analysis of the critical control points (HACCP) which need
to be controlled in order to prevent infection should be carried out so as to
enable decisions to be made on where best to focus existing or additional resources.
(iii) As results of surveillance of HAls are increasingly being used as indicators
of performance and quality, such indicators require to be established.
1.4.15.4 Monitoring of Hospital Hygiene
(1) The ICT should be active in ensuring that the appropriate policies
and procedures required to ensure a safe environment for patients, staff and
visitors are in place and implemented. To this end Infection Control Environmental
Audits should be performed throughout the Trust and cover the full range of
Trust activities. Areas which should be audited include safe disposal of clinical
waste; cleaning, disinfection and sterilisation procedures; food hygiene; protective
clothing; domestic services; handwashing; ward facilities, e.g., toilets, bathrooms,
sluices and treatment rooms.
(ii) Audit Reports should be conveyed to the individual responsible for the
ward/department, and to the appropriate senior manager(s) for action. Whilst
the ICT may perform the audits, the Line Managers are responsible for rectifying
the faults identified. Action Plans should be returned to the ICT within a specified
time scale. Summaries of the Audit Reports should be tabled at the TICC. Serious
or persistent problems should be addressed by the Committee, and the appropriate
support given to the ICT to address deficiencies.
1.4.15.5 The Provision of Safe Food and Catering Services in Hospital
Provision of safe and nutritious food in hospital for patients and staff is a major undertaking which is achieved by having a combination of good management, staff trained in safe hygiene practices and catering skills, and appropriate quality controls.
Catering Managers should ensure that the risk of food becoming microbiologically contaminated is minimal by ensuring that staff have a working understanding of the principles of hygiene and of their obligation to report to management any infectious or potentially infectious conditions, e.g. gastro -enteritis and skin infections. They should also ensure that staff are supervised. Although catering staff are mainly responsible for providing food in hospitals, nursing and domestic staff are also involved. Management should ensure that everyone who handles, prepares, processes and distributes food has an understanding of the principles of both food hygiene and good food handling practices.
All food businesses - which include hospital catering, must meet their responsibilities under the Food Safety Act and the Food Safety (General Food Hygiene) Regulations (see Appendix 2). Food hygiene implies more than cleanliness. It means the use of policies, practices and procedures to protect food from contamination, prevent multiplication of bacteria to numbers capable of causing food poisoning or food spoilage and to ensure the destruction of pathogens by thorough cooking. Appropriate training should be available and all catering staff should be encouraged to obtain the relevant food hygiene certificates.
Hospital catering can be entirely conventional or a cook-chill, cook-freeze catering system or a combination of the two systems (see Department of Health guidance on this issue)3.
Hospital catering contracts should specify the quality control standards required, which should be monitored and periodically reviewed in the normal way. The ICT are well placed to help in the evaluation of the catering contract, setting up of quality measures and participating in inspecting food handling areas4.
Care deliverers must consider their responsibilities in relation to consumables brought in for patients by all agencies, including voluntary organisations and relative s/friends. Precise arrangements will be a matter for local policies.
Responsibility for the enforcement of the food safety legislation and for the enforcement of statutory measures to control foodborne disease rests with Local Authorities (LAs) via the Environment Health Officer (EHO).
1.4.15.6 Pets
A number of medical, psychiatric and long stay wards have adopted the use of animals as part of their therapeutic processes. Whereas pets can provide valuable companionship, stimulation and comfort, they represent an infection control hazard through the diseases that they can transmit to patients. Facilities considering the use of animals in therapy should do so against a background of a comprehensive risk assessment and against written operating procedures which specify the veterinary and other care required to minimise these dangers.
1.4.15.7 Other Relevant Matters
(i) Suitable procedures should be established for the admission, transfer
and discharge of patients with infection or colonisation, including liaison
with the medical and nursing staff responsible for the care of patients during
admission and after discharge or transfer. Collaboration with the CPHM(CD/EH)
in the preparation of these procedures is essential.
(ii) The ICT should set and audit standards for its own work and contribute
to the standardsetting and audit processes in other clinical and support services.
