Infection Prevention and Control Outbreak Policy IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 1
Policy Title: Outbreak Policy Executive Summary: This policy details the actions to be followed during outbreaks of communicable diseases, using a collaborative approach to contain the impact of outbreaks on patients, staff and visitors by minimising transmission of pathogenic microorganisms. Supersedes: Outbreak Policy Version 2, 2015 Description of Updated to reflect National guidelines and organisational Amendment(s): changes This policy will impact on: All staff employed by the Trust including contractors Financial Implications: Increased use of Personal Protective equipment although this would be within current Directorate ordering Policy Area: Infection Prevention and Control Trust Wide Document Reference: ECT002613 Version Number: V3 Effective Date: December 2016 Issued By: Infection Prevention Review Date: October 2018 and Control Group Authors: Lead Nurse Infection Prevention and Control Impact Assessment Date: December 2016 APPROVAL RECORD Consultation: Committees / Group Infection Prevention and Control Group Date December 2016 Approved and Ratified Infection Prevention and December 2016 Control Committee Director of Nursing Quality and Performance, DIPC Received for information: Directorate SQS Groups December 2016 IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 2
Contents Page 1 Introduction 4 2 Purpose 4 3 Organisational responsibilities 5 4 Definitions 6 5 Outbreak Management 7 6 Monitoring compliance 9 7 Training 9 8 Monitoring Compliance 9 Legislation, Guidance and References 10 Appendix 1 Norovirus outbreak pack 12 Appendix 2 Generic outbreak pack 20 Equality and Human Rights Policy Screening Tool 28 IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 3
1 Introduction This policy details the actions required to minimise the impact an outbreak of communicable disease will have on patients, staff and visitors by mitigating the risk of transmission of pathogenic microorganisms. Coordination of outbreak management will be led by the Infection Prevention and Control Doctor and the Infection Prevention and Control team (IPCT) who will involve key personnel in the assessment of the suspected outbreak. Recommended actions may vary from observation of the situation to closure of areas. It may be necessary to liaise with Public Health England (PHE), and where appropriate they will be invited into the Trust to support the outbreak management. Outbreaks and the subsequent impact on patient flow are not contained to acute inpatient bed areas; community closures may also have serious implications, and therefore the IPCT will liaise closely with the community infection control provider to implement communication strategies with relevant personnel to minimise the impact. Community staff should be aware that the Public Health Community Infection Prevention and Control team may contact them with specific advice re- entering areas which are closed due to outbreaks( these controls are not detailed in this policy). Dependent on the outbreak causative organism it may be necessary to implement other interventions which include (any interventions required for staff will be undertaken in conjunction with Occupational Health): Screening of patients and or staff Offering prophylaxis to exposed contacts Any escalation of the outbreak situation either locally or nationally will be managed in accordance with the Trust Major Incident policy and business continuity plans. 2. Purpose This policy is to ensure that all staff within East Cheshire NHS Trust (ECNHST) takes prompt action in the event of an outbreak by implementing general principles of infection prevention and control. During normal working hours advice must be sought from the Infection Prevention and Control Team (IPCT) on actions to be implemented, including appropriate placement of patients. Out of hours advice must be sought from the on call Microbiologist this must be accessed via the Site Manager. The clinical area must collate the relevant information using the outbreak pack held in the yellow infection control resource boxes on each ward area or from the Infection Prevention and Control infonet page (see Appendix 1). Please note that clinical care must not be compromised and discharge planning and services should continue, for example Dieticians, Therapies, Patient Journey and Nursing home assessments can be undertaken during the outbreak at ward level. IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 4
3. Organisational Responsibilities The Chief Executive has overall responsibility for ensuring that the Trust has appropriate policies in place and that robust monitoring arrangements are in place. The Director of Nursing, Performance and Quality has the designated responsibility for ensuring that appropriate arrangements to ensure robust Infection Prevention and Control within the Trust with support of the Lead Nurse Infection Prevention and Control and the Infection Prevention and Control Doctor. The DIPC will determine whether an Outbreak Control Group (OCG) is required based on the pathogenicity, potential for spread in the affected area and the potential impact to other areas. In the absence of the DIPC the responsibility will be delegated to the Infection Prevention and Control Dr or the Lead Nurse Infection Prevention and Control. Providing assurance to the board that systems and process are in place to ensure compliance with agreed standards. The Infection Prevention and Control Team (IPCT) have responsibility for ensuring the policy is implemented and monitored across the Trust in addition they will ensure compliance with any national initiatives or directives and- Provide support and advice to clinical areas on the detection of an outbreak (this may be detected via microbiological results but in general will be due to the vigilance of clinical staff) ensuring that all controls are in place to minimise risk of spread to other patients, staff and visitors. Report all outbreaks using the approved internal and external notification process as appropriate. Providing and supporting a sustainable programme of audit and education across the health economy. All Employees must ensure they are compliant with Infection Prevention and