CDAD Trigger Tool by dix06N


									       Generic Outbreak Control Measure Trigger Tool

  This tool can be used to gain control in any hospital outbreak where there has been identified person-to-
   person transmission, or where person-to-person transmission presents an ongoing risk. NB Person-to-
  person transmission includes both direct and indirect transmission as a consequence of environment or
                                         equipment contamination.

 The assumption in this document is that Standard Infection Control Precautions (SICPs) are continuously
                 being applied. The control measures in this tool are in addition to SICPs.

Trigger Organism

Hospital ward/Clinical Area

Date Trigger Tool Commenced

Date Trigger Tool Closed

Person closing the Trigger

Health Protection Scotland

October 2012
                                  Generic Outbreak Control Measure Trigger Tool

This Generic Outbreak Control Measure Trigger Tool is designed for use in any hospital outbreak where
there has been identified person-to-person transmission – via direct or indirect routes - and/or where person-
to-person transmission presents an ongoing risk. The Tool provides a means of assessing outbreaks as they
progress, as well providing a checklist of evidence-based control measures to ensure that everything that
needs to be done to stop any ongoing transmission is being done. The first action is an assessment to
determine if the Trigger is real and if the Trigger Tool needs deployed. If the Trigger is real, then the Key
Information Sheet and the Day 0 Action Checklist should be completed. The Daily Actions Checklist should
be performed everyday thereafter until the risk is considered resolved.
Day 0 Actions checklist includes:
         Key Information Sheet completion to provide key specific information for the clinical team.
         Initial Control Measures to prevent any further direct person-to-person cross-transmission including
          Immediate Decontamination of the environment and equipment. The assumption at the start of an
          outbreak is that there may be environment and/or equipment contamination. Therefore initial control
          measures need to include decontamination to ensure any ongoing risk from these sources is
Daily Actions Checklist includes:
         Continuous assessment of the incident
         Confirmation that existing control measures are being effectively applied
         Consideration of whether Trigger Actions can be stopped.

                                                   Roles and Responsibilities
 Senior Charge           Ensure implementation and ongoing compliance with SICPs
        Nurse            Recognise and report to the IPCT any incidences of clinical conditions where the
        (Ward             signs/symptoms are suggestive of an outbreak, i.e. patients having similar
                          signs/symptoms of infection (diarrhoea, or pneumonia, or surgical site infections)
                         Work with the IPCT in completing the daily assessments
                         Report using Risk Management Reporting systems as locally required
                         Ensure that sufficient staff are available to deal with patient care needs
    Clinicians           Recognise and report to the IPCT any incidences of clinical conditions where the
                          signs/symptoms are suggestive of an outbreak, i.e. patients having similar
                          signs/symptoms of infection (diarrhoea, or pneumonia, or surgical site infections)
                         Confirm that the clinical care of patients is compliant with local/national guidance,
                          including observations, specialist referrals and antibiotic therapy
                         Report to IPCT directly if they have concerns regarding infection prevention and control
    Infection            Have effective surveillance systems to detect and investigate outbreaks
  Prevention &           Determine whether this Outbreak Control Measure Trigger Tool is required
  Control Team           Apply this Outbreak Control Measure Trigger Tool when there is evidence of an outbreak
        (IPCT)           Consider the need for additional control measures if transmission continues
                         Ensure that actions required after HIIAT assessment are in place
   Pharmacist            If requested, review the antibiotic regimens of all patients in the ward ensuring this is
   (If required)          consistent with local policy
                         Provide recommendations for prescribing to reduce the risk to patients
                         Report triggers to the Antimicrobial Management Team
     General             Ensure the ward team has the resources to provide a safe patient environment and safe
     Manager              patient care

HPS. Version 1.0 October 2012                                                                                 page 2 of 8
                                Generic Outbreak Control Measure Trigger Tool

Initial Assessment                      Date: ……/……/….                (the date the trigger was identified)
                 Assessment to determine if the Control Measure Trigger Tool is required
                                         to be completed by the IPCT
 Location: Hospital and Clinical Area

 What is the outbreak trigger for this ward? (e.g. 2 new cases of
 alert organism in 30 days; for many organisms it could be 1 case)
 What is the number of cases prompting this trigger?
 (This could be higher than the set trigger if more than 1 case is
 identified on the same day)
 Assess the patients’ data to confirm if the Trigger is real:
    Is there a possibility of laboratory error?
    Is the number of cases correct (no double counting of
    Is the organism being acquired in this clinical area?
    Are there any recent changes in the patient population that
     could account for this trigger?
    Can the clinical conditions be explained by other diagnosis?

                                Situation Report – To be completed by IPCT

 Today, how many patients on this ward are known to have this
 alert organism and/or symptoms?
 Today, how many other patients are asymptomatic but are
 known to have the alert organism?
 Today, how many staff are symptomatic and/or known to be
 colonised/infected with the alert organism?
 In the last 30 days, has the alert organism / infection been
 recorded on any patients’ death certificates?
 What is the Hospital Infection Incident Assessment Tool (HIIAT)       Red
 for this incident?                                                    Amber
 (NB inform SGHD and HPS if HIIAT Red or Amber).                       Green
 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     No
 If the Trigger is considered to be natural variation STOP here        Signature:
 and sign to say this the Trigger is not real

If the Trigger is real, then IPCT complete: The Key Information Sheet, Day 0 Actions Checklist. Complete
            a Daily Actions Checklist every day thereafter until the Trigger is considered resolved.

