Policy No: IC24 Version: 5.0 Name of Policy: Outbreak Management Policy Effective From: 13/09/2012 Date Ratified 27/07/2012 Ratified Infection Prevention & Control Committee Review Date 01/07/2014 Sponsor Director of Nursing & Midwifery/DIPC Expiry Date 26/07/2015 Withdrawn Date This policy supersedes all previous issues.
Version Control Version Release Author/Reviewer Ratified by/ Authorised by 1.0 22 November 04 Control of Infection Committee Date 22 October 04 Changes 2.0 April 07 V Atkinson Trust Policy Forum 10 November 04 3.0 October 08 V Atkinson Infection Prevention and Control Policy Approval Meeting 4.0 A Cobb Infection Prevention and Control Committee 5.0 13/09/2012 A Cobb Infection Prevention & Control Committee 29 October 08 30 July 10 27 July 12 See summary sheet IC 24 Outbreak Management Policy V5 2
Contents Section Page 1 Introduction 4 2. Policy scope 4 3. Aim of policy 4 4 Duties (Roles and responsibilities) 5-6 5 Definitions 7 6 Risk Assessment 7-9 6.1 Initial Investigation 7 6.2 Period of Increased Incidence/Outbreak Of Infection Confined to the Trust 7 6.3 Cohort Nursing 8 6.4 Diarrhoea and Vomiting 8 6.5 Other Infections 8 6.6 IPCT Communication 8 6.7 Email Communication 8 6.8 Weekend Planning 9 6.9 Press Communication 9 6.10 Health Protection Agency 9 7. Training 9 8. Equality and diversity 9 9. Monitoring compliance with the policy 10 10. Consultation and review 10 11 Implementation of policy (including raising awareness) 10 12 References 10 13 Associated documentation (policies) 10 Appendices Appendix 1 Patient Daily Diarrhoea and Vomiting Record 11 Appendix 2 Staff Daily Diarrhoea and Vomiting Record 12 Appendix 3 Daily Outbreak Summary 13 Appendix 4 Coding System For Use During Unexplained Increases In Nausea/Vomiting and Diarrhoea 14 Appendix 5 Advice for Visitors when there is Gastroenteritis (diarrhoea and vomiting) Infection on the ward 15 Appendix 6 Ward Outbreak Summary Report 16 IC 24 Outbreak Management Policy V5 3
Outbreak Management Policy 1 Introduction The Health & Social Care Act 2008 dictates that the Trust must protect staff, patients and visitors from the acquisition of healthcare associated infection. This policy indicates the measures necessary to prevent and minimise the spread of cross infection. Dependant upon the infection, cases may or may not also be evident within the community. The Infection Prevention and Control Team (IPCT) will involve key personnel in the assessment of each situation; recommendations will range from close observation of the situation to reduction in activity. Other interventions such as staff/patient screening, offering prophylaxis to exposed contacts etc may also be considered depending on the infection concerned. For suspected gastro enteric outbreaks please refer to risk assessment tools. Occupational Health Department will be involved in the collection of staff specimens, results, receipt and supporting infection control advice to staff. The IPCT will liaise with the Health Protection Agency (HPA) when appropriate, and will be invited to support any Outbreak Meeting. Outbreaks which originate within the community may have serious implications for the trust and vice versa. The infection control team will liaise closely with the Health Protection Unit and other essential personnel. See Infection Prevention and Control Policy No1 and the Trust Pandemic Plan from the Major Incident Plan. 2 Policy scope This policy applies to all employees of Gateshead Health NHS Foundation Trust, all students, visiting health professional, locum and agency staff as well as patients and visitors. Infection prevention and control is everyone s responsibility and the guidance within this policy is based on the EPIC 2 guidelines, 2007. This policy with should be read in conjunction with the suite of IPC policies available on the Trust intranet: http://pandora/docs/policies/documents%20policies/forms/infection%20control.aspx Appendix guides are used wherever possible in order that the latest guidance for the management of outbreaks is available for Trust staff and service users and to facilitate updating as required prior to formal review of this policy 3 Aim of policy All requirements with this policy require equal attention and compliance. The policy aims to reduce the risk to staff and service users from infection and cross infection whilst minimising the disruption to the organisation. IC 24 Outbreak Management Policy V5 4
