Infection Control Plan
INFECTION CONTROL PLAN
TABLE OF CONTENTS
Infection Control Surveillance ....................................................................................................... 3
Healthcare-Associated Infection Summary Report by Outpatient Visits ...................................... 5
Monthly Infection Rates by Site ................................................................................................... 6
Line listing of Outpatient Infections .............................................................................................. 7
Infection Prevention Surveillance Data Entry Form ...................................................................... 8
Surgical Site Infection (SSI) Ambulatory Surgery ........................................................................ 9
Definitions of Infections for Surveillance Activities ................................................................... 10
Infection Prevention Plan ............................................................................................................. 16
Reportable Diseases ..................................................................................................................... 21
Outbreak Investigation ................................................................................................................. 22
Outbreak Investigation Form ....................................................................................................... 24
Healthcare-Associated Infections and Sentinel Events ................................................................ 26
Healthcare-Associated Infections Reviewed as Sentinel Events ................................................. 27
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Infection Control Plan
Infection Control Surveillance
PURPOSE
To have knowledge of patient and employee infections to guide prevention activities and so appropriate
actions/follow-up may be done.
POLICY

The Infection Preventionist does surveillance of infections among patients and employees.

Healthcare-associated infections in ambulatory care are those associated temporally with an
ambulatory care visit or with the care provided during the visit.

Targeted surveillance may be done in the ambulatory setting with a focus on high-risk areas
and those with a potential to reduce risks (i.e., surgical procedure-related infections).

Ambulatory surgery centers shall develop a system for post-discharge surveillance.
I.
The Infection Preventionist does surveillance of healthcare-associated infections by:
A.
Review of culture reports and other pertinent lab data
B.
Nurse consultation and referral
C.
Medical record review
D.
Patient examination
E.
Personal consultation by employees
F.
Follow-up on communicable disease exposure
G.
Review of employee's physical assessments
H.
Maintenance of the employee infection record
I.
Physician consultation
II.
Specific definitions of healthcare-associated infections are used consistently.
(See "Definitions") Healthcare-associated infections are reported monthly to the Quality or
Infection Prevention Committee.
III.
Surveillance documentation is maintained on the:
IV.
A.
Line Listing of Patient Infections
B.
Log of Employee Infections
Outcome measures shall be monitored:
A.
Focus on the results of an activity, e.g., surgical procedure.
B.
Healthcare-associated infections are outcome measures.
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Infection Control Plan
V.
Process measures shall be monitored:
A.
Involves monitoring of practices that directly or indirectly contribute to a health outcome.
B.
Focuses on observations and analysis of practices and environmental conditions.
C.
May include but not limited to:
Enviromental Cleaning
Sterilization process
Medication use and storage
VI.
Reporting of infections to the Health Department is done as required by law.
Reference:
Friedman, C and Petersen, KH. Infection Control in Ambulatory Care (APIC). MA:
Jones and Bartlett Publishers, Inc., 2004. Guidelines for Enviromental Infection
Control in Health-Care Facilities, CDC 2005
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Infection Control Plan
Healthcare- Associated Infection Summary Report by Outpatient Visits
Year
1
QUARTER
2
3
4
TOTAL
Infections/1000
Outpatient visits
Respiratory
Upper
Lower (pneumonia or bronchitis)
Wound
Surgical
Decubitus
Other (skin)
Conjunctivitis
Sepsis (Bloodstream)
Other
TOTAL BY SPECIALTY OR UNIT
A. This month’s total infections:
÷
÷
B. Total outpatient Visits
for month:
X
1,000
=
X
1,000
=
C. Infections per 1000
outpatient visits:
Specific Trends:
Actions Taken:
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Infection Control Plan
Monthly Infection Rates by Site
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Total
Respiratory Infection
Cold
0
Pneumonia
0
Bronchitis
0
Sinusitis
0
Influenza-like illness
0
Total Respiratory
0
0
0
0
0
0
0
0
0
0
0
0
0
Gastrointestinal
C-diff
0
Noro-virus
0
Total Gastrointestinal
0
0
0
0
0
0
0
0
0
0
0
0
0
Skin
Cellulitis/soft tissue/wound
0
Fungal skin infection
0
Herpes simplex (fever blister)
0
Herpes zoster (shingles)
0
Total Skin:
0
0
0
0
0
0
0
0
0
0
0
0
0
Eye
0
Conjunctivitis
Total Eye
0
0
0
0
0
0
0
0
0
0
0
0
0
TASS
Total TASS
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Other
Total Other
Healthcare-Associated
Infections (HAI) Total:
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total Outpatient Visits
HAI Rate per Outpatient Visits
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Infection Control Plan
Line Listing of Outpatient Infections
Month___________ Year______
Name_______________
Date most recent visit_______
Type of Infection______
Symptoms/Date
Cultures:
Date/Site/Results
Treatment
Other actions
(if needed)
Does not meet
infection criteria
HAI
CAI
Name_______________
Date most recent visit_______
Type of Infection______
Symptoms/Date
Cultures:
Treatment
Other actions
(if needed)
Does not meet
infection criteria
HAI
CAI
Name_______________
Date most recent visit_______
Type of Infection______
Symptoms/Date
Cultures:
Date/Site/Results
Treatment
Other actions
(if needed)
Does not meet
infection criteria
HAI
CAI
Name_______________
Date most recent visit_______
Type of Infection______
Symptoms/Date
Cultures:
Date/Site/Results
Treatment
Other actions
(if needed)
Does not meet
infection criteria
HAI
CAI
Name_______________
Date most recent visit_______
Type of Infection______
Symptoms/Date
Cultures:
Date/Site/Results
Treatment
Other actions
(if needed)
Does not meet
infection criteria
HAI
CAI
Name_______________
Date most recent visit_______
Type of Infection______
Symptoms/Date
Cultures:
Date/Site/Results
Treatment
Other actions
(if needed)
Does not meet
infection criteria
HAI
CAI
Name_______________
Date most recent visit_______
Type of Infection______
Symptoms/Date
Cultures:
Date/Site/Results
Treatment
Other actions
(if needed)
Does not meet
infection criteria
HAI
CAI
Date/Site/Results
HAI = healthcare-associated infection for this facility
CAI = community acquired infection (not healthcare-associated for this facility)
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Infection Control Surveillance Data Entry Form
Patient ID #:
Patient Name:
Visit Date:
Age
Infection Date:
Site:
Sex
48 hrs Preceding Infection
Service:
Operation

