OUTBREAK MANAGEMENT IN RESIDENTIAL CARE FACILITIES (RCFS)

Transcription

1 Metro South Public Health Unit OUTBREAK MANAGEMENT IN RESIDENTIAL CARE FACILITIES (RCFS) Dr Bhakti Vasant (Public Health Physician) and Deb Judd (Public Health Nurse)

2 LEARNING OUTCOMES 1.Definition of an outbreak 2.Potential causes 3.Outbreak recognition 4.Outbreak management 5.Resources Image source:

3 Outbreak Management Guidelines

4 DEFINITION OF AN OUTBREAK Occurrence of more cases of disease than expected in a given area among a specific group of people over a particular period of time Two or more linked cases of the same illness NHMRC Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010) pp. 121

5 POTENTIAL CAUSES OF OUTBREAKS IN RCFS Viruses, bacteria and parasites Viruses are most common Respiratory virus infection Influenza, Parainfluenza, HMPV, RSV, Rhinovirus Gastrointestinal infection Viruses: Norovirus, Sapovirus, Adenovirus, Rotavirus Bacteria: Salmonella, Camplyobacter, E. coli Parasites: Giardia, Cryptosporidium Can only be definitively identified by laboratory testing Slide: West Morton Public Health Unit

6 Outbreak Recognition Respiratory Three (3) or more people (residents or staff) with influenza like illness (ILI) within the same 3 days (72 hour period) indicates a potential influenza outbreak Gastroenteritis Two (2) or more associated cases of diarrhoea and/or vomiting in a 24 hour period. NB: excluding cases which have a known cause, e.g. bowel disease CDNA 2010, CDNA 2017

7 CASE DEFINITIONS Respiratory (influenza like illness (ILI)) Sudden onset of symptoms And at least one of the following three respiratory symptoms Cough (new or worsening) Sore throat Shortness of breath And at least one of the following four systemic symptoms Fever or feverishness - Headache Malaise - Myalgia CDNA 2017

8 CASE DEFINITIONS Gastroenteritis (Suspected) Three or more loose stools or bowel movements in a 24 hour period that are different from normal and/or Two or more episodes of vomiting in a 24 hour period CDNA 2010

9 OBJECTIVE OF OUTBREAK MANAGEMENT To interrupt transmission as quickly as possible and prevent further cases This requires: Early case & outbreak recognition Elimination of source Rapid implementation of Infection Control measures Prevention of recurrence Effective communication Dissemination of lessons learned Source of image:

10 MANAGEMENT OF SINGLE CASES Isolate resident or exclude staff member Apply appropriate infection control measures (e.g PPE) Review outbreak management plan and vaccination status of residents and staff (influenza) Be vigilant for further cases

11 Outbreak Management Four Phases of Outbreak Management 1. PREPARATION Outbreak Management Plan 2. RESPONSE Activation of the plan 3. MONITORING Assess and modify the plan 4. CONCLUSION Declare outbreak over, debrief and update Outbreak Management Plan CDNA 2017

12 PHASE 1: PREPARATION Resources Develop/Update Outbreak Management Plan (OMP) Develop/Update IC Policies Include a medical practitioner in the development of the OMP antivirals Tools Ensure adequate stock of Personal protective equipment (PPE) how will you obtain further stock Cleaning materials Pathology collection onsite swabs, faecal pots are in date Outbreak kit Early Detection Develop/Maintain system for detection of staff/resident illnesses Consider active surveillance for cases Develop a tool for recording cases Communication Consider how you will communicate to staff, residents, relatives, Consider how you will communicate and notify your GPs, service providers, hospitals, QAS,

13 PHASE 1: PREPARATION Vaccination RCFs should aim to achieve 95% Influenza vaccination rates for staff and residents annually think how is your facility going to achieve this? (Education/communication strategies, vaccination clinics on-site..) Compile vaccination register for staff and residents Encourage visitors to have annual influenza vaccination Antivirals Develop processes with attending GPs for antiviral prescriptions/standing orders prior to flu season Consider GP assessment of renal function prior to Influenza season Prepare for logistics of mass Tamiflu distribution (liaison with community pharmacy, staff training ) Establish if GPs will be happy to prescribe tamiflu to unvaccinated staff members if required. Staffing Develop a staffing strategy Consider the additional staffing will you required during an outbreak (cleaning, support, nursing) Training Ensure staff receive training in outbreak management, are aware of relevant resources, and that these resources are readily accessible Ensure that there are contingencies in place in case staff in outbreak management roles are absent/ill