                  After the Trigger is closed the IPCT will arrange for a Post Outbreak Debrief.
HPS. Version 1.0 October 2012                                                                          page 3 of 8
                                 Generic Outbreak Control Measure Trigger Tool

Day 0 Actions                                   KEY INFORMATION SHEET
       (completed by IPCT: this sheet can be updated over time as new information is identified)
Case Definitions:

A case          Any person (patient or HCW) with (include symptoms or communicable disease / place / time period)

A suspect       Any patient or HCW with                              symptoms from who microbiological
case            investigations are yet to be completed.
Relevant symptoms/signs that cases and suspect cases could present with in this outbreak are:

Diarrhoea (without or without blood)                          Sore throat
Vomiting                                                      Any purulent or change in wound discharge
Cloudy urine +/- other symptoms of (CA)UTI))                  Inflamed wound or surgical site
Exfoliative or inflamed skin areas                            Invasive device insertion site inflammation
Pyrexia                                                       Chest symptoms (productive cough)
To confirm if a person with relevant symptoms is a case, list the following specimens required:

Take specimens from any patient who develops any of the symptoms/signs indicated above

Complete with recommended decolonisation regimen if relevant for cases in this outbreak:

Product / Drug          Mode of application                                                   Frequency / duration

Modes of transmission/Survivability in the Environmental

Droplet                                                                                    * Airborne dissemination
                                                                                           includes for example, skin
Contact (direct/indirect)
                                                                                           scales containing
Airborne                                                                                   staphylococci, liberated
                                                                                           on bed-making or vomitus
Airborne(re-)dissemination in the environment *                                            contain norovirus
This organism can survive in dry environments for up to                                    expelled during vomiting.

This organism can survive in moist environments for up to
High-Contamination Procedures (clinical or non-clinical): that could increase environmental or personal
contamination, during this outbreak, e.g. wound dressings, bed-making, AGPs

 High-Contamination Procedures             State any procedure modifications needed to reduce risk

Admission Restrictions (Patient):

Do not admit to ward:                      Do not admit to bay number(s):                  No restrictions
Visitor restrictions Recommended:
Criteria to discontinue isolation of a case:

HPS. Version 1.0 October 2012                                                                                page 4 of 8
                                   Generic Outbreak Control Measure Trigger Tool

Day 0 Actions Checklist            Date: …………/………./………. (the date the trigger was identified)

                   Initial Control Measures (This is a do, then confirm done, checklist)

                                               Patients Placement:
   Isolate/cohort patient(s) who are considered to present an ongoing transmission risk (patients
    with the communicable disease/alert organism or symptomatic).
   Close doors to isolation cohort areas (undertake safety risk assessment for door closure).
   Place signage on entry to isolation/cohort areas indicating admission restrictions.
   When patients are readmitted check if they have been previously positive pre-placement
                                             Admission Restrictions
   Close the ward or bay to admissions if, the safe separation of cases from non-cases cannot
    be achieved or new admissions are at risk from other reason, e.g. staff shortages. Complete:
    Admission Restrictions section on Key Information Sheet
   Reduce patients’ visitors if considered beneficial to gaining control/or to reduce visitor risks.
    Complete: Visitor Restrictions section on Key Information Sheet
                                       Transfer and Discharge Restrictions
   Avoid unnecessary intra-hospital transfer of patients from closed and open areas. If
    clinically necessary confirm with receiving area they are infection control ready before patient
   Avoid inter-hospital transfer to other healthcare facilities unless advised/agreed by IPCT.
   Discharge patients to their home if safe to do so and patients/relatives/GPs are aware of
    signs/symptoms to report and any ongoing control measures they should take.
                                Healthcare worker (HCW) Practices and Restrictions
   Ensure that all staff on duty are asymptomatic (See: Relevant Symptoms)
   Refer all symptomatic staff to Occupational Health/GP
   Allocate staff to care for cases or, non-cases for the duration of the incident
   If they are considered to present an infection control risk, modify ways of working for staff
    scheduled to work in multiple clinical areas - including closed ward areas, e.g. phlebotomists,
    physiotherapists, occupational therapists.
                                    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 not at increased risk due to inappropriate medications e.g. aperients or
   If the alert organism is drug resistant or cases have CDI, the overall prescribing and
    compliance with local antimicrobial policy for all patients on the ward should be reviewed (e.g.
    by an antimicrobial pharmacist working with the ICD/microbiologist, clinicians).
   For patients with diarrhoea – ensure there is an up to date stool chart, with all stools passed
    recorded and described, e.g. using the Bristol Stool Chart.
   Ensure patients are not at increased risk due inappropriate use of invasive devices (i.e.
    invasive devices that are no longer clinically required or that have signs of inflammation /
   From the High-Contamination Procedures identified on the Key Information Sheet, identify
    the patient specific modifications in routine practice that could reduce personal, equipment and
    environment contamination.
   If MRSA, start decolonisation regimens. (See Decolonisation Regimen).

