Queen Elizabeth University Hospital: case note review - overview report

This overview report examines the incidence and impact of qualifying episodes of infection in paediatric haemato-oncology patients cared for at the Queen Elizabeth University Hospital and the Royal Hospital for Children from 2015 to 2019 and the potential link to the hospital environment.



Adverse Event (AE)

An adverse event is defined as an event that could have caused harm, or resulted in harm, to people within the healthcare system.


National Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) Scotland is responsible for the coordinating of national surveillance and reporting of healthcare associated infections and the monitoring of antimicrobial resistance and antimicrobial prescribing. It forms a part of NSS (National Services Scotland)


Bacteria (plural) / Bacterium (singular)

Microscopic, single-celled organisms. They thrive in many different environments and may or may not be the cause of illness in humans


The presence of bacteria in the blood, detected by a blood culture test. Bacteraemia may result in sepsis which is when clinical illness results from bacteria entering the blood stream. This can be very serious and potentially fatal.

Blood Stream Infection (BSI)

This describes infections present in the blood. Blood is normally a sterile environment, so the detection of microorganisms in the blood is always abnormal.

Bundle (of Care)

A small set of evidence-based practices that, when performed collectively and reliably, have a greater effect on patient outcomes if done together, rather than separately


Central Venous Line (CVL) / Central Line

A soft plastic tube placed in a large vein to allow frequent access to the blood stream, to take samples for tests and to give fluids, medications or blood product transfusions. If required for longer periods of time, these are usually inserted into a vein in the neck via a short tunnel under the skin of the chest, emerging for a short distance and sealed with a cap. See also Port.

Chilled beam

A type of radiation/convection heating, ventilation, and air conditioning system designed to heat and cool buildings.


Central Line Associated Blood Steam Infection - defined as a laboratory-confirmed blood stream infection in a patient with a central line which is not related to an infection at another site.

Clinical Portal

The electronic system used by HNS GGC that integrates and allows access to all relevant patient information (e.g. clinical notes; laboratory tests and results; radiology tests and results).


Refers to suspected linked cases (linked in time or place).


A fungus widely found in the environment. The species ‘C. neoformans’ is the major human pathogen, most commonly affecting patients with compromised immunity.



Data collection system used by NHS Greater Glasgow and Clyde for clinical and non- clinical incident reporting.



Infections that arise from within the patient him/herself.

Epidemiology / Epidemiological

The branch of medicine which deals with the incidence, distribution, causation and approaches to the control of diseases and other factors relating to health.


Infections caused from sources in the external environment. This includes the environment experienced by the patient both inside and outside the hospital building.



Having or showing the symptoms of a fever.


Genetic Fingerprinting

A way to define the identity of a microorganism by describing the sequence of the ‘building blocks’ that make up its DNA (its genetic code). This can be used to determine how closely microorganisms are related to each other.


The name for a class, or group of bacteria marked by common characteristics or by one common characteristic

A genus usually consists of more than one species.

Gram-negative (bacteria)

This is a way of classifying bacteria by their appearance under the microscope when stained in a particular way. Gram-negative bacteria are more resistant to antibiotics and can cause serious infections both in the blood stream and at other sites in the body.

Greater Glasgow and Clyde Health Board (NHS GGC)

The body responsible for the delivery of health care services in the Greater Glasgow and Clyde region.

Gut Translocation

The ability for bacteria normally resident in the gut to pass into the blood stream. This usually occurs when the lining of the gut is damaged by, for example, chemotherapy.


Haematology Oncology

The medical sub-specialties concerned with the diagnosis and treatment of blood diseases (Haematology), including leukaemia, and of other malignant (cancer) diseases (Oncology)


Originally used to mean ‘hospital acquired infection’, but the official Scottish Government term is now ‘Healthcare Associated Infection’. These are considered to be infections that were not present prior to contact with a healthcare facility or whilst undergoing a healthcare intervention.


Healthcare Associated Infection Reporting Template. The format used to provide regular reports to the NHS GGC Board about Infection Prevention and Control issues.


Healthcare Associated Infection System (for) Controlling Risk in the Built Environment. The procedure by which staff in hospitals work together to identify, manage and mitigate issues posing a risk to infection that may arise in the built environment as a result of building work, repairs or maintenance activities.

Hard Surface Sample

Hard surface sample in this context refers to samples taken for microbiological examination from environmental surfaces in the hospital environment. Examples would include samples taken from equipment, floors, chilled beams, sinks, and drains.


Healthcare Associated Infection.

Healthcare Infection Incident Assessment Tool (HIIAT)

Healthcare Infection Incident Assessment Tool (HIIAT). An infection assessment and reporting tool found in the Scottish National Infection Prevention and Control Manual, used to gather epidemiological data and clinical information on the patient’s condition.

Healthcare Infection Incident and Outbreak Reporting Template (HIIORT)

Healthcare Infection Incident and Outbreak Reporting Template (HIIORT) – more detailed assessment and reporting of an incident within the Scottish National Infection Prevention and Control Manual.

Health Facilities Scotland (HFS)

Provides operational guidance to NHS Scotland bodies on a range of healthcare facilities topics.

Health Protection Scotland (HPS)

Health Protection Scotland is the organisation that co-ordinates health protection in Scotland. It is part of Public Health Scotland.


Healthcare Improvement Scotland. The purpose of Healthcare Improvement Scotland is to enable the people of Scotland to experience the best quality of health and social care.



