Infection Preventionist Starter Kit: Outbreak Management

Develop an outbreak management plan in collaboration with your facility’s medical director. Regularly revisit and update the plan as the situation changes or new information becomes available. It’s essential to clearly communicate and educate staff and partners on the outbreak management plan.

Plan components

• Facility wide outbreak policies and procedures: Including how you will detect an outbreak, who will be notified of the outbreak, and what measures will be taken to mitigate the spread through the facility.
• Employee immunity or vaccination policies and procedures: Including which vaccines are required, where employees can receive their vaccinations, and whether immune status of employees must be determined. Review CDC (Centers for Disease Control and Prevention) resource on vaccination recommendations for adults and health care personnel.
• Employee illness policies and procedures: Including when employees should stay home dependent upon illness or symptoms, when an employee should return to work dependent upon illness or symptoms, and a culture that encourages employees to remain home when ill. 

 IP tip: Conduct outbreak investigations in a standardized way each time. 

You may consider an outbreak when you observe an increase over the expected occurrence of an event. Confirm the presence of the outbreak through review of medical records and facility illness logs to determine if multiple similar illnesses have occurred that may be related to each other.

Notification

• Notify the facility’s medical director. It’s important to first notify the facility’s medical director any time you suspect an outbreak.
• Notify additional individuals within your organization. Include administration, staff, employee or occupational health, risk management, and communications or public affairs. Wisconsin statutes also require notification of the local or Tribal health department (LTHD).

 IP tip: While additional information is being collected and notifications are being made, implement control measures as appropriate based on the pathogen’s likely mode of transmission or clinical syndrome.

Reasons for outbreaks are often multifactorial, but common factors include lapses in infection prevention practices, contaminated equipment, unrecognized colonized or infected individuals, delays in initiation of isolation precautions, or sick employees at work.

Considerations for conducting outbreak investigations

• Determine the mode of transmission, incubation period, contributing factors, and appropriate control measures.
• Develop a case definition and identify additional cases by reviewing labs results, reasons for admission, current illnesses, and staff sick calls or absences. Revise the definition as new information is available.
• Communicate with staff about the importance of identifying and reporting any new illnesses among patients, residents, volunteers, visitors, or staff. Ensure it is clear what signs or symptoms should trigger an alert and who should receive the report.
• Maintain a line list or spreadsheet of ill individuals throughout the outbreak. A line list template (Excel) is available from the CDC. The line list should include information that allows you to track the course of the outbreak. Typical data points to include are demographics, unit, date of admission, date of symptom onset or diagnosis, diagnosis or pathogen identified, signs and symptoms, and risk factors. Ideally, make an epidemic curve based on how many individuals became ill each day to assess the trend.

Use these strategies to help control outbreaks:

• Implement transmission-based precautions (TBP), also referred to as isolation precautions, based on the pathogen or clinical picture. Refer to the CDC’s Appendix A to determine the type and duration of isolation by pathogen or condition. Reminder: Enhanced barrier precautions (EBPs) should be utilized in nursing homes for those colonized or infected with an MDRO and those with indwelling medical devices and chronic wounds, regardless of multidrug-resistant organism status in the facility. Learn more about EBPs by visiting the DHS precautions webpage.
• Avoid transferring patients or residents from an affected area to another unit, wing, floor, or facility if not needed. If movement within your facility or to another facility is needed, notify the receiving unit or facility of the outbreak situation. Determine whether other restrictions, such as cohorting, within your facility are appropriate.
• Review personal protective equipment (PPE) requirements for staff and visitors.
• Review cleaning and disinfection procedures and required frequency for the patient or resident room and equipment.
• Ensure strict hand hygiene is followed prior to and after patient or resident contact. For some pathogens, such as norovirus, only traditional soap and water should be used, as alcohol-based hand rub (ABHR) may not be effective.
• Work with employee health to ensure ill employees are assessed and appropriate restrictions are in place, requirements for returning to work are prepared, and if appropriate, prophylactic medications are obtained.
• Consider whether additional measures need to be taken by facilities such as construction containment, air handling verification, and pressure management.
• Determine if environmental sampling or patient screening would be beneficial. This is never the first step and should not be done on every outbreak. It’s a good idea to consult with your regional IP prior to initiating this step.

Use these strategies to prevent future outbreaks:

• Provide education for staff, patients or residents, visitors, and providers. Modify messages based on what they need to know.
• Audit compliance of prevention efforts to seek employee insight into potential underlying causes. Do not assign blame. Instead ask to observe procedures and variations and clarify challenges to good techniques.
• Continue to monitor for new cases occurring outside the incubation period. This is an indication that the current measures are ineffective and additional steps are needed to control the event.
• Provide regular updates on the effectiveness of the control measures. After the event has passed, present a final report to your IP committee to determine the effectiveness of measures and if further education or auditing is needed to prevent future occurrences.

• Wis. Stat. ch. DHS 145: Control of Communicable Diseases and Reporting Appendix A: Reportable Conditions
• Wis. Stat. ch. 252: Communicable Disease
• Wis. Admin. Code ch. DHS SPS 332.15

• Interim Guidance for Influenza Outbreak Management in LTC and Post-Acute Care Facilities
• Seasonal and Pandemic Influenza Resources for Health Care Professionals
• Steps for Evaluating an Infection Control Breach
• Recommendations for Prevention and Control of Acute Gastroenteritis Outbreaks in Wisconsin LTC Facilities (P-00653), (PDF)
• Preventing and Controlling Respiratory Illness Outbreaks in Long-Term Care Facilities

Reference and use the following observational and assessment tools as applicable in your facility.

• Current Known Wide Impact Outbreaks in Wisconsin, DHS
• Local Public Health Contact Information, DHS
• Standard Precautions Observation Tools, CDC (PDF)
• Transmission-Based Precautions Observation Tools, CDC (PDF)