Control Policies training and standards which are monitored through the appraisal process. Any member of staff reporting sick due to a suspected infectious disease (e.g. chicken pox, diarrhoea and vomiting, influenza) must inform their line manager as detailed in the attendance management policy. They MUST not return to work until symptom free (e.g. 48hours after the last episode of diarrhoea and or vomiting) further advice on exclusion periods should be obtained from Occupational Health Outbreak Control Group (OCG): The OCG will discuss the available information and agree an action plan; coordination for implementing this plan will be the ICN, Matron and Ward Senior Sister (or deputy). Major Outbreak Control Group (MOCG): This group will be convened by the DIPC following an assessment of the current situation e.g. identification of multiple cases across various wards which may be declared as a major outbreak. The group s remit will include: To agree case definition including the clinical symptoms IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 5
To cascade/ inform key stakeholders - Trust Board, Bed managers, Directorate managers, clinicians as appropriate To implement appropriate steps to maintain the clinical care of patients during the outbreak period To identify any resource implication of the outbreak and how they will be meet (e.g. additional PPE, extra staffing). To agree and co-ordinate policy decisions on the investigation and control of the outbreak (e.g. potential need to cohort patients in one clinical area). Ensure that identified actions are implemented by allocating specific responsibilities to members of the MOCG. Work in partnership with Public Health England (PHE) and other agencies as required. Establish appropriate channels of communication including briefing papers for the media and information leaflets for patients, families. This may include a dedicated helpline dependent on the scale and nature of the outbreak. To identify the escalation process in line with the Trust Silver and Gold command requirements, this may include direct access to the Department of Health (e.g. Flu pandemic). To meet as a minimum daily and feed the progress into the trust capacity meetings. To define the end of the outbreak and evaluate lessons learnt To produce accurate minutes this will be incorporated into a final report. Identify lessons learnt which can facilitate the opportunity to change practice and reduce the risk of reoccurrence. To ensure appropriate and timely cold debrief following the outbreak within the Directorates and outside the organisation as appropriate. 4. Definitions Outbreak Period of increased incidence (PII) Healthcare Associated Infection Incubation Period Protective Isolation Source Isolation An outbreak is defined as increased number of linked cases within a 24 hour period i.e. two cases of diarrhoea in the same bay/care Home with no links to treatment or underlying health conditions. At least 3 episodes of type 7 stool within 24 hours (Per patient). Please note for some serious infections restrictions may be necessary for one case i.e. confirmed or suspected smallpox Referred to for clusters of known or unknown infections for example increased numbers of MRSA patients in the same bay/ ward areas. Healthcare Associated infections (HCAI s) can develop either as a direct result of healthcare interventions such as medical or surgical treatment or from being in contact with a healthcare setting. For example when the patient has been in the Trust for longer that the incubation period of the disease. The time which normally elapses between, acquiring an infectious agent and developing symptoms. This will be used as part of the epidemiological assessment of the outbreak. Isolation of a susceptible patient to protect them from acquiring an infection from other patients such as the immuno- compromised patient Isolation of the infected patient to prevent the spread of IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 6
Strict Isolation Cohort nursing Airborne transmission Contact transmission Droplet transmission ICNET Outbreak Control Group (OCG) Major Outbreak Control Group (MOCG) infection to others Used for the management of high risk pathogens to protect others. Nursing together people with the same infection (Maintaining mixed sex accommodation requirements). Occurs by dissemination of droplet nuclei or dust particles containing the infectious agent; microorganisms can be dispersed widely and over long distances. Involves either direct person to person contact or indirect contact via a contaminated immediate object e.g. hands of healthcare workers Occurs when oral or nasal secretions infected with an illness enter the eyes, nose or mouth of another person An electronic system used by the IPCT to enable robust management and surveillance of Healthcare Associated infection. This group will be convened to manage basic outbreaks. The Membership should include- Infection Prevention and Control Nurse Consultant Microbiologist/ Infection Control Dr Senior Sister from Clinical area (or Deputy) Clinical Matron Clinician Facilities Manager Soft FM ISS manager Administration Support This group will be convened in the event of a multiple outbreak (e.g. two or more ward closed in the same time period). This group would also be convened in the event of outbreaks of pandemic influenza in line with PHE escalation process. The group should include the OCG plus DIPC Lead Nurse Infection Prevention and Control Associate Director of the relevant Directorate Occupational Health Lead Consultant in Communicable Disease Control Admin support Communications Lead Other members to be co-opted in as required. 5 Outbreak management The Infection Prevention and Control Team will initially investigate suspected outbreaks immediately they are notified to confirm whether they fit the pattern of an outbreak in line with policy 5.1 Initial report of an outbreak risk assessment: Clinical staff must use the action cards and documentation contained in the outbreak guidance pack, (one is for IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 7
