3.1. INTRODUCTION
3.1.1 Infection is one of the major causes of morbidity in the general population. Many people with minor infections will not seek treatment. A significant proportion of work in primary care is, however, associated with the management of infection. A relatively small fraction of the total number of patients with infections require specialist investigation and treatment in hospital. There is also substantial variability in the proportion of patients with serious infection managed in hospital. This is influenced by the availability of specialist Infectious Disease Units and different referral patterns among GPs.
3.1.2 Most infection is acquired by patients in the community. HAI represents a relatively small but important component of the total infection morbidity. Given the potential for the spread of infection from community to hospital and vice versa, the actual setting in which any infection is acquired is less important than the type and nature of the infection itself. The trend towards earlier discharge of hospital patients has also increased the need for community care of infected patients, e.g. surgical wound infection. There is therefore a greater need to co-ordinate the management of infection across all health care sectors.
3.1.3 There is a clear need to improve the general level of knowledge and understanding of infection control principles amongst health care staff working in the hospital and community. This aspect will become increasingly important in order to ensure that patients with infection are cared for in the most appropriate setting and to enable the most efficient use of health service resources.
3.2. OVERALL AIMS
3.2.1 The principal aims when managing infection should be to:
a) ensure the accurate diagnosis and management of individual cases,
making efficient use of laboratory and clinical resources;
b) minimise levels of persisting infection, carriage and further transmission
of pathogenic organisms;
c) ensure the appropriate management of outbreaks by making effective
use of health service and public health resources;
d) adopt a co-ordinated approach to surveillance, investigation, control
and prevention of infection, involving community and hospital based health care
staff, public health doctors, the residential care sector and other relevant
individuals and agencies;
e) improve the general level of education and understanding of infection
control principles and measures.
3.2.2 Irrespective of where the causative organism originates, good liaison between primary health care and hospital staff is essential for the effective management of patients with infection. Hospital staff require full information on potential infection risks posed by patients being admitted from the community. Similarly, primary health care and community residential care staff need timely and comprehensive information regarding infection risks and management of patients being discharged from hospital.
3.2.3 The co-ordination of surveillance for infection in a health board area is a statutory responsibility of the Director of Public Health. This is only possible, however, with the active co-operation of local clinicians, microbiologists, infection control nurses and others involved in the communicable disease field.
3.2.4 An awareness of the potential public health significance of infectious illness is essential as is an understanding of the role of the CPHM(CD/EH). All doctors should be aware of their statutory responsibilities regarding the reporting of notifiable diseases. Notification of cases to the CPHM(C13/EH) should be by the most timely and appropriate means available, thus enabling decisions to be made on the need for further investigation and action.
3.2.5 Doctors and other infection control staff must also be aware of the need to liaise with local CPHM(C13/EH) regarding other cases of infection or outbreaks which may have public health implications. The regular liaison which occurs between microbiologists and clinicians provides opportunities to remind clinical staff of the need to ensure that colleagues in public health are informed of relevant information.
3.3. COMMUNITY BASED INFECTION
3.3.1 Most infection occurs in the community and is either self limiting, self treated or requires only primary care management. Patients with infection therefore, constitute a significant proportion of a GP's workload.
3.2.2. Accurate diagnosis and effective treatment of infection in primary care requires a high standard of hospital based support in the form of ready access to expert clinical and medical microbiological advice. Access to appropriately accredited (CPA or equivalent) microbiological laboratory services is required for identification of causative organisms. GPs should be encouraged to request microbiological testing both to ensure confidence in the diagnosis and to facilitate microbiological and epidemiological surveillance of infection in the local population.
3.3.3 Expert medical microbiology input is equally important for advice on appropriate antibiotic therapy and monitoring of local antibiotic resistance patterns of organisms. Recent trends reveal an increasing use of antibiotics in general practice and emphasise the need for continued access to medical microbiological advice to ensure appropriate usage and prevent development of antibiotic resistance.
3.3.4 To ensure the efficient use of hospital and community infection control resources, specific efforts should be made to develop clinical guidelines and audit of good practice for the investigation and management of patients with infection. Guidelines should be based on multi-disciplinary input from GPs, hospital clinicians, microbiologists, infection control nursing and public health. The local Infection Control Advisory Group or equivalent body could provide a co-ordinating role for guideline development. Topics should include:
a) appropriate microbiological investigations for specific infections;
b) antibiotic drug formularies;
c) clinical management, including criteria for referral to an infectious
diseases physician or other hospital specialist for in-patient care or outpatient
appraisal;
d) pre-admission procedures including liaison arrangements for community
based patients, both cases and asymptomatic carriers of infection;
e) advice on procedures for notifying the local CPHM(CI)/EH) to facilitate
area wide surveillance and control.
3.4. HOSPITAL BASED INFECTION
3.4.1 The principal objective of infection control management is to minimise the risk of persisting infection, carriage or transmission of infection in health service settings and following discharge into the community.
3.4.2 Patients may be admitted to hospital with a primary diagnosis of an infection, may be asymptomatic carriers of organisms with the potential for causing infection or may acquire a nosocomial infection during their inpatient treatment.
3.4.3 Diagnosis of nosocomial infection depends on clinical awareness and effective surveillance within the hospital setting during inpatient treatment and after discharge to the community. The surveillance of nosocomial infection should be an integral component of clinical audit. The incidence of nosocomial infection must be regarded as one key indicator of quality of care.
