Outbreak Management Policy for Communicable Infections
Dr Judith Hooper
25 March 2009
NICE GUIDANCE Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgment. However, NICE guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian or carer.
Version Control Current versions of all policies can be found on NHS Kirklees internet and intranet. If printing a document, please check internet/intranet for most up-to-date version. Document Title: Document number: Author: Contributors: Version: Date of Production: Review date: Postholder responsible for revision: Primary Circulation List:
Outbreak Management Policy 1 Yvonne Hanson Jane Oâ€™Donnell 1 March 2009 March 2011 Deputy Director of Infection Prevention and Control
All ratified policies, strategies, procedures and protocols are published on the Trust Intranet and Public Website.
Infection prevention and control team
Restrictions: Standard for Better Health Map Domain: Core Standard Reference:
1. Safety C4a,
1. A reduction in the incidence of healthcare associated infections 2. Minimise the spread of a known infection status
Contents Section 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 22 23 24 25 26 27 28 29 30 31 32 33 A B C D E F G H
Page Introduction Acute/Minor outbreaks Major outbreaks Associated policies and procedures Aims and objectives Scope of the policy Accountabilities and responsibilities Isolation Documentation of affected patients Patient hygiene facilities Hand hygiene Compulsory daily uniform change Personal protective equipment (PPE) Gloves Aprons Goggles/visor Communication Management of specimens Management of waste Management of laundry Management of spillages Decontamination of equipment Bed Management and the movement of patients Infected staff Movement of staff Therapy staff Visitors Cleaning during an outbreak Deep cleaning post outbreak Equality impact assessment Training needs analysis Monitoring compliance with this policy References Patient daily review outbreak details Personal protective equipment guidance Outbreak notices for display at ward entrance Staff daily review outbreak details Deep cleaning guidance post outbreak Infection control post outbreak performance audit Stakeholders consultation Equality impact assessment
4 4 4 5 5 5 5 6 6 6 6 6 7 7 7 7 7 7 8 8 8 8 8 9 9 9 9 10 10 10 10 10 11 12 13 14 15 16 19 20 21
Policy Statement NHS Kirklees will, in accordance with the Health Act, 2006 and the Health and Social Care Act 2008, ensure that outbreaks of infections within Kirklees are: • • •
identified immediately managed in order to contain and prevent further spread to other susceptible persons/areas and reoccurrence of the infection that all staff members involved in an outbreak will have a clear understanding of their roles, procedures and responsibilities
1. Introduction The aim of the following policy is to identify suspected outbreaks of infection, investigate and implement containment measures that control and contain the infection to prevent spread to other areas An outbreak can be defined as: two or more related cases of an infective disease. 2. Acute/minor outbreaks Are those that lead to a sudden increase in the number of people with symptoms and non-acute outbreaks are those that develop over a number of days or weeks. The infection prevention and control team in conjunction with the ward manager/head of service, will manage this type of outbreak 3. Major outbreak Generally this is characterised by similar clinical signs and symptoms affecting a significant number of people (e.g. 10 or more patients and or staff) in one unit, ward or home. However an infection may be considered major either due to the number of cases or because of the seriousness of the disease. Please note that the infection prevention and control team will manage acute/minor outbreaks. Where there is a significant outbreak, the outbreak team will become involved and the major incident plan may be implemented. The infection prevention and control team will initiate this action in conjunction with the Director of Infection Prevention and Control. Infection prevention and control must be integrated into each and every aspect of caring for patients. Microscopic infections, either viral or bacterial may affect a small amount of people at the beginning of a potential outbreak, but if not managed efficiently and effectively, the outbreak may escalate into a major outbreak. It is therefore imperative that all staff remain vigilant in identifying potential sources of infections and they must remain rigorous in the management of infected patients.
