Chapter 3 - Healthcare Infection Incidents, Outbreaks and Data Exceedance
The purpose of this chapter is to support the early recognition of potential infection incidents and to guide IPCT/HPTs in the incident management process within care settings; (that is, NHSScotland, independent contractors providing NHS services and private providers of care).
This guidance is aligned to the Management of Public Health Incidents: Guidance on the Roles and Responsibilities of NHS led Incident Management Teams (2017)
Built environment incidents/outbreaks
HPS are currently working towards delivery of comprehensive evidence-based guidance which will form Chapter 4 of the National Infection Prevention and Control Manual (NIPCM) on the built environment and decontamination.
In the interim two Aide-Memoires have been produced to provide best practice recommendations to be implemented in the event of a healthcare water-associated or healthcare ventilation-associated infection incident/outbreak. These will ensure clinical staff, estates and facilities staff, and Infection Prevention and Control Teams (IPCT) have an understanding of the preventative measures required and the appropriate actions that should be taken.
3.1 Definitions of Healthcare Infection Incident, Outbreak and Data Exceedance
The terms ‘incident’ and ‘Incident Management Team’ (IMT) are used as generic terms to cover both incidents and outbreaks
A healthcare infection incident may be:
An exceptional infection episode
- A single case of an infection that has severe outcomes for an individual patient OR has major implications for others (patients, staff and/or visitors), the organisation or wider public health e.g. infectious diseases of high consequence such as VHF or XDR-TB, botulism, polio, rabies, diphtheria.
See literature review for Infectious Diseases of High Consequence (IDHC)
A healthcare infection exposure incident
- Exposure of patients, staff, public to a possible infectious agent as a result of a healthcare system failure or a near miss e.g. ventilation, water or decontamination incidents.
A healthcare associated infection outbreak
- Two or more linked cases with the same infectious agent associated with the same healthcare setting over a specified time period.
- A higher than expected number of cases of HAI in a given healthcare area over a specified time period.
A healthcare infection data exceedance
- A greater than expected rate of infection compared with the usual background rate for the place and time where the incident has occurred.
A healthcare infection near miss incident
- An incident which had the potential to expose patients to an infectious agent but did not e.g. decontamination failure.
A healthcare infection incident should be suspected if there is:
- A single case of an infection for which there have previously been no cases in the facility (e.g. infection with a multidrug-resistant organism (MDRO) with unusual resistance patterns or a post-procedure infection with an unusual organism).
Further information can be found in the literature review Healthcare infection incidents and outbreaks in Scotland.
3.2 Detection and recognition of a Healthcare Infection incident/outbreak or data exceedance
An early and effective response to an actual or potential healthcare incident, outbreak or data exceedance is crucial. The local Board IPCT and HPT should be aware of and refer to the national minimum list of alert organisms/conditions. See Appendix 13.
Healthcare associated infection (HAI) Surveillance systems should be used to aid incident/outbreak detection using a combination of retrospective detection of cases alongside prospective enhanced surveillance in high risk settings (ICU/PICU/NICU, oncology/haematology). A risk based approach should be applied for other vulnerable groups e.g. cystic fibrosis, oncology and those undergoing renal dialysis.
Local surveillance/reporting systems should be used for recognition and detection of potential healthcare infection incidents /outbreaks within NHS Boards. Systems should make use of ‘triggers’ to allow prompt detection of any variance from normal limits.
The Infection Prevention & Control Team (IPCT)/Health Protection Team (HPT) should utilise surgical site infection (SSI) surveillance systems to identify specific post-surgical healthcare infection incidents/outbreaks (in line with national SSI surveillance program as a minimum).
Following detection/recognition of an incident/outbreak a member of IPCT or HPT will:
- Undertake an initial assessment, utilising the Healthcare Infection Incident Assessment Tool (HIIAT) - Appendix 14, gather epidemiological data and clinical assessment information on the patients condition as per:
- NHS Boards are required to report all HIIAT assessed Green, Amber and Red reports to ARHAI Scotland through the electronic outbreak reporting tool (ORT).
- NHS Boards should monitor the ongoing impact of the incident by escalating and de-escalating as appropriate, using the HIIAT assessment tool. The HIIAT assessment should remain Amber or Red whilst there is ongoing risk of exposure, identification of new cases.
3.2.2 Investigation, management and communication
The IPCT/HPT will establish an IMT if required.
