• Promptly identify, communicate, and manage any outbreak of infection

• Quickly identify the source, method of spread and causative organisms responsible for the outbreak

• Prevent further spread of the organism through implementation of appropriate control measures and restrictions

• The guideline serves to ensure all individuals, departments, and any outside agencies likely to be involved in an outbreak have a clear understanding of their roles and are fully briefed

• Disseminate information concerning the outbreak timely and efficiently to ensure the rapid mobilisation of resources

• The guideline covers general principles of outbreak management. Specific guidance is available for a pandemic situation (e.g., COVID-19 and Pandemic influenza).

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition. Print copies must be destroyed after use.

Abbreviations

Outbreaks of infection vary greatly in extent and severity, ranging from a few cases, to a large outbreak of food poisoning involving hundreds of people. Outbreaks of a limited extent are those confined to the hospital. Major outbreaks are ones not confined to the hospital.

This guideline sets out the key elements of the Outbreak Management Plan to be implemented in the event of outbreaks / incidents of communicable disease including those which may be water-borne (e.g. cryptosporidiosis). The terms ‘incident’ and ‘Incident Management Team’ (IMT) are used as generic terms to cover both incidents and outbreaks.

A healthcare infection incident may be:

2.1 An exceptional infection episode

• A single case of any serious illness which has major implications for others (patients, staff and/or visitors), the organisation or wider public health e.g. infectious diseases of high consequence such as VHF.

2.2 A healthcare associated infection (HCAI) outbreak

• Two or more linked cases with the same infectious agent associated with the same healthcare setting over a specified time period.

or

• A higher than expected number of cases of HCAI in a given healthcare area over a specified time period (Period of Increased Incidence (PII)).

2.3 A healthcare infection exposure incident

• Exposure of patients, staff, public to a possible infectious agent as a result of a healthcare system failure or a near miss e.g. ventilation, water or decontamination incidents.

2.4 A healthcare infection data exceedance

• A greater than expected rate of infection compared with the usual background rate for that healthcare location.

An early and effective response to an actual or potential healthcare incident, outbreak or data exceedance is crucial. The IPC Team (IPCT) and local Health Protection Team (HPT) should be aware of and refer to the national minimum list of alert organisms/conditions. Actual or potential outbreaks of infection may be identified by one or more of the following methods:

• Clinical staff may notice an increased incidence of a specific organism, or patients with similar symptoms in their clinical area.
• Laboratory surveillance of microbiology reports may show an increase in the number of isolates of a single species.
• Occupational Health & Safety may note an increased incidence of a specific infection or similar symptoms in staff members. It is essential that any member of clinical staff report their suspicions to the IPCT promptly. There is 24-hour cover for the team; out-of-hours, a Consultant Medical Microbiologist is contactable via the hospital Switchboard.

The Site Management Team must also be notified of any suspected outbreak.

3.1 Assessment

Following detection/recognition of an incident a member of IPCT will:

• Visit and review the identified patient/ ward/ department.

• Report the incident/ outbreak via InPhase.

• Liaise with the Patient Safety Team as to whether the incident requires reporting as a Serious Incident (SI).

3.2 Closure of Inpatient Beds for Infection Prevention & Control Reasons

3.2.1 The closure of any bed(s) as an IPC measure has serious implications in terms of impact on clinical services but can be beneficial in control of outbreaks such as norovirus and allow for effective investigation and surveillance of outbreaks. For this reason, the decision is not taken lightly and is based on the number of affected patients, the organism involved, and mode of transmission.

3.2.2 Where possible, patients with communicable infections should be isolated in single rooms (implementing IPC procedures based on the mode of transmission of the pathogen (refer to the IPC 04: Isolation of Patients, and NIPCM (NHSE 2024) chapter on Transmission-Based Precautions)). It is unacceptable for a bay to close for one patient with an infection, when a single room is available for their use.

3.2.3 The decision to close a bed/ bay/ ward for an IPC reason should not be made without consultation with:

• The IPCT (out-of-hours this will be the On-call Consultant Medical Microbiologist. – contact via switchboard)

• The Ward Manager/ Head of Nursing/ Midwifery/ Silver On-call

• Site Manager/ Chief Operating Officer or their Deputy.

3.2.4 A member of the IPCT will attend daily Site Management meetings while bays/ wards are closed. Additional meetings will be arranged to manage bed capacity in the event of closures significantly impacting on patient flow.