4. Associated policies & procedures This policy should be read in accordance with the following Trust policies, procedures and guidance: • • • • • • • • • • • • •
Infection Control Policy Waste Management Guidelines Hand Decontamination Policy Incident Reporting Policy Disciplinary Policy and Procedures Diversity and Equal Opportunities in Employment Policy Health and Safety at Work Policy Moving and Handling Policy Aseptic technique policy Dress code policy for clinical staff Decontamination of reusable medical devices Isolation Policy Major incident plan
5. Aims and objectives The aims and objectives of this policy are to ensure that outbreaks of communicable infections are: • • •
identified immediately managed in order to contain and prevent further spread to other susceptible persons/areas and avoid reoccurrence of the infection that all staff members involved in an outbreak will have a clear understanding of their roles, procedures and responsibilities
6. Scope of the policy This Policy must be followed by all NHS Kirklees employees who are developing policy and procedural documents or developing guidance for colleagues. It must be followed by all staff who work for NHS Kirklees, including those on temporary or honorary contracts, bank staff and students. Breaches of this policy may lead to disciplinary action being taken against the individual. Independent Contractors are responsible for the development and management of their own procedural documents and for ensuring compliance with relevant legislation and best practice guidelines. Independent Contractors are encouraged to seek advice and support as required. 7. Accountabilities and responsibilities The Chief Executive (CE) is accountable for ensuring that effective arrangements for the management of outbreaks are in place within NHS Kirklees. 5
The Director of Infection Prevention and Control (DIPC) has responsibility to give assurance to the Board and to have direct accountability for the management of outbreaks within the NHS Kirklees. The Infection Prevention and Control team will: • • •
Ensure this policy is reviewed as required and work with Heads of Service to implement necessary changes in practice. Act as a link between the Trust and specialist agencies and networks Take a lead role in investigating outbreak incidents and the dissemination of findings
Heads of Service are responsible for ensuring that healthcare professionals involved in the management of outbreaks adhere to policy. 8. Isolation Refer to Isolation Policy. 9. Documentation of affected patients In accordance with the Nursing Midwifery Council (NMC) 2008, clear and accurate records must be kept of all patient’s discussions, assessments, treatments, medicines and how effective these have been. All patients affected by the outbreak must be recorded on the patient daily review outbreak details form and information disseminated to the infection prevention and control team. (See Appendix A). 10. Patient hygiene facilities • • • •
Use en suite facilities or a dedicated commode or toilet for each patient Commodes and toilets must be decontaminated between each use with detergent wipes Bathrooms must be de-cluttered A designated hand hygiene pack must be available for each patient and particular emphasis given to hand hygiene: i) Before and after meals ii) Before and after using the toilet/commode
11. Hand hygiene Hand hygiene is the single most important factor in the prevention of healthcare associated infections (Ayliffe et al 2000). NHS Kirklees employs a Dress Code Policy for Clinical Staff which states that “bare below the elbow” is an essential part of practice and must be engaged by all staff caring for patients. Hand hygiene using soap and water is essential before and after every patient contact. Alcohol hand rub in these instances should only be used AFTER washing with soap and water if the removal of resident bacteria is necessary, for example when carrying out an Aseptic technique. 12. Compulsory daily uniform change Refer to Dress Code Policy for Clinical Staff. 6
13. Personal protective equipment (PPE) Where there is a potential for contamination/exposure to blood or bodily fluids the Personal Protective Equipment at Work Regulations 1992 must be followed. Healthcare workers must wear the appropriate personal protective equipment supplied by NHS Kirklees and they must be worn wherever there are risks to health and safety that cannot be adequately controlled in other ways. 14. Gloves If direct contact with blood or body fluids is anticipated staff must wear well-fitting, seamless, powder free, sterile or non sterile disposable gloves, depending upon the procedure. These should be discarded after each procedure and hands must be washed. Gloves should also be worn for: • • • • •
Cleaning equipment Handling disinfectants Cleaning spillages Venepuncture. Any task where contamination is likely
Where cuts and abrasions are present, they must be covered with a waterproof dressing before applying gloves and performing clinical procedures. 15. Aprons If direct contact with blood or body fluids is anticipated staff should wear a disposable plastic apron. 16. Goggles/visor Any procedure in which there is a risk of splashing blood or body fluids into the eyes or face, protective eyewear should be worn. Refer to Appendix B 17. Communication Ineffective communication has been identified by the Health Care Commission as a major factor in the spread of infection within health care. It is therefore imperative that clear, concise and effective communication is given at all times. Information leaflets should be disseminated to patients, visitors and essential therapy staff. A poster must be displayed at the entrance to the health care facility. See Appendix C. Where media interest is expressed, please direct all enquiries to NHS Kirklees Communication Team. 18. Management of specimens: Appropriate specimens should be submitted from affected patients.