Date
Duration
Yes

No
Procedure
Hrs
Min.

MD visit
date
ER visit
date
Post-op antibiotics
Type and route
PNEU:
CXR Confirmed
Surgeon

General Anes
ASA

Yes
No
2nd
Wound Class
H&P


Implant R L
Scheduled case
Yes



Yes

No

Yes

No
Yes
Bloodstream infection
No
DX:
No
NOTES:






Yes
Yes
Yes
Yes
Yes
Yes
Yes







Room #
Prophylactic antibiotics
Incision
Time
Surg prophy abt (type & Route)
Time Admin
Culture
Date
Source
Results
Comments
SIGNS/SYMPTOMS WITHIN 24 HOURS OF VISIT/PROCEDURE
(Circle and indicate dates for all that may be considered related to suspected infection.)
Fever (38° C/100.4° F)
Chills
Leukocytosis (>10k)
Hypertension (systolic <90)
Oliguria
Apnea
Tachypnea
Decreased O2 sat.
Respiratory distress
Bradycardia
Resp
Rales
Dullness to percussion
Wheezing cough
Change in character of sputum
Increased production of respiratory secretions
New onset of purulent sputum
LRI
Rhonchi
Lung abscess
Empyema
URI
Erythema of pharynx
Sore throat
Cough
Hoarseness
Purulent exudate
Abscess
Vascular
Pain, erythema, or heat at vascular site
Skin/wound
Pain/tenderness
Localized swelling
Erythema
Heat
Pustules
Vesicles
Boils
Change in burn wound appearance
Eye
GI
Rhinorrhea
Purulent drainage at vascular site
Purulent drainage
Abscess
Purulent exudate from (circle one or more):
Conjunctiva, eyelid, cornea, meibomian glands, lacrimal glands
Eye pain
Visual disturbance
Hypopyon
Conjunctivitis
Nausea
Vomiting
Abdominal pain/tenderness
Diarrhea (acute onset)
Mental confusion
Hyperglycemia
Mental confusion
Anorexia
Purulent material from intraabdominal space
Urinary
Urgency
Frequency
Bone/Joint
Drainage from suspected site
Abscess
Jaundice
Abdominal distension
Gross blood in stools
Prefeeding residuals
Dysuria
Suprapubic tenderness
Pyuria (>10wbc/mm3)
Bone pain
Joint pain
Vertebral disc pain
Effusion or limited motion
Reference: Friedman, C and Petersen, KH. Infection Control in Ambulatory Care (APIC). MA: Jones and Bartlett Publishers, Inc., 2004.
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No
No
No
No
No
No
No
Surgical Site Infection (SSI)
Event #:
Patient Name
Age
Event Type: SSI
Date of Event
Outpatient
 Yes
Date of Procedure
 No
MDRO Infection:
 Yes
 No
Specific Event
 Superficial Incisional Primary (SIP)
 Deep Incisional Primary (DIP)
 Superficial Incisional Secondary (SIS)
 Deep Incisional Secondary (DIS)
 Organ/Space (Specify Site:)
Specify Criteria Used - Check all that apply:
Signs & Symptoms
 Purulent drainage or material
 Pain or tenderness
 Localized swelling
 Redness
 Heat
 Fever
 Abscess
 Hypothermia
 Bradycardia
 Lethargy
 Cough
 Nausea
 Vomiting
 Other evidence of infection found on direct exam, during
surgery, or by diagnostic tests
 Other signs & symptoms
Detected
Secondary Bloodstream Infection
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Laboratory
 Positive culture
 Not cultured
 Blood culture not done or no organisms detected in blood
 Positive Gram stain when culture is negative or not done
 Other positive laboratory tests
 Radiographic evidence of infection
Clinical Diagnosis
 Physician diagnosis of this event type
 Physician institutes appropriate antimicrobial therapy
 Post-discharge surveillance
 Yes
 Return for follow-up
 No
Definitions of Infections for Surveillance Activities
Ambulatory care facilities generally have lower healthcare-associated infection rates than acute
care facilities, yet surveillance is important to detect infections and to determine if there are
opportunities for improvement by the facility.
In order to have reliability and validity of surveillance data, specific definitions of infections
must be used consistently. Specific national definitions for ambulatory care facilities have not
yet been developed, therefore the following summary of definitions for long term care facilities
is adapted from definitions published by McGeer and others in 1991.
NOTE: Ambulatory facilities that are more acute care (e.g., surgery centers, dialysis) should use
the CDC National Healthcare Safety Network (NHSN) definitions of healthcare-associated
infections.
http://www.cdc.gov/ncidod/dhqp/pdf/NNIS/NosInfDefinitions.pdf
Reference:
McGeer A, Campbell B, Emori TG, et al. Definitions of Infection For
Surveillance In Long-Term Care Facilities. Am J Infect Control 1991; 19:1-7.
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Site: Upper Respiratory
Common Cold Syndromes
Criteria
Conditions
TWO or more of:
 running nose or sneezing
 stuffy nose (i.e., nasal congestion)
 sore throat or hoarseness or difficulty
swallowing
 dry cough
 new swollen or tender glands in the neck
(i.e., cervical lymphadenopathy)
Symptoms must be acute and not related to
allergy (seasonal or medication)
Comments
Fever not required, but does not exclude
diagnosis
Ear
Criteria
Diagnosis by a physician of any ear infection
or
Any new drainage from one or both ears
Mouth (and Peri-Oral)
(includes oral candidiasis)
Criteria
Diagnosis by physician or dentist of any infection
Sinusitis
Criteria
Diagnosis by a physician
Criteria
Conditions
Fever and THREE or more of:
 chills
 headache or eye pain
 malaise or loss of appetite
 sore throat
 dry cough
Symptoms must be acute and
Must be during influenza season
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Comments
When this definition is met, it takes precedence
over others
Influenza-Like Illness
Site: Lower Respiratory
Pneumonia
Criteria

Interpretation by a radiologist of a chest x-ray as demonstrating pneumonia,
probable pneumonia, or presence of an infiltrate with a compatible clinical syndrome
Other Lower Respiratory
Criteria
Comments
THREE or more of:
Symptoms must be acute and
either no chest x-ray, or x-ray does not
meet the above criteria for pneumonia