generic outbreak e.g. flu VRE and there is a specific pack for the management of diarrhoea and vomiting Appendix 1 and 2) Clinical staff who suspect an outbreak in their area must report to the IPCT (out of hours all the information gathered should be discussed by the site manager with the on-call microbiologist) to undertake a suitable risk assessment based on the current situation i.e. location, number of cases and symptoms. This will be followed by daily reviews by the Infection Prevention and Control Nurse (ICN), Nurse in charge and or Matron to monitor and assess the situation. The operational Control group will identify who will undertake the reviews over a weekend period. Out of hours the Site Manager must contact the On Call manager to brief them on the situation they will then escalate to the Executive on call as appropriate. Collate the information on patients, location and symptoms on the form in the Outbreak pack using the action cards as clear guides (Appendix 1). A decision to close beds will be based on the information provided by the ICN in consultation with the Consultant Microbiologist, in the absence of the Consultant Microbiologist this will be with the Lead Nurse Infection Prevention and Control Information relating to the outbreak will be communicated to the following individuals as appropriate bed managers, Clinical matron, Consultant Microbiologist, DIPC, Lead Nurse Infection Control, General Manager for the directorate, CCG and PHE as appropriate, communication team, head of facilities/iss. During the outbreak period a member of the IPCT will attend as a minimum the 12.30 capacity meeting to update on the current situation and the impact on patient flow. ISS will be notified by the Ward using extension 1999 (24hour service) to request enhanced cleaning once the outbreak has been declared. The DIPC in conjunction with the Lead Nurse IPC and the Consultant Microbiologist will identify the need for an outbreak control meeting based on case by case assessment. Communication relating to the outbreak will be sent out daily (by 14.30hrs)by the ICN responsible for managing the outbreak this will include : Number of patients affected Number of staff affected Symptoms Laboratory diagnosis if available Control measures including cohort nursing, identified staff and restrictions on visiting Cleaning requirements Planned reopening Out of hours the Site Manager will update via the Trust status information. The IPCT will agree a weekend plan on a Friday detailing patient management over the weekend; this will be reviewed by the site manager on a daily basis who will provide an update for the IPCT for the next working day. The OBCT will identify if the IPCT are required to support out of hours during a major outbreak contact information will form part of the Trust weekend plan. Please note that if a patient clinically needs to be admitted to a closed area e.g. Ward 4 for Non-invasive ventilation this should occur in consultation with the patients primary Consultant, and or the Consultant microbiologist. The patient/ family must be informed that the area is closed however that admission to that area is essential for their clinical care needs. IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 8
5.2 Increased incidence in multiple areas: If there is an increase in reported outbreaks across the Trust then the above actions will be followed for all areas. At this point an Operational Outbreak Control (OOC) meeting will be held daily prior to the 12.30 capacity meeting to review the situation. Public Health England will be invited to attend these meetings as required. Additional measures will include Increased notices at the hospital entrances to inform visitors to the trust of the current situation Announcements over the Tanoy system Restrictions on visiting to specific areas Restrictions on staff movements between areas, including allocation of bank/ agency staff to none affected areas if practicable. Increased vigilance on hand hygiene and use of Personal Protective equipment Requests for samples from clinical staff who report symptoms may be required these will be co-ordinated through Occupational Health. 6 Training All clinical staff must undertake annual Trust infection control mandatory training which incorporates management of Outbreaks. Specific Infection Prevention and Control training to support clinical practice will be delivered by the Infection Prevention and Control Team. 7 Monitoring compliance The infection prevention and control team will review and investigate incidents reported relating to this policy and audit departments compliance with Outbreak requirements. This will include audit of time to isolate patients utilising the CRIS bed management system and the Infection Prevention and Control ICNET patient record system. Failure to follow the guidance in this policy will be reviewed as part of the Post Infection Review process and consideration given if this constitutes a Lapse in Care contributing to the further spread of infection. Non-compliance with the policy will be managed via the appropriate HR process; this will be supported by the Director of Nursing, Performance and Quality,DIPC, and the Medical Director. This policy should be read in Conjunction (as a minimum) with the following Policies which are available on the trust infonet infection control page http://nww.eastcheshire.nhs.uk/infectionscontrol/default.aspx Isolation Policy Hand Hygiene Policy Specific Microorganisms e.g. MRSA, CDI Standard Precautions Respiratory policy Cleaning Policy IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 9
