REPORT TO INFECTION CONTROL COMMITTEE. Infection Prevention and Control Related Incidents

Transcription

1 Appendix 10 REPORT TO INFECTION CONTROL COMMITTEE Date of ICC Meeting: THURSDAY 6 th MAY 2010 Report Title: Infection Prevention and Control Related Incidents Author: Audit & Effectiveness Assistant/ Clinical Governance Facilitator Lead ICC Member: Clinical Governance Facilitator Aim of the report: To brief the Infection Control Committee on Infection Prevention and Control related Incidents which have been reported during the period of April 2009 to March 2010 To identify any actions and to highlight any trends. Recommendation: The Infection Control Committee is asked to note the commentary within each section of the report.

2 Infection Prevention and Control Reported Incidents Introduction Dudley and Walsall Mental Health Partnership NHS Trust is firmly committed to ensuring best practice in respect to infection prevention and control across all clinical settings. As part of this on-going work the Trust has established incident reporting processes across all services. In accordance with the Trusts Incident, Near-Miss and Serious Untoward Incident all staff are encouraged to report incidents and near-miss events, including those related to infection prevention and control. Data from the Incident Reporting systems is analysed centrally at the Governance Department, and this information is utilised to promote robust risk management controls and improved practice. This report has been prepared for the attention of the Infection Control Committee and identifies all Infection Prevention and Control related Incidents which have been reported within the Trust between April 2009 and March Commentary Table 1.1 (and diagram 1.1) shows all reported infection control incidents grouped into categories. Table 1.2 shows the same information highlighting the location of the reported incident. Table 2.1 (overleaf) provides a more detailed description of each individual reported incident. Analysis Overall it is noted that the levels of incident reporting seems exceptionally low. Recommended Actions All managers and Infection Control Link Workers to actively promote and encourage the reporting of all infection prevention and control incidents (including near-miss events). Governance Team to promote awareness of reporting infection prevention and control related incidents through the roll-out of Safeguard Training. Governance Team to promote awareness of local policies and processes in respect to infection prevention and control through an Infection Prevention and Control focused edition of Mind the GAP. Table 1.1 Number of Infection Control Incidents, by Category Category Number of Incidents Percentage Sharps / Needle stick Injuries 5 46% Clinical Waste / Environment 3 27% Outbreak of Infectious Disease 2 18% Wound infection / Pressure Sores 1 9% Total 11 Table 1.2 Number of Infection control incidents by Location Location Number of Incidents Percentage Bushey Fields Hospital 6 55% Bloxwich Hospital / Day unit 2 18% CMHTOP 2 18% Dorothy Pattison Hospital 1 9% Diagram 1.1 Infection Control Incidents by Category 18% 27% 9% 46% Sharps / Needlestick Clinical w aste / Envirom ent Outbreak of Infectious Disease Wound infection / Pressure Sores

3 Infection Prevention and Control Reported Incidents Table 2.1 Summary of the Incidents Sharps Staff reported that she sustained a needlestick injury. After taking blood from a patient, staff member was handed a tray with the needle on and was asked to put it in the sharps bin. The plastic sheath had come off the needle and when staff member tried to replace it, she sustained a needlestick injury to her right index finger. She encouraged it to bleed and put under a running tap and washed her hands with soap and water. Reported to occupational health dept Assisting Pt to have her regular insulin - when she became resistive. Insulin given but when retracting it she moved, knocking the needle into my (L) index finger drawing blood. I drained blood and rinsed it under the tap and informed s/n she as reported via to manager, matron and clinical lead to report it to occupational health tomorrow. Whilst doing the clinical waste and domestic waste round, staff member put their hand on one of the black bags in Wrekin Bunker and felt something sharp on their hand. On checking their hand they realised that they were bleeding quite badly. They removed their latex gloves and went onto Clee Ward where they knew there was a first aider. They were administered first aid to try and slow down the bleeding and advised to go to the A&E Department, Russell's Hall Hospital. They had a circular cut on their right thumb. Syringe was found in patient room by staff member. Decision was made by them to discharge patient. When told by Dr, patient became verbally hostile and aggressive, refused to leave ward. Staff members doing observations saw patient in corridor, patient was verbally threatening towards staff member and patient had a syringe in their hand. Police were called, patient decided to leave ward, police met patient at reception and escorted them off the premises. When preparing Insulin for a patient, a needle was already on the pen, so when trying to replace it with a new one accidentally stabbed a finger with the needle. Usual Precautions taken: 1. Injury Bled, 2. Washed, 3. Covered, 4. Reported to management, Occupation Health, 5. Incident recorded on Sentinel, 6. Senior Nurse informed, 7. Staff will visit Occupational therapy tomorrow (8/5/09) for a blood test. Clinical Waste / Environment Staff have covered cleaning duties for the last two weeks due to the cleaning staff being off sick - informed today that this will continue for four further weeks with no cover for cleaning/domestic duties. Sharps boxes are now placed in a large yellow bin which doesn't close properly or lock. Health and Safety hazard. Inner plunger of insulin syringe found under bin. Clinical Governance checked with ward manager 25/01/ No further information available regarding insulin plunger No patients identified on self administer insulin who may have dropped it. Outbreak of Infectious Disease Please see report appendix 1 Please see report appendix 2 Wound infection / Pressure Sores The patient was admitted to Linden ward suffering from extensive ulceration to both legs and large pressure sores to her buttocks and back. Patient was receiving district nursing input for leg ulcers - no identification of pressure sores.