Specimens are a potential risk and must be packaged and handled appropriately. All specimens must be sent to the laboratory as soon as possible. However, where storage is required this should be in a designated specimen refrigerator and not stored with drugs, food or vaccines. The specimens must be placed in an appropriate container for the type of specimen. The specimen must be labelled clearly and correctly. If the sample is considered to be high risk, a label should be attached to the specimen form. In accordance with the Hazardous Waste Regulations, 2005, specimens must be transported in a UN approved container.. This must be leak proof, easy to clean and protect the handler from contamination. After each use, the transport containers must be cleaned and dried. 19. Management of waste Please refer to NHS Kirklees Waste Management Guideline. 20. Management of laundry Bed linen, towels, and clothes should be changed daily. Soiled linen should be placed into water soluble bags and then into red linen bags and sent to laundry as infected linen. 21. Management of spillages All blood/body fluid spillages must be dealt with immediately. Wearing the appropriate PPE use the Guest Medical spillage kits, if not available, use paper towels to absorb the fluid, clean with fresh hot water and detergent and then disinfect using Chlorclean. 22. Decontamination of equipment Wearing the appropriate PPE, all equipment must be decontaminated in accordance with NHS Kirklees Decontamination of Reusable Medical Devices Policy. 23. Bed management and the movement of patients The risks of healthcare associated infections are greatly increased by the extensive movements of patients with the hospital/healthcare environment. In accordance with the Health Act, 2006 there should be joint working between the infection prevention and control team and the bed/ward managers in planning patient admissions, transfers, discharges and movements between departments and other healthcare facilities. Where necessary ambulance trusts may need to become involved in such planning. Do not send patients with symptomatic vomiting and diarrhoea to another ward/department unless strictly necessary, and in the patientâ€™s best interest, ie the health of the patient should take priority over the infection problem. The Health Act, 2006 states that: Suitable and sufficient information on a patientâ€™s infection status whenever it arranges for that patient to be moved from the care of one organisation to another, so that any risks to the patient and others may be minimised. It is therefore essential that the receiving ward/health care facility must be informed and a single room organised. 8
Patients can be transferred after they have been symptom free for 48 hours Do not discharge asymptomatic patients to their own homes if they will require the intervention of home care/social services. 24. Infected staff • • • •
Staff who develop symptoms must be excluded from work until 48 hours symptom free. All absences due to the outbreak must be reported to the infection prevention and control team/ward manager and Occupational Health; stool samples may be requested. Upon returning to work, staff may be requested to work within the affected area. Any staff with symptoms must be recorded on the Staff Daily Review Outbreak Sheet, see Appendix D
25. Movement of staff •
Nursing and domestic staff working in affected area should not work in an unaffected area unless they have been away from the affected area for at least 48 hours; this includes bank and agency staff
Bank/agency nurses or staff brought in to help must not work in any other areas until the outbreak has been declared over. Agencies must be kept informed of the current outbreak status of the ward.
26. Therapy staff •
All non essential therapy should be cancelled until the outbreak has been declared finished.
Essential therapy intervention should be carried out as the staff member’s last visit.
Effective communication regarding the outbreak must be disseminated to the visiting staff member.
27. Visitors • • • • •
Inform ward visitors of the outbreak, by placing information notices at the entrance and in strategic places in the premises (see Appendix C). All visitors (members of the public and essential visiting staff) should report to the nurse in charge of the patients care before entering the ward. All visitors must be advised on the correct hand washing procedures before entry and exit of the ward. Visitors should be discouraged from bringing children onto the ward. Visitors should be advised not to eat on the ward.
28. Cleaning during an outbreak Frequency of environmental cleaning must be increased to at least twice daily. Fixtures and fittings in toilets and environmental surfaces should be cleaned with Chlorclean using a disposable colour coded cloth, particular emphasis should be placed on all frequently touched surfaces, for example door handles 29. Deep cleaning post outbreak Once an outbreak has been declared over, a deep clean of all affected areas must be conducted. See Appendix E. 30. Equality Impact Assessment This Policy was found to be compliant with this philosophy (See appendix G). 31. Training Needs Analysis NHS Kirklees is committed to the training and continuing development of all staff including independent contractors on all relevant issues surrounding the outbreak of community infections. All induction programmes and Infection Prevention and Control mandatory training will include outbreak and isolation information. 32. Monitoring compliance with this policy NHS Kirklees will have key indicators for the monitoring of outbreaks within the community and these indicators will be included in all performance processes including the Assurance Framework •
Infection control post outbreak performance audit will be undertaken following the completion of the outbreak. (See Appendix F.)
Percentage of incident reports attributed to an outbreak
Percentage of clinical and non-clinical staff undertaking mandatory annual infection prevention and control training.
