Download Influenza Outbreak Control Measure Trigger Tool for Hospitals

Influenza Outbreak Control Measure Trigger Tool
for Hospitals
(this Trigger Tool is not suitable for the control of MERS CoV or Avian influenza)
The control measures in this tool include:
Standard Infection Control Precautions (SICPs) and
Transmission Based Precautions (TBPs)
Influenza type (if known)
Hospital ward/Clinical Area
Date Trigger Tool Commenced
Date Trigger Tool Stopped
Person stopping the Trigger
This trigger tool should be commenced when two or more confirmed or suspected cases of
influenza are identified within the same ward/clinical area.
Health Protection Scotland
Version 1.0 September 2015
Influenza Outbreak Control Measure Trigger Tool for Hospitals
This Influenza Outbreak Trigger Tool is designed for the control of influenza outbreaks in hospitals and
should be used when there is evidence of ongoing transmission in the healthcare facility (or the potential for
nosocomial transmission).
The Influenza Outbreak Trigger Tool comprises:

Roles and Responsibilities Table.

An assessment to determine if the trigger presents a risk.

A Key Information sheet.

A checklist of everything that needs done at Day 0 (when the trigger is recognised).

A daily checklist for every day until the outbreak stops being a risk to people.

General information on A) respiratory hygiene and B) transferring patients to care homes.
Roles and Responsibilities for assessment of HAI cases of influenza
Senior Charge

Nurse
Ensure implementation of this trigger tool and ongoing compliance with Standard
Infection Control Precautions (SICPs) and Transmission Based Precautions
(TBPs); Contact/Droplet Precautions.
(Ward Manager)

Recognise and report to the IPCT any clinical conditions which could indicate a
person has acquired influenza while in hospital.
Clinicians

Work with the IPCT in completing the daily assessments.

Report using Risk Management Reporting systems as locally required.

Recognise and report to the IPCT any patients who may have influenza.

Ensure samples are taken as appropriate and treatment started as per guidance

Confirm that the clinical care of patients is compliant with local/national guidance.

Report to IPCT directly if they have concerns regarding infection prevention and
control.

Where local/national policy cannot be implemented, there is a robust risk
assessment in place which is reviewed daily and as circumstances change .
Infection

Prevention &
Determine whether this Influenza Outbreak Trigger Tool is required by using the
assessment overleaf.
Control Team

Ensure the listed control measures in this tool are being applied.
(IPCT)

Consider the need for additional control measures if transmission continues.

Ensure that actions required after a HIIAT assessment are in place.

Complete documentation for HPS/SGHD as required.

Communicate to relevant staff, internal and external if outbreak is confirmed.

Ensure the ward team has the resources to provide a safe patient environment
General
Manager/Delegated
Responsible
Person
and safe patient care.

Communicate to appropriate staff and management team.
Further information on Standard Infection Control Precautions and Transmission Based Precautions
can be found in the National Infection Prevention and Control Manual
http://www.hps.scot.nhs.uk/haiic/ic/publicationsdetail.aspx?id=49785
Acronyms ‘LD’ indicates a local decision for the control measure is required.
HPS. Version 1.0. September: 2015
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Influenza Outbreak Control Measure Trigger Tool for Hospitals
Date: ……/……/….
Initial Assessment
(the date the trigger was identified)
Assessment to determine if this Influenza Control Measure Trigger Tool is required.
Section to be completed by the IPCT.

The assessment should consider the time period from the onset of the first patient’s
symptoms/admission date if hospital acquired.

There is no requirement to follow-up discharged patients.