(iii) Assessment and management of the risks of infection to other patients
and staff must be undertaken in accordance with the requirements of the COSHH
Regulations and other health and safety at work legislation and best practice.
(iv) Where appropriate the ICT should be involved in the contracting process
when considering aspects relating to infection prevention and control.
1.4.16 Trusts need to have flexibility in the use of their resources, but there are advantages for the planning and implementation of an effective programme in the creation of a separate budget for routine infection control work. Either the ICD or WN could be the budget holder, although in practice the ICD normally takes this role. Alternatively, the WN component could be included within a Trust's Quality Management Structure.
The budget would cover the costs of:
a) the employment of the ICN(s);
b) the ICUs time spent on infection control;
c) clerical and laboratory support staff;
d) additional microbiological tests and equipment specifically needed for
infection control purposes;
e) computer equipment for surveillance;
f) educational aids (videos, posters);
g) training and education of ICT members and the provision of books and journals;
h) printing and dissemination of policies and manuals;
i) travel between the institutions covered by the ICD and ICN(s).
1.4.17 The costs of managing outbreaks (or major infection incidents) will require to be met from other sources.
1.4.18 If an ICT provides infection control services outside the "base TrusC these will be the subject of a clearly defined service level agreement. It is the responsibility of the ICT in the "base TrusC to manage that service level agreement to ensure it is fulfilled.
1.4.19 The ICT is accountable to and acts on behalf of the CE. As the leader of the Team, the ICD should have immediate access to the CE or Medical Director when urgent decisions are required.
The Infection Control Doctor
1.4.20 The ICD should normally be a CMM. Exceptionally, medical staff of other disciplines (for example a physician specialising in infectious diseases) may have the appropriate background and training.
The ICD provides leadership for the ICT and is responsible to the CE for its work within the framework and resources provided by the CE. This role should be clear to clinical colleagues. The ICD must work closely with the ICN(s). The ICD should be based within an acute hospital and must have ready access to laboratory facilities and be able to arrange additional laboratory tests whenever these are required for infection control purposes. If the ICD is not a CMM, he or she will need to liaise closely with the CMM who is a member of the ICT. The Department of Microbiology may design-ate one of its technical staff to assist the ICT in laboratory aspects of its work. Some Trusts currently have more than one ICD; in these circumstances the responsibilities of each should be clearly defined and their approaches agreed and consistent. One individual should take the lead on infection control matters, possibly on a rotating basis.
1.4.21 The ICD should be trained in all aspects of hospital infection control, including hospital microbial epidemiology. There is a need for continuing education by regular attendance at meetings and courses. Support for this should be provided. Establishment of a course for ICDs leading to a recognised qualification is clearly desirable.
1.4.22 Long stay, and other non-acute or small hospitals, will not usually have amongst their medical staff anyone with the appropriate training and experience of infection control to act as ICD. They should therefore either nominate an IC1) from within their staff and arrange for suitable training (if required) or appoint an ICD who is based in a larger neighbouring hospital.
1.4.23 An outline job description for an ICD is available from the Association of Medical Microbiologists (address at Appendix 5).
Infection Control Nurses
1.4.24 ICNs should be Registered General Nurses with appropriate training and expertise (see 1.4.28) and are usually the only members of the ICT with full time responsibility for infection control. All Trusts should appoint at least one WN and larger Trusts and tertiary referral centres should consider appointment of additional appropriately trained staff as a matter of priority. WN staffing levels are a matter for local determination, but managers should assess their needs according to the size of their Trust, the case-mix and the throughput of patients, as well as the other considerations highlighted in this report. The current UK norm for WN staffing is one WN per 450 beds.
1.4.25 As a member of the ICT, the ICN is responsible for the surveillance, prevention and control of infection in hospitals and, when appropriate, in the community. The fulfilment of this role requires expert knowledge of general and specialist nursing practice, risk management and clinical audit, plus educational and research skills. It is important that the WN is sufficiently senior to be able to relate to a wide range of NHS and non-NHS personnel at all levels and from all disciplines.