Healthcare associated infections due to an outbreak of infection identified after completion of Root Cause Analysis investigations.
Quality indicators will be a part of normal performance monitoring against a set of local, regional and nationally, (nationally via the evidence for Standards for Better Health which will be superseded in 2009 by the Care Quality Commission).
References Ayliffe G, Fraise A, Geddes A, Mitchell K. 4th Edition (2000) Control of Hospital Infection, A practical handbook. Arnold. London. NHS Kirklees Decontamination of reusable medical devices (2009) Chin J. (2000) Control of Communicable Diseases Manual. 17th Edition. American Public Health Association. Washington. Department of Health Getting ahead of the Curve: A Strategy for Combating Infectious Diseases, Department of Health, 2002 Lawrence J and May D. (2003) Infection Control in the Community. Churchill Livingstone. Edinburgh. National Audit Office. (2000) The management and control of hospital acquired infection in acute NHS trusts in England. Nursing & Midwifery Council (NMC) 2007. The Code standards of conduct, performance and ethics for nurses and midwives. London The Health Act 2006. Code of Practice for the Prevention and Control of Health Care Associated Infections. Department of Health (revised January 2008). Working Group of the former PHLS Advisory Committee on Gastrointestinal Infections. Preventing person-person spread following gastrointestinal infections: guidelines for public health physicians and environmental health officers. (2004) Communicable Disease and Public Health. 7 (4) 362-384 Department of Health, Winning Ways: Working Together to Reduce Healthcare Associated Infection in England, 2003 Chief Medical Officer Department of Health 2008 â€“ a Guide to Best Practice: Isolation of Patients, London DH.
Appendix A INFECTION PREVENTION AND CONTROL TEAM Patient daily review outbreak details Ward:
Commencement date of symptoms:
Results Date Date Date Date Date Date Patient/ Previous Symptoms Bed of specimen location staff number/ specimen sent of details cohort patient room
Symptom Codes: D = diarrhoea; V = vomiting; N = nausea; A = abdominal pain; H = headache; X = asymptomatic
Assess Risk of Task
No contact with blood / body fluids
Contact with blood / body fluids Low risk of splashing
Contact with blood / body fluids High risk of splashing
No gloves / aprons
Gloves / aprons
Gloves, aprons, eye / mouth protection
PLEASE NOTE: WE ARE CURRENTLY RESTRICTING ADMISSION TO THIS AREA/WARD YOU MUST CHECK WITH THE NURSE IN CHARGE BEFORE VISITING MAY WE REMIND YOU TO CLEAN YOUR HANDS ON ENTRY AND UPON LEAVING THIS AREA
INFECTION PREVENTION AND CONTROL TEAM 14
Staff Daily Outbreak Monitoring Form: Location of work:
:Date this form commenced:
* Symptom codes: D = diarrhoea, V = vomiting, N = Nausea, A = abdominal pain, H = headache, X = asymptomatic Date returned Result of Other Date * Symptom Date Name of staff Date to work specimen specimen relevant code member affected symptoms last information sent for information on reported MC & S duty and virology
Appendix E Deep cleaning post outbreak: This is a general cleaning specification designed to provide guidance to premises who will be undertaking post outbreak “Deep Cleaning.” Please not that items or surfaces that cannot be cleaned in accordance with this schedule may need to be replaced. NB: COSHH, Health & Safety, Moving and Handling, and personal protective equipment precautions are taken into account. It is essential that the NHS colour coding for cleaning equipment is adopted:
PLEASE WORK FROM THE CLEANEST AREA TOWARD THE DIRTIEST AREA. (THIS GREATLY REDUCES THE RISK OF CROSS CONTAMINATION).