- In the NHS hospital setting the ICD will usually chair the IMT and lead the investigation of healthcare incidents. Where there are implications for the wider community e.g. TB or measles, or rare events such as CJD or a Hepatitis B/HIV look back, or where there is an actual or potential conflict of interest with the hospital service, the CPHM may chair the IMT. A draft agenda for the IMT is available.
- The membership of the IMT will vary depending on the nature of the incident.
- A healthcare infection incident investigation will usually consist of the following elements; an epidemiological investigation, a microbiological investigation and a specific investigation to identify how cases were exposed to the infectious agent (environmental investigation)
- As part of the epidemiological investigation, a case definition(s) must be established by the IMT. A case definition should include the following: the people involved (e.g. patients, staff); the symptoms/pathogen/infection (e.g. with Group A Streptococci); the place (e.g. care area(s) involved); and a limit of time (e.g. between January and March year/date). The case definition(s) should be regularly reviewed and refined (if required) throughout the incident investigation as more information becomes available. A working hypothesis regarding the transmission route and source of the exposure must be formed based on initial investigation findings
- A microbiological investigation into the nature and characteristics of the implicated hazard /infective agent must be conducted.
- An environmental investigation must be conducted if the findings of the epidemiological investigation suggest a common exposure to a potential environmental source/ environmental reservoir.
- An infection prevention and control assessment to review the existing IPC practices must be conducted, so that areas for immediate improvement can be identified.
- Identify any change(s) in the system: staffing, procedures/processing, equipment, suppliers. A step-by-step review of procedure(s). A generic outbreak checklist is available.
- Identify and count all cases and/or persons exposed: This includes the total number of confirmed/probable/possible exposed cases. An incident/outbreak data collection tool is available.
- The IMT should receive and discuss all information gathered and epidemiological outputs e.g. an epidemiological (epi) curve, a timeline and a ward map to:
- Determine whether additional case finding and control measures may be necessary.
- Confirm that all incident control measures are being applied effectively and are sufficient.
- Control measures must be directed at the source of the exposure and/or at affected persons in order to prevent secondary/ further exposure to the agent. Control measures must be initiated within 24 hours of receiving the initial report and should be implemented based on relevant guidance (e.g. pathogen specific) and investigation findings of the nature of the outbreak.
- A follow-up period may be defined after an infection incident/ outbreak has ended to ensure its termination, including assessment of any ongoing control measures and would be determined by the PAG/IMT.
- Identify any change(s) in the system: staffing, procedures/processing, equipment, suppliers. A step-by-step review of procedure(s). A generic outbreak checklist is available.
- Identify and count all cases and/or persons exposed: This includes the total number of confirmed/probable/possible exposed cases. An incident/outbreak data collection tool is available.
If staff screening is being considered as part of the investigation DL (2020)1 must be followed.
- HAI deaths, which pose an acute and serious public health risk, must be reported to the Procurator Fiscal, refer to SGHD/CMO(2018)11.
- The IMT must ensure affected patients, and where appropriate their next of kin, have been informed of any actual or potential harm as a result of the HAI. Duty of Candour must be considered at each IMT.
- All significant adverse event reviews involving a category 1 adverse event (events that may have contributed to or resulted in permanent harm, for example unexpected death) should be reported to
- If no new cases arise and any remaining cases are considered to no longer pose a risk, the IMT should agree on actions prior to resumption of normal service.
- Following the PAG/IMT, the NHS Board is required to communicate all HIIAT Green, Amber and Red assessments with ARHAI Scotland, by completing the electronic Outbreak Reporting Tool (ORT) within 24 hours of HIIAT assessment. Incidents assessed as RED, AMBER and where ARHAI support is required GREEN will be reviewed for onward communication to SGHSCD.
- Any adverse event related to equipment or medication must be reported as soon as possible (within one working day) to the Incident Reporting and Investigation Centre (IRIC) and the escalation/de-escalation flowchart followed.
Closure of incident/outbreak with lessons learned
- Once the incident is over and in addition to mandatory electronic reporting, the IMT/NHS Board should decide on the most appropriate format for a report, to communicate incident management/lessons learned (IMT report /SBAR/Hot Debrief Tool). This is not a mandatory requirement but for the purpose of sharing lessons learned across Scotland.
The IMT Chair, in discussion with the IMT, should determine whether further reporting on the incident and the incident management is required i.e. SBAR Report and full IMT report template are available in the resources section of the NIPCM website.