Influenza period of infectivity: 1 day before to 7 days after becoming sick

Influenza incubation period: Average 48 hours range 1-4 days
 Read the Case Definitions and then count the cases.
Today, how many patients on this ward are confirmed to have influenza and are
symptomatic?
Today, how many other patients are asymptomatic but are known to have tested
positive for influenza? (includes recovered cases)
How many of the above patients have acquired influenza in this care setting?
How many patients have influenza like symptoms (see Relevant Symptoms page 4)
but are awaiting confirmation?
Today, how many staff have an influenza like illness or are known to be infected with
influenza?
Have any patients in the past 30 days died of, or with, hospital acquired influenza?
Is there evidence of, or a risk of, influenza cross-transmission in this ward?
See case definitions overleaf.
What is the Hospital Infection Incident Assessment Tool (HIIAT) for this incident?
Red
Inform HPS if HIIAT Red or Amber.
Amber
N.B Contact HPS by phone: 0141 300 1175: Out of hours 0141 300 1100
Green
Email: [email protected] (HPS will inform SGHSCD)
Who is the lead IPCT member for this trigger?
Who is the Senior Charge Nurse/Ward Manager for the ward?
Is the Trigger confirmed as real?
Yes
or
If there is no evidence of ongoing influenza transmission/risk STOP here and
Signature:
No
sign to say that this Trigger is not real.
If the Trigger is real complete: The Key Information Sheet, Day 0 Actions Checklist. Complete a Daily
Actions Checklist every day thereafter until the Trigger is considered resolved.
If the Trigger is not real: keep this sheet as a record of decision making.
HPS. Version 1.0. September: 2015
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Influenza Outbreak Control Measure Trigger Tool for Hospitals
Day 0 Actions
Key Information Sheet
The IPCT: will adapt this sheet to provide key information on the outbreak to the clinical team
‘LD’ indicates a local decision for the control measure is required.
Case Definitions:
A Case
Any patient who has/has had an influenza like illness and has tested positive for
influenza in [clinical area
] since [time period
]
Asymptomatic
case
Any patient who is asymptomatic but has tested positive for influenza in [clinical area
since [time period ]
(Time period is 24 hours before first case).
A possible case
Any patient with an influenza like illness whose test results are awaited.
A staff case
Any member of staff or student off with influenza like illness whether or not laboratory
confirmed
Hospital
Acquired
Any case whose symptoms developed >48 hours after admission
Relevant signs/symptoms that could indicate patients may have/be developing influenza
Rhinorrhoea (runny nose)
Sore throat
Myalgia (muscle aches)
Nausea/vomiting
Pyrexia > 37.50C
Productive cough
Lethargy
Breathing difficulty
Joint pains
Headache
Advocated treatment regimen for confirmed cases: The following link is to the guidance for influenza
prophylaxis and treatment: http://www.hps.scot.nhs.uk/resp/guidelinedetail.aspx?id=53562
Modes of transmission for influenza
Droplets: Disseminated via the respiratory tract during coughing, sneezing etc., usually within 1 metre.
Contact (direct/indirect): Infectious particles disseminated during coughing/sneezing can land on surfaces
and subsequently be transmitted via gloved (and un-gloved hands) to infect patients and/or staff.
High-Contamination Procedures: (procedures which are likely to result in contamination of the
environment).
High-Contamination
Procedures
State any procedure modifications needed to reduce risk
Aerosol generating
procedures (AGPs)
Follow guidance in the National Infection Prevention and Control Manual.
AGPs Include: Intubation, extubation, cardiopulmonary resuscitation,
bronchoscopy, surgery and post mortem procedures in which high-speed devices
are used, some dental procedures (e.g. drilling), Non Invasive Ventilation (NIV),
High Frequency Oscillatory Ventilation (HFOV), induction of sputum.
Admission Restrictions (Patient):
Do not admit to ward:
LD
Do not admit to bay number(s):
LD
No restrictions
LD
Consider temporary suspension
of visiting.
Criteria to discontinue isolation and droplet precautions of a case
When the patient is asymptomatic and no longer considered infectious by resolving symptoms and 5 days
post onset of symptoms. Immunocompromised patients will be infectious for long periods therefore discuss
with the ICD before discontinuing isolation.
Day 0 Actions Checklist
HPS. Version 1.0. September: 2015
Date: …………/………./………. (the date the trigger was identified)
page 4 of 9
]
Influenza Outbreak Control Measure Trigger Tool for Hospitals
Initial Control Measures
LD = Local IPCT decision required
Patients Placement:
Initial