LEGISLATION, GUIDANCE AND REFERENCES Control of Substances Hazardous to Health Regulation (COSHH) 5 th Approved Code of Practice and Guidance Health and Safety Executive Books ISBN 0-7176-2981-3 Edition Damani, N (2012) Manual of Infection Prevention and Control Third edition. Oxford University Press, Oxford. Department of Health (2015) The Health and Social Care Act 2008, Code of Practice on the prevention and control of infection and related guidance Available at: https://www.gov.uk/dh Department of Health (2007). Isolating patients with HCAI. Summary of best practice. http://webarchive.nationalarchives.gov.uk/20120118164404/hcai.dh.gov.uk/files/2011 /03 /Document_Isolation_Best_Practice_FINAL_100917.pdf Department of Health (2013). Infection Control in the built environment HBN 00-009, Department of Health (2013) Environment and Sustainability Health Technical Memorandum - Safe Management of Health Care Waste, 07-01 Department of Health (2007). Isolating patients with HCAI. Summary of best practice. http://webarchive.nationalarchives.gov.uk/20120118164404/hcai.dh.gov.uk/files/2011 /03 /Document_Isolation_Best_Practice_FINAL_100917.pdf Department of Health (2013). Infection Control in the built environment HBN 00-009, Department of Health (2013) Environment and Sustainability Health Technical Memorandum - Safe Management of Health Care Waste, 07-01 Health and Safety Executive(2013) Health and Safety (Sharp Instruments in Healthcare) Regulations 2013, Guidance for employers and employees, accessed http://www.hse.gov.uk/pubns/hsis7.pdf Loveday H.P. et al (2014) epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospital in England. Journal of Hospital Infection 86S1 S1-S70 Norovirus Working Party (2012) Guidelines for the management of norovirus outbreaks in acute and community health and social care settings IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 10
NICE (2014) Infection Prevention and Control Nice Quality standard. https://ww.nice.org.uk/guidance/qs61 Hospital Infection Society Working Party. (2001). Review of Hospital Isolation and Infection Control Related Precautions. http://www.his.org.uk/ WHO (2006) Your 5 moments of hand hygiene [pdf] Available at: http://www.who.int/gpsc/tools/five_moments/en/ IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 11
Appendix 1 D&V Outbreak pack Infection Prevention and Control Guidance for Clinical staff Managing diarrhoea and / or vomiting outbreak. To be used in conjunction with the appropriate Infection Prevention and Control Trust Policies. Definition of an Outbreak An outbreak is defined as increased number of linked cases within a 24 hour period i.e. two cases of diarrhoea in the same bay with no links to treatment or underlying health conditions. At least 3 episodes of type 7 stool within 24 hours (per patient). The bay/ward may be closed following advice from Infection Prevention and Control or site managers. Thereafter appropriate precautions must be implemented. The bay/ward will only be reopened if an outbreak is excluded or managed as per Trust policy General Principles All patients admitted with diarrhoea and or vomiting must be admitted to a single room (preferably en-suite) and isolation precautions applied until an infective cause is excluded. In existing in-patients it is important to establish the most likely cause of the patient s symptoms as this will affect the patient s subsequent management, and influence the resulting actions if the patient is identified as the index patient for an outbreak. SIGHT Suspect that a case may be infective where there is no clear alternative for diarrhoea Isolate the patient while determining the cause of the diarrhoea Gloves and aprons must be used for all contacts with the patient and their environment Hand washing with liquid soap and water must be carried out before and after each contact with the patient and their environment Test the stool by sending a specimen after 3 episodes of diarrhoea type 6,7. IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 12
During normal working hours the ward must inform Infection Prevention and Control team (ext 1597) of the suspected outbreak in order to provide advice and support. Out of hours please follow the attached action cards. Please note clinical care must not be compromised and discharge planning and services should continue, for example Dieticians, Therapies, Patient Journey and Nursing home assessments can be undertaken during the outbreak at ward level. Nurse in Charge of clinical area - Outbreak Action Card Areas Identifying Outbreak of infectious illness for example Diarrhoea and Vomiting (Norovirus). No Action Completed by: (date, time and name) 1 Check the patients symptoms against the outbreak criteria to ensure case definition 2 Review all patients suspected of symptoms to assess the following- The patient is not being treated with laxatives which could be responsible for the symptoms. If possible stop laxatives for 24 hours, if symptoms persist > 3 episodes of diarrhoea in 24 hours send stool sample. After a second episode of diarrhoea commence patient(s) on stool chart using the Bristol stool matrix as a benchmark for stool type. Ensure the chart is completed each time the patient(s) has their bowels opened detailing time and type of stool. If at the end of the shift the patient has not had their bowels opened this must also be documented. If the patient has a medical history which demonstrates long standing bowel problems e.g. chrons disease, colitis, IBS, diverticulitis etc. A clinical review should be undertaken to establish if this is abnormal for them. Establish if the patient is constipated or experiencing overflow Request Medical staff to review patients drug treatment e.g. antibiotics therapy. Discuss with Consultant Microbiologist any changes which may be required. Review the date of supplemental feeding, discontinuing if appropriate. Request medical reviews of patients as appropriate 3 During normal working hours contact the Infection Prevention and Control team (Ext 1597) and ask them to visit the ward and review the situation with you. IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 13
No Action Completed by: (date, time and name) Ensure the above analysis has been undertaken. 4 Out of hours contact the bed manager/night sister providing them with the current situation after the above assessment has been undertaken. They will contact the on call Consultant Microbiologist for further advice on the closure of bays and / or the whole ward and inform the on call manger re the closures. The Site manager will notify the on call manager of the situation who will then escalate to the Executive on call as required. 