4 Duties (Roles and responsibilities) For Trust Accountability Framework see Infection Prevention and Control Policy No 1 and Infection Prevention and Control web page Staff listed all have a duty to assist the Trust in the achievement of national standards for infection prevention and control by compliance with this policy and all other Infection Prevention and Control policies. All staff have a responsibility to disseminate good practice. Specific responsibilities are outlined as follows: Chief Executive - The Chief Executive has ultimate responsibility for ensuring that effective systems and processes are in place to minimise the risk of infection to patients, staff and visitors. All Staff - All Trust staff has a responsibility to adhere to Trust policy and ensure that appropriate measures are taken to reduce risks associated with infection. All Trust Staff have a responsibility to ensure they receive annual training in Infection Prevention and Control and where appropriate are using the Infection Risk Assessment tool to screen patients. Director of Nursing, Midwifery and Infection Prevention and Control - The Director of Nursing, Midwifery and Infection Prevention and Control has delegated responsibility for ensuring that effective systems and processes are in place to minimise the risk of infection to patients, staff and visitors. Trust Board - The Trust Board has a responsibility to ensure that the risk of infection to patients, staff and visitors is minimised to its lowest potential and therefore supports the full implementation of this policy. Medical Director/Director of Infection Prevention & Control - The Medical Director has a shared responsibility with the Director of Nursing, Midwifery and Infection Prevention and Control for ensuring effective Clinical Governance within the organisation. Director of Estates and Facilities - Lead on Decontamination for the Trust Provide an annual report to the Trust board Consultant Microbiologist Lead for Infection Control - Provide expert advice in line with Trust infection control needs and national policy to the Infection Control Team, Director of Infection Prevention and control and service users. Assess the clinical significance of MRSA Bacteraemia with the relevant clinician and report all mandatory surveillance and other significant infections to the Health Protection Agency. Produce an annual Forward programme for infection control. Take specific responsibility for achievement of national infection control targets and the Forward Programme for Infection Prevention and Control. Present an annual report to the Trust Board and assist the Director of Infection Prevention and Control in the production of quarterly Trust Board reports. Assist the Director of Operational Services in their role as Decontamination lead for the organisation. Report cases of infection to the Health Protection Unit. IC 24 Outbreak Management Policy V5 5
Provide input into Trust builds from pre planning to post commissioning phases. Antimicrobial Pharmacist/Lead Consultant Microbiologist have responsibility for promoting good antibiotic prescribing and monitoring antibiotic usage in conjunction with clinical leads. Head of Infection Prevention and Control - Has a duty to provide expert infection control advice and support to the Director of Infection Prevention and Control, the Infection Control Team and other service users. Produce an annual Forward programme for infection control. Take specific responsibility for achievement of national infection control targets and the Forward Programme for Infection Prevention and Control. Provide input into the Trust Building Programme from pre planning to post commissioning phases. Ensure that Education and Training programmes are appropriate to meet national guidelines and the local needs of service users. Infection Prevention and Control Team - Has a duty to provide expert advice, education and training to service users. Assist in achievement of the Forward programme. Deliver Mandatory Education and Training to service users. Participate in daily surveillance and patient management for actual and potential infection. Divisional Director/ Manager/Clinical Lead - Divisional Managers and identified leads within departments/directorates have a duty to ensure compliance with Trust policy. Divisional Managers are responsible for ensuring all staff attend mandatory training on Infection Prevention and Control and that those non-attendees are followed up in accordance with the Trust Mandatory Training Policy (PP25) Ensure that infection control is an agenda item for directorate meetings and that infection rates are discussed at appropriate fora. Produce an annual Infection Prevention and Control report for the Infection Prevention and Control Committee, which