1.1 This appendix describes the key elements
for routine surveillance together with the public health and epidemiological
principles to be applied. Illustrative protocols for priority
surveillance and monitoring activities are also included.
2. PUBLIC HEALTH
2.1 Surveillance is a continuous process
of systematic collection, effective collation and analysis of
pertinent data with prompt dissemination of the results to those
who need to know, particularly those with responsibility for prevention
2.2 Surveillance of healthcare associated
infections covered by this Agreement will:
address the public health priorities
set by DH;
utilise a common approach across
the NHS, including appropriate linkages between surveillance required
for hospital infection control purposes and that needed to protect
the public health;
facilitate the collection and analysis
of data locally for local needs whilst also contributing to regional
and national surveillance;
wherever possible, only collect data
that has utility at the local level;
identify and monitor the impact of
the problem, including infections associated with healthcare that
become manifest in the community;
be based on defined populations so
that meaningful comparisons can be made; and
be supported by appropriate IT systems.
Purpose of surveillance
The purpose of surveillance is to provide information
for action. The systems covered by this specification are required
to describe the pattern HAI in the NHS and contribute to:
2.3.1 National level:
the development of policy;
planning and monitoring services;
assessing effectiveness of interventions;
informing Ministers, Parliament and
2.3.2 Regional and Health Authority level:
the development of local and regional
monitoring healthcare delivery; and
performance management of infection
2.3.3 Local level:
detect problems at an early stage,
to assist in timely action; and
monitor the effectiveness of prevention
and control measures in place.
2.3 The first phase of this specification
nationally co-ordinated surveillance
of HAI; and
monitoring of incidents and events
2.4 Data relating to individual hospitals
shall be handled in the strictest confidence. Identifiable data
should be known only to the individual hospitals.
2.5 Service providers shall comply with
the Data Protection Act (Date) and other statutory requirements,
relating to data and information management.
3.1 An adverse incident involving an NHS
patient is an event that actually (or potentially) results in
unintended harm to the patient. Some such incidents are related
to infection which, on occasion, have resulted in severe illness
or even death. The majority of infections are an inevitable consequence
of clinical interventions, a minority are preventable. It is important
that where such infections are preventable all appropriate actions
are taken to achieve this and when infections do occur their potential
to spread is contained.
3.2 Following committees of inquiry into
two major outbreaks of communicable disease, salmonella food poisoning
at Stanley Royd Hospital in Wakefield and Legionnaires' disease
at Stafford and a subsequent inquiry into the public health function,
guidance was issued to the NHS on the arrangements for communicable
disease control [EL(91)123 and HSG(93)56]. These communications
required the development and adoption of plans for the management
of major incidents of infection, including such incidents occurring
in NHS premises.
3.3 When a serious problem actually or potentially
exists (eg outbreaks of Salmonellosis), the Infection Control
Doctor will, in conjunction with the Consultant in Communicable
Disease Control, convene an outbreak control committee. This is
a matter of professional judgement, but guidance in these matters
is contained in Outbreak Control Plans that all Trusts are required
to have in place. Within these plans there is also a requirement
that the incident be reported beyond the Trust, to the Health
Authority and to the Regional Director of Public Health.
3.4 Monitoring of adverse patient incidents
will be a part of routine audit of clinical practice. As a result,
it will neither be necessary nor appropriate for every adverse
event to be reported beyond the context in which the event occurs.
However, the National Patient Safety Agency requires an initial
analysis of such incidents to determine the risk to patients.
In the event that a serious problem actually or potentially exists
then central reporting arrangements need to be invoked.
3.5 Following untoward events associated
with other areas of healthcare, the Government, medical professions
and the NHS gave a commitment to minimise the incidence of unintended
harm to patients arising as a consequence of clinical treatment.
Doing less harm: Improving the safety and quality of care through
reporting, analysing and learning from adverse incidents involving
NHS patientsKey requirements for health care providers
(DoH 2001), provides a framework for corporate learning from
3.6 Trusts will have surveillance and other
arrangements in place for monitoring problems of infection arising
in patients under their care. Therefore, it is not intended that
the system described in the attached protocol will monitor all
events. Rather it seeks to identify only those events that have
a significant impact on the ability of the Trust to care for patients
or on the health of the wider community.
3.7 The protocol for reporting of such incidents,
together with the specification of the data to be collected, seeks
to embed existing arrangements set out in major outbreak plans
into the framework being developed by the Department of Health
and NHS Patient Safety Agency.
3.8 Chief Executives in NHS Trusts and PCTs
in conjunction with their Control of Infection Teams and the local
Consultant in Communicable Disease Control will need to ensure
that their Outbreak Control Plans reflect the guidance issued
in Doing Less Harm and the protocol outlined in this document.
4. ALERT ORGANISM
4.1 Alert organism surveillance comprises:
the routine and systematic collection
and collation of data on specified micro-organisms isolated from
patients with infection occurring in a health care facility;
timely analysis of data to allow
the prompt identification of changes in patterns of infection;
the prompt distribution of the nature
and extent of change to those who need to know, specifically those
responsible for the care of individual patients and the prevention
and control of infection; and
periodic systematic review of the
systems in place.
4.2 Alert organism surveillance will be
part of routine surveillance activities of infection control teams
working in the NHS. Certain organisms will be of particular interest
in particular situations. Not all will be of relevance on a wider
4.3 This specification sets out a protocol
for surveillance of specified organisms that have wider, as well
as local, relevance. It is anticipated that all the organisms
included in this specification will form an essential and useful
part of the surveillance programmes at the local level. The use
of a specified dataset by all infection control teams will provide
a basis on which meaningful comparisons can be made.
4.4 An essential feature of this approach
to surveillance is that:
local surveillance, including the
analysis and distribution of information, will be undertaken locally;
national and regional surveillance,
including the analysis and distribution of data to DH and RDsPH,
will be the responsibility of CDSC.
4.5 The organisms included in this specification
for local, regional and national surveillance are:
S aureus, including MRSA;
Glycopeptide resistant enterococci
4.6 A requirement of this agreement is that
any system provided to Trusts to enable them to report to the
regional and national centres, should also allow them to survey
additional organisms, should they wish to do so.
5.1 In order to achieve the overall objectives,
a set of definitions and recommended methods are set out for each
infection or event identified as a priority. These are set out
in the form of protocols.
5.2 Each protocol is set out systematically,
in a format promulgated by WHO.
Rationale for surveillance: Describes
the public health significance of the infection/event.
Trigger for surveillance: Indicates
the point at which the implementation of surveillance should be
considered or existing arrangements reviewed.
Recommended type of surveillance:
Describes the type of surveillance to be undertaken (using
Recommended case definition: Sets
out the criteria for an infection/event to be included in the
particular surveillance activity covered by the protocol.
Recommended minimum dataset: Describes
the minimum data items required. Others may be added by agreement.
Others: Include analysis,
presentation and uses of data are self-explanatory.