Control of an Outbreak of Infection in Hospital

• Summary of Guideline
• Aims
• Objectives
• Background
• Recognition of an outbreak
• Investigation
• Actions to be taken if an Outbreak Exists
• Auditing and Monitoring of Compliance
• Provenance
• References
• Appendix A - Outbreak Criteria for ALERT organisms 
• Appendix B - Outbreak Criteria for CoVID-19 
• Appendix C -Terms of Reference of the Outbreak Control Group (OCG) 
• Appendix D- Terms of Reference of a Major Outbreak Control Group (MOCG) 
• Appendix E - Groups to consider informing in the event of a major outbreak 
• Appendix F- Outbreak Control Group Agenda Template 
• Appendix G - Outbreak Control Group Minutes Template 
• Appendix H - Outbreak Control Group Action Tracker Template 
• Appendix I - Standard Outbreak Report Template 
• Appendix J - CoVID-19 Timeline Template 
• Appendix K - CoVID-19 Outbreaks Summary Template 

Summary of Guideline

All LTHT staff need to be alert to an increase in infections of any type in their clinical areas, and to report these to the Infection Prevention and Control Team (IPCT) for assessment/action.

• In hospitals, situations occasionally arise in which the number of infections of a certain type increase in a particular area or patient group. In these situations it is important to determine whether this is a random occurrence or whether the infections are, in some way, related to each other. A preliminary meeting with Matron (for relevant area), Ward Manager, Infection Prevention & Control Nurse (IPN), Microbiologist +/- relevant Lead Clinician (or other ward clinician) may be appropriate to review the circumstances and available evidence, and advise whether an Outbreak should be declared.

An Outbreak is a situation in which there are 2 or more cases of the same organism in a patient group or clinical area within LTHT in a defined time frame. The level of outbreak management required is determined by the Infection Prevention Leadership Team (IPLT), +/- other members of the IPCT, taking into account the number of cases and severity of disease.

If an outbreak is declared, an Outbreak Control Group (OCG) or a Major Outbreak Control Group (MOCG) will be set up to co-ordinate the investigation and management of the outbreak.
Outbreaks are  reviewed at the regular HCAI Action Team meetings, chaired by the Director of Infection Prevention & Control (DIPC) and, if deemed appropriate, they will be referred for review by the Quality Committee Meeting for consideration of a Serious Incident

At the end of the outbreak a report will be written by the Clinical Service Unit(CSU) Management Team or delegated deputy, circulated to the relevant clinical team,  IPC  (via the generic LTHT IPC email address), placed on DATIX and presented at the IPCC in order that lessons can be learned for future practice.

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Aims

The purpose of this guideline is to ensure rapid detection and early and appropriate management of infectious disease outbreaks within LTHT in order to minimise the spread of infection to other patients.

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Objectives

To provide recommendations for appropriate diagnosis, investigation and management of Outbreaks

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Background

Infectious diseases are either endogenous or exogenous. Endogenous disease arises from the micro-organisms which are already present in or on that person (“normal flora”). Exogenous infection is acquired from another source, e.g. another person, an animal or an environmental source. In hospitals, situations occasionally arise in which the number of infections of a certain type increase in a particular area or patient group. In these situations it is important to determine whether this is a random occurrence or whether the infections may be related. Interventions may be required to reduce further transmission of infection.

LTHT classifies two categories: “outbreak” and “major outbreak”. The objective of this guideline is to define the actions that will be taken to determine whether an outbreak is occurring and, in consultation with Risk Management if appropriate, the level of management that is required.

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Recognition of an Outbreak

A key responsibility of all LTHT staff is to be alert to an increase in infections of any type in their clinical areas and to report these to the IPCT so that appropriate assessment and/or action can be taken. 

If an infectious disease is notifiable by law, the medical staff responsible for the patient must also notify the Consultant for Communicable Disease Control (CCDC) on the appropriate form (see Appendix E - Communicable Notifiable Diseases in Infections (Alert Organisms And Conditions) That Require Source Isolation)

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Investigation

When the IPCT become aware of an apparent increase in the number of cases of a particular disease or micro-organism from laboratory reports, or receive an alert from a clinical team, they will make an assessment as to whether an outbreak is occurring.