3.3 COVID-19 Definition of confirmed and suspected case
COVID-19 case definitions are regularly reviewed and can be found in the Public Health Scotland COVID-19 Guidance for Health Protection Teams.
A laboratory confirmed detection of SARs-CoV-2 by polymerase chain reaction (PCR) in a clinical specimen OR a positive LFD test for SARS-CoV-2.
Possible COVID-19 Case
Persons with any of the symptoms of a respiratory infection and with a high temperature or not well enough to go to work or carry out normal activities, should be considered a possible case.
Symptoms of COVID-19, flu and common respiratory infections include:
- continuous cough
- high temperature, fever or chills
- loss of, or change in, your normal sense of taste or smell
- shortness of breath
- unexplained tiredness, lack of energy
- muscle aches or pains that are not due to exercise
- not wanting to eat or not feeling hungry
- headache that is unusual or longer lasting than usual
- sore throat, stuffy or runny nose
- diarrhoea, feeling sick or being sick
A wide variety of additional clinical signs and symptoms have also been associated with COVID-19. Fever may not be reported in all symptomatic people and cases may also be asymptomatic. Healthcare staff should be alert to the possibility of atypical and nonspecific presentations in children, older people with frailty, those with pre-existing conditions and those who are immunocompromised. People with epidemiological links to COVID-19 outbreaks or clusters should also be considered with a high degree of suspicion.
People must be assessed for other infectious or non-infectious causes of symptoms, as appropriate.
3.4 COVID-19 Notification of positive cases
It is essential that NHS Boards have systems in place to ensure that test confirmed cases of SARS-CoV-2 isolated from patients are reported to Infection Prevention and Control Teams (IPCTs) as promptly as possible to allow any inappropriately placed patients to be identified and isolated.
COVID-19 is a notifiable disease and as such, directors of diagnostic laboratories must inform their health board, the common services agency and Public Health Scotland of all COVID-19 isolates. This is a requirement of the Public Health etc (Scotland) Act 2008 and notification of infectious disease or health risk forms are available.
3.4.1 Communicating results
On confirmation of a positive COVID-19 patient isolate, the ward staff should be informed by the reporting laboratory or IPCT if the patient is still an inpatient. There must be agreed processes in place for communicating results and IPC advice out of hours when IPCTs are not available.
IPCTs should agree local notification process for any patients who have been discharged home since the COVID-19 test was undertaken to ensure that the patient is contacted at home and provided with the appropriate self-isolation advice.
There should be processes in place to ensure that IPCTs and OHS share intelligence which may indicate an outbreak is occurring in a specific ward/department.
3.4.2 Communication with other care facilities and NHS boards
Where a confirmed case or an identified contact has been transferred to another care facility (care home, hospice, mental health facility), the facility must be notified as soon as possible to make them aware of the positive COVID-19 result or COVID-19 exposure to ensure that the appropriate control measures can be implemented where applicable. There should be a local agreement in place to determine whether clinical teams or IPCTs will notify the facility and HPTs where required. Local agreements should include reporting arrangements out of hours.
If a confirmed case or an identified contact has been transferred to another NHS board,
the receiving NHS board must be notified by the IPCT or clinical team and alert them to the positive COVID-19 status or exposure to ensure the appropriate control measures are implemented.
Similarly, if a confirmed case has transferred from another board within 48 hours of symptom onset or positive test, the IPCT must inform the NHS board from which the patient transferred to allow risk assessment to be undertaken and contacts to be identified where applicable.
Active surveillance should be undertaken by IPCTs to allow clusters/incidents to be detected at the earliest possible opportunity.
3.5 COVID-19 clusters/incidents definitions
The definitions below should be applied to determine if a COVID-19 cluster/incident within a healthcare setting is occurring and determine when it can end. When assessing patient and staff clusters to determine if an outbreak is occurring, a high degree of suspicion should be applied.
3.5.1 Criteria to declare a COVID-19 cluster/incident in an inpatient setting
Two or more patient and/or staff cases of COVID-19 within a specific setting where nosocomial infection and ongoing transmission is suspected. For the purposes of this reporting, a high degree of suspicion should be applied and should be completed for any ward where there are unexpected cases of suspected or confirmed COVID-19. e.g. any cases that were not confirmed or suspected on admission. No time limit should be applied to determining whether a case is nosocomial e.g. 48 hours.