new or increased cough
new or increased sputum production, fever,
pleuritic chest pain
new physical findings on chest exam (rales,
rhonchi, wheezes, bronchial breathing)
ONE or more of:
 new shortness of breath
 increased respiratory rate (>25/min.)
 change in mental status
 change in functional status
Site: Gastrointestinal Tract
Gastroenteritis
Criteria
Conditions
Three or more loose or watery stools above
what is normal for the patient in a 24 hour
period or
For the first two criteria, there must be no
evidence of a non-infectious cause; e.g. for
diarrhea: laxative, change in tube feeding or
medication; for vomiting: change in
medication, peptic ulcer disease
THREE or more episodes of vomiting within
a 24 hour period or
Stool culture positive for a pathogen
(Salmonella, Shigella, Campylobacter
species, or Clostridium difficile) with a
compatible clinical syndrome
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Site: Eye
Conjunctivitis
Criteria
Conditions
One of the following:
No evidence of trauma (e.g., foreign body)
Pus appearing from one or both eyes >24 hours or allergy as a cause
New or increased conjunctival redness, with or
without itching or pain, present for at least 24
hours (pink eye)
Site: Skin
Cellulitis / Soft Tissue Wound
Fungal Skin Infection
Criteria
Maculopapular rash
and
physician diagnosis or laboratory confirmation
Conditions
No evidence of a non-infectious cause
(e.g., allergy to new medication)
Herpes Simplex (cold sores) or Herpes Zoster (shingles)
Criteria
Vesicular rash
and
physician diagnosis or laboratory confirmation
Scabies
Criteria
Maculopapular and/or itching rash
and
physician diagnosis or laboratory confirmation
Conditions
If there is no laboratory confirmation, then
there must be no evidence of a noninfectious cause
Unexplained Febrile Episode
Criteria
Documentation in the medical record of fever
on 2 or more occasions at least 12 hours apart
in any three day period
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Conditions
No known infections or noninfectious cause
for the fever (e.g., infection at any site,
medication)
Glossary
CHANGE IN
CHARACTER OF
URINE:
Any significant change in the gross (e.g., new bloody urine, foul smell or amount of
sediment) or microscopic (new pyuria or microscopic hematuria) character of the urine.
For microscopic changes, this means that the results of a previous urinalysis must be on
the chart. There is no time limit on when the previous urinalysis may have been done.
CHANGE IN
FUNCTIONAL
STATUS:
A significant change in the patient's ability or willingness to carry out activities of daily
living. For instance, new incontinence, new inability to walk to the dining room or
increased difficulty in transfers would all be recorded as change in functional status.
CHANGE IN MENTAL
STATUS:
A significant change in the patient's cognitive function: for most patients, this will mean
an increased level of confusion (e.g., new non-recognition of nurses).
COMPATIBLE
CLINICAL
SYNDROME:
An acute illness with symptoms related to the relevant system (respiratory or
gastrointestinal). In general, the symptoms will be some of those included in the
definitions for either lower respiratory infection or gastroenteritis, but the criteria for the
infection need not be met.
DIAGNOSIS BY A
PHYSICIAN:
Requires one of: a written note by a physician specifying diagnosis, a nursing note
specifying that a diagnosis was made by a physician or a verbal report from either a
physician or nurse that a specific diagnosis has been made.
EAR INFECTION:
Includes infections of the external ear (otitis externa), middle ear (otitis media) or
