INFECTION CONTROL MANUAL
Chapter 2
Policy for Reporting of Infections to the
Trust Infection Prevention and Control Team
Version 7
Document Summary
This policy describes the Trust internal arrangements for the appropriate
actions and responsibilities in relation to reporting of potentially transmissible
infections to the Infection Prevention and Control Team.
DOCUMENT NUMBER
APPROVING COMMITTEE
DATE APPROVED
DATE IMPLEMENTED
NEXT REVIEW DATE
ACCOUNTABLE DIRECTOR
POLICY AUTHOR
TARGET AUDENCE
KEY WORDS
STHK0040
Patient Safety Council
10 September 2014
1 October 2014
1 October 2017
Sue Redfern, Director of Nursing, Midwifery &
Governance
Karen Allen, Director of Infection Prevention &
Control
All clinical staff
Notification, infection, infectious diseases
Important Note:
The Intranet version of this document is the only version that is maintained.
Any printed copies should therefore be viewed as “uncontrolled” and, as such,
may not necessarily contain the latest updates and amendments
Infection Control Manual - Chapter 2-Reporting of Infections to the Trust IPCT- Version 7 (clinical)
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Issue Date: 1st October 2014
Policy Reference number: STHK0040
St Helens & Knowsley Teaching Hospitals NHS Trust
Document Version History
Date
Version
1 February 2000
1
1 May 2000
2
1 September 2003
3
1 September 2006
4
1 November 2008
5
1 October 2011
6
1 October 2014
7
Review
date
1st October 2017
Summary of key changes
Format changed. Contact
details updated. Title of
policy amended.
Format changed
Author
Designation
Infection Prevention
& Control Service
Manager
Infection Prevention
& Control Service
Manager
Infection Prevention
& Control Service
Manager
Infection Prevention
& Control Service
Manager
Infection Prevention
& Control Service
Manager
Infection Prevention
& Control Service
Manager
DIPC
Lead Nurse,
Infection Prevention
& Control
Infection Control Manual - Chapter 2-Reporting of Infections to the Trust IPCT- Version 7 (clinical)
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Issue Date: 1st October 2014
Policy Reference number: STHK0040
St Helens & Knowsley Teaching Hospitals NHS Trust
CONTENTS
Item No.
Subject
Page No.
1.
Scope
4
2.
Introduction
4
3.
Statement of Intent
4
4.
Definitions
4
5.
Duties, Accountabilities and Responsibilities
4
6.
5
7.
Process for reporting of potentially transmissible infections to
the IPCT
Training
8.
Monitoring compliance
6
8.1.
Key Performance Indicators of the Policy
6
8.2.
Performance Management of the Policy
6
9.
References and Bibliography
6
10.
Related Policies and Procedures
7
11.
Equality analysis
7
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6
St Helens & Knowsley Teaching Hospitals NHS Trust
1. Scope
This policy applies to all clinical staff within St Helens and Knowsley Teaching
Hospitals NHS Trust to ensure that appropriate actions are taken when a patient with
a potentially transmissible infection is identified.
This policy refers to internal reporting of infection to the Infection Prevention and
Control Team. Details of all infections/infectious diseases requiring statutory
notification to the Consultant in Communicable Disease Control (CCDC) of the
Cheshire and Merseyside Health Protection Team can be found in Chapter 3,
Infection Control Manual.
2. Introduction
In order to minimise the risks associated with health care acquired infections and to
promote a safe environment for patients and staff, notification of all infectious
diseases and specific infections (suspected or confirmed) should be made to the
Infection Prevention and Control Nurses. Initial notification must be made by
telephone.
3. Statement of Intent
This policy ensures appropriate internal reporting of potentially transmissible
infection in order to minimise the risks of transmission of infection and to promote a
safe environment for patients and staff.
The policy does not cover the statutory notification of infectious diseases to the
CCDC.
4. Definition
5. Duties Accountabilities and Responsibilities
For full details of infection control responsibilities see Infection Control Policy,
Chapter 28B Infection Control Manual.
5.1. Staff
It is the responsibility of all clinical staff to:
 be aware of the current guidelines.
 put these guidelines into practice.
 bring to the attention of the Unit Manager or Infection Prevention and Control
Team any problems in applying these guidelines
Breaches of this policy may lead to disciplinary action being taken against the
individual.
5.2. Unit managers (person in charge of a ward or department) must ensure that
 The policy is readily accessible to all staff.
 The required facilities and equipment are available to enable compliance with
the policies.
 All staff within their area of responsibility have received training in the
appropriate procedures with respect to infection control.
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Issue Date: 1st October 2014
Policy Reference number: STHK0040
St Helens & Knowsley Teaching Hospitals NHS Trust
6. Process
Reporting of potentially transmissible infections to the IPCT
Unit Managers (Person in charge of a ward or department) must ensure that any
cases of the following (confirmed or suspected) are reported to the IPCT as soon as
practicable:
 All confirmed or suspected infectious diseases including Hepatitis A, B,
C, Human immunodeficiency virus (HIV), meningitis, tuberculosis
including multi-drug resistant TB (MDR TB) and new variant
Creutzfeldt-Jakob Disease (nv CJD).