The software system used at NHS GGC that supports the IPC nurses/team in advising and following up infections in the hospital environment.


A person who is incapable of developing a normal immune response making them more susceptible to infection: in this context this is as a result of disease or its treatment.

Incident Management Team (IMT)

An Incident Management Team comprises clinicians, the IPC Team, public health clinicians, and colleagues from estates and facilities. They meet to investigate potential causes of the infection(s) under consideration and to agree and direct necessary infection control measures.

Infection Prevention Control (IPC)

The clinical discipline and the collection of interventions aimed at preventing and controlling healthcare associated infections.

Information Governance

Handling information in a confidential and secure manner to appropriate ethical and quality standards.

Information Sharing Agreement (ISA)

An agreement that sets out the basis for the use of personal data by the public sector for the protection for the individuals concerned.


Infection Prevention & Control Nurse / Team / Doctor / Manager



A term for diseases in which abnormal cells divide without control, can invade nearby tissues, or spread to other parts of the body through the blood and lymph systems. Also called cancer. Children and young people with these diseases are cared for by Haematologists and Oncologists. Note also that some conditions (typically some kinds of brain tumour) may not be truly malignant but remain capable of causing serious disease/damage/death and require treatment of a similar nature.

Medical Microbiology

The clinical and laboratory discipline that diagnoses, treats and prevents infections.

Microorganisms (Microbes)

Organisms that are too small to be seen by the naked eye and are found everywhere. They may exist in a single-celled form or in a colony of cells. They can live in water, soil, or in the air. The human body is home to millions of these: some can cause sickness, while others are critical for health.

Mortality and Morbidity Reviews/ Meetings (M&M)

Mortality and morbidity meetings support a systematic approach to the review of patient deaths or care complications to improve patient care and provide professional learning.



The National Health Service (NHS) in Scotland

National Services Scotland (NSS)

Is a Non-Departmental Public Body which provides advice and services to the rest of NHS Scotland. Accountable to the Scottish Government, NSS provides national strategic support services and expert advice to NHS Scotland.

Neutropenia (Neutropenic)

A blood condition characterised by low levels of neutrophils, which are white blood cells that protect the body from infections. Having neutropenia increases the risk of all types of infection, especially from bacteria. This is a common side effect of chemotherapy but may also occur as a result of disease (like leukaemia) affecting the bone marrow (the site of production of neutrophils in the body).


A tumour that is not cancerous. Non-malignant tumours or conditions can nevertheless sometimes cause serious problems and require treatment by Haematologists and Oncologists.



Two or more linked cases with the same infectious agent associated with the same healthcare setting over a specified time period or, a higher than expected number of cases of HAI in a given healthcare area over a specified time period.


Paediatric Trigger Tool (PTT)

A structured case note review tool that identifies and measures the rate of adverse events in a hospital setting using paediatric-specific triggers.


Paediatric Intensive Care Unit – a specialist ward that provides treatment and monitoring for children and young people who are very ill, often requiring artificial ventilation or other organ support.


The presence of several species of microorganisms in the same bacterial culture.


A port is a small chamber or reservoir that sits under the skin at the end of a central venous line. The other end of the line sits in a large vein. You can feel the chamber of the port under the skin but the system is completely sealed and requires a special needle to access the port and obtain blood samples, give fluids, medication or blood products.

Problem Assessment Group (PAG)

A team of specialists who come together to undertake an initial assessment of a potential infection outbreak and determine if an Incident Management Team should be established.



Queen Elizabeth University Hospital



Royal Hospital for Children. It is located adjacent to the QEUH and replaces the former Royal Hospital for Sick Children located in Yorkhill.

Root Cause Analysis (RCA)

A structured approach to problem solving used for identifying the root causes of (in this context) infections.



Situation, Background, Assessment, Recommendation. A structured reporting tool often used to describe clinical situations.


Sepsis (sometimes called septicaemia) is the body’s extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection that is already present triggers a chain reaction throughout the body. Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death.

Serious Adverse Event (SAE)

An event that may have contributed to, or results in permanent harm to a patient. It includes (but is not restricted to) situations where there is unexpected death or the need for intervention to sustain life. This is defined by the Scottish National Framework as a Category I adverse event.


Groups of similar organisms within a genus.

Standard Infection Control Precautions (SICP)

Basic guidelines for the prevention and control of infection in the hospital environment. They include: hand washing; using protective barriers like gloves and masks; handling infectious waste material properly; and keeping the environment clean.

Standard Operating Procedure (SOP)

A set of step-by-step instructions compiled by an organisation to help workers carry out complex routine work in a consistent way.



Telepath is the Laboratory Information Management System (LIMS) used by NHS GGC. The system is used to store laboratory sample results for patients and has the capacity to store patient notes recorded by microbiologists.

Terms of Reference (ToR)

Define the purpose and structures of a project (committee, meeting etc.) to accomplish its objectives.


Is the Patient Management System for NHS GGC. All patient episodes (Outpatient, Inpatient and Emergency) are recorded and managed on TrakCare.

(Microbiological) Typing

Laboratory technique(s) to assign a microorganism to a predefined group (type). These groups can be wide or narrow; the narrower the group, the more confidence there is that microorganisms in this group are related. See also: Genetic Fingerprinting


Water Sample

Water samples can be taken from a wide variety of sources in the water supply and delivery system for the hospital - for example: taps; showers; and tanks.



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