Communicable Disease Control Program Policy & Practice Standards Manual Population and Public Health Disease Control Department

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1 Communicable Disease Control Program Policy & Practice Standards Manual Population and Public Health Disease Control Department Gastrointestinal Illness Outbreak Management - LTC and Integrated Facilities Approved: Number: Date: 09/12; R-06/13; R Page: 1 of 11 Policy The Communicable Disease Control Program (CDC), in collaboration with the LTC home and Infection Control Program is responsible for the investigation of outbreaks in LTC and Integrated Facilities in the Saskatoon Health Region. The CDC Program is responsible for the development and maintenance of the LTC GI & Respiratory Outbreak Management Manual. LTC home staff are required to: Collect stool samples within 24 hours from a resident, at first symptoms of acute illness. Send data from the electronic outbreak management database via encrypted every work day by At minimum 3 staff at each LTC home must be trained in entering data onto the electronic outbreak management database. A minimum 6 staff must have access to the folder where the electronic outbreak management database is saved. The Medical Health Officer declares a confirmed outbreak and declares the outbreak over. Purpose 1. To provide guidelines for the investigation and management of gastrointestinal outbreaks. 2. To control and prevent further disease by: a) limiting the duration of the disease b) limiting the attack rate during an outbreak.

2 GI Outbreak Management-LTC & Integrated Facilities Page 2 of 11 Definitions 1. Gastrointestinal (GI) Illness is one of the following: a) Two or more episodes of loose watery stool, above what is considered normal for the resident/client/staff, in a 24 hour period. b) Two episodes of vomiting in a 24-hour period. c) One episode of vomiting and one episode of loose watery stool in a 24- hour period. d) One episode of bloody diarrhea in a 24-hour period. e) One episode of explosive diarrhea in a 24-hour period. 2. Suspect Gastrointestinal Outbreak is: a) Two (2) cases of GI illness 1 in residents/staff in one geographic area (ie. unit/floor/home) within a 24 hour period. 3. Confirmed Gastrointestinal Outbreak is: a) Three (3) or more cases of GI Illness 1 in residents/staff in one geographic area (ie. unit/floor/home) within a 24 hour period. 1 For which no other cause can be found for the symptoms (ie. medication reaction, food intolerance, bleeding hemorrhoids, laxative administration, etc.) Procedure A Long Term Care (LTC) Home Actions RN/LTC Staff: 1. Monitors the unit/ward site for signs and symptoms of gastrointestinal illness as per the definition. 2. Reviews and posts Don t Wait Isolate poster. 3. Places resident displaying acute GI Illness, appropriate precautions (Contact and Droplet as per the ICP manual) immediately. 4. Looks for other symptomatic people. 5. Reports the Outbreak immediately by notifying the administrator/on call manager for the LTC home. 6. Contacts Communicable Disease Control (CDC) Nurse at and the Long Term Care (LTC-ICP) at (Monday to Friday ( hrs.) After hours and on weekends call (MHO on call 24hrs/7days) and provides the following information: a) number of ill residents/staff b) total number of residents in home c) number of vacancies in home d) symptoms e) dates of onset