4 REPORT TO THE DIRECTOR OF INFECTION PREVENTION AND CONTROL Date of Report 15 th January 2010 Report Title: Final Outbreak Report Author: Head of Nursing Executive Lead: Director of Infection Prevention and Control Purpose of Report: This report describes the managerial and operational control of an outbreak of Norovirus within the location of Malvern Ward, Bushey Fields Hospital as advised within the Outbreak of Infectious Disease Management Policy. Lessons learnt are identified within the report.

5 FINAL OUTBREAK REPORT Date of Outbreak 31 st December 2009 to 14 th January Name and Designation of Person Completing Report Head of Nursing, Vice Chair of Dudley & Walsall Mental Health Partnership NHS Trust Infection Control Team. Organism and Location Suspected Norovirus on Malvern Ward, Bushey Fields Hospital. Definition of Outbreak Two or more staff/patients with similar symptoms in one clinical area. Executive Summary Between 31 st December 2009 and 14 th January 2010 Malvern Ward was the location of an outbreak of Norovirus. Confirmation that the organism was Norovirus occurred on 13 th January 2010 following a laboratory analysis from the faecal specimen of one patient. The first indication of a suspected outbreak occurred on 31 st December 2009 when index case symptoms of diarrhoea and vomiting were present amongst two patients. During the subsequent days within the timeframe of this outbreak it became apparent that several members of Malvern Ward staff were experiencing mixed aetiology of diarrhoea, vomiting, abdominal cramps and nausea. From the outset of the suspected outbreak, immediate infection control procedures were activated and suspected patient cases were isolated. Dudley PCT Infection Control and Prevention Service provided all the necessary expertise and advice to Malvern Ward staff to ensure that appropriate measures were in place. On 4 th January 2010 Dudley PCT Infection Control and Prevention Lead Nurse alerted the Director for Infection Prevention and Control for Dudley and Walsall Mental Health Partnership NHS Trust of the situation. An Outbreak Control Group was established and the Outbreak of Infectious Diseases Management Policy was followed. The outbreak was managed effectively at local level and an opportunity to learn lessons was taken in the second and final meeting of the Outbreak Control Group on Wednesday 13 th January The lessons learnt included issues of communication, information sharing, accurate data and policy awareness. Immediate local actions were activated following consideration of these lessons and the wider learning will be shared at the Embedding Lessons Group.

6 Introduction/Case Definition (Description of the organism, mode of transmission, clinical features) This report describes an outbreak of diarrhoea and vomiting. The mode of transmission is that of Norovirus, faecal and oral route mixed and potential environment contamination. The clinical features presented are of a mixed aetiology of diarrhoea, vomiting and abdominal pain in both patients and staff. Investigation Chronology of Events (timeline) Date when index case symptoms started 31 st December 2009, initially amongst two patients. One patient presenting with diarrhoea and one patient presenting with vomiting. It is noted that relatives had contacted the ward to inform staff that they were themselves unwell with symptoms of diarrhoea and vomiting. Location of index case Malvern Ward Malvern Ward is a 22 bedded ward for individuals aged over 65 with functional mental illness. The ward provides an assessment and treatment service. Date Sample went to laboratory No concrete evidence could be ascertained as to the activity pertaining to sample taking, submitting of sample to the laboratory. Samples were identified as being received by the laboratory on two patients dated 6 th January and 11 th January The index case of 31 st December 2009 did not produce a sample relevant for testing. Date when diagnosis confirmed Norovirus confirmed on 13 th January Date when Infection Prevention and Control Service were notified Malvern Ward staff informed the Infection Prevention and Control Services of suspected cases on Monday 4 th January 2010 and that suspected cases had been isolated. The Infection Prevention and Control Service gave immediate advice with regard to further best practice precautions which were implemented by Malvern Ward staff. Use of Personal Protective Equipment was activated straight away and cleaning procedures were intensified. Dates when other cases confirmed One case of Norovirus confirmed on 13 th January 2010 (patient). Locations of cases Malvern Ward staff and patients. Dates of Outbreak Control Meetings and Communications Initial meeting of the Outbreak Control Group (OCG) took place on Monday 11 th January This meeting was convened and chaired by the Director of Infection Prevention and Control. The second and final meeting of the Outbreak Control Group took place on Wednesday 13 th January 2010.