3.4.4 Management of infection in hospital, irrespective of its original source, requires effective collaboration between clinicians, nursing staff and the hospital ICT. There should be clear policies and guidelines for the management of patients with infection in hospital, including guidance on:
a) routine infection control procedures, emphasising the benefit of basic
universal precautions and good hand hygiene;
b) isolation protocols and special infection control requirements for designated
infectious diseases, e.g. chickenpox, infective gastro-enteritis;
c) screening procedures for cases, and for patient and staff contacts in
order to identify continued carriage of organisms or their microbiological clearance;
d) specific infection control policies for specialised areas such as Intensive
Therapy Units (ITUs), High Dependency Units (HDUs), neonatal units, theatres
and labour suites;
e) disinfection, sterilisation and waste disposal policies;
f) health and safety and occupational health policies to protect staff, patients
and visitors from preventable infection risks.
3.4.5 Discharge management is important for all patients - but especially for those with persisting infection requiring active treatment or those identified as carriers of pathogenic organisms. Guidance for hospital staff should specify the need to:
a) alert GPs to a patient's infection status in advance of discharge;
b) advise appropriate family members, community nursing and residential care
staff of the patient's infection status and potential for infectivity;
c) give advice on further necessary infection control procedures, treatment
or eradication regimens;
d) ensure relevant information is passed to the CPHM(CI)/EH) to enable surveillance
and ongoing monitoring of infected patients/carriers in the community.
3.5. OUTBREAKS OF INFECTION
3.5.1 The principal objective is to ensure a well co-ordinated response to outbreaks of infection originating in the population, making efficient use of all appropriate health service resources, notably the dedicated units for managing infection.
3.5.2 Although much infectious disease presents as sporadic cases, outbreaks do occur on a regular basis within the community and health care facilities. Community based outbreaks have an impact on health services not only by generating demand for hospital care of infected patients but also in that infection may spread to patients and staff within health care facilities. Similarly, outbreaks of infection in hospital will have implications for spread in the community.
3.6. COMMUNITY BASED OUTBREAKS
3.6.1 Early identification of outbreaks depends on effective population surveillance of infection. This underlines the need for good communication and co-operation between clinicians, microbiologists and public health doctors. Early indications of an outbreak passed to the local CPHM(CI)/EH) should enable prompt investigation, enhanced active surveillance, case finding and alerting of local GPs and other health service deliverers. The CPHM(CI)/EH) also has responsibility for informing the S0DoH of significant outbreaks.
3.6.2 The co-ordination of outbreak investigation and management is the responsibility of the CPHM(CMEH) supported by LA departments, responsible for environmental health, local health service deliverers and (depending on the nature of the outbreak) a variety of other relevant agencies including the HSE, Scottish Environment Protection Agency (SEPA), SCIEH and Scottish Office Departments. (See also S0DoH Guidance on The Investigation and Control of Outbreaks of Foodborne Disease in Scotland19. It should be noted that this guidance is currently under review, and it is anticipated that revised guidance will be issued in due course.)
3.6.3 An OCT will be convened for any significant outbreak, chaired by the CPHM(CD/EH). Members of the team should include a medical microbiologist and clinical staff drawn from local health service deliverers. Trust management must therefore acknowledge the professional responsibilities and accountabilities of such staff and enable them to fulfil this role.
3.6.4 Health Service care deliverers must also address a number of issues in order to respond effectively to any community based outbreak including:
a) developing contingency plans for accommodating infected patients
admitted during a community outbreak e.g. a large number of patients with
food poisoning or infective gastro-enteritis requires rapid provision of suitable
beds and availability of trained staff;
b) planning appropriate provision of infectious disease units and
designated areas for the isolation and management of patients with infection
is critical;
c) ensuring the availability of appropriately trained specialist medical
and nursing staff;
d) provision of adequate clinical microbiology and infection control services;
e) potential use of hospital staff to support and enhance management of cases
at home or in community care settings e.g. Nursing Homes;
f) agreement with Health Boards on funding arrangements related to the outbreak;
g) continued provision of routine clinical services during a period of increased
demand due to large numbers of patients with infectious disease;
h) addressing staff occupational health needs in order to protect them from
acquiring infection or to prevent them transmitting infection;
i) maintaining close liaison with ambulance service staff to ensure that
appropriate control of infection procedures are used during transit of patients.
3.7. HEALTH SERVICE FACILITY BASED OUTBREAKS
3.7.1 Early identification of such outbreaks will depend on effective routine infection surveillance, which in turn relies upon an adequately resourced and trained ICT.
3.7.2 Suspected or actual outbreaks should be reported to the local Trust management and to the local CMM(CI)/EH) who should be included in the OCT.
3.7.3 In addition to the investigation and management of the outbreak itself (under the auspices of an outbreak control committee), health service care deliverers should address issues relating to the potential impact of an outbreak on the local community including:
a) the effect of unit or ward closures on the continued provision of routine
clinical services;
b) alternative provision of key clinical services;
c) provision of advice for primary health care staff regarding post discharge
management and liaison regarding patients discharged early due to an outbreak;
d)arrangements to minimise the rotation of ward staff through infected areas
in particular the use of agency, bank and temporary staff who may also work
in other hospital or community health care facilities