Isolate/cohort case patient(s) case(s)

Risk Assessment must be in place for failure to isolate/cohort case patient(s)

In cohort areas: Patients to be separated by minimum 1 metre & privacy screens to be drawn

Close doors to isolation cohort areas (undertake safety risk assessment for door closure).

Place signage on entry to isolation/cohort areas indicating admission restrictions and that
SICPs and TBPs/ are in place.

Check that the patients readmitted within 4 days of discharge are asymptomatic preplacement.
Admission Restrictions

Close the ward or bay if instructed by the IPCT.
LD

Consider Temporary Suspension of Visiting if considered beneficial to gaining control/or to
reduce visitor risks. Offer the same PPE worn by HCWs.
LD
Transfer and Discharge Restrictions

Avoid unnecessary intra-hospital transfer of symptomatic and asymptomatic patients
from closed and open areas. If clinically necessary, confirm with receiving area they are
prepared to accommodate the patient. Inform the IPCT of any transfers.

Avoid inter-hospital transfer to other healthcare facilities of symptomatic and
asymptomatic patients unless advised/agreed by IPCT and clinical receiving unit. If possible
symptomatic patients to wear surgical mask during transfer. Inform the IPCT if transfers.

Discharge patients to their home if safe to do so. (Ensure patients/relatives/GPs are aware
of signs/symptoms to report and any actions they should take).

Asymptomatic patients may attend for essential treatment or therapy out of the ward but
they should not mix with patients from non affected wards.
Healthcare worker (HCW) Practices and Restrictions

Ensure that all staff on duty are asymptomatic (See: Relevant Symptoms).

Refer symptomatic staff to GP or Occupational Health for assessment and prior to return if
having ongoing symptoms.

Exclude staff from work until resolution of temperature for at least 24hrs (without the use of
antipyretics).

Further consideration must be taken for temporary reassignment or exclusion from work for 7
days from symptom onset or until resolution of symptoms, whichever is longer if returning to
care for patients in high risk clinical environments e.g. stem cell transplant patients.

If possible allocate staff to care for cases or, non-cases for the duration of the incident.

Reiterate to all members of the healthcare team including, phlebotomists, physiotherapists,
occupational therapists that SICPs/TBPs/ must be practiced.
Patient Care Checks (Cases and non-cases)



Ensure patients have had their clinical condition reviewed today and if clinically indicated,
been referred to a specialist for their infection condition, e.g. microbiologist, infectious disease
physician, respiratory physician.
Ensure patients are receiving antiviral therapy treatment or prophylaxis as recommended
http://www.hps.scot.nhs.uk/resp/guidelinedetail.aspx?id=53562
Medical staff/microbiologist to consider vaccination for unvaccinated patients (and staff). This
may help should further incidents arise.
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Influenza Outbreak Control Measure Trigger Tool for Hospitals
Day 0 Actions Checklist cont.
Hand Hygiene (HH) and Personal Protective Equipment (PPE)

As per WHO 5 moments use Alcohol Based Hand Rub (ABHR) if hands clean, otherwise
wash with liquid soap and water.

HH before PPE (apron [gown] and/or gloves); PPE before entering area; PPE off before
leaving area, HH after PPE removed.
Wear a surgical face mask [IIR compliant with EN14683] if within a minimum distance of
approximately 1 metre of a suspect case/entry to a confirmed case’s room.
If carrying out Aerosol Generating Procedures, FFP3 respirator must be worn. Must be
removed be removed in a safe area (eg outside the isolation/cohort area)


Safe Patient Environment

Assess the risk of possible airborne dissemination of organisms. To reduce contamination,
remove fans or other equipment that could exacerbate any environmental contamination.