1.4.26 The functions of the WN are the same as those of the ICT (see 1.4.13-1.4.14). In order to carry out these responsibilities the WN will, on behalf of the team, contribute to the formulation and promulgation of policies., procedures and protocols designed to prevent and control infection. He/she should also lead the ICT's input into educational and other programmes, (including induction programmes) to educate, inform and raise awareness of all staff on infection prevention and control measures. ICNs should be members of all relevant committees, notably those dealing with audit, health and safety and occupational health.
1.4.27 ICNs need to have an understanding of each service area e.g. acute surgery, maternity and long stay, including a knowledge of research based practice, reinforced by daily experience. Service managers will be responsible for the local implementation of the expert advice of the ICN and other members of the ICT on infection prevention and control measures.
1.4.28 ICNs should receive initial training at a hospital with an experienced ICT and should, within one year of appointment, undergo a recognised specialist training programme and should be expected to have reached Diploma level. Thereafter they should attend appropriate courses, conference s/seminars to enable them to keep up to date with new developments within their specialty and the profession generally. Study leave and financial support are needed for this purpose. Employers will be mindful of United Kingdom Central Council for Nursing Midwifery and Health Visiting (UKCC) requirements concerning the maintenance of an effective registration, and of new standards for education leading to specialist practice.
1.4.29 The management framework within which an ICN works will be determined locally. It is often appropriate for the ICD to act as the team leader and for the ICN to be accountable managerially to the ICD and, professionally to the Director of Nursing or equivalent post-holder in the unit in which he/she is based. Some Trusts have also chosen to have ICNs as part of their Quality Assurance teams as an alternative management arrangement. As a trained professional, the ICN is responsible for his or her own actions and work (as set out in the UKCC Code of Professional Conduct and the Scope of Professional Practice). Although the detailed guidance on infection control services in non-NHS community settings is outside the scope of this document, the role of the ICN in this area is increasingly being recognised. In some places dedicated NHS community service based ICN posts have been created.
1.4.30 An outline job description for an ICN is available from the Infection Control Nurses' Association (address at Appendix 5).
Infection Control Link Nurses
1.4.31 Link nurses are being increasingly used to facilitate liaison between clinical areas of the hospital and specialist teams. One model for achieving a high level of infection control awareness is a network of infection control liaison nurses and midwives acting under the supervision of ICNs, as a resource and role model for colleagues. They are generally first level- registered nurses with sufficient experience and standing to have authority with colleagues and managers, and are drawn from ward/departmental staff to undertake the link role alongside their other duties. They may be particularly useful in outlying or non-acute hospitals, or in specialised units. A key part of their role is to assist in the early detection of infection outbreaks. They should also draw the attention of the ICNs to those changes in practice which have implications for infection control. It is essential that, when acting as link nurses, they undertake only those duties which are appropriate to that role. These duties should be included in their job description. There are special training requirements in infection control, and the necessary education should take the form of a training programme, under the direction of an ICN, as part of the link nurse's continuing professional development.
It is important to stress that a link nurse is not a substitute for an ICN and that all major acute hospitals providing equivalent services to those of a District General Hospital should have at least one full-time ICN based on the premises. Although the benefits of having a link nurse in small units are recognised, cover by an ICT nurse is essential.
Other Support
1.4.32 The ICT needs secretarial support, photocopying facilities and the means to distribute letters/leaflets to hospital departments; access to current literature and the excellent education materials (posters, leaflets, films and videos) that are available; and access to telephone, electronic mail or facsimile transmission (FAX). These will be especially useful if information has to be disseminated or received without delay where the ICT is covering more than one site. Hardware and software will be needed to support surveillance activity and, confidential links with other electronically -held patient data will greatly facilitate effective surveillance.
Consultant In Public Health Medicine (Communicable DiseaseslEnvironmental Health)
1.4.33 A CPHM(CI)/EH) is appointed by each health board to its Department of Public Health Medicine and is responsible for the surveillance, prevention and control of communicable disease and infection in the Health Board area. Communicable disease control is a complex activity which relies on teamwork and liaison between agencies, including all parts of the Health Service. Hospitals also have a role to play in the control of infection in the community. Close collaboration between the CPHM(CI)/EH) and the ICT is essential if both are to fully contribute to efforts to the prevention of communicable disease and infection inside and outside hospitals.