HPS. Version 1.0 October 2012                                                                              page 5 of 8
                                  Generic Outbreak Control Measure Trigger Tool

Day 0 Actions Checklist cont.
                                Hand Hygiene and Personal Protective Equipment
   Use ABHR if hands clean and not a diarrhoeal outbreak.
    o    For diarrhoeal outbreak or visibly dirty hands use either: soap and water wash followed
         by AHBR or Antimicrobial soap wash
   HH before PPE (apron [gown] and/or gloves); PPE before entering area; PPE off before
    leaving area, HH after PPE removed.
   If advocated by the IPCT, wear a surgical mask if within <1 metre of a suspect case/entry to a
    case’s room.
                                           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 frequently touched surfaces and any area possibly contaminated
    following a High-Contamination Procedure, e.g. toilets, over-bed tables with 1000 ppm av cl.
                                            Patient Care Equipment
   Decontaminate all communal patient equipment with 1000 ppm av cl (or the manufactures
    recommended solution). Then commence a daily cleaning regiment which includes
    decontamination with 1000 ppm av cl should be carried out and protocols put in place for this
    to be maintained.
   Provide patient-dedicated care equipment for isolation/cohort areas (thermometers/
    commodes/washbowls/blood pressure equipment/lifting-equipment, stethoscopes etc).
   If the allocation of certain equipment cannot be achieved, ensure all patient care
    equipment is adequately cleaned and disinfected in use, post use and prior to next patient use.
                                 Communications and Knowledge Management
   Inform all members of staff on the ward (including domestic staff) of the situation, the
    organism, how it spreads in the ward environment and what they need to do to further reduce
    risk to patients, to themselves and to 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.
   Ensure all members of the clinical team are aware of any modifications to High-
    Contamination Procedures to prevent contamination of people/environment/equipment
   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.
   Confirm all members of the clinical team of what to do should they develop any relevant
    symptoms over the next 30 days, i.e. seek medical help – report to Occ Health not for duty.
   Inform patients/parents/relatives of situation, precautions/restrictions and risks (document in
    the case notes)
   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 (Scottish Government if HIIAT is Amber or Red).
                                      Microbiological screening of people
   Following confirmation by the IPCT, take samples from any patients who are, or have
    been, in the same room as a case (non-diarrhoeal conditions).
   Take samples from any patients with relevant symptoms (See Relevant Symptoms).

HPS. Version 1.0 October 2012                                                                         page 6 of 8
                                                             Generic Outbreak Control Measure Trigger Tool

Daily Actions Checklist: Day__ Date: …/…./…. (the date the trigger was identified)

Daily Outbreak Trigger Checklist for IPCT & Nurse in Charge complete daily until Trigger is resolved
Date (dd/mm/yy)
Completed by (initials)
New symptomatic pts today
New positive (micro)
Total symptomatic pts today
Total positive today (include sym)
Increase or Decrease from yesterday
Are any patients giving cause for concern due to outbreak organism/infection?                             Y/N   Y/N   Y/N   Y/N   Y/N   Y/N           Y/N
New symptomatic staff today
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
Discharge/Transfer Restrictions: Inter-care facility transfers are pre-agreed with IPCT. Intra-hospital
transfers are only if clinically necessary and the receiving area is infection prepared.
Patient care checks: Clinical assessments are completed for today.
Patient care checks: Antibiotic prescribing for all patients has been reviewed today.
Patient care checks: A daily invasive device check has been completed today.
Patient care checks: Decolonisation, if recommended, is established.
Patient care checks: High-contamination procedures are modified to reduce contamination.
Microbiological screening of people: Has been completed as per Key Information Sheet
HCW practices and restrictions: Staff on duty are asymptomatic.
HCW practices and restrictions: Sufficient staff are on duty for all areas.
HCW practices and restrictions: Staff are allocated to isolation area or non-isolation area.
HH and PPE: Soap and water if diarrhoeal illness. HH before PPE; PPE before entry to area; PPE
removed before exit; HH after PPE removed (+ surgical mask if advocated by the IPCT).
Safe Patient Environment (SPE): All areas are clutter free.
SPE: Cleaning of isolation areas is established with includes 1000 ppm av cl.
SPE: X2 daily decontamination of frequently touched sites with 1000 ppm av cl and following any High-
Contamination Procedure is established. See High-Contamination Procedures.
SPE: There are sufficient supplies of PPE and other sundries for safe practice.
SPE: Following patient discharge, terminally cleaning is done pre-resuming normal services.
Equipment: All ward equipment is visibly clean and in a ready for next-patient use condition.

                                                                      COMPLETE OTHER SIDE
HPS. Version 1.0 October 2012                                                                                                           page 7 of 8
                                                         Generic Outbreak Control Measure Trigger Tool

                                                                                                         Date (dd/mm/yy)

Equipment: There is sufficient dedicated equipment available in isolation/cohort areas.
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 of 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

HPS. Version 1.0 October 2012                                                                                              page 8 of 8

To top