internal ear (otitis internal, labyrinthitis, vestibular neuronitis).
FEVER:
A single temperature, taken by any route, of > 100.5° F.
HYPOTHERMIA:
A temperature which is below 94° F or which does not register on the thermometer
being used.
LABORATORY
CONFIRMATION:
With respect to skin infections, acceptable lab confirmation consists of
1.
2.
3.
Candida:
Other fungi:
Herpes zoster
or shingles:
4.
Scabies:
positive culture from swab
positive culture from scraping
positive electron microscopic (EM) findings from
scraping or positive culture of scraping on swab
(note that EM cannot distinguish different species of Herpes)
ositive microscopic exam of scrapings
NEW PHYSICAL
FINDINGS ON CHEST
EXAM:
New findings on examination of the chest with a stethoscope which
suggest pneumonia: i.e., rales (crackles), rhonchi (wheezes) or bronchial
breathing.
ORGANISM
THOUGHT TO BE A
CONTAMINANT
(in blood culture):
Organisms which are common skin flora may contaminate blood cultures and a single
blood culture positive for one of these may be non-significant.
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Medical Terms
CONJUNCTIVA:
Mucous membrane covering the eyeball.
FLANK:
Side of the body, below the rib cage and above the hip (the area in which pain is usually
felt in upper urinary tract infections, referred to as the "costovertebral angle", is a
relatively posterior area of the flank just below the ribs and extending from the side
nearly to the backbone).
LYMPHADENOPATHY:
Enlargement of lymph glands.
MACULOPA-PULAR:
Applied to a rash characterized by abnormally colored (usually red) areas of skin, of
varying size, which may be either flat or slightly raised.
MALAISE:
A feeling of generalized discomfort or uneasiness or being "out-of sorts".
PATHOGEN:
A microorganism capable of causing disease.
PLEURITIC
CHEST PAIN:
Pain caused by inflammation of the pleura (lung lining), a sharp pain felt at any site over
the rib-cage, which is brought on or made much worse by deep breathing.
PURULENT:
Containing the by-products of inflammation (pus).
SEROUS:
With watery consistency (as opposed to purulent).
SUPRAPUBIC:
Above the pubic arch (i.e., the area of the bladder, in the central lower area of the
abdomen).
VESICULAR:
Applied to a rash characterized by blister-like lesions (i.e., localized areas of elevated
skin, usually only a few mm in size, containing a watery substance).
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Infection Prevention Plan
PURPOSE
To develop and maintain a written plan for infection prevention including an assessment of risk,
services provided, the population served, strategies to decrease risk, and a surveillance plan.
POLICY
I.
A current written infection prevention plan will be implemented.
II.
The written plan will include:
A.
Assessment of risk
B.
Assessment of services provided
C.
Assessment of the population served
D.
Prioritized strategies to decrease risk
E.
Evaluation of effectiveness of strategies
F.
Surveillance plan based on analysis of previous data.
III.
The written infection prevention plan will guide the activities of the infection prevention
department.
IV.
The plan will be updated at least annually and more often as needed (e.g., changes in
services provided, risks, etc.).
V.
The written plan with the evaluation of effectiveness of the strategies may facilitate
development of an annual summary of the infection prevention program.
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Infection Control Plan Assessment
This plan has been developed by the Infection Prevention Committee
with input and collaboration from the following:


