Management of Public Health Incidents: Guidance on the Roles and Responsibilities of NHS led Incident Management Teams - October 2011

ANNEX D

Management of incidents in healthcare settings

1. The Hospital Outbreak Advisory Group (HOAG) was set up in 2008 to devise tools to aid in reducing the number and size of outbreaks in healthcare settings in Scotland. In order to achieve patient, healthcare worker and visitor safety during outbreaks, a variety of tools have now been developed. To ensure these tools can facilitate and promote optimal 'equivalent pilot' outbreak management responses, these tools are underpinned by Human Error Theory (HET). Human Factors research has also been taken into consideration in the design of the tools; that is, the tools must make it easy for the Infection Prevention and Control Teams (IPCTs) to do the right thing, and to be sure what is the right thing to do.

2. According to HET, when failures (outbreaks) arise they can be categorised into 2 types. Those where the causes of the outbreaks and modes of transmission are known and those where they are unknown. Where the causes of the outbreaks are known, e.g. how Clostridium difficile or norovirus spreads in a hospital environment, then control measures can be pre-prepared, and an optimal 'equivalent pilot' outbreak response expected. Where the causes of the outbreaks are unknown, then tools can be used to reduce the number of attempts to gain control.

3. These outbreak tools are also designed to reduce the risk of the most common type of human error, omission. Reduction in omission error can be achieved by, for example, the use of checklists to prompt all necessary outbreak actions.

4. In addition to these tools, a systems approach to preventing recurrence is also advocated. A systems approach assumes that the system as currently designed, is vulnerable to outbreaks and the system must be changed to reduce this risk of recurrence. The adage: 'every system is perfectly designed to get the results it gets' summarises this approach. As a consequence every outbreak should result in a system review and wherever possible system strengthening.

5. The tools prepared by the HOAG are under continuous review. To continuously strengthen systems new areas of work in HAI outbreak prevention and management are also being requested nationally. The key tools available to assist IPCTs are detailed at the end of this section. A full list of the current tools, which includes tools to better prepare and reduce the risk of outbreaks is available via the HPS HAI Compendium of Guidance at:
http://www.hps.scot.nhs.uk/haiic/haicompendium.aspx

Responsibilities in assessment and managing incidents in healthcare settings

6. The responsibility in leading the management of incidents in healthcare settings depends on the size and complexity of the incident. Single-ward norovirus incidents may be effectively managed within the IPCT. For larger incidents where the routes of transmission are unknown, or where within the IPCT there is a lack of experience or expertise, assistance must be sought from the CPHM and or Health Protection Scotland. Use of the Hospital Infection Incident Assessment Tool (HIIAT) will guide IPCTs as to who they should inform and involve in any local healthcare outbreak or infection incident.

7. The Chief Nursing Officer set out guidance on the assessment of hospital infection incidents giving the role of overall HAI situation needs assessment to Health Protection Scotland [CNO (2010) 1]. This letter complements the arrangements set out in the HIIAT.

Communications with the Scottish Government Health Directorate (SGHD)

8. The HIIAT details when the SGHD is to be informed of an outbreak or infection incident, i.e. HIIAT amber or red. To ensure effective communications from NHS Boards, in 2009 the SGHD requested completion of the 'SGHD HAI INCIDENT AND OUTBREAK REPORTING TEMPLATE' for outbreaks and infection incidents which are HIIAT amber or red. This reporting template provides the SGHD with assurance that all incidents are being effectively assessed and managed.

Communications with patients and their relatives during incidents

9. In incidents in healthcare premises it is imperative that patients and/or their relatives are kept informed regarding any personal risks, and in particular in relation to actions they should take to minimise any future risks. Information on an incident should not be issued via the media before those directly affected are informed.

Communications with the media during incidents

10. Depending on the HIIAT assessment, communications via the media may be necessary. It is essential that when such communications are required, SGHD is aware of the situation. Additionally, all those affected by the incident should also be aware of the release. All such media releases must be open and honest.

The IPCT approach to healthcare incidents:

11. IPCTs should take a High-Reliability approach by demonstrating the characteristics designed to achieve reliability in managing incidents, i.e.

• Continuously reviewing data and systems to identify the weakest points and previously unrecognised potential failures and by trying to make their systems of incident management more robust.
• Always deeply examining situations and events and not dismissing signals by assuming the easiest answer is correct.
• Being mindful that healthcare settings are always vulnerable to incidents and taking / promoting actions to reduce risks, and promptly seeking help from experts when they are unsure of the required actions to take to resolve incidents.

