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OUTBREAKSWhat’s Now, What’s Next. Carol Shenold, RN, CIC Deaconess Hospital, Oklahoma City 2006 “Mold Control and Remediation in Healthcare” “The Infection Control Trainer’s Toolkit” “The CDC’s Tuberculosis Guidelines: Strategies for Compliance” What’s the next outbreak? • • • • • • SARS-carried by humans, cats ??? “Mad Cow Disease” Bird Flu - spread by wild birds and… Botulinum Toxin A - contaminated carrot juice - 2006 September E coli 0157 - fresh spinach-2006-September West Nile - mosquitoes New Food Groups • • • • • • Can’t eat beef - Mad Cow Can’t eat chicken and eggs - salmonella Can’t eat spinach - E. coli 0157 Can’t drink carrot juice - botulism No fish - mercury poisoning I believe that leaves wine and chocolate! Pets and People • Are we at risk from our animals? – – – – – Chickens - Bird Flu Cats - toxoplasmosis-don’t scoop Deer Mice - Hanta Virus Birds - histoplasmosis In the United States, we have 139 million cats and dogs as pets and 569,774 Iguanas. And now with the bird flu thing Pets and People cont. • • • • • We have pet therapy for children’s hospitals, nursing homes, regular hospitals, behavioral health and as therapy animals. What if a pet, or several pets carried a mutated virus or just a more deadly form of campylobacter. Track that outbreak. 58.3% of U.S. households have pets 62 million dogs, 69 million cats, 10 million birds 3 million reptiles. I DID NOT SAY GET RID OF YOUR PETS! Just be aware, use good hand hygiene and etc. Pandemics • • Avian Flu - need person to person transmission Pandemic Flu - One that flu vaccine might not slow down and is transmitted person to person (Why avian flu could be scary if it mutated.) Bioterrorism • The usual suspects – Plague – Anthrax – Small Pox • Not on the front page as much due to the Weapons like planes, trains and automobile weapons. Viral Agents • Small Pox(Variola) – – – – – – – Wiped Out 1980 highly contagious kills 20% of exposed dangerous vaccine No chemotherapy Isolation with droplet and airborne precautionsN95 masks-gowns and glovesDispose of or destroy bed linens and clothing – – – – Pre-event vaccination at issue in many states at this time Some hospitals are opting for the formation of a team but not preevent vaccinating. Screening and reimbursement issues as well as worker’s compensation Fear of side-effects for family. Viral Agents cont. • Viral Hemorrhagic fever – Ebola, Marburg, Lassa – Mortality rates 56-92% – Supportive care for major blood loss – Ribivirin being used – No real vaccine in use – Contact precautions, strict barrier nursing – Decontamination of double-bagged spec. – Disinfection excreta Bioterrorism continued • • • • • • Geographically unusual disease high disease rate among exposed Vector borne disease in wrong area More than one epidemic at once Higher morbidity/mortality than usual Rapidly increasing incidence in healthy population • • • • • Epidemic curve rising and falling In short period of time Unusual increase in people with fever or resp. symptoms seeking treatment Epidemic disease at unusual time Clusters of patients from single locale Presentation with pulmonary anthrax, tularemia or plague Case Definition • We already have case definitions. For example, we know the definition of CAMRSA involves a skin lesion or cellulitis with abscess, purulent drainage, a positive culture for MRSA, in a young healthy person with no history of contact with hospital acquired MRSA. Case Definition continued • We have many more case definitions like those for Community Acquired Pneumonia or Ventilator Associated Pneumonia • When you see a cluster of infections and suspect an outbreak, decide on your case definition so you know what you are looking for. Employee surveillance • One way to spot an in-house outbreak is by surveillance of employee call-in/illness patterns. If you see a cluster of GI disease among employees, do they all work on the same unit? Is there a patient on that unit with GI symptoms? Or did that group all attend the same event? Can the symptoms be passed on to the patient population? Employee patient surveillance • • • • Patient Diarrhea, nausea, vomiting, especially bloody diarrhea. Illness with fever, rash, sore throat, temperature, chills headache, fatigue, decreased appetite, change in mental status. Influenza-like syndromes Acute respiratory distress syndromes. • • • • Employee Clusters of employees reporting diarrhea/nausea/vomiting Clusters of employees reporting illness with fever, rash, sore throat with white or yellow membrane, red swollen lymph nodes Increased absenteeism or unusual sick leave pattern. Employee surveillance continued • Even without a cluster, one employee can make a difference. – OKC 2006-one nurse with active TB, small hospital, over 150 patients, visitors and employees tested so far in Sept. 2006. Mass Exposure • • • • • • • • • Diseases with Mass Exposure Potential *Starred Diseases require only one case to start investigation *Anthrax Resistant Organisms (MRSA,VRE,VISA, VRSA Botulism Respiratory Syncytial Virus Chickenpox Rubella Hepatitis A Scabies Influenza A or B *Small Pox Legionnaires Disease Tuberculosis *Measles Tularemia Meningococcal Meningitis Viral Conjuntivitis Pertussis Viral Gastroenteritis (Rotavirus, Norwalk)-cruise *Plague Viral Hemorrhagic Fevers *Polio SARS Is it really an outbreak? • General definitions of an outbreak includes: – – • Two or more linked cases of the same illness or an increase in the number of observed cases over expected cases Two or more persons with same illness after exposure to common source Any time you have several people exposed at a mass event who then become ill, be suspicious. The same would apply to multiple cases of influenza when it’s not flu season. Several cases of c.difficile where you rarely see any cases. Investigation of an Outbreak • • • • Control ongoing outbreak Detect and separate implicated source Identify specific risk factors Prevent future outbreaks • • • • Date of onset, duration severity Proximity to other patients Common factors-same Dr., same unit, same surgery, same organism, common risk