7 Other relevant communications Clinical area contacted Infection Prevention and Control Service on 4 th, 6 th and 7 th January 2010 to advise how many cases had become apparent and what relevant infection control measures were in place. Infection Prevention and Control Service issued advice and guidance regards general best practice measures. On 7 th January 2010, the Associate Director of Operations was informed of the situation by a member of Malvern Ward staff. The Infection Prevention and Control Service visited Malvern Ward on 8 th January 2010 to make sure appropriate measures were in place and informed the Acute Services Manager and Director of Infection Prevention and Control of potential problem. From 31 st December 2009 until 11 th January 2010 it became apparent that several members of staff have been sick during their rest days with mixed aetiology of diarrhoea, vomiting, nausea and abdominal cramps. The Infection Prevention and Control Service received information from Malvern Ward staff on 8 th January 2010 detailing a record of outbreaks of gastrointestinal cases of both patients and members of staff. Ward staff discussed the outbreak at every hand-over meeting between 31 st December 2009 and 13 th January 2010 and appropriate information was placed within the clinical area advising on hand washing and infection control measures. The Outbreak Control Group met on the first available working day (11 th January 2010) following the information being brought to the attention of the Director of Infection Prevention and Control on 8 th January The Outbreak Control Group took action to close the ward to admissions and visitors as an immediate measure following it s initial meeting on 11 th January The reason that the ward was closed was due to an outbreak of diarrhoea and vomiting affecting five patients and 10 staff. At this point there were no confirmed cases of Norovirus but it was felt it would be good practice to follow the Outbreak Policy as a precaution. The Director of Infection Prevention and Control and the Outbreak Control Group which was supported by Dudley PCT Infection Prevention and Control Lead Nurse, were satisfied that all precautions and infection control procedures were being followed. There were a number of operational issues that were identified as immediate actions and roles and responsibilities were allocated by the Outbreak Control Group. On 14 th January 2010 a final terminal clean was activated and the ward re-opened to admissions and visitors. Assistance from Outside Agencies The expertise of Dudley Primary Care Trust Infection Control and Prevention Service was accessed. It was not necessary to involve any other external agencies on this occasion. The Director of Infection Prevention and Control informed relevant others at the Strategic Health Authority, Health Protection Agency, Dudley Group of Hospitals Microbiology Department and Dudley PCT Director of Public Health on 11 th January 2010.

8 Data Analysis The outbreak has involved five patients and 10 staff for the period of 31 st December 2009 to 11 th January The following pie charts demonstrate the local picture of patients and staff affected. Figure 1 - Patients Patients Total Number of Patients on Ward - 8 Total no. of patients Total no. of patients affected 5 F unaffected - 3 Figure 2 Staff Staff Total Number of Staff on Ward - 38 Total no. of staff affected 10 Total no. of staff (inc. a domestic) unaffected - 28

9 Control of Transmission Chronology (what initiatives were used?) Expert advice and support given to Malvern Ward staff from Infection Control and Prevention Service Isolation Policy followed Infection control measures implemented Enhanced cleaning activated Display of hand washing posters increased Restricted visiting Closure to admissions from 11 th January 2010 No visiting from 11 th January 2010 Limiting medical staff on ward Restriction of staff movement including Bank staff Liaison with Catering Department to ensure individual breakfast packs provided Intense clean of staff kitchen Deep clean of food preparation areas Access and distribution of NHS Norovirus posters for attention of visitors (poster This may not be the only gift you take into hospital If you have sickness or diarrhoea wait at least 48 hours after those symptoms have gone before visiting. Date of advice to healthcare workers 31 st December 2009 Date isolation commenced 31 st December 2009 at commencement of symptoms Date of cohorting patients Not applicable Date of non-essential patient transfers discontinued 8 th January 2010 Date staff movement restricted 11 th January 2010 Date non essential staff excluded 8 th January 2010 Date visitors excluded 31 st December 2009 visiting restricted and appropriate telephone communications were made by staff to visitors/carers advising them accordingly. Visitors completely excluded from 11 th January Date ward closed to new admissions 11 th January 2010, to be reviewed 13 th January 2010 by the Outbreak Control Group. Date ward re-opened 14 th January 2010 following terminal cleaning procedures and following a 48 hour symptom free ward environment.