De-clutter the ward and the clinical environment.

Decontaminate all hand contact surfaces with 1000 ppm av cl., that may have been
contaminated by patients with influenza before they were segregated.

Terminal Clean bed space post patient discharge or transfer with 1000ppm av cl.
Patient Care Equipment

Decontaminate all communal patient equipment with 1000 ppm av cl (or the manufacturers
recommended solution) after use, between patients and prior to removal of any equipment
from the isolation/cohort area. Commence daily cleaning with 1000 ppm av cl.

Provide patient-dedicated care equipment for isolation/cohort areas (thermometers/
commodes/washbowls/blood pressure equipment/lifting-equipment, stethoscopes etc).

If single patient allocation of certain equipment cannot be achieved, ensure all patient
care equipment is cleaned and decontaminated after use.


Communications and Knowledge Management by the IPCT and or Clinical team
Inform all members of staff on the ward (including domestic staff) of the situation, how
influenza spreads in the ward environment and what they need to do to further reduce risk to
patients, themselves and co-workers. Advise them of their part in monitoring for deterioration in
the situation, e.g. changes in cleaning frequencies and the need to add disinfectants to routine
cleaning regimens.
Staff Knowledge of appropriate PPE, putting on and removing PPE

Ask all members of the clinical team to consider their practice and identify any actions or
inactions that could have contributed to the increased number of patients with this alert
organism, and discuss this with the clinical leads or the IPCT.

All members of the clinical team know what to do should they develop any relevant
symptoms, i.e. do not come on duty if symptomatic. Seek advice from GP or Occupational
Health as necessary.

Inform patients/parents/relatives of the situation, precautions/restrictions and risks
(document in the case notes/nursing notes) Provide information leaflets.

Inform the wider management of the Trigger and the HIIAT assessment:
o All Consultants with patients on the ward; Antibiotic pharmacist; HAI Executive Lead;
Entire IPCT; Local Management as specified in Local Governance Reporting Procedure
e.g. Risk Manager, Bed Manager, General Manager, Communication Representative and
Health Protection Team
o HPS (HPS will liaise with Scottish Government if HIIAT is Amber or Red).
o HPS HAI will inform HPS flu team who will inform HPT at SGHD if required
o IPCT to complete HAI-ORT if amber or red
o IPCT to be responsible for ensuring completion of HPS flu team information
Microbiological