5 Once the bay / ward has been closed Cohort/Isolate symptomatic patients in either single rooms or dedicated bays as appropriate. Using the diarrhoea and / or Vomiting record sheet at the end of this document record each individual patient s symptoms. In addition it may be helpful to use the ward map to plot patient s locations. Document on the symptom sheet type of symptom diarrhoea (D), vomiting (V) and time of each symptom. IT IS CRITICAL THIS INFORMATION IS ACCURATE AS THIS DIRECTLY EFFECTS THE DECISIONS THAT WILL BE MADE ABOUT THE WARD / BAYS CLOSING / RE-OPENING 6 If patient(s) has 3 or more episodes of type 7 stool a sample must be sent. Wherever possible involved medical staff in this decision. Details on the microbiology form must include the following potential outbreak of Diarrhoea and Vomiting please send for Virology 7 Ensure doors at front of ward are closed. Disable magnetic automatic closing device, contact estates for assistance if required. Ensure doors to affected bays are kept closed. 8 Display IPC notices at the entrance to the ward and on bays/single rooms. Including notices identifying which bathroom / toilet is dedicated to each bay. Posters must be laminated prior to use. 9 In conjunction with medical staff allocate dedicated staff to care for affected patients; these staff will need to change into scrubs. In addition, staff should not be moved to another clinical area until 48 hours has lapsed since working in an affected area. 10 Commence patient(s) on a fluid balance chart (as appropriate). 11 Contact ISS domestic supervisors (ext 1999) to undertake infection cleans in the affected areas focusing on frequently touched areas e.g. tap handles, toilets and bed areas using Tristel. At the end of the outbreak a post infection clean will be required co-ordinated via the outbreak control group. 12 Do not transfer patients to another ward unless clinical need requires this. This must be undertaken with involvement from medical / IPC team / matrons / site managers to prevent transmission of the infectious organisms to other areas of the Trust. 13 Visiting times designate a person e.g. ward clerk, housekeeper to greet visitors and explain that the bay / ward is closed due to a suspected / confirmed infection and that visiting may be restricted. If requested provide patients / relatives / staff with norovirus information sheet available on IPC website patient information sheets. Advise that it would be preferable for the visitors not to visit other patients in the Trust, unless unavoidable. Advise relatives to postpone visiting, especially if they are displaying symptoms e.g. D&V until they are 48 hours clear of symptoms. Staff and Visitors do not require face masks unless a respiratory illness is suspected ( as per PHE guidance) as face masks will not prevent the IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 14
No Action Completed by: (date, time and name) transmission of viral diarrhoea and or vomiting e.g. Norovirus. Managing Staff No Action Completed by: (date, time and name) 1 Ensure there are sufficient scrubs to be worn by staff and that these do not leave Trust premises 2 Staff who are required to review patients in an affected clinical area(s) e.g. physiotherapists, should wherever practicable visit patients in unaffected area prior to reviewing patient(s) in affected area. However this must not compromise patient and must be risk assessed. 3 Staff experiencing symptoms must remain off duty until 48hrs has lapsed since their last symptom. As per Human Resources policy affected staff are required to submit a diarrhoeal sample to Occupational Health detailing they are part of an outbreak. Policy available on Infonet or from ward Senior Sister 4. If staff experience symptoms (diarrhoea and / or vomiting) on the ward e.g. in staff toilets, please ask ISS (Ext 1999) to undertake a Tristel clean of that area. IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 15
Bed/Site Managers Outbreak Action Card Areas Identifying Outbreak of infectious illness for example Norovirus. No Action Completed by: (date, time and name) 1 Following notification of patients with symptoms visit the ward to elicit facts then contact the on call Consultant Microbiologist via switchboard to discuss potential closures of clinical areas. If the outbreak is contained to one bay then this should be closed rather than the whole ward. However the situation should be reviewed each shift as this may be a rapidly changing picture. Two or more bays affected may require the whole ward to be closed. The diarrhoea and / or vomiting record sheet is a helpful tool to observe if the number of patient(s) affected is improving / worsening. 2 Notify the on-call Manager of the situation; in addition send an email to the Director of Nursing Quality and Performance, Service Manager, Matron of the Clinical area, Lead Nurse Infection Prevention / Infection Prevention and Control team notifying them of the current situation. Messages can be left on the Infection control answerphones Ext 1417/1597 3 Remind ward staff in the affected area they must complete and update the diarrhoea and / or vomiting record sheet to keep an accurate record of patient symptoms 4 Attend the outbreak meetings as convened in accordance with the relevant IP&C policies. 5 Residents, who have been admitted to hospital from a Nursing or Residential Home that has a known or suspected outbreak, can be discharged back to the home when declared clinically fit for discharge from the hospital. 6 Patients who have been admitted to hospital from a Nursing / Residential Home which has been closed due to an outbreak can be transferred back to the home however patients requiring a nursing home bed who are in a closed ward should not be transferred back to the home until the ward has been fully opened. 7 If the patient is to be transferred to another department due to clinical need please discuss with the Consultant microbiologist / Infection Prevention and Control team and the Consultant responsible for the patient s care. 8 Clinical staff must advise the receiving area that the patient is coming from an area with a bay / ward closure in order for the receiving area to take appropriate actions. IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 16