3 GI Outbreak Management-LTC & Integrated Facilities Page 3 of 11 f) location of ill residents within home g) Infection Control measures that have already been implemented. 7. Obtains an outbreak number from the CDC Nurse for specimen submissions. If the outbreak is reported on the weekend, an outbreak number will be assigned on Monday. 8. Collects stool specimens within 48 hours (preferably within 24 hours), of onset of illness, ensuring that: a) Specimens are collected from up to 6 symptomatic residents unless directed otherwise by public Health. b) Two stool specimens are collected per resident: i. One for C&S, place in Carey-Blair transport media ii. One for viral studies, (Norovirus and Rotavirus), place in a stool specimen container that has no transport media or preservative (urine/sputum sterile pink top specimen container). iii. Do not submit stool specimens that are formed. 9. Completes specimen and lab requisition (see sample in manual) with the following information: a) first and last name b) Health Services Number (HSN) c) date of birth (DOB) d) Outbreak number e) Indicate Outbreak query Norovirus and Rotavirus f) date and onset of symptoms g) date and time of collection h) place Dr. C. Neudorf, Medical Health Officer beside the Requesting Physician in the case of a suspect or confirmed outbreak i) add in the resident s physician and the Long Term Care Home s Specific Unit the resident is on in the section entitled Additional Copies of the Report. 10. Arrange for transportation of specimens to the lab immediately. For best results specimens should be processed within 24 hours. a) For evening and weekends, you do not need an outbreak number or an outbreak to be declared to collect samples. Contact CDC Nurse on Monday and an outbreak number will be assigned. PHS will contact the lab to add the outbreak number to specimens that have been sent to the lab. b) For urban LTC facilities: i) in the evening (Monday-Friday, weekends and statutory holidays), Dynamex Courier ( ) will pickup and deliver to SPH lab. Note: There will be an after hours charge. ii) Staff calling will need the LTC facilities account # (check outbreak kit for number). Tel Jay Communications will answer and arrange Dynamex courier.

4 GI Outbreak Management-LTC & Integrated Facilities Page 4 of 11 DOC/Clinical Leader/Manager or Designate: 1. When a Suspect Outbreak is declared by the Medical Health Officer (MHO), he/she becomes actively involved by: a) ensuring specimens have been collected on ill residents. b) notifying all departments of suspect outbreak (laundry, kitchen, cleaning staff, etc.) c) implementing the following Infection Control Measures (ICMs) immediately: i. reinforce strict hand hygiene for all staff, residents and visitors. ii. posting additional hand hygiene posters. iii. ensuring there is a hand hygiene station at the entrance of the LTC home. iv. directing staff to watch the hand hygiene video at v. enhanced cleaning (2 times/day) with focus on high hand contact areas in affected areas/units and ill residents room. d) starting the line list on ill residents and staff (see step 4 in this section). 2) When a Confirmed Outbreak is declared by the MHO, he/she becomes actively involved by: a) locating the LTC Outbreak Manual on the SHR website. le-diseases/pages/ltc-outbreak-manual.aspx. b) ensuring specimens have been collected on ill residents. c) implementing infection control measures immediately as listed in the Long Term Care GI Outbreak Infection Control Measures (DC-318) checklist. d) notifying all departments of confirmed outbreak (i.e. laundry, kitchen, cleaning staff, etc.). e) notifying groups coming into facilities such as VON, Home Care, etc. g) establish an outbreak team. Membership may include, but is not limited to, infection control, DOC/Manager, housekeeping, laundry, dietary, occupational health. The team meets regularly (e.g. daily) for updates. h) ensuring outbreak signs are posted at each entrance and affected areas of home to advise visitors of respiratory illness. Discourage visiting if visitors have GI illness. i) ensuring hand hygiene signs are posted at each entrance and that alcohol hand sanitizers available. j) cancelling group/social activities k) cohort staff as much as possible - dietary staff should not have contact with ill residents l) Starting or continue the line list on ill residents and staff see Monitoring the Outbreak Data Line Listing. m) Reporting outbreak to OH&S if: i. SHR owned and operated site Rural Facilities Call SCH OH&S Office at Urban Facilities - Call SPH OH&S Office at ii. SHR affiliate

