Part 8: Managing Outbreaks of Hospital-acquired Infection

• Introduction
• Survey Responses on Plans for Managing Outbreaks
• Effective Communication During Outbreaks
• Eight Survey Responses on Overseeing the Management of Outbreaks
• Reporting of Outbreaks
• Survey Responses on the Distribution of Reports on Outbreaks

Introduction

8.1
Every hospital needs to establish its “normal” (or baseline) incidence of hospital-acquired infection so that it can identify abnormal levels or outbreaks when they occur. An outbreak may be defined as an increase in the occurrence of a disease by reference to a recorded baseline rate – although, in practice, timely notification of a possible outbreak often relies on the past experience of clinical and laboratory staff, and on them being alert to the condition of individual patients.

8.2
An outbreak may also be identified by cases of infection that are clearly associated (in time and place). Although outbreaks represent only around 10% of cases of infection acquired in hospital, any major increase in cases is evidence that an infection has begun to spread and is beginning to pose a possible serious threat to other patients and staff.

8.3
Hospitals need to have plans to deal with outbreaks of hospital-acquired infection. The infection control committee should be closely involved in drawing up and endorsing these plans. The infection control team must have access to managers and medical and nursing staff who have the authority to take the actions necessary to contain the outbreak.

8.4
In this part we examine how outbreaks are managed. We asked:

• whether hospital services had documented arrangements or plans to deal with outbreaks of hospital-acquired infection;
• whether the infection control committee was consulted and whether it endorsed the plans;
• how often committees were convened specifically to deal with an outbreak during 2000-01;
• whether outbreaks led to the production of a report; and
• whether any such reports gave rise to changes in policies or procedures.

Survey Responses on Plans for Managing Outbreaks

8.5
An outbreak first needs to be recognised. Information related to the event then needs to be gathered and an action plan put in place. All but one hospital service reported that they had documented infection outbreak response arrangements or plans that had been endorsed by the infection control committee.²²¹ Outbreak plans should:

• define what is meant by an outbreak;
• assign responsibility for notifying and investigating a suspected outbreak;
• specify what information should be gathered;
• set out how a team or committee will be formed to control the outbreak, the membership of the team or committee, and the team’s mandate and tasks;
• specify required communications with external agencies; and set out requirements for reporting and follow-up.

8.6
In most hospital services, the infection control team or a specific infection control practitioner was responsible for managing a range of types of outbreak.²²² One hospital service’s plan for the management of infection outbreaks specified in detail the roles and responsibilities of the outbreak committee, managers, and clinical and laboratory staff, and other hospital staff. The plan specified the control measures to be taken, outlined the procedures for convening a committee to manage the outbreak, and defined the committee’s membership and roles.

8.7
Putting strict controls in place is a vital aspect of containing an outbreak. The controls should include rigorous screening of patients, ongoing education, and careful clinical practices. One hospital service that we visited had successfully halted an MRSA outbreak by following its documented control plan while maintaining close monitoring of the course of the outbreak. The steps that staff had taken to contain crossinfections included:

• screening all patients in the ward at the time in order to establish a baseline infection rate;
• screening all new admissions for a two-week period, followed by selective screening of patients most likely to be colonised or infected;
• screening at-risk staff;
• providing additional education for staff; and
• using disinfection agents to help prevent the spread of infection through patient contact.

Effective Communication During Outbreaks

8.8
Communication is a vital part of outbreak management. Above all, staff should be kept informed and made aware of special precautions to be taken.

8.9
Keeping patients informed is also an important aspect of a hospital’s communications strategy, and their co-operation can help contain a threatened or actual outbreak. Patients isolated for infectious conditions need to know about their infection, how it might affect them, and how to stop it spreading. Some hospitals had published helpful brochures for this purpose.

8.10
Keeping the public informed of the management of outbreaks and the prevention and control of hospital-acquired infection can serve a number of useful purposes:

• to assure the public about measures taken to manage risks to patient safety;
• to secure the co-operation of the public in preventing the emergence and spread of infection; and
• to maintain or restore public confidence after notification of an outbreak.