Where two or more staff cases of suspected or confirmed COVID-19 are identified and where transmission between the staff members is suspected to be associated with workplace exposure/behaviours
Note: If there is a single suspected or confirmed case in a patient who was not suspected as having COVID-19 on admission, this should initiate further investigation and risk assessment This single case may constitute a possible cluster depending on the contacts and exposures identified. Where the patient has been in a side room with transmission based precautions in place for 48 hours prior to symptom onset, and where all staff were wearing appropriate PPE appropriately, the IPCT may decide that there is no further action needed other than active monitoring for any new unexplained cases associated with the ward.
3.5.2 Criteria to determine that a COVID-19 cluster/incident in an inpatient setting has ended
No new test-confirmed or suspected cases with illness onset date 10 days following the last new confirmed case (from date of symptom onset or date of positive test if case has remained asymptomatic), within the affected ward or department. The cluster can be closed provided that these criteria are met.
3.6 COVID-19 Roles and Responsibilities
NHS Boards should have a COVID-19 outbreak response plan which details the roles and responsibilities of Infection Prevention and Control Teams (IPCTs) ,Health Protection Teams (HPTs) and the occupational health services (OHS) within their board when responding to COVID-19 outbreaks.
3.6.1 Convening an Incident Management Team (IMT)/Problem Assessment Group (PAG)
In a healthcare setting, the CPH(M) or the Infection Prevention and Control Doctor (IPCD) will chair the IMT depending on the circumstances and this should be agreed in advance and documented in the COVID-19 outbreak response plan. The ICD will usually chair the IMT, lead the investigation and management of incidents limited to the healthcare site, where no external agencies are involved and where there are no implications for the wider community. The CPH(M) would normally chair the IMT where there are implications for the wider community.
More information on IMTs and PAGS can be found in the Management of Public Health incidents: guidance on the roles and responsibilities of NHS led Incident Management Teams
An IMT generic COVID-19 agenda and a supporting agenda aide memoire for use by the chair or wider IMT members to support consistency in discussion points during COVID-19 IMTs across NHS Scotland are available.
3.6.2 Contact tracing responsibilities
The board COVID-19 outbreak response plan should include clarity on the responsible teams for contact tracing.
The COVID-19 Test and Protect service in Scotland ceased on the 1st May 2022 for the general community and as such contact tracing undertaken by public health will focus on outbreaks of COVID-19 associated with closed/high risk settings.
Contact tracing within acute inpatient settings should continue where an unexpected case of COVID-19 has been identified e.g. any cases that were not confirmed or suspected on admission.
3.6.3 Case definition for the incident
A case definition for the purpose of the incident must be agreed by the IMT and should include the following:
- the people involved (patients, staff, visitors);
- the pathogen (SARS-CoV-2);
- the place (the ward and hospital);
- a time period (commencing 48 hours prior to index case symptom onset or positive test if asymptomatic).
In determining cases, case definitions in line with section 3.3 should be used.
3.7 COVID-19 Investigations
The extent of the investigations should be decided by the IMT with an emphasis on active case finding and identifying any factors which have contributed towards the development of the cluster. Investigations undertaken and subsequent findings should be documented by the IMT.
3.7.1 Epidemiological data/Timelines
A basic epidemiological investigation characterising the cluster in time, place and person should be undertaken. This process will help identify potential sources and mode of transmission.
3.7.2 Identifying missed opportunities to isolate
Review of patient cases should consider any potential missed opportunities to isolate a patient, a delay in which may have resulted in onward transmission. In particular, consider any missed atypical presentation of COVID-19. Any learning should be widely communicated to all clinical staff in the board.
3.7.3 IPC practice and compliance (including AGPs)
Compliance with IPC practice on the ward should be reviewed to determine any practice which may have contributed towards onward transmission. Previous hand hygiene audits and any audits of staff practice and the environment undertaken should be reviewed to establish any education gaps which are required to be addressed.
Where AGPs are undertaken on the ward, IPCTs should check to ensure staff are wearing the appropriate PPE and the correct fallow times are being observed prior to other patients using the room in which the AGP was undertaken. The IMT may choose to repeat audits as part of the investigation.
Ensure that staff on the ward are compliant with COVID-19 IPC guidance contained within thethe National Infection Prevention and Control Manual (NIPCM) and advice contained within Appendix 21 COVID-19 pandemic controls.