will be taken to the Trust Board. Support Matrons in the reduction of Healthcare Associated Infection and achievement of the annual Forward programme for infection control. Modern Matron - Matrons are responsible for the reduction of Healthcare associated infection. They monitor adherence to Infection control policy via clinical presence/expertise and the Infection Control Audit tool. Ensure that Infection Prevention and Control Link staff are released to attend study sessions and perform audits for their areas which will provide the Trust with evidence of compliance in infection control. Occupational Health Department - Provide support and direction to Trust staff for individual and outbreak infection control issues. Ensure implementation of the Trust Immunisation policy. Bed Managers - Ensure compliance with patient placement tools for individual infections and outbreak situations within the Trust. Infection Prevention and Control Link Persons - Perform Infection Prevention and Control audits as directed by the IPCT/Modern Matron. Attend Link group meetings and cascade information to the ward manager and ward teams Ward Manager or Nurse in charge of ward - Daily completion and continuous update of diarrhoea outbreak management form for IPCN review or update incident as required e.g. pandemic flu. IC 24 Outbreak Management Policy V5 6
5 Definitions An outbreak is the occurrence of two or more actual or potentially related infections within a ward/department/area of practice within the trust. This is also referred to as a Period of Increased Incidence (PII) for clusters of known/unknown infections (Norovirus Working Party, 2012). For some serious infections restrictions may be necessary when only one case presents within the trust i.e. confirmed or suspected smallpox. New and re emerging infections, present a potential risk within the trust (Getting Ahead of the Curve, 2002). The level of restriction placed on a facility will depend upon the: nature of the infection numbers affected, timescale and ability to effectively manage the situation i.e. adequate side rooms and healthcare worker/patient ratios. 6 Risk Assessment 6.1 Initial investigation Information regarding an actual or potential infection incident emerges in different ways. Staff caring for patients, responsible for staff and for visiting personnel should always be alert to a potential PII. For example: An increase in specific positive specimen results for a particular facility/ward. Staff who have any concerns about potentially connected cases of infection should contact a member of the IPCT to discuss or the on call microbiologist An increase captured via routine surveillance data collection. An increase in the number of specimens sent from a facility/ward. An increase in staff absence due to related illness i.e. vomiting and/or diarrhoea. NB viral diarrhoeal illnesses require special laboratory tests requested on Stool specimen submission. Clinical diagnosis and subsequent alerting/informing the IPCT of suspected outbreak straight away. Health Protection Unit may be aware of linked cases that have been hospital in-patients and will advise the Trust. 6.2 Period of Increased Incidence/Outbreak of Infection Confined to the Trust Episodes confined to the Trust will be coordinated in conjunction with the appropriate Divisional Manager by a member of the infection control team. Outbreak meetings will be arranged and chaired by the appropriate Service Manager, inviting the Health Protection Agency. The IPCT will inform the HPA of the PII for vomiting and/or diarrhoea via the intranet on the electronic reporting system http://www.hpabioinformatics.org.uk/noroobk/home.php The IPCT will communicate current outbreak risk areas on a daily basis via email alerts and bed management meetings (appendix 3). The Trust incident reporting systems will be used as appropriate for outbreak reporting. The Trust will implement the Major incident plan when large numbers of people require hospital admission due to an infection or exposure to infection (See Trust Majax plan). IC 24 Outbreak Management Policy V5 7