14 Strategies for a successful RCF staff vaccination program Provision of free or subsidised influenza vaccines Staff vaccination clinics at workplace Education to improve knowledge, help dispel vaccine misconceptions emphasis individual benefits Participation of local staff leaders and vaccine advocates Inclusion of recognition, rewards and incentives for vaccinated staff RCF vaccination policies linked to broader infection control policies and staff health programs Share you experiences of what has worked Image source:

15 PHASE 2: RESPONSE IMMEDIATE Notify GPs of suspected outbreak Implement infection control Request appropriate laboratory tests to confirm the diagnosis Collate a line listing Notify Public Health Unit Form an Outbreak Management Team (OMT)

16 PHASE 2: RESPONSE Infection Control Hand hygiene Most important hygiene measure in preventing spread Gloves are not a substitute for hand washing Wash hands with soap and water before and after contact with each client, if hand washing facilities are not available use alcohol based hand rub

17 PHASE 2: RESPONSE Infection Control Compliance with Precautions Gloves When in direct contact with ill persons or potentially contaminated surfaces likely. Change gloves and wash hands after each client Masks When entering room or working within one metre (flu). If risk aerosolisation vomit/faeces (gastro) Remove when leaving Dispose - Wash hands Gowns When soiling of clothes with respiratory secretions, vomit, or faeces is possible Eye Protection Where potential for splattering/spraying blood, body fluids, secretions or excretions

18 PHASE 2: RESPONSE Laboratory Testing What tests should I request? Gastroenteritis Faeces multiplex, MCS, Viral PCR including Rotavirus, Norovirus and Adenovirus Vomitus Norovirus Respiratory Respiratory virus PCR Ensure correct swabs used check with pathology company How many specimens need to be collected? Generally specimens over the course of outbreak, public health may request additional specimens from time to time Image source:

19 PHASE 2: RESPONSE Outbreak Management Team (OMT) Direct and oversee management of the outbreak Communication, dissemination of information Staff support Resource allocation Monitor outbreak progress and initiate changes in response, as required Liaise with GPs and PHU Evaluation Source of image:

20 Phase 2: Response Outbreak Management Team (OMT) Members: Chairperson co-ordinating Outbreak Control team meetings, setting times, agenda, delegating tasks Secretary organises meetings, notifies of changes, records and distributes minutes Outbreak Co-ordinator IC decisions of OMT carried out, coordinates actives to contain and investigate outbreak Media spokesperson provide information to the media Visiting General Practitioner identified during the planning phase

21 PHASE 2: RESPONSE Infection Control Environmental Cleaning Step One Clean Step Two Disinfect Increase cleaning frequency twice daily High touch areas may require more frequent cleaning after high usage times Clean with Neutral detergent followed by a bleach solution (1000 ppm) In order for bleach to be effective: Sufficient contact time (10 minutes) Surfaces free of vomit/faeces or organic matter Dilution of bleach to made up fresh, just before using (CDNA 2010)

22 PHASE 2: RESPONSE Infection Control Environmental Equipment Should be dedicated for use of an individual resident If shared, items must be cleaned and disinfected between each resident use. Linen Soiled linen and clothing should be removed immediately, placed in collection bag or leak proof plastic bag at source Alginate bags Laundered in hot water and detergent Dried on a hot setting in a dryer Use appropriate PPE when handling Crockery and cutlery Idealy in dishwasher or with detergent + hot water and dried

23 PHASE 2: RESPONSE Infection Control Environmental Isolation and Cohorting Isolate ill residents to single rooms where possible Attempt to separate ill people from well ( Cohorting ) Ensure ill residents - > 1 metre apart (draw privacy screens where necessary) Separate toilet facilities (ill from well) Close common areas such as dining rooms, communal living areas Cease group activities such as day trips...