Ensure that patients are wearing face masks appropriately as per the NIPCM and Scottish Government Extended use of face masks guidance.
3.7.4 Review of visiting
When investigating a COVID-19 cluster, ascertain from ward staff if there has been any non-compliance with visiting rules for example, visitors presenting symptomatic or declining to wear face coverings. Consider what, if any, measures need to be introduced to mitigate any risks identified.
3.7.5 Testing during an outbreak
Proactive case finding should be supported through selected testing of any suspected symptomatic cases and when indicated, asymptomatic testing as determined by the IMT. The highest level of benefit in terms of reducing transmission will be from identifying those most likely to have been infected. The highest level of benefit in terms of reducing harm will be from detecting asymptomatic positive cases who may transmit the infection.
A PCR test, Rapid Diagnostic Test (incl POCT) or LFD test may be undertaken to enable early detection of cases however, regardless of test results, a confirmatory follow up laboratory based PCR test must also be undertaken.
- Patients: All patients symptomatic of COVID-19 should be tested.
- Staff: All staff who are symptomatic of COVID-19 must be tested and excluded from work and follow advice laid out in ‘Managing Health and Social care Staff with Symptoms of a respiratory infection, or a positive COVID-19 test, as part of the test and protect transition plan’ DL (2022) 12
3.7.6 Whole Genome Sequencing
Public Health Scotland now offer a sequencing service to expedite outbreak investigations and address important clinical and epidemiological questions.
3.7.7 Contact tracing
This is a 2 step process involving identification of contacts and then risk assessing which contacts will require self-isolation.
Anyone who has been in the same room/area with the confirmed case in the 48 hours prior to symptom onset (or 48 hours prior to positive test if asymptomatic) until the point when the confirmed case was appropriately isolated/cohorted/discharged should be considered as a potential healthcare setting contact.
The case definitions below should be applied to determine who is a potential contact requiring self-isolation and should take account of all staff, patients and visitors. IPCTs should then consider any mitigating factors which will exclude staff being identified as a contact. An assessment tool is available to support the process.
Case definitions for contacts
A contact is defined as a person who, in the period 48 hours prior to and 10 days after the confirmed case’s symptom onset, or date a positive test was taken if asymptomatic and had at least one of the exposures listed below.
- Those that are living in the same household as a case for example those that live and sleep in the same home, or in shared accommodation such as university accommodation that share a kitchen or bathroom.
- Those that do not live with the case but have contact within the household setting.
- Those that have spent a significant time in the home (cumulatively equivalent to an overnight stay and without social distancing e.g. 8 hours or more) with a case during the infectious period.
- Sexual contacts who do not usually live with the case.
- Cleaners (without protective equipment) of household settings during the infectious period, even if the case was not present at the time.
- Face to face contact with a case within 1 metre for any length of time, including: being coughed on.
- Having a face-to-face conversation.
- Having skin-to-skin physical contact.
- Any contact within 1 metre for one minute or longer without face-to-face contact.
- A person who has travelled in a small vehicle with someone who has tested positive for coronavirus (COVID-19); or in a large vehicle near someone who has tested positive for coronavirus (COVID-19).
- A person who has been between 1 and 2 metres of someone who has tested positive for coronavirus (COVID-19) for more than 15 minutes, cumulatively, during the period defined above.
Contact tracing patients
Typically, any patients in the same bed bay as a confirmed case should be considered household contacts. For larger open bedded areas such as ITUs or nightingale wards. IMTs may choose to use proximity contact definition however, as a minimum this should include patients on either side of the confirmed case and an assessment of the whole area/ward must take account of the patient group and circumstances surrounding potential exposures such as:
- Whether or not all the patients were bed bound (e.g in an ITU area).
- Whether or not the confirmed case had an AGP performed during the exposure period.
- The patient population and patients who may mobilise between bed spaces including the confirmed case.
- Any reported suspected COVID-19 symptomatic cases in other parts of the ward or department.
- Ventilation; is the area poorly ventilated? i.e only natural ventilation and windows have been closed?
Depending on the findings of the considerations above and any other potential contributing transmission risks, the IMT may decide that all the patients and staff in the large open bedded area should be considered contacts.
For cases who have been in a single side room for the exposure period, only staff, patients and visitors who have entered the room of the confirmed case should be considered potential contacts. If the confirmed case has entered the room of any other patients or shared communal spaces with others, these should also be considered as potential contacts.