6.3 Cohort Nursing - nursing together people with the same infection When several patients have the same infection the infection prevention and control team may advise cohort nursing of same sex patients. Other recommendations would be for each ward team to care for either all infected or non-infected patients. 6.4 Diarrhoea and Vomiting Staff should complete the Patient and Staff daily Record Sheet documentation attached as Appendix 1 and 2 to keep an overview of patients and staff affected/potentially affected by a viral gastroenteritis outbreak. This documentation is in addition to the patients own care plan/medical records. A stool and fluid balance chart MUST be maintained for all affected/suspected patient cases. Appropriate specimens should be sent to the laboratory for affected cases, the IPCT can provide advise if required. 6.5 Other Infections The documentation will be adapted by the IPCT to manage other PII for other infection in the Trust and will be supplied as required. 6.6 IPCT Communication The IPCT will use Appendix 3 to facilitate good communication during an outbreak. The persons chosen to receive the emails have been selected as key vehicles, and must ensure that information is cascaded in a timely fashion within their teams or to relevant colleagues. For viral gastroenteritis management, IPCT will communicate daily with key personnel to indicate precautions required for each area affected. Domestic service staff are included in emails and alerted to actual or potential terminal enhanced cleans that are required. Risk assessment during Norovirus outbreaks will be scored by the IPCT using the Code system enclosed as (Appendix 4). Personal attendance at bed meetings by a member of Infection prevention and control will further assist in minimising the spread of infection and assist in bed allocation. See also Bed Escalation Policy. The clinical area will place a laminated notice at the ward entrance to communicate the PII to visitors to the Trust (appendix 5). 6.7 E mail Communication The IPCT will use e-mail to communicate outbreak updates to a wider Trust audience. The persons chosen to receive e mails have been selected as key vehicles, and must ensure that information is cascaded in a timely fashion within their teams or to relevant colleagues. IC 24 Outbreak Management Policy V5 8
6.8 Weekend Planning The IPCN and Microbiologist on a Friday will agree and communicate a plan for patient management in affected areas for the weekend. The Senior nurse-on-call and Director-on-call will be informed of the plans as appropriate. Currently when several wards are affected IPCN will telephone or be on-site on the morning to review as appropriate. 6.9 Press Communication The Head of Communications will manage all press communications (out of hours the Director on call). 6.10 Health Protection Agency The Consultant Microbiologist will inform the Health Protection Agency Epidemiologist of serious untoward infection incidents (SUIs)/outbreaks requiring ward closure/reduced patient activity. Communications from the HPA and Trust will inform where clusters of infection may impact upon the services. For example patients affected by diarrhoeal illness within care facilities, this will assist with placement of individuals on admission and appropriate discharge planning to care facilities or sheltered accommodation. 7 Training All staff at induction must read Infection Prevention and Control Policy No.1 All staff involved in patient care will understand their local arrangements for the containment of infected /potentially infected patients. All staff will be aware of their role in the management of viral outbreaks eg noroviruses which cause diarrhoea and/or sickness. (See Appendix 1 and 2 for Patient and Staff Daily Record Sheet to be completed by staff prior to contacting the IPCT). Documentation and communication will assist in managing the outbreak. All staff will attend mandatory infection control sessions on an annual basis, which will address the principles of Evidence Based Practice for Infection Control (EPIC 2) guidance (Pratt et al 2007); The Health & Social Care Act 2008 Code of Practice Staff will be able to risk assess the individual patient as to their suitability for isolation nursing. Staff will contact the IPCT if they are unable to decide on best placement of a patient(s) within their facility. 8 Equality and diversity The Trust is committed to ensuring that, as far as reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on the grounds of any protected characteristic (Equality Act 2010). The policy has been appropriately assessed. IC 24 Outbreak Management Policy V5 9