5 GI Outbreak Management-LTC & Integrated Facilities Page 5 of 11 Responsible for staff management. n) Participating in the scheduled teleconference with ICP and PPH (OH&S if owned and operated) as deemed appropriate. 3) Determines the media spokesperson. All media inquiries should be handled by Communications ( ). 4) Refers to LTC Outbreak Database section in the LTC Outbreak Manual and begins monitoring the outbreak using the line listing database by: a) Ensuring previous outbreaks have been deleted from the outbreak database on the S Drive b) Updating the MDS (patient demographics). Refer to LTC Outbreak Database section in this manual. c) Entering the line listing information and sending it to PPH on the day the outbreak is declared as follows: i. For Residents: Complete a Resident Line listing form (DC-134) including all symptomatic residents beginning with the first day ill residents were identified. This line list is given to the Electronic Outbreak Reporting System data entry person. After the first day, front line staff update(dc-134) or printed off electronic resident line list with new and additional information that may include: - wanderer - new symptoms - hospitalized where and when - improved duration of illness - deceased when - date recovered - names of new symptomatic residents as they are identified. Entering updates into electronic outbreak reporting system daily. ii. For Staff: Completing the Staff Line listing form (DC-133) with symptomatic staff on the first day ill staff are identified. This line list is given to the Electronic Outbreak Reporting System data entry person. After the first day, update the printout of the electronic staff line listing as needed add any new symptomatic staff identified. 5) s the encrypted line list to: phs.epidemiologist@saskatoohealthregion.ca by 2:00 p.m. each day Monday to Friday. See manual for instructions. If there are no new cases or updates, still the encrypted line list as it will reflect the current date and PHS& ICP will know that it is the most current data. 6) When the MHO declares the outbreak over, the LTC home: a) receives a phone call from the CDC PHN advising of same. b) receives a letter and Outbreak Summary Report.

6 GI Outbreak Management-LTC & Integrated Facilities Page 6 of 11 c) celebrates your success include the front line staff as well as the outbreak team. d) debriefs with LTC home outbreak team. B Infection Prevention and Control Infection Control Practitioner (ICP): 1. Participates in the teleconference with LTC staff and CDC designate to identify or resolve any infection control questions. 2. Liaises with CDC PHN to assist with outbreak monitoring. 3. Documents notes and recommendations in the electronic outbreak management tool. 4. Provides a site visit as necessary (see Appendix B: Criteria for a site visit during an outbreak). C Communicable Disease Control (CDC) CDC PHN designate: 1. Instructs the LTC home, when a suspect outbreak is declared to: a) ensure specimens have been collected on ill residents. b) notify all departments of suspect outbreak (laundry, kitchen, cleaning staff, etc.) c) implement the following Infection Control Measures (ICMs) immediately: i. reinforce strict hand hygiene for all staff, residents and visitors by: posting additional hand hygiene posters ensuring there is a hand hygiene station at the entrance of the LTC home directing staff to watch the hand hygiene video at ii. enhance cleaning (2 times/day) with focus on high hand contact areas in affected areas/units and ill residents room. iii. start the line list on ill residents and staff. 2. Provides outbreak number to the home. The Outbreak Assigned Numbers log (DC-261) found in working file box. If samples already sent to lab, obtains names of residents and call lab to attach outbreak number to appropriate samples. 3. Initiates documentation on the electronic outbreak management tool found at I:\DC\Databases\CDC\LTC_Influenza_Tracking. 4. Creates folder in I:\DC\CDC\Disease Control\Outbreaks\LTC \ current year: a) home name b) type of outbreak c) month and year

7 GI Outbreak Management-LTC & Integrated Facilities Page 7 of Initiates a file folder for the outbreak. Cover of file folder includes: a) outbreak number b) name of home c) type of illness (G.I.) d) date reported e) causative organism (if known) f) contact person(s) for outbreak follow up (name, phone number, fax number) 6. Initiate the Ministry of Health Outbreak Notification and Summary Report found at: I:\DC\CDC\Disease Control\Outbreaks\Provincial forms a) save a copy in the appropriate I:drive folder and hard copy folder. b) s to Ministry of Health (cdc@health.gov.sk.ca) and cc CDC Clinician. c) chart in database that initial Notification ed to Ministry of Health. 7. If specimens are being processed in Saskatoon, notifies Virology Lab ( ) and Bacteriology Lab ( ) of GI illness and pending specimens being sent to lab. 8. If specimens are being processed in Regina, notifies Saskatchewan Disease Control Laboratory (SDCL) by ing sdcl.outbreaks@health.gov.sk.ca the Initial Ministry of Health Outbreak Notification and Summary Report. Include: a) outbreak number b) name of outbreak home c) type of outbreak (respiratory, GI or other) d) date of onset e) number of ill residents f) estimated arrival date of specimens 9. Import & review the electronic lists (see DC-199). If home not using outbreak database, reviews faxed line lists. 10. If suspect outbreak, is declared over and does not progress to a confirmed outbreak, completes the following tasks within 2 weeks: a) Updates the Ministry of Health (MOH) Outbreak Notification and Summary report indicating Not an Outbreak. b) Saves a copy in the LTC outbreak folder located on the I Drive with title of . c) s to Ministry of Health (cdc@health.gov.sk.ca) and cc CDC Clinician. d) Charts in database that not an outbreak status ed to MOH. e) Charts in the LTC electronic outbreak management tool (EOMT) found at I:\DC\Databases\CDC\LTC_Influenza_Tracking. f) Copies and pastes the charting in the LTC EOMT into a word document. g) Saves document in appropriate I Drive folder. Naming it Daily Notes: LTC NAME & MONTH & YEAR

