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OuTbReAk !!!!. Are you prepared? It could happen to any of us!. Always, its 4:45 on Friday before you are going out of town, and the phone rings. The nurse realized that the patient that came in the ER this afternoon had a similar rash to the two people walking in the door right now.
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OuTbReAk!!!! Are you prepared? It could happen to any of us!
Always, its 4:45 on Friday before you are going out of town, and the phone rings. The nurse realized that the patient that came in the ER this afternoon had a similar rash to the two people walking in the door right now.
Goal of the Outbreak Investigation • To identify the source of illness • To prevent the spread of infection in the public setting • To cause an intervention that will stop the spread of the illness • Reduce the threat to patient safety
What do you do first? The first thing you need to do is to confirm and/or verify the outbreak Outbreaks are when you have an increased incidence of a disease or symptom above the expected rate (or more commonly than your normal surveillance) for your population for the given time. This could be due to lapses in Infection Prevention practices, environmental effects, specific pathogens, or recognition of an unusual microbe, pathogen, or adverse event.
Not everything is an Outbreak! • You might hear a bunch of patients on the same wing have a severe respiratory illness, Yet you find one person has Influenza, another has respiratory allergies, and another one has bronchitis and all of these are unrelated to each other. This scenario is not an outbreak. • Several patients have abdominal pain and diarrhea, yet one tests positive for Salmonella and another one tests positive for Campylobacter, this is not an outbreak.
How to Confirm or Verify the Outbreak • Laboratory confirmed testing is not necessary. • Small outbreaks are referred to as clusters. • Surveillance helps you to know the expected disease rates, so levels far increasing this are indicative of an outbreak. • Most outbreaks are noted in areas that are not under direct surveillance, so your other healthcare personnel will tip you off. Encourage their observance and invite them to bring concerns to you. It takes a TEAM.
Verifying Diagnosis • Identify the Person, Date, Time and Place that the symptom occurred. Try to identify the exposure. • Look back to see if they were around other people, places, or animals that could have exposed them. • Also ask what foods they ate. • Rule out any misdiagnoses or testing error. A negative lab result can only mean it was not in the system at the time the sample was collected, but doesn’t necessarily mean that it wasn’t there.
Involve Administration and Staff • Administration will dictate what information can be given to the public, and what is to be told to patients and visitors. They also may make decisions on supplies or get you help if you need extra support can help you with supplies and support and help if you need it. • Informed staff are likely to help you with information gathering and will do better with their Infection Prevention behaviors. • Staff will be aware for their own health, and if they do find themselves sick encourage them to stay home but to report time and onset of symptoms to Employee Health staff for data.
Information Gathering • Patients might leave the facility, so its is important to gather as much information as you can, and get a contact number so you can ask further questions. • Begin a line list. Note the dates, signs and symptoms, patient information, Hospital rooms if they are inpatients, what food they ate, who visited them, anything you can think of. This may assist you in establishing an incubation period.
What’s in a Line List? • Patient Demographics ( Name, Medical Record Number, Age, Sex, Diagnosis, Unit on, Date of Admission, date of symptom onset) • Risk Factors (comorbidities, exposures, catheters, tubes, surgical history, Antibiotics, etc). • List symptoms and note if they had them daily for until well after the symptoms are gone. Note date and symptoms especially on dates testing is taken.
Hypothesis • Note signs and symptoms; Fever, headache, nausea, vomiting, hypertension, diarrhea, etc. • Definitions of what the potential disease is and note who does and doesn’t have symptoms. Review Literature and familiarize yourself with the information. • If a patient improves and does not have the symptom keep surveillance on them • Establish a preliminary case definition.
Initial Investigation • Expect to refine your case definition. • Not all involved in the Outbreak will have the same symptoms. Cohort those that do. • Interview your case patients to find out if they had any common exposures, activities, interactions, had been to common places at close time intervals, ate similar foods, etc. • Don’t wait for tests to come back before intervention is planned and initiated.