factors. Laboratory confirmation Basic Steps • • • • • • Establish a case definition Identify cases Data Analysis Who is at risk? Prevention measures Environmental testing, only if indicated Controlling an Outbreak • • The goal is to control the source (if known), control transmission and protect at-risk groups. Look at interventions. If, for example, you see an outbreak of c.difficile you will take multiple actions. Control continued • • • • • • Proximity of patients to one another, same room, hall, unit, physician, diagnosis. Proper isolation techniques Hand Hygiene-soap & water-no alcohol Antibiotics used Housekeeping processes Modifications of patient activity. Patient Surveillance Outpatient procedures increasing. How do we track them and potential infections? Phone Letters Physician self reporting ER Visits-chart review Evaluating Data • Once the outbreak is over, you can look at everything related to the outbreak and present data to Infection Control Committee, Patient Care Services and other involved committees. That’s where the bar graphs, pie charts, new process and procedures come into the picture. What have you learned from the outbreak? Is there anything you can do to prevent the next one? Epidemic curve C. Diff Incidence 10 8 6 4 2 0 Series1 10 /1 /2 00 10 6 /2 /2 00 10 6 /3 /2 00 6 10 /4 /2 00 10 6 /5 /2 00 10 6 /6 /2 00 10 6 /7 /2 00 6 10 /8 /2 00 10 6 /9 /2 00 10 6 /1 0/ 20 06 • The epidemic curve can give you a pattern of spread, magnitude of outbreak, outliers, time trend, exposure and disease incubation period. When making the graph, put reported cases on y axis, day or time of symptoms on x axis, make sure the time interval works, label clearly and add other info as needed, i.e. unit, organism Number of cases • Date Identified Presumptive Hypothesis • • The common factor in a multiple case outbreak of e. coli 0157 was all patients eating bagged, organic baby spinach therefore: The outbreak was caused by eating contaminated spinach. The common factor in a multiple patient outbreak of c.diff is one caregiver who did not use appropriate hand hygiene. The outbreak was caused by one caregiver failing to follow proper procedures. Hypothesis • • • Avian Flu can be found in water fowl. Donald Duck is a water fowl who lives in Disney world. You’ll catch Avian Flu if you visit Disney World Environmental Controls • When looking at results of an outbreak investigation-don’t forget to look at any environmental controls you could put in place like disease specific cleaning procedures, UV light units in waiting rooms likely to have active TB patients, additional isolation rooms, especially negative pressure. Planning for the impossible, improbable and life in general. • • Outbreak Management Plan Johns Hopkins Hospital-Outbreak Investigation Management Team. – – Could include IC, associate IC, IC Manager, IC director, Risk Management, Pharmacy, nursing management, microbiologist, disease specialist. Routine hospital outbreak in a moderate to small hospital, ICP, ID Dr., others as needed. Forming a Plan Outbreak Plan This is a general plan for investigating an outbreak and can be used to look at large and small clusters of disease. Not all outbreaks would be large enough to involve all aspects of the plan Disaster Plan A larger plan for handling any disaster but should include a plan for handling a large influx of contagious and could involve the outbreak investigation model depending upon the disease involved. What should I plan for? • Everything? You can’t. Keep it simple. Your plan for investigating outbreaks, large or small, should be the same. Remember your IC Risk Assessment? It is tailored for your facility. Use those perceived risks to form your outbreak investigation plan. Keep in mind that you may not have Johns Hopkins resources and your team may be you, your ID doctor and a lab technician. Who to include • When formalizing your plan involve the Infection Control Committee because the make-up of that committee is the same players that will be involved in a small outbreak on one unit or a large outbreak involving a city, county, state or country. JCAHO says… • • • • • IC.6.10 The hospital prepares to respond to an influx, or risk of influx, of infectious patients. Small or large City-wide influenza, Bioterrorism, county-wide pertussis etc. Incorporate into over-all disaster plan, move away from the disease specific boutique plans-Smallpox, SARS, Avian Flu. Disaster Planning-1 • • • • • Establish communication networks and lines of authority Plan for cancellation of non-emergency services and procedures Identify sources able to supply vaccines, immune globulin, antibiotics, and anti-toxins Determine the ability to handle a sudden increase in the number of cadavers on site Determine the ability to lock down the facility Disaster Planning-2 • • • • • • Plan for efficient evaluation and discharge of patients Develop discharge instructions for noninfectious patients Determine sources for additional medical equipment and supplies Plan allocation of scarce equipment Determine ability to isolate large numbers of patients. Determine the ability to increase security Policy Changes • • Like, when riding the mower, always watch the road ahead. After the outbreak, look at the overall incident and determine if process was part of the issue and what could be done to change the way things are done. If you have several surgical site infections and only half the patients received prophylactic antibiotics within 1 hr of cut time, do you need pre-printed orders? Prophylaxis • Side-note: In making plans for the influx of infectious patients, involve employee health in case prophylaxis of employees is called for and/or prophylaxis of families or other exposed individuals. Educate, educate, educate. • • • • • Educate staff, employees, visitors. If processes change, educate. If they stay the same, educate Must know what role is in disaster Need to understand disease dynamics of the outbreak – – – – Type of isolation Incubation Transmission Keep audience in mind FEAR • Effective communication and education will help allay fears and prevent unnecessary rumors and panic.