10 Care Delivery Problems The following barriers hindered the control of the outbreak as identified within a group discussion at the Outbreak Control meeting. Clearer communication pathways needed Adverse and severe weather conditions Christmas and New Year holiday period Staff sickness not reported during days off Vagueness of aetiology. No clear picture of why certain staff were on sick leave Staff not adhering to policy i.e. not ringing in sick on their days off Detergent and chlorine tablets being used for cleaning only as an additional measure on notification of outbreak (the Director of Infection Prevention and Control has subsequently activated continuing use of detergent and chlorine tablets) Lack of clarity with regard to local data in relation to aetiology and specimen sampling arrangements Policy awareness Major Outbreak This incident was not a major outbreak and was handled within the routine operational service arrangements with expert advice from Dudley PCT Infection Control and Prevention Service Date Dudley and Walsall Mental Health Partnership NHS Trust Chief Executive notified On 11 th January 2010 the Director of Infection Prevention and Control informed the Chief Executive. End of Outbreak The Director of Infection Prevention and Control confirmed end of the outbreak was on 14 th January 2010 when information was presented to reflect a 48 hour symptom free patient and staff ward environment. At this point terminal cleaning was activated and appropriate communications were progressed to declare the outbreak over and the ward was re-opened to admissions and visitors. Additional Local Information The Outbreak Control Group identified some immediate lessons to be learnt which will be discussed further within the Embedding Lessons Group to ensure that the learning is shared across the whole organisation. The Director of Infection Prevention and Control has advised on a range of local actions which will be taken forward within the Operational Management structures. The minutes of the Outbreak Control Group which detail these actions will be shared with all relevant parties and provides an evidence base for the local operational and managerial control of this outbreak.

11 Lessons Learnt React sooner, provide accurate information and be in a position to get a clear picture earlier Better communication needed Posters to be on wards throughout Trust informing relatives that they should not visit if they are unwell/have diarrhoea and vomiting. Process for evidencing taking of samples, transportation of samples and receipt of samples at laboratory needs to be clarified and consistently applied Infection Prevention and Control Service to be informed and invited to attend affected clinical area at the first sign or concern. If staff are sick on days off/rest days they must ring in sick so that data can be collected Samples from staff off sick to be produced by staff and taken to their GP for analysis so that appropriate data can be collected to confirm specific details of clinical features The involvement of the Occupational Health Department needs to be clarified in relation to supporting speedy staff specimen analysis Conclusion This outbreak was managed to a degree of assurance that all precautions and infection control procedures were followed appropriately. A number of operational issues were identified and actioned as a consequence of this outbreak. There are an array of lessons that have been learnt following the local management and control of this outbreak that Dudley and Walsall Mental Health Partnership NHS Trust will be taking forward. It is the intention that the Head of Nursing will present this report to the Infection Control Committee and Embedding Lessons Group. The Director of Infection Prevention and Control will communicate the details of this outbreak to the Executive Team.

12 REPORT TO THE DIRECTOR OF INFECTION PREVENTION AND CONTROL Date of Report Report Title: Final Outbreak Report Author: Interim Head of Service Executive Lead: Purpose of Report: Director of Operations and Nursing This report describes the managerial and operational control of an outbreak of Norovirus within the location of Linden and Cedars Ward, Bloxwich Hospital as advised within the Outbreak of Infectious Disease Management Policy. Lessons learnt are identified within the report.

