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N/R/EMI/LD – Please indicate Address Postcode : Notified By:

Call received by:

Tel No: Home Manager: Deputy: INITIAL INFORMATION: (Approx number of persons affected, symptoms, date of onset etc)


Outbreak Start Date: Date/Time of first visit: Total No clients at risk : IPCN/IPCP : Total No staff at risk : Outbreak Infection Prevention Daily Check list provided Yes/No Outbreak Ended Date: Numbers affected: Post Outbreak Audit Date/Time of visit: Clients : IPCN/IPCP : Staff: Outbreak Infection Prevention Daily Check list collected Yes/No Guidance overleaf - Contact details: All homes must contact the West Yorkshire Health Protection Agency Duty Desk – 0113 3860300 (Monday to Friday 0900 – 1700hrs) where two or more cases of diarrhoea and/ or vomiting have occurred. (Bristol Stool Chart grading 5 - 7) and it is unusual to the residents or staff member’s normal bowel action). For daily support and advise once an outbreak has been confirmed by the HPA Duty Desk (as above) contact the NHS Kirklees and Wakefield Infection Prevention and Control Team - 01484 464428 (Monday to Friday 0900 – 1700hrs) For Out of Hours/Bank holiday support Ask for the Public Health Consultant on call - HRI Switchboard – 01484 342000

MYHT Switchboard– 0844 8118110

Please Note If an outbreak is suspected out of office hours (which are 1700hrs – 0800hrs) Monday to Friday or on a weekend or Bank Holiday inform the oncall Public Health Consultant on Call as appropriate (identified overleaf) Guidance on how to complete the MICROBIOLOGY REQUEST FORM; Write the patients name, address and date of birth (in full) Clinical details: Write GI Outbreak and ILog Number (example WY/S.12 33333) (Include any other appropriate clinical information) You will be supplied an identifying ILog number to be labelled on the lab request form by the HPA. This number is the personal identifier at the laboratory for the outbreak at your home (it must be on the form otherwise the sample will be discarded by the lab). Test/Examination required: write Microscopy, culture and virology Sample Type/Specimen-write Faeces (must be Bristol Stool Type 5 - 7 (record time and date collected). Stool specimens must fill a maximum of half the specimen pot and can be contaminated with urine. Sampling early may identify the cause of the outbreak Consultant/Requestor Doctor details – write Dr. Okereke

Department of Microbiology Old Medical School Leeds General Infirmary Leeds LS1 3EX Essential health care appointments If appointments into hospital are essential discuss with the Health Protection Agency/Public Health Consultant on Call. If a resident has to be admitted to hospital /A&E from the home when the outbreak had already started they can be discharged back to the home even though the outbreak may still be ongoing (this is because they have been exposed to the infection already). Remember to use the transfer form and risk assessment stickers to alert other health care providers.