IMTs must also consider any patient transfers to other areas of the hospital within the exposure period e.g radiology, other wards and consider any potential contacts in these areas.
NB: Patients who have an overnight admission within a hospital setting who have been identified as a contact of a confirmed case of COVID-19 during their hospital inpatient stay must be isolated or cohorted for 10 days from the date of exposure. See also section 3.9.2 ‘Replacing Transmission Based Precautions with daily testing’.
Contact tracing staff
The flow chart in appendix 1 should be used to assess staff contacts in the healthcare setting and assumes that staff who have worn PPE have had training in its use and that the PPE worn at the time of contact met technical and quality standards.
Contact tracing visitors
There is no expectation that contact tracing amongst visitors will be undertaken routinely.
3.7.8 Ventilation considerations
Learning from the COVID-19 pandemic to date has highlighted the risk of COVID-19 transmission associated with closed environments that have poor ventilation. It is important to consider best practice on ventilation. See Appendix 20 - Hierarchy of controls for more information.
The impact of the ventilation and any contribution it may have had to the onward transmission of COVID-19 should be noted for future learning and wherever possible mitigated.
The following should be considered when deciding if the ventilation may have been a contributing factor in the outbreak;
- Is the planned preventative maintenance (PPM) programme up to date?
- When was the last PPM check performed?
- Is ventilation system functioning within normal set parameters?
- Are ventilation grilles, AHU, ductwork etc clean and free from dust/debris?
- Is cleaning schedule for the above up to date?
- Does the ventilation system meet current specification?
3.7.9 Bed spacing
Bed spacing in the affected ward should be reviewed to ensure that it is adequate to prevent onward transmission of Healthcare Associated Infections (HAIs) and to ensure that mitigation measures implemented to support physical distancing are adequate.
See chapter 4 of the NIPCM for more detail
3.7.10 COVID-19 messaging
IMT should consider if the COVID-19 messaging in the ward for both staff, patients and visitors is adequate. COVID-19 messaging should be in place to promote;
- Hand hygiene
- Appropriate use of face masks and face coverings
- Awareness of new onset respiratory symptoms and requirement for patients/staff/visitors to report symptoms to staff
- Good visiting advice including non attendance if visitor has respiratory symptoms
- Staff testing where applicable
Every opportunity to promote this messaging should be considered.
3.8 COVID-19 Formulate hypothesis
A hypothesis or hypotheses should be generated at the first IMT. The hypothesis should address the potential source and mode of transmission. The hypothesis should be re-visited at every IMT and consideration given as to whether it remains to be the most probable cause of the outbreak.
3.9 COVID-19 Control Measures
Control measures should be implemented immediately to prevent onward transmission of COVID-19. These must include:
3.9.1 Patient placement
- The PAG/IMT must agree the most appropriate placement for the suspected/confirmed cases and any contacts that are identified.
- Cohort areas may be established where required.
- Suspected cases (symptomatic) should be isolated on the ward and tested for COVID-19 as soon as possible. Symptomatic patients should not be cohorted together. The cohorting of symptomatic patients’ risks transmission of other respiratory viruses whilst the causative pathogen remains unknown.
- Doors to isolation rooms and cohorts should be closed and signage clear.
- Patient placement is regularly reviewed and documented in patient case notes.
- Restrict transfers to any other ward or department unless essential including for patients undergoing daily tests to prevent application of TBPs as a contact of a case
- A local risk assessment should be undertaken by the IMT and take account of whether the ward will remain open or closed.
Any asymptomatic contacts should be isolated or remain cohorted together until the 10 day isolation period has elapsed. It is possible to prevent the need for transmission based precautions for asymptomatic contacts where daily testing is utilised. See section 3.9.2 for more detail.
Contacts must be managed in the same manner as a confirmed case.
- If a contact develops symptoms during the 10 day isolation period, laboratory based PCR testing should be performed as soon as possible. If a contact tests positive for COVID-19 the isolation period should be reset to commence from the day of symptom onset.
- All efforts should be made to dedicate staff to the management of the cohort and ideally those staff must not then go between the case and contacts and all other unaffected patients on the ward. These staff cohorts should be maintained wherever possible for the duration of the isolation period.
3.9.2 Replacing Transmission based precautions with daily testing
Where these are available, rapid diagnostic tests (including POCTs) or LFDs can be used to prevent the need to apply transmission based precautions for contacts.