3.2.5 Communication about areas closed will be disseminated daily by email to the key personnel.

3.2.6 Signage will be placed at the entrances to the closed ward/ area by a member of the IPCT. No other signage relating to IPC should be displayed without consultation with the Team.

3.2.7 No patients should be admitted to a bed/ bay/ ward that is closed for IPC reasons.

3.2.8 Patients should not be transferred to other healthcare organisations unless it is clinically urgent, and on consultation with a member of the IPCT.

3.2.9 Non-critical visiting will be suspended.

3.2.10 Staff movement must be kept to a minimum. Ideally a specific cohort of staff will provide

3.3 Investigation

The IPCT (or HPT if community-based incident) will establish an Incident Management Team (IMT) if required.

3.3.1 The Infection Control Dr/ Infection Prevention Nurse Consultant will usually chair the IMT and lead the investigation of Trust healthcare incidents. Where there are implications for the wider community e.g. TB or measles, or rare events such as CJD or a Hepatitis B/HIV look back, or where there is an actual or potential conflict of interest with the hospital service, the CCDC may chair the IMT. A draft agenda for the IMT is in Appendix 1.

3.3.2 The membership of the IMT will vary depending on the nature of the incident, however will always include:

• The Infection Prevention Nurse Consultant/ Lead IPC Nurse

• Infection Control Doctor (Consultant Medical Microbiologist)

• The Consultant in Communicable Disease Control

• The Director of Infection Prevention and Control (or Deputy)

3.3.3 In addition to the above staff, the IMT will include senior representatives with the following as its core membership:

• Local Authority Environmental Health Department (EHO)

• Regional UK Health Security Agency representative

• Medical Director (or deputy)

• Chief Nurse/ Midwife (or deputy)

• Clinician of the incident area

• Head of Nursing/ Midwifery/ Clinical Matron of the incident area

• Occupational Health & Safety representative

• Site Manager/ Chief Operating Officer

• Communication/ media officer

The roles, responsibilities and duty of key players are outlined at Appendix 2.

*Please see Appendix 3 for the Tasks and Responsibilities of the IMT members (which is summarised in Appendix 4.

The overall objectives of the IMT are:

1. To bring together all the relevant people in the organisation to deal with the problem in a timely manner

2. To control the source or possible source of infection

3. To contain the spread of the infection

4. To communicate with the public and media

5. To monitor the effectiveness of the initial measures and record lessons learnt; making recommendations for potential changes.

6. When the outbreak is over, a report must be written and circulated to the pertinent agencies containing details of actions taken and any recommendations for further action. In addition to the overall objectives given above, at the first meeting of the IMT, the following will be considered:

7. The evidence provided by the IPCT regarding the suspected outbreak

8. Define the measures necessary to contain the outbreak, identify and control the source, and monitor the effectiveness of the prevention and control measures

9. Identify what assistance and other resources might be required

10. Ensure that all appropriate staff and agencies are kept informed

11. The frequency and timing of future meetings of the IMT.

12. Monitoring of the outbreak.

3.3.4 A case definition for the purpose of the incident will be agreed. A case definition should include the following: the people involved (e.g. patients, staff); the symptoms/pathogen/infection (e.g. with Group A Streptococci); the place (e.g. care area(s) involved); and a limit of time (e.g. between January and March year/date). The case definition(s) should be regularly reviewed and refined (if required) throughout the incident investigation as more information becomes available.

3.3.5 The investigation of the incident should include: an ongoing epidemiological investigation; the nature and characteristics of the incident e.g. a microbiological investigation; and how cases were exposed to the infective agent or other hazard to inform control measures.

3.3.6 Identify any change(s) in the system: staffing, procedures/processing, equipment, suppliers. A step-by-step review of procedure(s). A generic outbreak checklist is in Appendix 5.

3.3.7 Identify and count all cases and/or persons exposed: This includes the total number of confirmed/probable/possible exposed cases. A generic incident/ outbreak data collection tool is in Appendix 6.

3.3.8 The IMT should receive and discuss all information gathered and epidemiological outputs e.g. an epidemiological (epi) curve, a timeline and a ward map to:

• Generate hypotheses as to which cross-transmission pathways and clinical procedures may be involved.

• Determine whether additional case-finding and control measures may be necessary.