9 Monitoring compliance with the policy Any PII will be discussed and documented in the minutes of the IPCT surveillance meeting weekly. Ongoing PII of diarrhoea and/or vomiting will be reviewed daily by an IPCN, organisational e-mail sent to update the key personnel within the Trust. A ward outbreak summary report will be completed at the close of an outbreak by the IPCN and sent to the ward manager and Modern Matron for the area (appendix 6), which summarises compliance to the policy. It an exception is noted, it will be the ward managers responsibility to completed an action plan and return it to the Modern Matron and link IPCN. The link IPCN is available for support. If there has been a PII a summary is presented to the Infection Prevention and Control Committee bi-monthly. QWM s will support in monitoring compliance of prevention and/or containment of outbreak with the standard precautions, equipment, uniform and hand hygiene sections. These results are centralised via the Safecare dashboard. Domestics maximiser reports provided evidence of cleanliness of the environment and also the matron/infection prevention and control environmental inspections which are undertaken. 10 Consultation and review The policy has been circulated electronically to members of the Infection Prevention and Control Committee (IPCC) prior and agreed by the committee 11 Implementation of policy (including raising awareness) On ratification of this policy a Trust electronic e-mail will be sent via OD& Training to alert Trust personnel of the updated policy. 12 References References available via our web page: http://staffzone/ddi/departments/infection-control/index.php Guidelines for the Management of norovirus outbreaks in acute and community health and social care settings, Produced by the Norovirus Working Party: an equal partnership of professional organisation. March 2012 13 Associated documentation This policy should be read in conjunction with the following Policies: IC 2 Personal Protection Clothing in Clinical Practice Policy IC 3 Standard Precautions Policy IC 4 Hand Hygiene Policy IC 6 Isolation Policy IC15 Cleaning and Disinfection Policy IC 24 Outbreak Management Policy V5 10
APPENDIX 1 Patient Daily Diarrhoea & Vomiting Record Correlated information to be given to Infection Control Team following identification of 2 or more unexplained cases. Ward: N=Nausea V=Vomiting D=Diarrhoea Name & DOB DOA less than 7days ago Y/N Date & Time of Onset Date of Specimen & lab. No. Date of previous c.diff/gdh TEC = terminal enhance clean Other Potential Causes i.e. laxatives constipation antibiotics any relevant medical history N V D Position on Ward at onset of symptoms i.e. sideroom/ bed space no. Position on ward pt moved to and any empty beds in bay Stool chart Insitu Y/N Ongoing 24hrs clear 48hrs clear 72hrs clear Date of TEC Always notify the Infection Prevention & Control Team if 2 or more people have developed diarrhoea and/or vomiting/nausea with an unexplained cause within a 24 hr period. Consultant Microbiologist - Bleep 2092. Infection Prevention & Control Nurses ext 3161 - Bleep 2057 NB Following discussion with 1200 bleep holder a Medical Microbiologist will be available out of hours via switchboard if further advice is required for any infection control queries. IC 24 Outbreak Management Policy V5 11
APPENDIX 2 Staff Daily Diarrhoea & Vomiting Record Ward: N=Nausea V= Vomiting D=Diarrhoea NB: Staff must be symptom free for 48hrs prior to returning to work Name Designation Date & Time of Onset Date of Specimen N V D Last day on Duty Due back date Returned Always notify the Infection Prevention & Control Team if 2 or more people have developed diarrhoea and/or vomiting/nausea with an unexplained cause within a 24hr period. Consultant Microbiologist Bleep 2092. Infection Prevention & Control Nurses ext 3161 - Bleep 2057 NB Following discussion with 1200 bleep holder a Medical Microbiologist will be available out of hours via switchboard if required for any infection control queries. IC 24 Outbreak Management Policy V5 12
APPENDIX 3 DAILY OUTBREAK SUMMARY DATE TIME IPCN(S) Areas affected Ward Risk Status Total patients currently affected SR 2 BEDDER 4 BEDDER 6 BEDDER Potential Terminal Enhanced Cleans Comments Hand hygiene with soap and water is paramount. Phlebotomists not to visit these wards whilst assessed as High risk. Other visiting staff should not be restricted for essential care or investigations but must wear PPE and wash hands with soap and water. Portering staff must be informed of the precautions required. Visitors restricted to 2 per bed, avoid young children visiting and not to come in with symptoms themselves - see attached leaflet. Please refer to attached risk assessment tool for further management advice. A Microbiologist is on call via switchboard out of hours. IC 24 Outbreak Management Policy V5 13