Infection Prevention and Control team Outbreak Action Card Areas Identifying Outbreak of infectious illness for example Norovirus. No Action Completed by: (date, time and name) 1 Bed Managers or Clinical area will notify Infection Prevention and Control of a possible outbreak affecting patients and /or staff. 2 Visit clinical area to undertake assessment with the Nurse in charge of the clinical area, to establish if this is an outbreak. On-going reviews to occur with Matron and ward Senior Sister / nurse in charge by 9am each day a second review may also be requested after the 12.30 capacity meeting. Out of hours this review will be by the Site Manager or as identified by the Outbreak Control Team 3 Notify the Lead Nurse Infection Prevention, Consultant Microbiologist and appropriate Matron, Risk Manager. Ensuring the outbreak is recorded on Datix. 4 If two or more bays are closed discuss with the Consultant Microbiologist about closing the whole ward. 5 In co-ordination with the bed manager/ site manager ensure patients are isolated in single rooms (preferably en-suite) or cohort nursed in a bay as appropriate. 6 Ensure controls are in place including removal of hand gel from the end of patient s beds (dependent on the suspected outbreak organism). 7 Keep accurate records of patients affected using the ward maps and patient proforma in outbreak pack. Create outbreak incidence on ICNET, updating at least daily. 8 Request specimens from patients both MC&S and Virology. Inform Microbiology of outbreak and obtain an ILOG number from MRI Tel 0161 2768788 9 Request Infection clean of affected areas including toilets, frequently touched areas (door handles etc.) from ISS. This must be done using Tristel. Alternative products may be required these will be specified by the IPCT. 10 Provide update to Bed meetings and to Outbreak meeting (if convened as per Outbreak policy). 11 Ensure outbreak email update is sent out daily (preferably before lunch) in order that management decisions can be made regarding patient flow. Out of hours updated information will be issued via the Trust capacity status report issued by the Bed management team. 12 Work with Communication team to ensure effective communications as per the outbreak control group agreement 13 If a patient is to be transferred to another department from an affected area due to clinical need this must be done in conjunction with the Consultant Microbiologist and the patient s Consultant. As far as practicable the patient should be moved to a single room. 14 Discharges can be made to the patient s own home but should not be to another healthcare care setting unless clinical care dictates otherwise. Patients can return to care homes once they are asymptomatic. 15 If the patient must be moved to another healthcare setting contact their IP&C department and inform them of the transfer and suspected outbreak organism so they can take appropriate actions to accommodate the patient. IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 17
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Infection Prevention and Control Ward Diarrhea and Vomiting Ward Monitoring Form Ward to Document the time of each symptom and the type of each symptom e.g. vomiting, diarrhoea. Ward. Date reported to Infection Prevention and Control ILOG NUMBER. Essential data to retrieve result and reopen department Date Date Date Date Results Bed Number Patient name, DOB, NHS/Hospital No / staff name Date of onset of symptoms Date & Time sample sent Early Late Night Early Late Night Early Late Night Early Late Night IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 19
Patient name, DOB, NHS/Hospital No / staff name Date of onset of symptoms Date & Time sample sent Early Late Night Early Late Night Early Late Night Early Late Night IPCT Outbreak Policy V3, Lead Nurse IPC, November 2016 Page 20
APPENDIX 2 GENERIC OUTBREAK PACK Infection Prevention and Control Guidance for Clinical staff on the management of an Outbreak including influenza, increased cases of other alert organisms for example VRE/MRSA. To be used in conjunction with the appropriate Infection Control Policies. Definition of an Outbreak An outbreak is defined as increased number of linked cases within a 24 hour period. I.e. two cases of influenza type symptoms or increased cases of VRE/MRSA in the same bay with no links to treatment or underlying health conditions. The bay/ward should be closed and all precautions implemented. The bay/ward will only be reopened once an outbreak is excluded General Principles All patient with suspected viral influenza type MUST be admitted to a side room and isolation precautions applied until an infective cause is excluded. In existing in-patients it is important to establish the most likely cause of the patient s symptoms as this will affect the patient s subsequent management and the actions if the patient is identified as the index patient for an outbreak. Increased incidence of other infections e.g. VRE/ MRSA may be managed using this guidance. During Normal working hours the outbreak must be notified as soon as possible to the Infection Prevention team who will provide advice and support for advice and support. Out of hours please follow the attached action cards. Please Note Clinical Care should not be compromised and discharge planning and services should continue, for example Dieticians, Therapies, Patient Journey and Nursing home assessments can be undertaken during the outbreak at ward level. 21
Nurse in Charge Outbreak Action Card Areas Identifying Outbreak of infectious illness for example Influenza, increased cases of VRE/MRSA. No Action Completed by: (date, time and name) 1 Check the above criteria to ensure case definition 2 In conjunction with the Medical team review all patients suspected of symptoms to ensure the following- Underlying clinical infections/ Other Risk factors Review antibiotics discuss with Consultant Microbiologist any changes required. Request medical reviews of patients as appropriate 3 During normal working hours contact the ICN and ask them to visit the ward and review the situation with you. 4 Out of hours contact the bed manager/site Manager providing them with the current situation after the above assessment has been undertaken. They will contact the on call Consultant Microbiologist for further advice on the closure of bays and or the whole ward. 5 Once the bay / ward has been closed Cohort/Isolate symptomatic patients in either single rooms or dedicated bays as appropriate. Using the symptoms record sheet at the end of this document record each individual patient s symptoms. In addition it may be helpful to use the ward map to plot patient s locations. Document on the symptom sheet type of symptom Cough (C) time of onset of symptom. IT IS CRITICAL THIS INFORMATION IS ACCURATE AS THIS DIRECTLY EFFECTS THE DECISIONS THAT WILL BE MADE ABOUT THE WARD / BAYS CLOSING / RE-OPENING 6 Commence patients on a fluid balance chart. 