8 GI Outbreak Management-LTC & Integrated Facilities Page 8 of 11 h) Prints the latest line list and epi graph from the LTC EOMT and puts into hard copy folder. i) Saves any labs associated with outbreak in the hard copy folder. i. If the organism is not reportable saves the original lab. ii. If the organism is a reportable disease saves a copy of the original lab. j) Gives folder to CDC Clinician. 11. If suspect outbreak becomes a confirmed outbreak OR the number of cases meets the confirmed outbreak as per DC-99: a) Consults with and notifies the Medical Health Officer (MHO) that there is a home that meets criteria for an outbreak. b) Declares home in outbreak. c) Informs epidemiologist and LTC-ICP. d) Updates the Ministry of Health Outbreak Notification and Summary Report as necessary (ie: outbreak confirmed, causative organism identified) i. s to Ministry of Health (cdc@health.gov.sk.ca) and cc CDC Clinician. ii. Chart in electronic database that updated ed to MOH iii. Save a copy in the appropriate I: drive folder. e) Imports & reviews the electronic lists daily (see DC-199). If home not using outbreak database, reviews faxed line lists. f) Arranges the teleconference with LTC home staff, ICP and OH&S. g) Communicates with home, as per Momentum Conference Calling word document located I:\DC\CDC\Disease Control\Outbreaks\LTC's h) Enters notes into the electronic outbreak management tool. i) Documents when top 5 ICMs implemented in the Infection Control Measures Timeline box. j) Notifies Safe Communities Supervisor-Food Safety and/or Public Health Inspector (PHI) responsible for the LTC (done by notification from CDC Clinician or designate 12. When MHO declares outbreak over: a) Notifies the DOC/Clinical Leader/Manager of LTC home. i. Completes LTC electronic outbreak management tool (EMOT) and summary report of outbreak within 2 weeks. ii. Generates the summary report. b) Prints one copy of summary report (to attach to letter (DC 171) to home) c) Prints off one copy of the epi graph from the LTC EMOT with the data table. d) Completes and s Ministry of Health Outbreak Notification and Summary Report to CDC Ministry of Health cdc@health.gov.sk.ca within 30 days and cc the CDC Clinician. e) Electronically saves to I:\DC\CDC\Disease Control\Outbreaks\LTC for appropriate year and home: i. Ministry of Health Notification Report (Final copy) ii. Copies the charting in the LTC EOMT and pastes into a word document.