1.4.34 The CPHM(CD/EH)'s role in infection control is:
a) to advise Health Boards, Trusts and GPs on appropriate requirements for
infection control services and on monitoring the agreements and other relevant
arrangements not incorporated into agreements;
b) through Chairmanship of HBICAC to facilitate liaison with other ICTs in
the Health Board area and other local agencies, and the development of agreed
common policies;
c) as a member of the TICC, to contribute to the development and monitoring
of the hospital's infection control policies;
d) to collaborate with the ICT in the management of infection outbreaks;
e) to liaise with the ICT regarding the implications of hospital infection
s/outbreaks for the community, and on the implications of community based outbreaks
for the hospital, and act accordingly;
f) to provide epidemiological advice, whenever it is needed, routinely and
in outbreaks;
g) to contribute a wider community perspective.
1.4.35 Medical staff have a statutory duty to notify certain infectious diseases and food poisoning identified in patients to the CPHM(CI)/EH) (see Appendix 4). Notification forms (obtainable from the Health Board) should be available in all clinical departments.
Telephone reporting of those infections with serious implications for public health, whether or not they are statutorily notiriable, is important. Where a foodborne outbreak of infection is thought to originate in hospital premises, the CPHM (CD/EH), acting as the Designated Medical Officer (DMO) to the LA, should be immediately informed. The CMM and the CPHM(CI)/EH) should also agree which isolations of micro-organisms should be reported by the laboratory to the CPHM(CI)/EH) who has a statutory right to have access to patients (and their medical records) suffering from infections with implications for public health.
1.4.36 The CP11M(CI)/E11) is the link between the Health Service and the local authority in the control of communicable disease and should know about any problem within the hospital that may have implications for the local community. The Trusts will also expect that the CPHM(CI)/EH) will supply information about relevant community infection.
1.4.37 The involvement of the CPHM(CI)/EH) in particular aspects of infection control is dealt with in the relevant sections.
Isolation Accommodation
1.4.38 Trusts require to provide suitable accommodation
for the clinical care of patients with community acquired infection or HAI.
With the move of many Infectious Diseases Units to district general hospitals, such accommodation may be present within the Trust or part contracted out. Health and Safety at Work legislation (see Appendix 2) requires Trust Management to ensure that formal risk assessments are carried out and that arrangements are in place to minimise the risks of transmission of infection to other patients or staff. The nature and extent of the isolation facilities available need to be considered as part of this process. The Trust will need to assess how patients with various types of infection requiring isolation will be managed in normal circumstances and in small or major outbreaks. In outbreaks it may be possible to nurse affected patients together in one ward (or part of a ward) and most acute hospitals have wards or units which could be quickly adapted to provide additional temporary isolation facilities. Contingency arrangements should be included in the hospital's major outbreak plan for provision of larger numbers of beds if necessary.
1.4.39 There is little published evidence about the value of having an isolation ward in a hospital without an Infectious Diseases Unit - but this concept is quite new in the UK.
A fully staffed Infection Unit is clearly pivotal in the management of both outbreaks and sporadic cases, and acquisition of nosocomial infection in a patient with another condition has potential litigious implications. There are published reports of MRSA outbreaks which proved impossible to control until such a ward was made available. If there is an isolation ward, other wards may be able to function relatively normally during an outbreak; otherwise closure of some wards may be necessary, disrupting the hospital's routine activity.
1.4.40 In an Infection Unit there may sometimes be lower than average bed-occupancy rates due to fluctuations in the number of infected patients requiring treatment. However, flexible arrangements permitting the use of the beds by non-infected patients, when they are not needed for infected patients, can help to prevent this and this can be done in a modern, appropriately designed Infection Unit. Some modern Infection Units embedded in teaching hospitals have an occupancy rate of 85% with rapid patient turnover.
1.4.41 A significant benefit of a separate isolation ward is that it can be staffed by "dedicated" and appropriately trained doctors and nurses, to whom compliance with isolation procedures become second nature. Patients isolated in side rooms on general wards still need to be nursed by staff with experience and training in isolation procedures if the isolation is to be effective. Factors likely to affect the cost/benefit equation are the staff/patient ratio and the rate of turnover of nurses, since a nurse unfamiliar with the hospital, and caring for a large number of patients, is less likely to be able to follow infection control procedures. Hospitals which regularly use agency staff and have high turnover rates should particularly consider the provision of a permanent separate infection ward with dedicated fully trained medical and nursing staff.