The components of the assessment are as follows:

• The Infection Prevention and Control Team (IPCT) will collect information from the relevant clinical area(s) and the microbiology laboratory to determine the nature and severity of the disease and the number of cases.
• A preliminary meeting with Matron (for relevant area), Ward Manager, IPN, microbiologist +/- relevant Lead Clinician (or other ward clinician) may be held to review the circumstances & available evidence and advise whether an Outbreak should be declared.  
• The Lead Doctor for IPC (or in his/her absence the relevant CSU Microbiologist) is responsible for determining the category of any outbreak in consultation with DIPC.

If the IPCT considers that no outbreak exists at that time, it may be appropriate for the clinical area to be under enhanced surveillance.  Ward staff should always be encouraged to report similar situations in the future.

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Management - Actions to be taken if an Outbreak Exists

ACTIONS TO BE TAKEN IF AN OUTBREAK EXISTS
Outbreak: The existence of the outbreak must be communicated by a member of the IPC team (usually Consultant Microbiologist or IPC nurse) to:

• CSU Triumvirate Team (Clinical Director, Head of Nursing and General Manager)
• Lead Clinician
• Matron (for relevant area)
• Ward Manager
• Head of Facilities
• Pharmacy Antimicrobial Lead
• Decontaminaton Lead
• Yorkshire & Humber Health Protection Team who will assign a representative to attend.

The outbreak will be managed by an Outbreak Control Group (OCG) and chaired by the relevant CSU Clinical Director, or in his/her absence, a designated deputy e.g. CSU Head of Nursing (HoN). It is the responsibility of the CSU Triumvirate Team to organise the OCG. Terms of Reference and membership for an OCG are shown in Appendix C.  There are also specimen agenda, minutes and action tracker templates as Appendices  F, G and H respectively along with a specimen/template report in Appendix I. 
The outbreak will be monitored on a daily basis by IPCT, and recorded on the outbreak database for auditing and surveillance purposes, along with the ability for additional interventions to be considered should it be prolonged or increase in severity.

The number of OCG meetings required is at the discretion of the OCG Chair, as advised by IPCT, and will vary depending on the extent of the outbreak. The first OCG meeting should be held within five working days of the notification of the outbreak being declared. Agreement should be made on the criteria to be met to declare the outbreak closed.

At the end of the outbreak a short written report will be produced by the OCG Chair (or designated deputy) within 2 weeks of the closure of the outbreak,  uploaded to DATIX and circulated to the IPCT (via the generic LTHT IPC email address) and members of the OCG. This will assist in surveillance and also in informing staff where lessons can be learnt for the future (NB: outbreak reports are circulated widely and therefore must not contain any identifiable patient details). Outbreaks are reviewed at the quarterly meetings of the Trust Infection Prevention and Control Committee. Certain outbreaks may also be individually reviewed at a meeting between the CSU representatives and the IPC leadership team, chaired by DIPC.

Major outbreak
A major outbreak is one in which the number of cases, the pathogenicity of the organism, its potential for spread within the hospital and community and/or the likely overall impact of the outbreak on the Trust and surrounding area are considered by the IPCT to have major significance. Major outbreaks will include those which are believed to have contributed to excess patient deaths and/or outbreaks which worsen or become unusually persistent.

The existence of a major outbreak must be communicated as soon as possible by the Lead Doctor for IPC (or in his/her absence the CSU Microbiologist) to the same group as an outbreak, and additionally:

• Chief Executive
• DIPC
• Chief Nurse
• Chief Medical Officer
• Head of Communications
• Head of Health and Safety
• Consultant in Communicable Disease Control (CCDC)
• Consultant in Public Health Infection, PHE, Yorkshire & Humber
• Local Authority Public Health

Appendix E highlights other key staff groups who may need to be informed in the event of a major outbreak.
The outbreak will be managed by a Major Outbreak Control Group (Appendix D).The meeting should occur within three  working days of the notification by the Lead IPC Doctor. A major outbreak may be reported and, if required, the Trust Major Incident plan may need to be followed and the incident investigated as a serious incident (SI). This will be determined by the Major Outbreak Control Group in consultation with Risk Management.