• Confirm that all incident control measures are being applied effectively and are sufficient.

3.3.9 If staff screening is being considered as part of the investigation, this must be only on advice and management by Occupational Health & Safety.

4.1 If no new cases arise and any remaining cases are considered to no longer pose a risk, the IMT should agree on actions prior to resumption of normal service.

4.2 Before re-opening beds closed for infection prevention and control purposes, it is essential that the affected bays are terminally cleaned (See IPC28b: Decontamination and Management of the Care Environment)

4.3 Once the incident is closed, the IMT should summarise the incident in a full report.

Monitoring of the Outbreak Management Plan will be via the outbreak/ incident/ SI summary report.

Department of Health 2022 The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance. Available at: https://www.gov.uk/government/publications/the-health-and-social-care-act-2008-code-of-practice-on-the-prevention-and-control-of-infections-and-related-guidance.

Department of Health 2015 Foodborne and non-foodborne gastrointestinal outbreaks surveillance: https://www.gov.uk/guidance/foodborne-and-non-foodborne-gastrointestinal-outbreaks-surveillance

Foods Standards Agency 2008 Management of Outbreaks of Foodborne Illness in England and Wales. Available at: https://old.food.gov.uk/sites/default/files/multimedia/pdfs/outbreakmanagement.pdf

NHS England 2024 National Infection Prevention and Control Manual for England. Available at: https://www.england.nhs.uk/national-infection-prevention-and-control-manual-nipcm-for-england/

UK Health Security Agency 2023 Communicable disease outbreak management: appendices. Available at: https://assets.publishing.service.gov.uk/media/6569c4981104cf000dfa733c/communicable-disease-outbreak-management-appendices.pdf

UK Health Security Agency 2024 Communicable Disease Outbreak Management: Operational guidance. Webpages. Available at: https://www.gov.uk/government/publications/communicable-disease-outbreak-management-operational-guidance

1. Introduction (Reminder of confidentiality and need for accurate records)

2. Appropriate membership

3. Declarations of conflicts of interest

4. Duty of candour

5. Minutes of last meeting (if applicable) including review of actions agreed

6. Incident update

1. General situation statement

2. Patient report

3. Microbiology report

4. Other relevant reports

7. Risk Management/Control Measures

• Patients

• General

• Public Health

• Staff

8. Care of Patients - Hospital and Community

9. Further Investigation

• Epidemiological

10. Healthcare Infection Incident Assessment Tool (HIIAT)

11. Communications

• Advice to public (letters, printed materials, media, social networking, websites, helplines etc)

• Advice to professionals (GPs, clinical staff)

• Media (print, radio, TV, websites, social networking sites)

• Any need to inform other authorities

• NHSE/I national team

12. AOB

13. Action list with timescale and allocated responsibility

14. Date and time of next meeting

FHFT Staff

All staff

Responsible for ensuring they access understand and adhere to the IPC guidelines including the outbreak policy. All staff must complete yearly mandatory infection prevention & control updates.

Ward/ Department Manager (or nurse in charge)

Responsible for ensuring that IPC advice is followed, and safe practices are adhered to. Monitoring compliance with IPC mandatory training through appraisals. Reporting any suspected or confirmed outbreak timely.

• Inform the IPCT if an outbreak is suspected. Out of hours inform the Site management team for a comprehensive assessment and escalation to on call microbiologist.

• Isolate affected patients in liaison with Site Management Team

• Collect and record accurately any specimens advised

• Ensure there is adequate, appropriate PPE available

• Liaise with housekeeping if additional cleaning is required as a result of any bed moves

• Ensure all outbreak points are communicated at the hand-over/ huddle.

Associate Directors/ HoN/Ms/ Clinical Matrons/ IPC Working Group Lead Clinicians

Responsible for the safe and effective care of patients in their areas, ensuring resources are available and systems in place to monitor and deliver appropriate IPC practice

Site Operational Team

Responsible for ensuing patients are placed in accordance with the guideline for escalating situations where safe patient placement cannot be achieved. Out of hours, conduct initial assessment and gather information liaising with the medical team prior to escalating to on call microbiologist. Timely communication of a suspected outbreak is critical.

IPC Team

The IPC Team reports to the DIPC and has responsibility for the development and implementation of the FHFT IPC Strategy and Annual Plan. This includes the development, management, implementation, and audit of this guideline.