1.4.42 Paediatric isolation facilities should be in a demarcated area of the Paediatric Unit with, where possible, separate nursing and cleaning staff as with adult isolation facilities. The clinician responsible for adult beds will usually be a physician with training in infectious diseases, while paediatric patients will be cared for by suitably trained paediatricians.
Communications With Other Key Individuals And Groups
1.4.43 Experience has shown the importance of good communication and infection liaison in the control of hospital infection. It is essential that advice and policies on infection control and prevention are widely disseminated, fully understood and strongly supported by senior management.
1.4.44 Those with whom the team will need to work are listed in paragraphs 1.4.45 - 1.4.66.
Within The Hospital
1.4.45 Consultants in charge of infected (or colonised) patients - or those at particular risk of infection, have a responsibility for the health and safety of staff, visitors and other patients within the hospital. The ICT should inform consultants of microbiological hazards arising from their patients, reminding them regularly of the statutory duty to notify certain infectious diseases and the need to discuss with the CPHM(CI)/EH) any case where the treatment of contacts outside the hospital may be required. The consultant in charge will also need to liaise with the ICT about the admission of any patient with an infection which may spread to others. Some clinical departments may find it valuable for one consultant to take the lead interest in infection control in that department, e.g. ITU or orthopaedic surgery.
1.4.46 The consultant who has clinical responsibility for any patient with hospital acquired infection normally has the final decision on that patient's management. The ICT advises the clinician on appropriate actions, bearing in mind the risks to, and needs of, others. In almost all cases, agreement can be reached on a course of action which fulfils the needs of the individual patient and the requirements of infection control. In these situations, the consultant in charge of the patient and the IC1) are responsible for reaching a balanced judgement together. If all else failed however, the IC1) would need to inform the CE or other senior management of a situation involving avoidable risk to other patients or staff.
1.4.47 Unless clinical judgement dictates otherwise, patients should be informed at the earliest reasonable opportunity of hospital infections that affect them. The responsibility for this lies with the consultant clinicians concerned. The consultant clinician may wish to delegate the responsibility of informing patients or relatives about the nature of the hospital infection to the ICT.
1.4.48 OHS advise managers and employees about the effect of work on health - and health on work, and devise risk management programmes to ensure that the hazards which staff face during their work are minimised. There will always be areas where the roles of the OHS and the ICT overlap and local arrangements should ensure that their respective roles are clear.
1.4.49 Other Medical Microbiology staff need to be aware of significant episodes of infection in the Trust which may affect the advice they offer to colleagues so that they can deputise for the ICI), if necessary.
1.4.50 Clinical Scientists in Microbiology and experienced Medical Laboratory Scientific Officers (MLS0s) can give important assistance in the laboratory aspects of hospital infection control.
1.4.51 Pharmacists make an important contribution to the work of the ICT through their involvement in the production, implementation and monitoring of antibiotic and disinfectant policies. Pharmacists are also responsible for the quality control of sterile fluids. They will collaborate with the ICT in the investigation of infection which may be related to the use of any pharmaceutical product.
1.4.52 Catering Service Managers with direct responsibility for catering have an important role in ensuring that their hospital meets its legal obligations to comply with the requirements of food safety legislation (see 1.4.15.5).
1.4.53 Domestic/Housekeeping Services Managers are responsible for providing an effective cleaning service for the hospital. They are of great assistance to the ICT in implementing infection control policy and should be regularly informed of infection control matters which impinge on the work of their staff. Where the domestic services are being provided by commercial contractors, the site manager fulfils the domestic services manager's role. The ICT should have the opportunity to advise on the contract, which should include provision for staff training in infection control procedures and should aim to avoid the rotation of staff between different departments within the hospital and between the hospital and other buildings. The ICT may undertake monitoring audits and will require access for inspections.