Surveillance of healthcare related outbreaks

12. National surveillance of outbreaks is ongoing via SHORS and via the Monday Norovirus Point Prevalence. However, national surveillance is not a substitute for effective local surveillance for the detection of outbreaks. Guidance on local surveillance is available in the HPS HAI Compendium of Guidance

References

All available, together with any updates, via the HPS HAI Compendium of Guidance at: http://www.hps.scot.nhs.uk/haiic/haicompendium.aspx

CNO (2010) 1 National support framework for NHS Boards

Healthcare Associated Infection (HAI): reporting of incidents and outbreaks and norovirus guidance. CNO letter Dec 2009

Additional reading:
Human Error Theory: Reason J (1990) Human Error. New York, Cambridge University Press.
High-Reliability Theory: Weick et al (1999) Organizing for high-reliability: processes of collective mindfulness. Research in Organizational Behavior. 54; 81-123

Key Healthcare Outbreak Management Tools

Tool	Purpose & How to use
Hospital Outbreak Management Process	Designed to optimise patient, healthcare worker and visitor safety during outbreak management. This process tool specifies the actions, assessments, communications and documentation required during and after any outbreak. The IPCT can use this tool as an algorithm and checklist to guide and remind them of all the essential actions to be taken during an outbreak.
Hospital Infection Incident Assessment Tool (HIIAT)	Designed to guide IPCTs in the assessment of any outbreak or infection incident. The criteria for the assessment are the impact on the patients, the service, public health and public anxiety. The HIIAT replaced the Watt Risk Matrix. Use of this tool is mandatory. In the early stages of an outbreak there may be insufficient information to enable categorisation of the potential risk. In such instances, IPCTs should take a precautionary approach to the assessment. The assessment can be reduced should information become available to downgrade the incident.
Norovirus Outbreak Recognition and Action Tools	A suite of tools are currently available to reduce the risk and impact of norovirus. This includes: Norovirus Control Measures, Norovirus data record / control measure checklist / poster: is it a norovirus outbreak? These tools can be used directly, or locally adapted to ensure optimal outbreak response.
Clostridium difficile Infection Trigger Tool	This tool lists all the actions required when a CDI trigger is identified. The tool also provides space to document actions and findings. Consequently, this tool reduces the risk of omission errors in the management, and in the documentation, of hospital outbreaks.

All tools are available via the HPS HAI Compendium of Guidance http://www.hps.scot.nhs.uk/haiic/haicompendium.aspx

Hospital Infection Incident Assessment (HIIA) Tool (Watt Risk Matrix Replacement)

Objective: to provide all those who manage and need to know about hospital infection incidents with a simple impact assessment tool

Step 1 - Assess the infection impact on: Patients, Services, Public Health and Public Anxiety as Minor, Moderate or Major

	Patients	Services	Public Health	Public Anxiety*
Minor	Only minor interventional support needed as a consequence of the incident. No mortality.	No, or only very short term closure of clinical area(s) with minor impact on any other service.	No, or only minor implications for public health.	No significant increased anxiety or concern anticipated.
Moderate	Patients require moderate interventional support, but no mortality as a consequence of the incident.	Short term closure(s) having moderate impact on some services, e.g. multiple wards closed or ITU closed.	Moderate implications, i.e. there is a moderate risk of only moderate impact infections to other persons.	Increased concern and or anxiety anticipated.
Major	Life threatening illness or death as a consequence of the incident in one or more patient.	Significant disruption and impact on services, e.g. hospital closures for any period of time.	Significant implications for public health, i.e. there is a moderate or major risk of major infection to someone else.	Alarm within at least some areas of the community anticipated.

Step 2 Calculate the Impact: All Minor = GREEN; 3 Minor and 1 Moderate = GREEN; No Major and 2-4 Moderate = AMBER; Any Major = RED;

Step 3 Take actions in line with HIIA Tool colour

GREEN	AMBER	RED
Manage within the NHS Board. Log on SHORS if an outbreak. Inform CPHM.	Report to SGHD. Engage with CPHM. Log on SHORS and report to HPS if an outbreak Ask HPS for support if required** Consider issuing press statement (prepare holding statement)***	Report to SGHD. Engage with CPHM. Report to HPS** Log on SHORS if an outbreak Issue press statement***
* Public Anxiety: If a press statement was released today summarising the situation what would be the likely impact on public anxiety. **Consider others who may be of assistance in managing hospital infection incidents: Food Standards Agency, Scottish Environmental Protection Agency (SEPA), Water Authority, Dental Public Health Consultant, Health and Safety Executive, etc. *** The outbreak status should be confirmed prior to a press statement being issued - this should take no longer than 24 hours. As far as is practicable, patients and relatives should be informed of an incident prior to press statement release. All press statements should be shared with SGHD and Health Protection Scotland.