For adult contacts who are asymptomatic of respiratory viral symptoms, and for all children and young persons aged 0 to 18 years and 4 months regardless of their vaccination status, a daily Rapid Diagnostic Test (including POCT) or LFD test should be performed for 10 days following the date of exposure. Application of transmission based precautions (TBPs) are only required should the Rapid Diagnostic Testing (including POCT) or LFD tests positive at any point and a follow up COVID-19 PCR undertaken. Whilst Rapid Diagnostic tests (including POCT) or LFD tests remain negative, application of SICPs is sufficient and there is no need to isolate the contact.
Any patient who has been COVID-19 positive (confirmed by PCR or Rapid Diagnostic Testing (including POCT) or LFD test) in the last 28 days does not need to be considered a contact should there be a subsequent exposure during that 28 period. Daily Rapid Diagnostic Testing (including POCT) or LFD testing of these patients is therefore not required during this time period.
3.9.3 Hand hygiene
- Reinforce hand hygiene techniques and opportunities to all staff groups and ensure hand hygiene signage is in place
- Adequate supplies of ABHR and plain liquid soap is available.
- Ensure patients are supported with hand hygiene where required and symptomatic patients are provided with disposable tissues and waste bag for disposal.
3.9.4 Personal Protective Equipment
- Reinforce appropriate PPE use as per NIPCM (general use and AGP) to all staff groups
- Ensure adequate PPE supplies are available
3.9.5 Safe Management of care Equipment
- All non essential items of equipment and any clutter removed from ward to aid cleaning.
- Dedicated equipment for the affected areas where possible. Ensure equipment is cleaned as per appendix 7 of NIPCM.
3.9.6 Safe Management of Care Environment
- As a minimum, twice daily cleaning with chlorine based detergent is in place throughout the ward paying close attention to touch surfaces
- Terminal clean is undertaken following a patient transfer, discharge, once the patient is no longer considered infectious and prior to ward reopening.
3.9.7 Waste and linen
- Waste associated with the affected area is disposed of as category B waste.
- All linen used by patients in the affected area should be managed as infectious linen.
- When a bed is vacated and the linen removed, new linen should not be put in place until the ward or bed bay has been terminally cleaned and is ready to re-open to admissions and transfers.
- Ward staff provided with regular updates and support regarding outbreak management.
- The number of staff entering the ward should be restricted as far as possible. The number of staff on wards rounds should be reduced to essential staff only. Non-essential patient assessments by staff external to the ward should be postponed until the outbreak is closed where possible. .
- Staff should be cohorted to the symptomatic patients and any contacts and avoid caring for other unaffected patients on the ward wherever possible.
- Regular symptom vigilance must be in place at all times especially during outbreaks and arrangements made for staff to leave the ward if symptoms develop during a shift.
3.9.9 Management of staff exposed to a case
- Staff members who have a positive test must inform their line manager and arrangements should be made for them to stop work immediately and return home, avoiding the use of public transport. Local arrangements for transport of infected patients should be followed.
- NHS Boards should have arrangements in place to backfill staff who test positive.
- The staff member who tests positive will need to self-isolate and follow advice laid out in Appendix 21 - COVID-19 Pandemic Controls; Patient facing HCWs Isolation and exemption.
3.9.10 Closure of the ward/unit
- If cases have limited patient contacts which can all be isolated or cohorted in a closed bed bay or single rooms, the IMT may decide that it is appropriate to keep the ward open taking account of bed availability and any specialist services provided in the affected ward. This must be reviewed regularly (at least twice daily) and where there is any other symptom onset identified in staff, patients or visitors outside of the affected bay, the ward should be closed to admissions and transfers.
- Where all contacts and subsequent cases are unable to be isolated or cohorted, the ward should be closed to admissions and transfers wherever possible.
3.9.11 Other control measures which may be considered by the IMT
- Visiting restrictions
- Education sessions for staff if knowledge gaps identified
- Wider screening of patients and staff during the outbreak period
3.9.12 Conversion of outbreak ward to COVID-19 ward
During the ongoing COVID-19 pandemic when COVID-19 admissions are high and where bed capacity in the board is extremely limited, the board may consider converting the outbreak ward into a COVID-19 ward to allow confirmed COVID-19 cases to be transferred/admitted to the area and utilise bed capacity within the ward. This is an operational decision which must be carefully considered, documented and undertaken as a last resort. The following must apply;
- It is important that patients are appropriately placed determined by confirmed laboratory testing and all efforts are made to prevent placing COVID-19 patients in the same bed bay as those who have other respiratory viruses.