13 FINAL OUTBREAK REPORT Date of Outbreak 7 th March 16 th March 2010 Name and Designation of Person Completing Report Interim Head of CAMHS, SMS & EI (Walsall) Organism and Location Suspected Norovirus on Linden Ward and Cedars ward, Bloxwich Hospital, Walsall Definition of Outbreak Two or more staff/patients with similar symptoms in one clinical area Executive Summary Between 7 th March 2010 and 16 th March 2010 Linden ward and subsequently Cedars ward was the location of an outbreak of Norovirus. Confirmation that the organism was Norovorus was received on 10 th March 2010 following laboratory analysis at the Manor Hospital of a specimen from one patient. The first indication of a suspected outbreak occurred on 7 th March at approx 5.00pm when index symptom of vomiting was observed in one patient. A second patient, nursed in the same bay presented with symptoms of diarrhoea at 5.30pm. Within the timeframe of this outbreak additional patients and members of staff from Linden and Cedars Wards experienced mixed aetiology of diarrhoea, vomiting, abdominal cramps and nausea. From the outset of the suspected outbreak, immediate infection control procedures were activated and suspected patient cases were isolated. Walsall Community Health, Infection Control and Prevention Service provided all the necessary expertise and advice to staff to ensure that appropriate measures were in place. On 7 th March ward staff informed the Infection Control and Prevention Service via the Public Health out of hours service. The ward contacted Infection Control Nurse at 9.00am on 8 th March. Following confirmation of a positive sample an Outbreak Control Group was established which met on 11 th & 15 th March. The outbreak was managed effectively at a local level and declared over following the meeting on 15 March. Introduction/Case Definition (Description of the organism, mode of transmission, clinical features) This report describes an outbreak of diarrhoea and vomiting which was confirmed to be Norovirus by Microbiology. The mode of transmission Norovirus via a faecal and oral route mixed and potential environment contamination. The clinical features presented are of a mixed aetiology of diarrhoea, vomiting and abdominal pain in both patients and staff.

14 Investigation Chronology of Events (timeline) Date when index case symptoms started 7th March 2010 at 5.00pm and 5.30pm, initial presentation of vomiting followed by one case of diarrhoea. Both patients had been nursed in the same bay on Linden ward. It is noted subsequently that two community staff had previously gone off sick with similar symptoms. During the course of the outbreak symptoms were reported as follows; 8th March - symptoms reported by an additional 4 patients and 2 members of staff on Linden ward 9 th March- a further 5 patients and 2 members of staff report symptoms on Linden ward 10 th March- symptoms reported by additional 1 patient, 5 members of staff & 1 hospital visitor on Linden ward 10th March- first suspected patient case on Cedars ward 11 th March- 1 patient & 2 members of staff, Linden ward 11 th March- 4 patients and 1 member of staff, Cedars ward 12th March- 2 members of staff, Linden ward 12 th March- 1 patient & 1 hospital visitor, Cedars ward In total 21 patients, 14 members of staff and 2 hospital visitors reported symptoms Total 37 suspected cases Cleaning of wards and day hospital was undertaken with Chlor-clean on a continuous loop. Location of index case Linden Ward, Bloxwich 20 bedded hospital ward for elderly patients suffering dementia. All beds were reported as full at the time of outbreak. Date Sample went to laboratory Sample sent to laboratory at Manor Hospital on 8 th March On 9 th Infection Control Nurse requested Microbiology test for Norovirus Date when diagnosis confirmed Diagnosis confirmed to Infection Control Nurse by Manor Hospital on 10 th March 2010 Date when Infection Prevention and Control Service were notified 7th March 2010

15 Dates when other cases confirmed No further samples sent following initial confirmation of positive result. See above chronology. Locations of cases Linden and Cedar wards, Bloxwich Hospital Dates of Outbreak Control Meetings and Communications Initial meeting of the Outbreak Control Group (OCG) took place on Thursday 11 th March This meeting was convened on behalf of and chaired by the Director of Infection Prevention and Control (DIPC). The second and final meeting of the Outbreak Control Group took place on Monday 15 th March Other relevant communications The IPC Nurse contacted the ward on 8 th March followed by a site visit on 9 th March. Advice on hand hygiene, staff sickness reporting, isolation, cleaning, laundry, food handling and staff movement were provided. A joint visit, including the day hospital, was undertaken with Head of IPC on 10 March. IPC Nurse informed Head of Nursing, Walsall Community Health, DIPC, DWMHPT,, Head of infection control, Walsall Community Health, Head of Infection control Walsall PCT, Head of ISS on 9 th March. Records of all incidents were recorded daily and made available to relevant personnel An update was provided by Infection Control Nurse on 10 th March and forwarded by Head of Nursing to senior managers in D&WMHPT. Outbreak Control Group (OCG) convened by Head of Nursing and chaired by the DIPC took place on Thursday 11 th March 2010, minutes distributed to all concerned. Control measures were implemented with immediate effect: Ward rounds cancelled Planned admissions cancelled and contingency plans circulated for emergency admissions Wards closed to routine visitors, relatives and carers Non urgent patient appointments cancelled External meetings at Bloxwich hospital cancelled Contract work suspended Deep cleaning to be activated Communications & Engagement Manager to co-ordinate media response Norovirus information sheet to be made widely available Access to day hospital re-routed Communication for IPC Lead (forwarded by Head of Nursing), on 12 March advising members of staff working at Bloxwich Hospital should not attend Outbreak meeting on 15 March Outbreak Control Group (OCG) convened by Head of Nursing and chaired by the DIPC took place on Monday 15 th March 2010, minutes distributed to all concerned