7 The Consultant Microbiologist may request samples for Virology. Details on the microbiology form must include the following potential outbreak (inserting the relevant organism e.g. flu please send for Virology 8 Ensure doors at front of ward are closed. Disable magnetic automatic closing device, contact estates for assistance if required. Ensure doors to affected bays are kept closed. 9 Display IPC notices at the entrance to the ward and on bays/single rooms. Including notices identifying which bathroom / toilet is dedicated to each bay. Posters must be laminated prior to use. 10 Contact relatives and request they postpone visiting especially if they are displaying symptoms 11 In conjunction with medical staff allocate dedicated staff to care for affected patients; these staff will need to change into scrubs. In addition, staff should not be moved to another clinical area until 48 hours has lapsed since working in an affected area. 12 Staff complaining of symptoms must remain off duty until 48hrs clear and submit a sample via Occupational Health detailing they are part of an outbreak. Please keep record of affected staff. 22
No Action Completed by: (date, time and name) 13 Contact ISS domestic supervisors (ext 1999) to undertake infection cleans in the affected areas focusing on frequently touched areas e.g. tap handles, toilets and bed areas using Tristel. At the end of the outbreak a post infection clean will be required co-ordinated via the outbreak control grop. 14 Do not transfer patients to another ward unless clinical need requires this. This must be undertaken with involvement from medical / IPC team / matrons / site managers to prevent transmission of the infectious organisms to other areas of the Trust. 15 Visiting times designate a person e.g. ward clerk, housekeeper to greet visitors and explain that the bay / ward is closed due to a suspected / confirmed infection and that visiting may be restricted. If requested provide patients / relatives / staff with relevant information sheet available on IPC website patient information sheets. Advise that it would be preferable for the visitors not to visit other patients in the Trust, unless unavoidable. Advise relatives to postpone visiting, especially if they are displaying symptoms e.g. D&V until they are 48 hours clear of symptoms. Staff and Visitors do not require face masks unless a respiratory illness is suspected and the Trust have identified this is appropriate as per PHE guidance). Managing Staff No Action Completed by: (date, time and name) 1 Ensure there are sufficient scrubs to be worn by staff and that these do not leave Trust premises 2 Staff who are required to review patients in an affected clinical area(s) e.g. physiotherapists, should wherever practicable visit patients in unaffected area prior to reviewing patient(s) in affected area. However this must not compromise patient and must be risk assessed. 3 Staff experiencing symptoms must remain off duty until advised by Occupational health, this will be decided dependent on the organism and the exclusion period required. As per Outbreak management and in line with Occupational Health affected staff may be required to submit a sample. The form should be clearly marked Occupational Health and detail part of an outbreak 23
Bed/Site Managers Outbreak Action Card Areas Identifying Outbreak of infectious illness for example Influenza, increased cases of VRE/MRSA. No Action Completed by: (date, time and name) 1 Following notification of patients with symptoms visit the ward to elicit facts then contact the on call Consultant Microbiologist via switchboard to discuss potential closures of clinical areas. If the outbreak is contained to one bay then this should be closed rather than the whole ward. However the situation should be reviewed each shift as this may be a rapidly changing picture depending on the organism for example cases of influenza will be a rapidly changing picture. However, increased cases of VRE may be slower as this is dependent on laboratory confirmation. Two or more bays affected may require the whole ward to be closed this will be a Consultant Microbiologists decision. The symptoms record sheet is a helpful tool to observe if the number of patient(s) affected is improving / worsening 2 Out of Hours notify the on-call Manager of the situation; in addition send an email to the Director of Nursing Quality and Performance, Service Manager, Matron of the Clinical area, Lead Nurse Infection Prevention / Infection Prevention and Control team notifying them of the current situation. Messages can be left on the Infection control answerphones Ext 1417/1597 During normal working hours this function will be undertaken by the IPCN. 3 Remind ward staff in the affected area they must complete and update the symptoms record sheet to keep an accurate record of patient symptoms 4 Attend the outbreak meetings as convened in accordance with the relevant IC policies. 5 Patients who have been admitted to hospital from a Nursing / Residential Home which has been closed due to an outbreak can be transferred back to the home however patients requiring a nursing home bed who are in a closed ward should not be transferred back to the home until the ward has been fully opened. If the patient requires transfer to another Hospital they must be informed of the outbreak and the patient s current status as they may require the patient to be isolated. This should not compromise clinical care, advice and support can be obtained from the Consultant Microbiologist. 6 If the patient is to be transferred to another department due to clinical need please discuss with the Consultant microbiologist / Infection Prevention and Control team and the Consultant responsible for the patient s care. 7 Clinical staff must advise the receiving area that the patient is coming from an area with a bay / ward closure in order for the receiving area to take appropriate actions. 24