Consultant Medical Microbiologist Hospital Infection Control Doctor

• Present to the IMT relevant microbiological information relating to the outbreak.

• Request identified resources to enable microbiological testing to be undertaken speedily and efficiently and to report on this to the IMT.

• Undertake microbiological testing of relevant human and non-human samples and to arrange, as necessary, further investigations by other laboratories / UKHSA.

• Provide the results/ advice on results of all testing to the source of the request and to the holder of the case list.

• To ensure that IPC measures in hospital and (in conjunction with the Consultant in Communicable Disease Control) (CCDC) in the community are appropriate.

• To participate, as necessary, in the inspection of premises and procurement of samples.

• Ensure all notifications of notifiable diseases have been done.

Estates and Facilities

Responsibility for ensuring the clinical environment if fit for purpose and complies with health build guidance, including cleaning to national cleanliness standards.

Director Infection Prevention and Control (DIPC)

The DIPC reports directly to the Chief Executive Officer and Trust Board. The DIPC oversees IPC policies and their implementation. DIPC is responsible for ensuring there are adequate resources available to manage IPC within FHFT and that there are appropriate arrangements for the prevention and control of infections throughout the Trust.

When a major outbreak is suspected/ confirmed the DIPC is responsible for:

• Convening an IMT and lead or delegate the lead

• Communicating to the executive team

• With the IMT, address decisions to suspend any services or ward closures

• Define and call the end of an outbreak

Chief Executive Officer

Has overall responsibility for ensuring that FHFT meets its statutory and non-statutory obligations in respect of maintaining patient safety and appropriate standards of clinical care in relation to IPC.

Consultant in charge of affected area/ Medical team

• Ensure timely and appropriate clinical assessment of all patients involved and feedback to the OCT • Ensure appropriate clinical care including all investigations advised by OCT is maintained. Advise on medical staffing capacity and capability to deal with outbreak

• Communicate with junior medical staff and management colleagues

• Implement advice from OCT regarding movement of medical staff and placement of locum doctors and medical students

Occupational Health

• Identify a key person in Occupational Health to communicate with the IPCT

• Monitor the health of staff in the wards/ departments affected

• Complete a list of staff contacts and arrange for the collection of specimens if required

• Advise the Deans of Medical, Nursing, AHP Universities and other relevant organisations with staff affected if applicable

• Advise on staff health as advised by the IMT.

Key External Personnel

Consultants in Communicable Disease Control (CCDC) - Tasks and responsibilities

1. Declare an outbreak following appropriate consultation
2. Convene the IMT and ensure appropriate membership
3. Chair the IMT unless a different chair has been agreed. For hospital outbreaks the Hospital Infection Control Doctor or Director of Infection Prevention and Control will normally chair the team. In such circumstances the Consultant in Communicable Disease Control (CCDC) will act as his/her deputy. In the event of major outbreaks, the CCDC will chair the IMT.
4. Ensure initial response and investigation begins within 24 hours of outbreak reported
5. Ensure an incident room is set up at an appropriate venue, if required
6. Identify resources that might be needed to manage the situation
7. Liaise with clinicians over need for testing and management of cases
8. Agree with IMT who will lead the media response
9. Ensure communications such as letters/bulletins/press statements and so on are agreed and disseminated
10. Arrange for appropriate identification and follow up of contacts
11. Provide advice on and arrange with partner organisations the provision of prophylaxis or immunisation as necessary
12. Provide epidemiological advice and support analysis and interpretation of data
13. Ensure appropriate stakeholders are informed and updated, including LA, NHS England, ICBs, acute trusts, microbiologists, UKHSA
14. Liaise with colleagues in adjacent HPTs as necessary
15. Inform relevant regional UKHSA director as necessary
16. Ensure all documentation relating to the outbreak is correctly managed and disseminated, incorporating information governance and data protection requirements
17. Ensure the constructive debrief is held and lessons learnt disseminated and acted on
18. Coordinate production of outbreak report and ensure recommendations are acted on

Environmental Health Officer (Representative of Chief Environmental Health Officer) - Tasks and responsibilities

In conjunction with the district Consultant in Communicable Disease Control (CCDC):