Safety Committee
Quality Assurance/Performance Improvement Committee


Leadership
Chief of Services/Medical Director
A risk assessment is a component of this plan.
The plan and risk assessment are formally reviewed at least annually
and whenever significant changes occur in the elements that affect risk.
Risk Assessment
Date:
Factors
Characteristics that increase risks
Geographic location and community
environment
Care, treatment and services provided, e.g.:


Surgery
Physician office visits
Population characteristics, e.g.:
Elderly, Diabetic
Analysis of infection prevention and control data
High Risk
Problem-prone
High Volume
Improvement needed
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Characteristics that decrease risks
Based on the risk assessment, the facility has identified the following risks and prioritized them in descending order:
Priority
Risk
For each prioritized risk, identify goals, strategies, responsible person, time frame, and evaluation of effectiveness.
IMPLEMENTATION
RISKS
GOALS
STRATEGIES
Responsible
Persons
Time Frame
Method &
Evaluation of
Effectiveness
Infection Control Plan Reviewed by:
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Leadership representative
Date
Date
Date
Leadership representative
Date
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Infection Control Plan
This plan has been developed by the Infection Prevention Committee
with input and collaboration from the following:


Important Aspects
of Care
Safety Committee
Quality Assurance/Performance Improvement
Committee
Indicators
SURVEILLANCE of
healthcare-associated
infections, targeted to
high-risk problemprone infections
EXAMPLE
Education
Benchmark
Data Source
EXAMPLE
EXAMPLE
Obtain from literature
or compare to this
facility
Medical records, lab
reports, staff clinical
evaluations
New hires & Annual
Within 30 days of
employment and
annually. Use
national recognized
organization’s
information for
training
Employee Files
Staff Immunizations
New Hires & Annual
(based on TB facility
risk assessment)
All new hires will
have documentation
of at least negative 1st
step TB prior to
patient care. Use
State and CDC
guidelines
Employee Files
Staff Immunizations
New Hires
Hep B
Employee
Infection/Communica
ble Diseases
Surgical Site
Infections
Community Acquired
Infections
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