Infection Prevention Team Outbreak Action Card Areas Identifying Outbreak of infectious illness for example Influenza, increased cases of VRE/MRSA. No Action Completed by: (date, time and name) 1 Bed Managers or Clinical area will notify you if there is a possible outbreak affected patients and or staff. 2 Visit clinical area to undertake assessment with the Nurse in charge of the clinical area, to establish if this is an outbreak. On-going reviews to occur with Matron and ward Senior Sister / nurse in charge by 9am each day a second review may also be requested after the 12.30 capacity meeting. Out of hours this review will be by the Site Manager or as identified by the Outbreak Control Team 3 Notify the Lead Nurse Infection Prevention, Consultant Microbiologist and appropriate Matron, Risk Manager. Ensuring the outbreak is recorded on Datix. 4 If two or more bays are closed discuss with the Consultant Microbiologist about closing the whole ward. 5 In co-ordination with the bed manager/ site manager ensure patients are isolated in single rooms (preferably en-suite) or cohort nursed in a bay as appropriate. 6 Ensure controls are in place including removal of hand gel from the end of patient s beds (dependent on the suspected outbreak organism). 7 Keep accurate records of patients affected using the ward maps and patient proforma in outbreak pack. Create outbreak incidence on ICNET, updating at least daily. 8 Request specimens from patients both MC&S and Virology. Inform Microbiology of outbreak and obtain an ILOG number from MRI Tel 0161 2768788 9 Request Infection clean of affected areas including toilets, frequently touched areas (door handles etc.) from ISS. This must be undertaken using Tristel. Alternative products may be required this will be agreed by the IPCT. 10 Provide update to Bed meetings and to Outbreak meeting (if convened as per Outbreak policy). 11 Ensure outbreak email update is sent out daily (preferably before lunch) in order that management decisions can be made regarding patient flow. Out of hours updated information will be issued via the Trust capacity status report issued by the Bed management team. 12 Work with Communication team to ensure effective communications as per the outbreak control group agreement 13 If a patient is to be transferred to another department from an affected area due to clinical need this must be done in conjunction with the Consultant Microbiologist and the patient s Consultant. As far as practicable the patient should be moved to a single room. 14 Discharges can be made to the patient s own home but should not be to another healthcare care setting unless clinical care dictates otherwise. 25
No Action Completed by: (date, time and name) Patients can return to care homes once they are asymptomatic. 15 If the patient must be moved to another healthcare setting contact their IP&C department and inform them of the transfer and suspected outbreak organism so they can take appropriate actions to accommodate the patient. 26
Infection Prevention and Control Ward Diarrhoea and Vomiting Ward Monitoring Form Ward to Document the time of each symptom and the type of each symptom e.g. vomiting diarrhea, pyrexia, cough Ward. Date reported to Infection Prevention and Control ILOG NUMBER. Essential data to retrieve result and reopen department Date Date Date Date Results Bed Number Patient name, DOB, NHS/Hospital No / staff name Date of onset of symptoms Date & Time sample sent Early Late Night Early Late Night Early Late Night Early Late Night 27
Patient name, DOB, NHS/Hospital No / staff name Date of onset of symptoms Date & Time sample sent Early Late Night Early Late Night Early Late Night Early Late Night 28
Infection Prevention and Control ward Influenza monitoring form: Ward staff to complete each of the columns below in preparation for patient review by Infection Control / Consultant Microbiologist / Pharmacy Date Ward & Ext No:.. Reported by:.. Patient Name, DOB, NHS No / Hosp. No Bay & bed No Relevant medical history including date of admission Influenza Vaccine (Y/N and date) Date of onset of symptoms and type of symptom A (aching limbs); T (temp) C (coughing); P (productive cough) Date Specimen sent Date & Result Date commenced on antiviral treatment 29
Equality Analysis (Impact assessment) Please START this assessment BEFORE writing your policy, procedure, proposal, strategy or service so that you can identify any adverse impacts and include action to mitigate these in your finished policy, procedure, proposal, strategy or service. Use it to help you develop fair and equal services. Eg. If there is an impact on Deaf people, then include in the policy how Deaf people will have equal access. 1. What is being assessed? Outbreak Policy Details of person responsible for completing the assessment: Name: Anita Swaine Position: Lead Nurse Infection Prevention and Control Team/service: Infection Prevention and Control State main purpose or aim of the policy, procedure, proposal, strategy or service: (usually the first paragraph of what you are writing. Also include details of legislation, guidance, regulations etc which have shaped or informed the document) This policy details the actions required to minimise the impact an outbreak of communicable disease will have on patients, staff and visitors by minimising the risk of transmission of pathogenic microorganisms. This policy principle is based on a multidisciplinary approach to outbreak management facilitating systems to safeguard the patient and ensure disruption to the organisational service delivery is mitigated by the implementation of key controls. 2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. Think about the information below how does this apply to your policy, procedure, proposal, strategy or service 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document Cheshire East (CE) covers Eastern Cheshire CCG and South Cheshire CCG. Cheshire West & Chester (CWAC) covers Vale Royal CCG and Cheshire West CCG. In 2011, 370,100 people resided in CE and 329,608 people resided in CWAC. Age: East Cheshire and South Cheshire CCG s serve a predominantly older population than the national average, with 19.3% aged over 65 (71,400 people) and 2.6% aged over 85 (9,700 people). Vale Royal CCGs registered population in general has a younger age profile compared to the CWAC average, with 14% aged over 65 (14,561 people) and 2% aged over 85 (2,111 people). 30