1. Investigate potential sources of outbreak and secure improvements where the LA is the enforcing authority or where it is the home authority for companies that operate across LA boundaries
2. Advise the IMT where enforcement falls to another body, for example the HSE
3. Provide help and advice including the investigation of cases or contacts
4. Provide mechanisms for out of hours communications with the IMT and stakeholders
5. Arrange collection of samples from cases and contacts and undertake appropriate sampling of food, water and environmental samples
6. Arrange delivery of all samples to appropriate laboratories
7. Liaise with the office of the public analyst and UKHSA laboratories for analysis of samples if chemical contamination is suspected
8. Provide reports to the LA and undertake necessary enforcement actions
9. Inform relevant food and non-food businesses of hazards as appropriate
10. Arrange for the identification, seizure, removal and safe disposal of contaminated food within their LA area
11. Ensure infection control advice is implemented, using relevant legal powers as necessary and working with UKHSA staff, NHS IPCTs or others
12. Ensure arrangements for collection and disposal of clinical waste remain appropriate. Discuss with IMT and contractors any changes required
13. Identify resources so that tasks can be undertaken efficiently
14. Monitor the progress of the investigation and provide updates to the IMT
15. Report to colleagues in the Environmental Health Department and liaise with those in neighbouring districts
16. Be jointly responsible for communicating the cessation of the outbreak to the stakeholders and the public in collaboration with the CCDC
17. Ensure continuity of evidence in case results are needed for subsequent criminal prosecution

Principal Scientist Water Authority (For waterborne outbreaks only) - Tasks and responsibilities

1. To provide professional advice to the IMT
2. To provide expert advise on water safety for the general public.
3. To keep the IMT appraised of any developments arising from the water companies’ actions.
4. To ensure, if indicated, that ‘Boil Water’ recommendations are managed through agreed mechanisms.
5. To ensure, if indicated, that water bowsers are available for public use.

Emergency Preparedness Resilience and Response

Frimley Health NHS Foundation Trust is classified as a category 1 responder by the Civil Contingencies Act 2004. FHFT works with partners across the local health economy and within local emergency services to ensure the Trust can respond to emergencies, guided by the NHS England EPRR Framework.

FHFT conducts regular internal training and Tabletop exercises to test procedures and ensure the Trust is prepared for a variety of incident types and causes. The Chief Executive has overall responsibility for the activities of the Trust, and is overall lead for Emergency Planning. EPRR activity within the Trust is the responsibility of the Accountable Emergency Officer (AEO) with the development of plans and processes being undertaken by Emergency Planning. Governance and oversight of arrangements are provided through the Trust Resilience Committee.

The Trust has an internal EPRR Group that considers all aspects of preparedness which is chaired by the Accountable Emergency Officer as well as being active members of the Local Resilience Forum (LRF) and the Local Health Resilience Partnership (LHRP).

The early duties of the IMT will include:

1. To review the epidemiological, microbiological and environmental evidence and verify an outbreak is occurring
2. Establishing case definitions
3. To regularly conduct a full risk assessment whilst the outbreak is on-going
4. To develop a strategy to deal with the outbreak and allocate responsibilities based on the risk assessment
5. To determine the level of the outbreak
6. Identification of resources required to tackle all aspects of the outbreak, including:

• Epidemiological investigation staff
• Environmental health staff
• Laboratory staff
• Clerical support staff
• Clinical care (nursing and medical staff)

7. To ensure that appropriate control measures are implemented to prevent further primary and secondary cases
8. To agree appropriate further epidemiological, microbiological, environmental and food chain investigations
9. To communicate with other professionals, the media and the public as required providing accurate and timely information
10. To determine when the outbreak can be considered over based on on-going risk assessment and taking account of risk management actions
11. To make recommendations regarding the development of systems and procedures to prevent a future occurrence of similar incidents and where feasible enact these
12. To produce reports at least one of which will be the final report containing lessons learnt and recommendations
13. Ensure all statutory and non-statutory obligations are met (including notification of notifiable infectious diseases where applicable).

The responsibilities resting with various individual / organizations for different aspects of outbreak investigation and control are set out below:

                    FUNCTION                 OFFICER 

[To be completed by IPC Team]

Date:

Confirmed/Suspected Infectious Agent:

Hospital/Clinical Area/Care Facility:

Case Definition:

Date of Ward/Area Closure (if applicable): Date of Ward/Area Re-opening:

Name/ Designation of person responsible for closure:

Name/ Designation of person responsible for Re-opening:

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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