All areas should be decluttered to ensure effective cleaning Prior to commencement of cleaning, protective gloves and an apron must be worn. Damp clean using the correct colour coded disposable cloth immersed in hand hot water containing the correctly measured cleaning solution and wring it out as dry as possible. Change the cleaning solution when dirty or every 15 minutes and prior to moving to different locations/areas. HARD FLOORS All hard flooring must be thoroughly washed and if possible scrubbed. SOFT FLOORS All carpeted areas including consulting rooms must be steam cleaned using a method appropriate to the type of carpet. Suction clean the carpet prior to deep cleaning. Protect the feet of furniture which cannot be moved with strips of cardboard or plastic. Spot clean heavy stains. TOILETS, SINKS, BASINS, BATHS, TAPS AND FIXTURES Porcelain, cubicle rails and plastic surfaces should be free from smudges, smears, body fluids, soap build-up and mineral deposits e.g. lime scale. Soap/ Alcohol gel/ towel dispensers must be thoroughly cleaned. Metal surfaces, shower screens and mirrors are to be cleaned free from streaks, soil, smudges, soap build-up and oxide deposits e.g. lime scale. Wall tiles and wall fixtures (including soap dispensers and towel holders) are to be cleaned free of dust, grit, smudges/streaks, mould, soap build-up and mineral deposits. Shower curtains and bath mats are to be cleaned free from stains, smudges, smears, odours, mould and body fluids. Sanitary disposal units are to be clean and functional. FURNITURE, FIXTURES, FITTINGS AND SOFT FURNISHINGS All horizontal and vertical surfaces must be cleaned including all fixed and freestanding furniture. This procedure applies to desks/trolleys/curtains rails/examination lamps/complete door frames including door furniture/examination couches/ chairs/light switches/sockets/worktops/pictures/radiators and pipe work/ledges/fire extinguishers/decorative plants and containers. All central heating radiator grills and fitments must be cleaned. The internal and external surface of all waste receptacles must be cleaned, including the foot operated mechanism where appropriate.
LOW LEVEL SURFACES All cupboards and storage areas should be emptied and the internal surfaces cleaned. All skirting boards and pipe work must be cleaned. HIGH LEVEL SURFACES All ventilation ducts/ventilation systems/fans must be cleaned. All lights and lighting equipment must be cleaned. All cupboards including wall mounted should be emptied and the internal and external surfaces cleaned surfaces cleaned. All curtain rails must be cleaned. CLINICAL EQUIPMENT All clinical equipment must be cleaned e.g. stethoscopes, blood pressure cuffs with detergent wipes. TELEPHONES & IT EQUIPMENT All movable IT equipment must be cleaned in accordance with the manufacturers recommended instructions e.g. telephones, computers including keyboard/mouse/headsets. PAINTWORK - WALLS AND DOORS Wall washing should be carried out where the walls are painted, or where the wallpaper is washable. WINDOW & BLINDS Any curtains, screens or blinds within the premises should be removed and cleaned e.g. washed/steam cleaned or dry cleaned as appropriate. All windows and windowsills should be cleaned inside and outside. It is recommended that a general use cleaning product is used for deep cleaning purposes. Where disinfection is required, then the use of a chlorine releasing product e.g. Chlorclean is the product of choice.
Appendix F Infection Control Post Outbreak Performance Audit Number Number of patients involved at the commencement of the outbreak Total number of patients involved at the finish of the outbreak
Number Number of staff involved at the commencement of the outbreak Number of staff involved at the finish of the outbreak
Identification and reporting of the outbreak was completed at an early stage and the Infection Control Team given immediate notification? Were staff fully aware of their responsibilities in reporting Immediately suspected outbreaks of infection to the infection prevention and control team and the ward manager/lead? Were effective infection and prevention control measures implemented and maintained? Has effective clear and concise communication been evident throughout this outbreak? Has a review of the outbreak been undertaken? Was an end of outbreak report submitted to the Board with copies to the Health Protection Agency and SHA? Were both clinical and non clinical staff aware of this policy? Have any actions and learning points identified? Please identify any areas of good practice: • • • Please identify any areas of poor practice. • • A copy of this form must be retained by the ward and a copy sent to the infection prevention and control team.
Appendix G Equality Impact Assessment Tool Insert Name of Policy / Procedure Yes/No 1.
Does the policy/guidance affect one group less or more favourably than another on the basis of: • Race
• Ethnic origins (including gypsies and travellers)
• Religion or belief
• Sexual orientation including lesbian, gay and bisexual people
• Disability - learning disabilities, physical disability, sensory impairment and mental health problems
Is there any evidence that some groups are affected differently?
If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?
Is the impact of the policy/guidance likely to be negative?
If so can the impact be avoided?
What alternatives are there to achieving the policy/guidance without the impact?
Can we reduce the impact by taking different action?
Key stakeholders consulted/involved in the development of the policy/procedure Key Participant Yes/No
Feedback requested Yes/No
Feedback accepted Yes/No
Jane Oâ€™Donnell, Deputy Director of Infection Prevention and Control
Kirklees Infection Control Committee
Policy Development Group
Kath Barraclough, HVMH
Stakeholders name and designation