Take specimens from any patient who develops any of the symptoms/signs indicated as per
local influenza testing arrangements Inform IPCT.
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Influenza Outbreak Control Measure Trigger Tool for Hospitals
Daily Actions Checklist: Day__ Date: …/…/…. (the date the trigger was identified)
Daily Outbreak Checklist for IPCT & Nurse in Charge complete daily until outbreak is resolved
Date (dd/mm/yy)
Completed by (initials)
Total number of patients on the ward today
New laboratory confirmed influenza cases today
New symptomatic patients today (influenza like illness) who may be cases and awaiting lab tests
Total confirmed and symptomatic cases on the ward today
Total number of patients on prophylaxis
Are any patients giving cause for concern due to outbreak organism/infection?
New symptomatic staff today
Total number of staff off with influenza like illness today
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Patients Placement: Isolation/cohort procedures are effectively established.
Patients Placement: Doors to isolation/cohort areas closed and signage is clear.
Admission Restrictions: Are complied with, includes previously positive checks pre-placement.
Transfer Restrictions: Transfer only if clinically indicated. Inter-care facility transfers if pre-agreed with
IPCT and receiving units. Intra-hospital transfers receiving area is infection prepared. Patient to wear
surgical mask.
Patient care checks: Clinical assessments are completed for today.
Patient care checks: Treatment and prophylaxis for influenza infections is as per the guidance.
Patient care checks: Prophylaxis for influenza infections is administered as per the guidance.
Patient care checks: High-contamination procedures are modified to reduce contamination.
Microbiological screening of people: Test all new symptomatic patients for influenza.
HCW practices/restrictions: Staff on duty are asymptomatic.
HCW practices/restrictions: Sufficient staff are on duty for all areas.
HCW practices/restrictions: Where possible staff are allocated to isolation area or non-isolation area.
HH and PPE: HH is with ABHR if hands clean otherwise with liquid soap and water as per WHO 5
moments. HH before PPE; PPE before entry to area; PPE removed before exit; HH after PPE removed
(surgical mask if within a minimum distance of approximately 1 metre of the patient area).
Safe Patient Environment (SPE): All areas are clutter free.
SPE: Cleaning of isolation areas is established with 1000 ppm av cl.
SPE: Increase frequency of cleaning of frequently touched sites with 1000 ppm av cl throughout.
SPE: There are sufficient supplies of PPE and other sundries for safe practice; FFP3 respirator for
AGPs
SPE: Following patient discharge or transfer, terminal cleaning is carried out with1000ppm av cl
Equipment: All ward equipment is visibly clean and ready for use condition.
COMPLETE OTHER SIDE
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Y/N
Influenza Outbreak Control Measure Trigger Tool for Hospitals
Date (dd/mm/yy)
Equipment: There is sufficient dedicated equipment available in isolation/cohort areas.
Prevention: Consider offering vaccination to vulnerable people.
Treatment: Ensure people are receiving antiviral therapy in line with the guidance.
Treatment: Ensure there are sufficient antiviral stocks on the ward.
Knowledge Management: HCWs know how the organism spreads, and how to practice safely.
Knowledge Management: Patients/relatives/GPs know the situation and what precautions to take
(includes patients being discharged).
Knowledge Management: For discharged patients, GPs are being informed by those discharging the
patient any additional ongoing monitoring needed and, any actions should symptoms develop post
discharge.
IPCT to advise on ward status (open/closed) and patients placement
HIIAT assessment today: Red/Amber/Green
IPCT to advise if daily actions checklist still required
If daily actions checklist no longer required – book terminal clean
IPCT to confirm if re-opening criteria have been met
Communicate all changes to email group
Criteria to reopen the ward will vary depending on the patient population (immunocompromised /
degree of infectivity) and layout of the ward (ability to isolate symptomatic patients). As a
minimum there should be:
 No new symptomatic cases for a period of 48 hours.
 Existing confirmed cases should be isolated/cohorted and symptoms should be resolving
 There should be sufficient staff to enable the ward to be reopened.
Control measures and trigger tool no longer required for clinical area/ward
Date: _____________________________________
IPCT Signature: ______________________________________________
Date: _____________________________________
SCN Signature: ______________________________________________
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Influenza Outbreak Control Measure Trigger Tool for Hospitals
General Information
o
The control measures in this tool are specific for influenza; however NHS Boards can localise this document as required for better staff understanding / compliance.
E.g. local designation names, and logos may also be used. As a consequence this document is available in word format.
o
The choice of gowns or aprons for PPE is a local decision to be based on an assessment of likely personal contamination based on the patient population involved,
i.e. the amount of likely exposure to secretions and other infectious body fluids.
o
Surgical mask (type IIR) denotes a surgical mask that is fluid resistant.
Abbreviations
ABHR: Alcohol based hand rub
AGP: Aerosol Generating Procedures
GPs: General Practitioner
HCW: Healthcare worker
HH: Hand hygiene
HIIAT: Hospital Incident Infection Assessment Tool
ICD: Infection Control Doctor
IPCT: Infection prevention and control team
PPE: Personal Protective Equipment
PPM av cl: Parts per million chlorine
SGHD: Scottish Government Health Department
SPE: Safe Patient Environment
WHO: World Health Organisation
1000 ppm av cl: parts per million of available chlorine
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