Hospital-acquired wound or urinary tract infections.

Infestation with scabies.

Meticillin resistant Staphylococcus aureus (MRSA), Vancomycin
Resistant
Enterococci
(VRE),
Carbapenemase
Producing
Enterobacteriacae (CPE) and other multi-resistant organisms.

Two or more persons with diarrhoea/vomiting, influenza, respiratory
infections. (N.B. two or more persons with identical infections
constitutes an outbreak).

Acute diarrhoea.

Clostridium difficile infection (CDI). Complete Datix for ward-acquired
cases.

Commencement of isolation for patients with infections.

Any incidence of infection according to the discretion of the clinician,
named nurse, or nurse in charge of the ward.

Herpes zoster (shingles)

Chicken pox

Measles
Initial notification must be made by telephone.
Further advice
Please contact the Infection Prevention and Control Team if you need further advice
or if there is a patient with a confirmed or suspected patient on the ward or
department.
Lead Nurse, Infection Prevention and Control
Ext. 1193
Clinical Nurse Specialists, Infection Prevention and Control
Infection Control Manual - Chapter 2-Reporting of Infections to the Trust IPCT- Version 7 (clinical)
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Issue Date: 1st October 2014
Policy Reference number: STHK0040
St Helens & Knowsley Teaching Hospitals NHS Trust
Ext. 2452/1384
Consultant Microbiologists
Ext. 1836/1622/1834 or duty microbiologist via switchboard out of hours
Glossary
CDI:
CCDC:
CPE:
HIV:
IPCT:
MDR TB:
MRSA:
Nv CJD:
VRE:
Clostridium difficile infection
Consultants in Communicable Disease Control
Carbapenemase Producing Enterobacteriacae
Human immunodeficiency virus
Infection Prevention and Control Team
Multi-drug resistant tuberculosis
Meticillin resistant Staphylococcus aureus
New variant Creutzfeldt-Jakob Disease
Vancomycin Resistant Enterococci
7. Training
Training required to fulfil this policy will be provided in accordance with the Trust’s
Induction Mandatory and Risk Management Training Policy - Training Needs
Analysis.
8. Monitoring compliance with this document
8.1 Key performance Indicators of the Policy
Describe Key Performance
Frequency of
Indicators (KPIs)
Review
Lead
None specific to this policy (see
related Infection Control Manual
chapters)
8.2 Performance Management of the Policy
Aspect of
Monitoring Individual
Frequency Group /
compliance
method
responsible of the
committee
or
for the
monitoring which will
effectiveness
monitoring activity
receive
being
the
monitored
findings /
monitoring
report
N/A
N/A
N/A
N/A
N/A
Group /
committee /
individual
responsible
for
ensuring
that the
actions are
completed
N/A
9. References/ bibliography
Department of Health 2008. The Health Act 2008. Code of Practice for the
Prevention and Control of Health Care Associated Infections.
http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/pr
od_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_110435.pdf
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Issue Date: 1st October 2014
Policy Reference number: STHK0040
St Helens & Knowsley Teaching Hospitals NHS Trust
10. Related trust policy/procedures
Chapter 4
Isolation Policy
Chapter 3
Notification of Infectious Disease Policy
11. Equality analysis
Please refer to the overarching document which covers all chapters of the Infection
Control Manual.
http://nww.sthk.nhs.uk/MANAGE/library/documents/EqualityAnalysisforICM.pdf
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