- If there are contacts on the ward who remain asymptomatic and do not have a confirmed COVID-19 positive test, these may be moved to other wards for the conversion to take place. However, these contacts must be placed in single side rooms on transfer and must be managed as a high risk patient until the 10 day isolation period is complete unless daily testing is in place (see section 3.9.2).
- There must be no patients remaining on the outbreak ward who have not yet tested positive for COVID-19 – all patients on the ward must be confirmed COVID-19 before the conversion takes place.
- The incident must remain open on the boards reporting dashboard to ensure all contacts are monitored regardless of where they are placed until the ‘ending a cluster’ criteria is met.
In choosing to convert the outbreak ward to a COVID-19 ward, IMTs alongside hospital management must weigh up the risk associated with transferring contacts to other wards and the demand for patient beds to accommodate emergency admissions.
3.10 COVID-19 Communications
- Internal communication plans should be agreed for each NHS board and this should include senior managers within the board, department leads for visiting staff such as clinical teams, phlebotomists, pharmacists, physiotherapists, all support staff, including porters, cleaners, volunteers.
- Regular updates should be reported to ARHAI in line with section 3.11.
- COVID-19 test results should be documented in individual case notes including any IPC advice issued.
- Where guidance cannot be followed, this should be risk assessed and documented by the clinical team or IMT.
- Media statements should be prepared by the IMT ready for release should it be required.
- Patients and carers where applicable should be kept informed of all screening investigations and provided with information leaflets where available or advice provided from NHS Inform.
3.11 COVID-19 Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) reporting requirements
Reporting should be led by the IPCT. Reporting of COVID-19 should occur on recognition of a COVID-19 cluster
COVID-19 Cluster (possible COVID-19 cluster as defined in section 3.5)
- A cluster should be assessed using the Healthcare Infection Incident Assessment Tool (HIIAT) as per Appendix 14 of the NIPCM.
- All confirmed clusters/possible outbreaks, must be reported to ARHAI.
- All COVID-19 Clusters should be reported through the electronic ORT
- All board-level data is accessible through the ARHAI Scotland interactive dashboards on the eViz portal
- The data submitted above is reported through ARHAI to the Scottish Government Healthcare Associated Infection Policy Unit and it is essential that all fields within the tools are completed to enable reporting requirements to be met.
- Any media statements prepared by the IMT in response to the incident should be shared with ARHAI.
3.12 COVID-19 Learning from the cluster/incident
As the COVID-19 pandemic continues, it is essential that NHS Boards record and disseminate learning from clusters internally and with ARHAI for sharing nationally.
There is a field within the ORT to capture this information and this should be completed with an evaluation of the effectiveness and efficiency of investigations and control measures. This will help inform the future management of COVID-19 patients and any COVID-19 outbreaks.
3.13 COVID-19 Cluster Resources
- COVID-19 Outbreak checklist v3 (February 2022)
- Outbreak data collection tool
- IMT generic COVID-19 Agenda
- IMT generic COVID-19 Agenda Aide-memoire
COVID-19 Appendix 1 - Assessing staff contacts in Acute Settings
This appendix should be used by Health Protection Teams (HPTs), Occupational Health Services (OHS) and Infection Preventon and Control Teams (IPCTs) aiming to apply some consistency in approach to assessment of staff contacts within healthcare and state health and care settings.
- 3.1 Definitions of Healthcare Infection Incident, Outbreak and Data Exceedance
- 3.2 Detection and recognition of a Healthcare Infection incident/outbreak or data exceedance
- 3.3 COVID-19 Definition of confirmed and suspected case
- 3.4 COVID-19 Notification of positive cases
- 3.5 COVID-19 clusters/incidents definitions
- 3.6 COVID-19 Roles and Responsibilities
- 3.7 COVID-19 Investigations
- 3.8 COVID-19 Formulate hypothesis
- 3.9 COVID-19 Control Measures
- 3.10 COVID-19 Communications
- 3.11 COVID-19 Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) reporting requirements
- 3.12 COVID-19 Learning from the cluster/incident
- 3.13 COVID-19 Cluster Resources
- COVID-19 Appendix 1 - Assessing staff contacts in Acute Settings