8.11
One hospital service had issued a media release (also available on their web site) to inform the public about the growth in new cases of MRSA-linked infections in hospitals and in the community. The statement outlined measures being taken by the hospital to combat the infection, and sought public co-operation in the responsible and safe use of antibiotics. Such published material can raise awareness, give assurance, and provide practical guidance.

Eight Survey Responses on Overseeing the Management of Outbreaks

8.12
Outbreaks can take weeks – or, in severe cases, months – to bring under control. MRSA outbreaks can occur in several wards at the same time and become established.

8.13
In these circumstances, having a committee to oversee the management of the outbreak can provide continuity and strengthen oversight. The committee may need to remain in place for some time or to re-convene to deal with subsequent events. Our survey responses suggested that oversight by the infection control committee or a subcommittee plays an important part in managing an outbreak – most respondents had convened at least one committee to help manage an outbreak at some time during 2000-01.²²³

Reporting of Outbreaks

8.14
Providing reports on outbreaks can help to identify important lessons for future infection control practices – prompting review of practices and giving rise to recommendations and action plans to address identified concerns.

8.15
Investigations commonly show where and how infection risks can be better managed – pointing to improvements that can potentially enhance the safety of staff and patients. One hospital ward had proposed wide-ranging measures to prevent the recurrence of an infection outbreak – encompassing the cleaning regime, education on use and cleaning of nebulisers, restrictions on antibiotic prescribing, and the application of contact precautions within the ward.

8.16
Outbreaks and their management affect all parts of a hospital. Changes in policies or procedures arising from reports of outbreak investigations may include aspects of hospital practice relevant to many different wards, units, and functions throughout the organisation, including:

• hand hygiene;
• bed management policy and/or practices;
• patient screening;
• intravenous procedures;
• means of notifying staff of an outbreak; and
• use of isolation facilities.

8.17
One hospital service sent us a report that followed the progress of an MRSA outbreak from March to December 2001. During this period, 49 patients with MRSA were isolated for extended periods of time.

8.18
Although policies and procedures were in place to manage the MRSA outbreak, a number of factors had contributed to the difficulties of managing the outbreak, such as:

• patients being admitted with the infection;
• a shortage of beds and overcrowding due to a large number of patients with winter-related illnesses, resulting in patient transfers between wards that increased the risk of spreading the infection;
• a shortage of regular nurses and (therefore) an unusually high number of casual staff and staff movements around hospital wards, creating additional risks of the infection spreading;
• a shortage of designated equipment for isolation rooms;
• inadequate facilities for isolating patients;
• poor cleaning standards;
• a shortage of toilets and showers; and
• toilets and showers with surfaces that were difficult to decontaminate.

8.19
The report made wide-ranging recommendations in relation to:

• staff education;
• auditing of hand hygiene;
• numbers of nursing staff;
• supervision of patient transfers;
• establishment of additional isolation facilities;
• faster implementation of actions to contain an identified outbreak; and
• improved cleaning standards.

Survey Responses on the Distribution of Reports on Outbreaks

8.20
Responsibility for responding to the lessons from infection outbreaks rests with a variety of managers throughout the hospital. Reports on the management of outbreaks should be distributed widely to ensure hospital-wide action to prevent and control infection and minimise future risks.

8.21
Not all relevant managers were receiving copies of outbreak reports²²⁴:

• the General Manager in 14 hospital services received outbreak reports;
• quality or risk managers in 13 received the reports; and
• • key clinical leaders – the Medical Director and the Director of Nursing – received the reports in only 11 and 13 hospital services respectively.

Conclusions

8.22
Nearly all hospital services had documented arrangements or plans to deal with outbreaks of infection, and used the infection control committee to oversee responses to outbreaks.

8.23
Reports that review how well outbreaks were handled can contain important lessons for the management of future outbreaks. Some hospital services were not making such reports widely available to those in the hospital charged with taking action on issues raised in the reports.

221: F3.3: Q36 – in one hospital service the plan had been discussed by the committee but had not been formally endorsed.

222: F3.3: Q38.

223: F3.3: Q37.

224: F3.3: Q40.