16 Actions from previous meeting confirmed as completed and telephone communications and updates between Head of Nursing, Interim Head of Service and Associate Director. communications from IPC Lead, acknowledging Excellent and vigilant staff at Bloxwich Hospital, complete confidence that all standard precautions are adhered to. Assistance from Outside Agencies The expertise of Walsall Community Health Trust Infection Control and Prevention Service and Walsall Hospitals NHS Infection Control Team was accessed. It was not necessary to involve any other external agencies on this occasion. The Director of Infection Prevention and Control informed relevant others at the Strategic Health Authority and Health Protection Agency Control of Transmission Chronology (what initiatives were used?) Expert advice and support given to Linden and Cedar staff from Infection Control and Prevention Service from 8 March 2010 Isolation Policy followed Infection control measures implemented Enhanced cleaning activated on Linden, Cedar wards and day hospital Display of hand washing posters increased. Hand washing advice provided to Assistant ward manager for dissemination to other staff Restricted visiting including community staff from Monday 8 March Closure to admissions on Linden ward from 8 March 2010 Ward rounds postponed Restriction of staff movement including Bank staff Increased access and distribution of NHS Norovirus posters for attention of visitors Entry route to day hospital altered Cedars ward closed to admissions/discharges and visitors at first outbreak meeting 11 th March. Restricted visiting and ward rounds cancelled Date of advice to healthcare workers 8 March 1010 Date of cohorting patients Monday 8 March Date of non-essential patient transfers discontinued 8 March 1010 Date staff movement restricted 8 March 2010 Date non essential staff excluded 8 March 2010 Date visitors excluded 8 March 2010

17 Date ward closed to new admissions 8 March 2010 Date ward re-opened 16 March 2010 Care Delivery Problems (patient) No adverse patient care delivery problems have been identified Care Delivery Problems (organisational) Difficulty in accessing results of initial samples from microbiology. Initial sample tested only for C-difficile and required further verbal request for Norivirus testing on 9 March. Temporary and interim management arrangements including sick leave inhibited clear communications and co-ordination between the local service and the organisational management structure. Lack of ratified organisation outbreak control policy Major Outbreak This incident was not a major outbreak and was handled within the routine operational service arrangements with expert advice from Walsall Community Health, Infection Control and Prevention Service End of Outbreak 16 March 2010 Additional Local Information The Outbreak Control Group identified some immediate lessons to be learnt which will be discussed further within the Embedding Lessons Group to ensure that the learning is shared across the whole organisation. The Director of Infection Prevention and Control has advised on a range of local actions which will be taken forward within the Operational Management structures. The minutes of the Outbreak Control Group which detail these actions will be shared with all relevant parties and provides an evidence base for the local operational and managerial control of this outbreak. Lessons Learnt Staff on Linden had commenced all necessary infection procedures at first indication of infection. Excellent and vigilant staff at Bloxwich hospital, complete confidence that all standard procedures are adhered to - Infection control team. Timely response from ISS cleaning service SUI and 24 hour report needs to be completed and returned to Governance Dept Need for overarching outbreak policy including advice to staff on sampling A senior operational manager, acting as a main point should ensure clear communication between the management team and the clinical areas An agreed system needs to be implemented across all areas of D&WMHT for the reporting of D&V cases.

18 Senior representation from Bloxwich Hospital may have added value to the second outbreak meeting Conclusion This outbreak was managed to a degree of assurance that all precautions and infection control procedures were appropriately followed. This report including lessons learned will be presented to the Infection Control Committee and Embedding Lessons Group. The Director of Infection Prevention and Control will communicate the details of this outbreak to the Executive Team.