PURPOSE:To standardize the action steps needed (a) if an outbreak of healthcare-associated infections (HAIs) or adverse events occur that are above the background rate or (b) when an unusual microbe or adverse event is recognized.The goal of any outbreak investigation is to identify probable contributing factors and to stop or reduce the risk for future occurrences.
Healthcare-associated outbreaks are often multifactorial and may be associated with:
- Lapses in infection prevention or clinical practices
- Contaminated or defective products or devices
- Colonized or infected healthcare personnel
- Patients or visitors who have, or are harboring, an infectious disease
In ambulatory care settings, post-discharge surveillance is critical to identify clusters of infections or outbreaks.
POLICY:
DEFINITION
An outbreak is defined as two or more cases over the usual (i.e., endemic) number of cases of healthcare-associated infections, usually produced by the same organism;however, a single case of an unusual organism(e.g., postsurgical Group AStreptococcus infection) may constitute an outbreak.
RECOGNITION OF A SUSPECTED OUTBREAK AND NOTIFICATION
Most outbreaks are recognized by observant healthcare personnel and infection preventionists. Any personnel who becomes aware of a possible outbreak or cluster of infections will immediately report this to their manager and the designatedinfection preventionist.The ASC medical director and the ASC administrator should also be notified.An outbreak investigation team should be identified and an investigative team leader identified.
INITIAL INVESTIGATION
Outbreaks generally do not unfold in a linear or orderly manner. Thus, not all of the actions described below will be applicable to all situations and many of the steps may occur simultaneously.The investigative team shall do the following:
- Confirm the presence of an outbreak, which might include laboratory confirmation.The lab may need to be instructedto save isolates of the involved organism(s) for further study (e.g., antimicrobial sensitivity typing, phage typing, serotyping, etc.)
- Alert key partners about the investigation, which might include the notification of appropriate state and local entities
- Perform a scientific literature review
- Determine if immediate control measures are needed and implement accordingly
- Establish a preliminary working case definition which may be refined during the investigation
- Develop a methodology for case finding, which might include a review of the charts, lab results, information obtained from medical providers and or involved patients or families; survey for additional cases linked to the outbreak and for the onset of new cases
- Prepare an initial line list and epidemic curve (case number by date of onset);include patient, operating room number, date and type of procedure, date of infection onset, site culture results, surgeon, and any other pertinent information
- Observe and review potentially implicated patient care activities, such as hand hygiene, surgical scrub preparation, re-useable instrument/equipment reprocessing, etc.
- Consider whether environmental sampling or additional facility testing (e.g., operating/procedure room air changes and air flow) should be performed
- The presumptive hypotheses for the mode of transmission of the organism and other circumstances will be developed;procedures for testing the hypotheses will be outlined
- If necessary, refine the case definition, continue case finding and surveillance, and refine control/prevention measures to prevent further or future illness
- If the cause of the infection is not evident as a result of the above investigation, seek expert consultation
- Consider whether an analytical study, such as a cohort or case control study, should be performed
COMMUNICATION DURING AND AFTER AN OUTBREAK
The investigative team leader will ensure that the medical director, attending physicians, facility administrator, nursing administrator, facility risk management,public relations representative,healthcare personnel, and others as needed will be kept abreast of developments and findings and should be queried regularly on any additional thoughts or insight they might have.Decisions about whether to notify patients about an outbreak must be made on a case-by-case basis.Decisions regarding personnel cultures, work restrictions, or the impounding or quarantine of patient care items should be carefully vetted and communicated.
CONCLUSION OF INVESTIGATION
The investigation is continued at least as long as there are cases of the infection occurring above the endemic level.A final written report of the investigation that outlines findings and recommendations should be prepared by the investigation team. The report should be presented to the committee charged with overseeing the infection prevention program, all attending physicians, and healthcare team.
REFERENCES
Association for Professionals in Infection Control and Epidemiology, Inc. (2009).APIC Text of Infection Control and Epidemiology, 3rd Edition.
Bennett, G. & Kassai, M. (2011).Infection Prevention Manual for Ambulatory Surgery Centers. ICP Associates: Rome, Georgia.
DISCLAIMER: All data and information provided by the Oregon Patient Safety Commission is for informational purposes only. The Oregon Patient Safety Commission makes no representations that the patient safety recommendations will protect you from litigation or regulatory action if the recommendations are followed.The Oregon Patient Safety Commission is not liable for any errors, omissions, losses, injuries, or damages arising from the use of these recommendations.
2.07 OUTBREAK IDENTIFICATION & MANAGEMENT POLICY 1