24 PHASE 2: RESPONSE Infection Control Staff Staff Dedicated staff to look after ill persons Staff should not move between wings or other areas Self monitor for symptoms exclude if unwell Respiratory illness Unvaccinated staff Work only if well Care for well residents ONLY Wear a mask when attending to any resident care (within 1 metre and change between residents) OR asymptomatic and taking antiviral medication if staff have been working in an outbreak affected area should not be moved to other wings Image source

25 PHASE 2: RESPONSE Infection Control Admission and Readmission New admissions Should be restricted depending on extent of the outbreak maybe applied one floor or wing or entire facility Re-admission of affected residents Require provision of appropriate accommodation, care and infection control. Re-admission of residents non affected residents Generally not recommended HOWEVER maybe required once outbreak under control Consider factors - appropriate accommodation, vaccination status, ability to protect returning resident, IC measures, provision of antivirals

26 PHASE 2: RESPONSE Infection Control Visitor restriction and signage Visitors Suspend group social activities that involve visitors such as musicians Postpone visits from non-essential external providers Inform regular visitors and families request essential visits only discourage unnecessary visitors Request visitors Visit one person only Enter and leave directly without spending time in communal areas Hand hygiene and PPE

27 PHASE 2: RESPONSE Antiviral Medication Should only be used in addition to other outbreak control measures Infection Control Decision to administer antivirals as prophylaxis should be made by the OMT in collaboration with local public health unit. Uses Treatment Prophylaxis

28 PHASE 3: MONITORING Line lists capture ongoing: Resident surveillance Cases initial and new Resident symptoms Status of ill residents hospitalisations, recovered, deceased Record of antiviral usage Pathology results Staff surveillance Cases initial and new Status of ill staff recovered, hospitalised Pathology results

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31 Potential Challenges Implementation of Public Health recommendations difficult and expensive for facility Building design not ideal to successful Infection Control Some RCF reluctant to move residents Residents with dementia Record keeping Transfer of residents, new admissions Source: Slide from West Morton Public Health Unit May 2017

32 Phase 3: Monitoring

33 PHASE 4: CONCLUSION The OMT (with approval from public health) has the responsibility of declaring the outbreak is over, and to communicate this to the RCF community Influenza - can be declared over if no new cases occur within 8 days following the onset of symptoms in the last resident case [8 days is the sum of the usual infectious period (5 days) plus maximum incubation period (3 days)]. Gastroenteritis can be declared over once the facility has reached 72 hours with no new cases, and no episodes of vomiting or diarrhoea at the facility.

34 PHASE 4: CONCLUSION The Debrief: Identifies strengths and weakness of outbreak response Allows investigations of processes to ensure management of future outbreaks is improved Provides a formal avenue for resident and staff feedback Should involve all members of the OMT Lessons learnt can help to PREVENT future outbreaks

35 Outbreak management issues identified by PHUs Lack of outbreak preparation and planning Late detection of outbreak within the facility Delays in implementing appropriate outbreak infection control practices Delays in cohorting staff and residents Inability to identify ongoing cases due to lack of knowledge of case definition Incorrectly collected specimens delaying diagnosis Delayed notification to public health Delayed return of request paperwork line listing Tamiflu lack of knowledge and timeliness in implementation Lack of notification to hospital of outbreak at RACF Lack of knowledge of appropriate cleaning products for gastroenteritis outbreak management

36 Infection Control issues Lack of appropriate Hand Hygiene Inappropriate use of PPE, especially masks Inappropriate storage of waste and ppe bags tied to/stored on banisters Inappropriately cleaning of shared equipment Lack of knowledge on the requirement for masks to be worn by unvaccinated staff whilst attending to patient care during outbreaks.

37 GUIDELINES Guidelines for the public health management of gastroenteritis outbreaks due to norovirus or suspected viral agents in Australia (CDNA 2010) Guidelines for the Prevention, Control and Public Health Management of Influenza Outbreaks in Residential Care Facilities in Australia (CDNA 2017) ile/rcf_guidelines.pdf Influ-info Influenza kit for home care (Department of Social Services 2017) Australian Guidelines for the Prevention and Control of Infection in Healthcare (NHMRC 2010) pdf

38 RESOURCES Influenza in residential care facilities (QLD Health) Outbreak control measures for non-influenza respiratory viral illnesses in residential care facilities (QLD Health) Influenza vaccination guidelines (QLD Health) The Australian Immunisation Handbook (Australian Govt) home~handbook10part4~handbook Hand washing for hygiene (QLD Health)

39 RESOURCES Hand Hygiene Australia Online learning package

40 QUESTIONS??