Leadership
Chief of Services/Medical
Director
Data Collection
Sample
Collected /
Tabulated Reports
EXAMPLE Infection
Preventionist (IP)
EXAMPLE
EXAMPLE
100% of patients for
one month prior &
proceeding the month
of FEB. 2010
On-going, Monthly/
Quarterly
Infection
Preventionist
100% of employee
records
Quarterly
100% employee
records
Quarterly
Healthcare Acquired
Infections
Reportable
Communicable
Diseases
Surgical Procedure
Surveillance
OR Cleaning
Surveillance
Sterile Processing
Surveillance
Housekeeping
Surveillance
Pharmacy
Surveillance
New
Products/Equipment,
(i.e. Medications,
sterilizer
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Reportable Diseases
PURPOSE
To report diseases to the state as required by law.
POLICY
Health care facilities are required by law to report certain diseases. A list of these diseases and
the report forms from the health department are maintained and reporting is done as required. An
exception to reporting is if there is knowledge that the disease has already been reported by the
laboratory or other provider.
Fill in your State Health Departments reporting information
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Infection Control
Outbreak Investigation
I.
DEFINITION
An outbreak is defined as two (2) or more cases over the usual (endemic) number of
cases of healthcare–associated infections, usually produced by the same organism. The
time period will vary according to the infection.
II.
RECOGNITION AND NOTIFICATION
Any personnel recognizing a possible epidemic will immediately report this to the
Infection Prevention department through which the facility management and medical
director will be notified.
III.
PRELIMINARY INVESTIGATION
The IP (and others as assigned), is designated as the investigation coordinator. He or she
will review the charts of the involved patients and determine that an epidemic exists. The
investigation coordinator, director of nursing, administrator, and medical director will
confer and prepare a preliminary plan of investigation including the following:
A.
A working definition of a case will be developed.
B.
The presumptive hypotheses for the mode of transmission of the organism and
other circumstances will be developed. Procedures for testing the hypotheses will
be outlined.
C.
The Infection Preventionist will gather and compile data related to the infection(s)
as follows:
1. Conduct case finding (review ongoing surveillance charts of other patients
at risk and microbiology reports) to determine whether there have been
other cases of the infection
2. Evaluate previous facility experience with the infection
3. Prepare a line listing of cases to include: patient, room number, date of
admission, date of infection onset, site culture results, and physician
4. Plot number of cases by date of onset (epidemic curve)
5. Review patient charts of cases and interview involved personnel for
various factors that conceivably may have played a role in transmission of
an infection, e.g., geographic locations of patients, specific personnel
having contact with patients, medications and treatments administered.
6. Review various Infection Prevention techniques (hand hygiene, use of
standard precautions, etc.) as actually practiced in the facility
7. Maintain surveillance for occurrence of any further infections
D.
The IP will communicate with the lab regarding:
1.
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Any need for isolates of the involved organism(s) to be saved for further
study (e.g., biotyping, antimicrobial sensitivity patterns, phage typing,
serotyping)
Infection Control
E.
IV.
The IP will communicate with management regarding:
1.
Whether any environmental and/or personnel cultures are to be taken by
whom and by what technique
2.
What patient care items suspected of being possible sources of infection
may need to be impounded or quarantined
COMMUNICATIONS
The IP will ensure that the following individuals are notified concurrently with the
preliminary investigation and advised at reasonable intervals of the progress of the
investigation: attending physicians, the DON, medical director, administrator, and others
as needed.
V.
IMMEDIATE CONTROL
Reasonable immediate control measures will be put into effect. Such measures might
include but are not limited to isolation, removal of common suspected sources of
personnel from patient contact, or immediate inservice training in certain Infection
Prevention techniques.
VI.
PUBLIC INFORMATION
Any questions from the community, uninvolved personnel, or news media are directed to
the administrator who will act as public information coordinator.
VII.
ANALYSIS OF DATA
The data collected in the preliminary investigation are reviewed by the investigators to
determine whether a common source of infection, break in technique, etc., can be
implicated as the cause of the epidemic. A preliminary written report will be prepared.
VIII. FURTHER INVESTIGATION
If the cause of the infection is not evident as a result of the above investigation, expert
consultation will be sought. Reporting of the potential outbreak will be done to public
health as required by law.
IX.
CONCLUSION OF INVESTIGATION
The investigation is continued at least as long as there are cases of the infection occurring
above the endemic level.
A final written report of the investigation, outlining findings and recommendations, is
prepared by the investigation coordinator and issued to the Infection Prevention
committee, others participating in the investigation, attending physician(s), director of