Infection Control Measures • Staff to heighten awareness, PPE use, hand hygiene, and concentration on surface sanitizing. You may decide to use ramped up PPE. • May need to limit visitors for hospitalized patients. • Is airflow a concern for this Outbreak? Maintenance may be involved. • May decide to close down the cafeteria or cancel public meetings held in your buildings. • May restrict visitation from a certain wing, or limit walkways.
Additional Measures • Administration may decide to put the facility in lockdown. • During the Swine Flu outbreak the CDC recommended that N95 masks were to be used, yet so many were used they were on backorder. Some had to Reuse them or use alternates. • Legionella outbreak in the water system – at times the Memorandums Of Understanding for your Emergency Preparedness can come in handy to supply drinking water, etc.
Involve your Local Health Jurisdiction • Have the health officer suggest how long to isolate or restrict patients from visitors. This may be extended beyond normal time required to stay at home. • Have them suggest when Health Care Workers can return to work (may choose extended time without symptoms). • They may want to help investigate or offer some assistance.
WAC 246-101-305 (1)Health Care Facilities shall: (a)Notify the local Health Department where the patient resides regarding (iv) Outbreaks or suspected outbreaks of disease that occur or are treated in the health care facility including, but not limited to suspected or confirmed outbreaks of varicella, influenza, viral meningitis, healthcare associated infection suspected due to contaminated products or devices or environmentally related disease.
On and On….. • Surveillance should continue well after the Outbreak has seemed to be concluded. There may be a resurgence or an isolated case later. • Do not remove the implemented IC measures right away so you have time to be sure it won’t reoccur. • Be able to report the numbers of patients as well as staff (if any) that were affected by the outbreak.
Lessons Learned • Its important to keep open communication with your Administration, Managers, and Staff. • Noting successes and things you don’t want to do again next time will be great feedback to share. • Patient safety can be improved by retrospective reviews of the scenario.
Mini Preparations for Pandemic? A speaker at one of the past WSHA Safe Table Learning Collaborative once likened any patient in Precautions or an Outbreak Intervention choice as a “drill” and “practice” for when the Pandemic comes. Do we look at this as a preparation for something bigger down the road?
Cholera epidemic in London • 1854, Soho, London. 600 people died within a quarter mile of each other over just a few days • Humans succumb to Cholera in a matter of days from diarrhea, bloody stools, and dehydration. • At the time it was thought this was airborne, yet Dr. John Snow realized it had already infected the gut before the people felt sick, so he felt it was ingested.
Investigation • During this massive illness he decided he was going to get to the bottom of this. • Through interviews he figured the common factor for ingestion was water. • The popular pump on Broad Street was accessed by many people who lived in the surrounding area. • Nearby workhouse had over 500 inmates and had only 5 deaths so when he conducted an interview to see why they were different he found the workers said they wouldn’t drink water because the workers only drank beer.
Discovery • John Snow followed the cases of death in the area, and identified some travelers came through and collected water from the Broad Street pump and traveled back home, where they died within days. • He went to told his theory, authorities had the had the pump handle removed, and slowly the deaths stopped. Later they found a sewer pipe ran very close to the water table 20 feet underground and leaked. • This was the beginning of the end of the Cholera epidemic in Britain, and an important icon for Public Health and investigation not known as well as Semmelweiss
A Little Recognition • John Snow went on to serve Queen Victoria as her chief Anesthesiologist, being the first to administer anesthetic to a Queen by giving her Chloroform for the birth of two of her children. • He died in 1858, a mere 4 years after he discovered the contaminated water source
What might you have to add? Would any IP’s like to share any suggestions that were helpful to them, or add any experiences they may have experienced? Please feel free to unmute and share for our new IP’s
Thank You So Much!! Tara Dockery RHQN TaraD@WSHA.org 509-760-7397