1.4.54 Other hospital staff have roles relevant to infection control in their routine work and in outbreaks. These include the Estates Manager, Hotel Services Manager, Sterile Services Manager, Operating Theatre Manager, Health and Safety Manager, Supplies Officer and the Laundry Manager. They may be the first to hear of the problems arising from infection and need to be consulted both about outbreaks and on policies for infection prevention. The Sterile Services Manager can provide advice on sterilisation and disinfection of equipment and should collaborate with the ICT in monitoring these processes and in the maintenance of safe practices in the Sterile Services Department. The manager responsible for the collection and disposal of clinical waste should liaise with drawing up the policy. Pest control is usually carried out by a commercial company, but a pest control officer should be appointed in every large hospital. The officer will co-ordinate local pest control activities, initiate and maintain a reporting system, assess control measures and negotiate contracts with the servicing company.
1.4.55 A representative of the Trust ICT should be on the HBICAC. The HBICAC has many functions, including acting as a forum for discussion of communicable disease and infection control issues affecting both the hospital and the community and facilitating communication between hospitals served by different ICTs.
1.4.56 Off-site laboratories. Changing arrangements for the provision of pathology services may result in the laboratory being some distance from the hospital, creating difficulties for infection control. An ICT with a base in the laboratory will, at the very least, require accommodation in the hospital being serviced, since a significant proportion of their time needs to be spent there.
1.4.57 Private or separately managed NHS laboratories. If the ICD is not directly responsible for the work of the laboratory, he or she will need to liaise closely with the CMM in the laboratory. Arrangements will be needed to ensure prompt reporting of results to the ICT and that appropriate investigations for hospital infection control purposes are carried out with the active co-operation of the laboratory, both on a dayto-day basis and in outbreaks. These will include both additional tests on clinical samples and examination of non-clinical materials such as food and parenteral fluids. A risk assessment of possible effects on infection control, both routinely and in outbreaks, should be carried out before any contracts for microbiological services are concluded.
1.4.58 Local Medical Microbiologists are likely to be ICDs in other hospitals with whom ICTs should be routinely liaising. They may be represented on the HBICAC.
1.4.59 Community Services. HAI may present after a patient has been discharged from hospital. Hospitals are responsible for passing on relevant information to the GP responsible for the care of the patient in the community and to the community nurses and midwives, as well as to the CPHM(CI)/EH). Trust Managers, the ICT and the CPHM(CI)/EH) need to collaborate in exchanging information on problems arising in the community. Trusts should be told of outbreaks suspected to be hospital related. Community nurses and midwives should also liaise with the ICT about infected patients who are to be admitted to hospital. This two-way communication is extremely important. Some Trusts employ a community ICN; others are employed by the Health Board and are part of the CPHM(CI)/EH)'s team. Whilst the overall responsibility for the surveillance of HAI presenting after discharge rests with the hospital, it is likely that Trust ICNs will contribute to the future local arrangements for such post-discharge surveillance.
1.4.60 Community Nurses are professionally accountable to the Director of Nursing or equivalent post-holder in the unit in which they are employed. However, in their dayto-day clinical practice they work alongside GPs, usually as members of primary health care teams. Community nurses will be involved in the care of patients with HAI particularly in view of the increasing practice of discharging surgical cases earlier. They need to liaise with the ICT, with GPs and with their nurse manager, and to receive relevant information from the hospital from which the patient has been discharged. It is also good professional practice for community nurses and GPs to provide feedback to the hospital both to the ICT and to the team who have treated the patient. Community nurses will also need access to infection control advice, from a Trust ICN, the CPHM(CI)/EH) or the hospital ICT, depending on local arrangements.
1.4.61 In managing patients with HAI, GPs work closely with community and practice nurses and with other members of the primary health care team. They require timely and relevant information from the hospital from which the patient has been discharged, and should be able to seek advice on management from the ICT. Infection data for the attention of community staff should form part of patient discharge planning. Feedback to the ICT from the primary health care team, when HAI presents after discharge, is valuable particularly for the routine surveillance of HAI. GPs will also liaise with the ICT about infected patients who are to be admitted to hospital.