9 GI Outbreak Management-LTC & Integrated Facilities Page 9 of 11 iii. Saves document in appropriate I :drive folder. Naming it Daily Notes: LTC NAME & MONTH & YEAR iv. Outbreak meeting Minutes if applicable. v. Scanned/electronic Public Health Inspection Report, if applicable vi. Saves to hard copy final outbreak file folder: Final line lists for residents and staff - Older dates of line lists can be shredded. Lab reports - Reportable organisms ensure are entered and closed in iphis and a copy is saved (original is filed as a reportable). - Non-reportable organism original lab is saved. f) Ensures Hard Copy Final outbreak file folder include: i. Labs- (copies of reportable diseases, originals if not reportable) ii. Final Line List with epi graph copy iii. Summary of Outbreak printed from electronic database iv. Copy of DC171 Letter to LTC Home (Clinician to complete) g) Ensures Electronic folder includes i. Ministry of Health Final Report ii. DC171 Letter to LTC Home (Clinician to complete) iii. Daily Notes iv. s sent out to distribution list (outbreak declared, update, over) v. Outbreak meeting minutes (if applicable) h) Notifies CDC clinician when complete. Public Health Inspector: 1. Arranges to do site visit if: a) The outbreak appears to be related to the eating establishment/food service b) The eating establishment/food service had deficiencies during the last inspection that require follow up. c) The number of cases is increasing over time for no apparent reason. d) The MHO requests Safe Communities assistance. e) If visit is done include PHI recommendations from inspection report and outbreak meeting minutes to file folder. CDC Clinician or Designate: 1. Adds home to the LTC Outbreak Linelisting Year at I:\DC\CDC\Disease Control\Outbreaks\LTC of the current year when an outbreak number is provided to LTC home. 2. Notifies via when a confirmed outbreak is declared, updates and when declared over to: a) SHR LTCs (this is sent to the Administrative Assistant for Director of Continuing Care and Seniors Health, who in turn forwards to all SHR LTC DOCs/Managers and SHR Staff Scheduling). b) Director of Continuing Care and Seniors Health; Deputy MHOs; Epidemiologist; LTC-ICP; ICP Director; Acute Care & Community ICPs;

10 GI Outbreak Management-LTC & Integrated Facilities Page 10 of 11 Division Head of LTC for SHR; SHR Infection Control Officer; Disease Control Manager; Safe Communities Food Services Supervisor; Public Health Inspectors; OH&S, EMS, and Fire & Protection Services c) Saves s electronically in outbreak electronic file at I:\DC\CDC\Disease Control\Outbreaks\LTC's\YEAR. 3. Saves a copy of the MOH Outbreak Notification and Summary Report sent to the MOH in I:\DC\CDC\Disease Control\Outbreaks\LTC's\YEAR\Copy of s sent to MOH when received from CDC PHN. 4. After outbreak is declared over by MHO and completed file is received from CDC PHN: a) Develops letter (DC-171) with attached summary report for MHO signature. i. Saves copy of letter to home (DC-171) signed by MHO. ii. Sends original letter to the DOC/Clinical Leader/Manager of LTC home iii. Sends a copy to LTC ICP via interoffice mail. b) Reviews the Final Ministry of Health Outbreak Notification and Summary Report and ensures ed to the Ministry of Health. c) Saves copy of sent to the Ministry of Health in I:\DC\CDC\Disease Control\Outbreaks\LTC s\year\copy of s sent to MOH. d) Completes electronic excel line list saved at I:\DC\CDC\Disease Control\Outbreaks\LTC for appropriate year and home. e) Gives the hard copy file to CDC OAA within 3 weeks. MHO: 1. Declares a confirmed outbreak in consultation with CDC PHN/Clinician. 2. Declares outbreak over in consultation with CDC PHN/Clinician. a) Generally outbreaks are declared over after 2 incubation periods have elapsed with no new onset of cases in residents. CDC OAA: 1. Prints label for hard copy outbreak folder including: a) LTC home b) organism (or type of outbreak if organism is unknown) c) month & year. 2. Files folder in DC file cabinet C row 2.

11 GI Outbreak Management-LTC & Integrated Facilities Page 11 of 11 D Occupation Health & Safety FOR SHR OWNED & OPERATED FACILITIES ONLY Occupational Health & Safety Nurse (OHN) 1. Contacts the home/department manager to request a line list (name and phone numbers) of all employees who have called in to work sick from the time of the declared onset of illness. 2. Directs management to post the identified organism information sheet in staff areas so staff can refer to the signs & symptoms to watch for (see infection control measures). 3. Follows-up and screens staff on the line list to determine if their illness is related to the outbreak. 4. Completes SHR Incident Reports & E1 (Employers reports) for WCB if required. 5. Advises staff of work restrictions. 6. Directs staff to their physician for assessment and treatment if necessary.