HAI INCIDENT AND OUTBREAK REPORTING TEMPLATE - (HAI-IORT)

A New Incident Form
NHS Board
Date and time of reporting
Person Reporting incident
Designation of above
Contact phone number
Email
Where is the incident/outbreak occurring?
Healthcare facility/hospital (including type)
Name of clinical area
What patient services does this area care for
How many beds in this area
What type of incident
Category of incident / Decontamination:
Outbreak: suspected or confirmed
Name of organism
Infection Category / Gastrointestinal Surgical site BBV
Mixed infection Respiratory Other state
Case definition
(Preliminary) / Any patient with: (symptoms and or organism) in ward/hospital/NHS Board from date
Decontamination incident (where no persons are currently ill at present)
What is the incident?
Number of patients exposed / Number of staff exposed
Outbreak – Total number of cases (patient) / Asymptomatic colonised
/ Symptomatic but not lab confirmed / Symptomatic and lab confirmed
Number of cases (staff) / Date first case symptomatic / /
Of the above patients, are any giving cause for concern as a consequence of this infection/incident?
Have any patients died as a consequence of this incident?
Has the organism been cited as a cause of death on a death certificate (if yes, which part of the certificate)
Additional info on cases
Is the clinical area closed to admissions/transfers / Y/N If yes date closed
Hospital Infection Incident Assessment Tool (link to tool)
Impact on patients / Minor/Moderate/Major
Impact on services / Minor/Moderate/Major
Impact on public health / Minor/Moderate/Major
Impact on public anxiety / Minor/Moderate/Major
HIIAT Score / Red Amber Green
What control measures are in place?
Outbreak specific control measures in place / Norovirus control measures; CDI Trigger Tool (TT); Generic Control Measure TT
Other Control Measures
What actions have and will take place
Involved ICM / Y/N
Involved CPHM / Y/N
Patients / Relatives informed / Y/N
Formal OCT meeting held / Y/N Date ......
Press statement / List: None, Holding, Release
Next meeting to be held / Y/N Date......
Other information:
Planned next update / Date

NB Please ensure all communications are shared with both the SG comms team and the SGHSCD

(Update Section)

Date
Incidence
New patients since last report who are symptomatic and are confirmed
New patients who are symptomatic but not yet confirmed
New patients asymptomatic but colonised
New patients giving cause for concern
New deaths as a consequence of the incident
Prevalence
Total number of new and existing cases (who have or have had symptoms and are confirmed)?
Total number of cases who have or have had symptoms but are not lab confirmed?
Total number of asymptomatic colonised?
Of the new and existing confirmed cases how many still have symptoms today?
Patients currently giving cause for concern
Total deaths as a consequence
If yes what part of certificate
Service Impact
Is the ward /services still closed
Is a service still restricted
Changes to HIIAT or Control Measures
HIIAT
Control measures unchanged
Narrative update Comment
Date:
Date:
Date:
Date:
Date:

SGHSCD: November 2015 Page 2 of 2