1.4.62 The Scottish Ambulance Service acts as the main transport link between hospitals and the community. In order to protect the health of both ambulance staff and patients using the ambulance service, it is essential that those responsible for arranging patient transport ensure that ambulance crews are fully informed of relevant patients who pose a potential infection risk so that appropriate systems of containment can be applied. The Scottish Ambulance Service has established and clearly identified protocols for transporting infectious patients which rely on close liaison with those requesting patient transport and the ICT.
1.4.63 EHOs, working for the LA as authorised officers, advise on and enforce food safety legislation as part of their remit. EHOs also have a role, working with the CPHM(CI)/EH), in the investigation and management of outbreaks, particularly of foodborne disease.
Outside The Hospital: National Level
1.4.64 The SCIEH (address in Appendix 5) is the Scottish specialist agency, and networks with a wide range of reference services. The Communicable Diseases Surveillance Centre (address in Appendix 5), is the sister organisation for England and Wales and can also provide expert opinion and support. Both centres house a multi - disciplinary team of scientists, nurses and doctors with experience in infection control, audit, epidemiology and surveillance and also offer certain specialised microbiology investigations from affiliated centres. In some types of outbreaks, e.g. salmonellosis, the microbiologists of other reference laboratories, including Scottish Office approved reference laboratories, may become involved.
1.4.65 The S0DoH. Staff at S0DoH need to be able to provide early accurate information to Ministers and the Chief Medical Officer (CMO) about the situation in any serious incident or outbreak of infection, and the Department is frequently approached by the media for information and comment. Where there is (or may be) public concern, for instance if large numbers of patients are affected, it is important that Trusts keep the Department informed through the CAMO(DPH). S0DoH co-ordinates the national response to any hazard involving medical supplies or drugs, and issues the appropriate hazard warning notices. In the case of food, The Scottish Office Agriculture, Environment and Fisheries Department (SOAEF13) takes the national lead. For the purposes of the Public Health Infectious Diseases Regulations (see Appendix 2), the CAMO(DPH) has a statutory duty to report immediately to the CMO any serious outbreak of disease, including food poisoning.
1.4.66 The HSE is a key agency for the enforcement of relevant health and safety legislation (see Appendix 2). Hospitals are required to report to the HSE certain diseases and dangerous occurrences (see Appendix 4).
Responsibilities Of ICT In Relation To Clinical Audit
1.4.67 The ICT's position in relation to clinical audit is complex in that its responsibilities for infection control encompass the whole hospital. It therefore contributes to standardsetting and audit for the range of clinical and support services, as well as setting its own standards and auditing its activities.
1.4.68 The ICT collaborates with others in the production of detailed standards, policies and procedures (and in the development of audit tools for these) and supports the audit process. Responsibility for audit rests with the main users of the standard. For example, standards underpinning policies and procedures are primarily the responsibility of users, whereas responsibility for the audit of standards for infection control education will mainly rest with the ICT.
1.4.69 Audit of infection control policies in wards and departments may be carried out by the ICT using a questionnaire and scoring system for a range of clinical procedures (e.g. isolation, use of IV devices, urinary catheterisation, and wound dressing techniques), use of disinfectants, hand hygiene, and disposal of needles and other clinical waste. The results of the audit for each ward (or area) are fed back to the ward staff, and an educational programme introduced as necessary to correct deficiencies. This type of audit, i.e. process control, is useful for providing evidence of infection control standards to the purchasers. Audit studies relating to non-clinical departments which contribute to the microbiological safety of the hospital environment will also require input from the ICT.
1.4.70 The ICT and the TICC contribute to setting the general standards which underpin an effective infection control programme. In general, responsibility for developing the tools and performing audit will lie with the ICT. An example of a suitable framework is set out in the document "Standards in Infection Control in Hospitals"5 .
1.4.71 Each ICT will set and audit standards for its own work, to meet the needs of the Trust and the TICC programme. The range of standards will, therefore, vary. The ICT's standards for itself will be distinct from those for the hospital as a whole. Standards likely to be applicable to the ICT in all hospitals include:
1.4.72 Audit tools derived from the standards will be used according to an agreed timetable. Analysis of the audit subjects should be considered regularly by the ICT, and lead to an agreed, documented course of action, with responsibility for action assigned to members of the team.