APPENDIX 4 Coding System For Use During Unexplained Increases In Nausea/Vomiting And Diarrhoea The risk codes will indicate the minimum actions recommended by the infection control team. The purpose of coding is to indicate best infection containment practice for the affected directorate on a daily basis. The support of individual areas in collecting detailed information to update the IPCT is vital and much appreciated. Swift action can minimise the extent of an outbreak of viral gastro enteritis. Only specimens of fluid faeces/diarrhoea should be sent to the laboratory for viral investigations. HIGH RISK 1. No patient or staff movement recommended. 2. Urgent investigations/operations following consultation, if feasible with Microbiologist/ outbreak bleep holder. Ward will then let department to be visited know of patient s condition. 3. Enhanced cleaning of ward by Domestic services. 4. Apron and gloves for activities with infected patients. 5. Ward staff to inform health-care visitors and relatives of patient s condition. 6. HAND Hygiene paramount patients, staff and visitors. 7. Staff to remain off duty for 48hrs post last symptom. SIGNIFICANT RISK 1. No staff movement recommended. 2. No patient movement to other care facilities i.e. QE/DHH, care homes unless patient has had symptoms and been symptom free for AT LEAST 48hrs. 3. Urgent investigations /operations following consultation, if feasible with Microbiologist/outbreak bleep holder. Ward will then let dept to be visited know of patient s condition. 4. Enhanced cleaning of ward by Domestic services. 5. Apron and gloves for activities with infected patients. 6. Ward staff to inform health-care visitors and relatives of patient s condition. 7. HAND Hygiene paramount patients, staff and visitors. 8. Staff to remain off duty for 48hrs post last symptom. MINIMAL RISK 1. Normal activity. 2. HAND Hygiene paramount patients, staff and visitors. 3. Staff to remain alert for possible sporadic cases and consult outbreak bleep holder if unsure that a case definition is indicated. 4. Enhanced cleaning of the ward by Domestic Services. NO RISK 1. Normal activity. 2. HAND Hygiene paramount. 3. Unexplained cases of diarrhoea and or vomiting should be placed in a side room if appropriate. 4. Staff to remain alert for possible sporadic cases and consult outbreak bleep holder if unsure that a case definition is indicated. 5. Enhanced cleaning of the ward by Domestic Services to continue for additional 72 hours. Revised May 2010 IC 24 Outbreak Management Policy V5 14
APPENDIX 5 Advice for visitors when there is gastroenteritis (diarrhoea & vomiting) infection on the ward There are times when gastroenteritis type infections, which are in the community setting, are unintentionally brought into the hospital by patients, visitors and staff. When this happens it is vitally important that measures to reduce the spread of infection are put into practice. For this reason you have been asked by the hospital to adhere to some simple guidelines. You are required to wash your hands with soap and water at the sink at the ward entrance when you enter and leave the ward. Please do not visit if you have any symptoms of infection such as diarrhoea, vomiting, nausea or flu-like symptoms. If you do have any symptoms please telephone the ward to speak to a member of staff who will give you advice. You may visit once you are 48 hours clear of symptoms. It is not advisable for very young children or children of school age to visit when there is an infection in the ward environment. Please do not use the patient toilet facilities; there are visitors toilets available. (Please ask a member of staff) Always wash your hands with soap and water before eating or drinking and after using the toilet. Thank you for your cooperation in this very important matter. Infection Prevention & Control Team Published April 2011 Updated dated July 2012 Review date June 2014 IC 24 Outbreak Management Policy V5 15
APPENDIX 6 Ward Outbreak Summary Report. Ward: Date IPCN contacted: Date of close of outbreak: Total number of days affected: Total number of patients affected Total number of appropriate samples sent to lab Any positive results Total number of staff affected Total number of appropriate samples sent to lab Any positive results Number of beds closed Total number of closed bed days Stools charts up to date: Yes/No Any exceptions for Hand Hygiene observed: Yes/No Any exceptions to Personal Protective Equipment observed: Yes/No Delay in Terminal Enhance Clean: Yes/No Any exceptions are shown in red. Please complete an action plan for the exceptions and return to Modern Matron and link IPCN. This will be presented at the Infection Prevention and Control Committee Meeting. AC/AB 11.07.12 Final formatting AB 13.09.12 IC 24 Outbreak Management Policy V5 16