nursing, and others as needed.
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Outbreak Investigation Form
Steps of an Investigation
1.
Verify the diagnosis; identify the agent.
Describe the initial magnitude of the problem and what symptoms got the facility's attention.
What diagnosis has been established?
What agent (bacterial, viral, other) has been identified?
Develop a case definition (specific criteria for a case).
Example: All patients who have had 3 or more loose stools in the last 24 hours.
Case Definition:
2.
Confirm that an outbreak exists.
Use your case definition to find all cases.
Based on your knowledge in #1, are the numbers of cases above what is endemic
(usually seen) in the facility? If yes, consider that an outbreak exists. (Realize that
one case of some organisms may constitute an outbreak, e.g. your facility's first
case of Vancomycin Resistant Enterococcus.)
 Yes
Total number of cases so far:
Date:
Do you have an outbreak?
3.
 No
Search for additional cases.
Encourage immediate reporting of cases (laboratory, physicians, and personnel).
Search for other cases by retrospective record review, lab reports, etc.
Total number of cases:
4.
 Yes
If yes, proceed.
 No
Date:
Characterize the cases by person, place, and time.
Person: (Patient characteristics - age, sex, disease, exposures, treatments)
Place: (Consider ward, hall, and room, outside exposures. May use facility maps.)
Time: What is the period of the outbreak? What is the probable source of exposure?
Record dates of onset and draw an epidemic curve.
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5.
Form a tentative hypothesis (best guess at the time).
Review data to determine common host factors and exposures. Develop a best guess on the:
Reservoir
Source
Mode Of Transmission
6.
Institute preliminary control measures.
Initiate control measures based on what you know. (Hand hygiene, isolation, cohorting, etc.) Determine if
you need outside assistance.
Control measures
Date implemented
Assistance needed?
7.
 Yes
 No
Test the hypothesis.
Many behavioral health facility problems never reach this stage. It may end without intervention or simple
control measures may cause the problem to cease.
Special epidemiologic studies may be needed and we may need to seek help.
8.
Refine the control measures.
Add additional control measures if needed.
Control Measure
9.
10.
Date Added
Monitor and evaluate the control measures.
Are control measures being used appropriately? If no, insure
compliance.
 Yes
 No
Evaluate control measures. Did cases cease?
If no, consider additional actions.
 Yes
 No
Prepare and disseminate a final report.
This form in a completed state may serve as the final report. Make the report as detailed as possible.
Date of final report:
Reported to:
Reported by:
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Healthcare-Associated Infections and Sentinel Events
PURPOSE
To manage as sentinel events all identified cases of death and major permanent loss of function
attributed to a healthcare-associated infection (i.e., except for the infection, the patient would
probably not have died or suffered loss of function).
PROCEDURAL GUIDELINE
I.
Identification of cases to be reviewed
II.
A.
During infection surveillance activities and following identification of healthcareassociated infections, the Infection Preventionist (IP) will be alert to cases of
death and/or major permanent loss of function among patients having been
identified as having a healthcare-associated infection.
B.
The sentinel event coordinator, in reviewing for sentinel events, will be alert to
cases of death and/or major permanent loss of function among patients that may
also have a healthcare-associated infection. If a potential case is identified, the
sentinel event coordinator will communicate that information to the IP.
C.
All unexpected deaths occurring in a hospital following transfer from the
behavioral health facility will be reviewed by the IP for presence of healthcareassociated infection and the potential for a sentinel event.
Review and follow-up of potential cases
A.
Once alerted to the potential of a healthcare-associated infection as a sentinel
event, the IP will conduct a review of the patient records to determine if the case
meets the definition of a healthcare-associated infection related sentinel event. If
the case clearly is not a sentinel event (e.g. the patient was terminally ill prior to
the infection, other life threatening events/illnesses were present, etc.), no further
review will be needed. If the IP cannot make the determination, the case will be
reviewed in the Infection Prevention (QA/IP) Committee and with the attending
physician if needed to make a determination.
If it is determined to be a sentinel event, the facility procedural guideline for sentinel events will
be followed, including completion of a root cause analysis.
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Healthcare-Associated Infections
Reviewed as Sentinel Events
Room
Unit
Name
Physician
Date and Symptoms of Healthcare-Associated Infections
Transfer to Hospital?

Yes

Yes

Reason for transfer
No
If yes, name loss of function
No
Death?

Yes

If yes, cause of death
No
Possible sentinel event?

Yes

Type of Infection
Diagnoses and conditions
If yes, date:
Permanent loss of function?

Admission Date
If yes, date to QA/PI
Committee
Determination by committee?
If yes, RCA
completed date
No
Rationale or discussion
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