1. Prepare for field work, Assemble an outbreak tea
2. Verify the diagnosis
3. Identify cases and the population at risk
4. Collect risk information
5. Tabulate the data in terms of time, place and person
6. Collect specimens for laboratory analysis
7. Conduct environmental investigations
8. Institute control measures
9. Formulate and tests hypothesis
10. Conduct additional systematic studies
11. Communicate the findings

1. Prepare for Field work, Assemble a team of outbreak investigators

Establish chain of command…
Once notified of an outbreak, the Hospital Epidemiologist (tHE) will:

• Serve as the main coordinator
• Act as the focal point for information
• Assemble the Outbreak Investigation Management Team (OIMT) if a disease with potential mass exposure is identified, or if the outbreak is large, the OIMT will meet as quickly as possible (on that day) and will meet daily until or unless the OIMT agrees upon an alternative schedule.

The Vice President of Medical Affairs will provide all necessary support to HEIC.

Standing OIMT members:
tHE or designee
Associate Director
Infection Control Epidemiologists
Chairperson, HEIC Committee
Vice President, Medical Affairs
Risk Management
Public Affairs
OHS Manager (if employees involved)
Pharmacy (if involves prophylaxis or drug utilization)
Nursing Management
Microbiologist or designee

Possible OIMT members
Pertinent members from implicated unit or service
Disease specialists
City/State Health Departments Centers for
Disease Control and Prevention

Designated Disease Specialists - OIMT Liasons

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Establish lines of communication…

• Between OIMT and the affected units a designated OIMT member will document all communication, in writing tHE designee, will document all communications, issues, and responses made under the aegis of the OIMT for the duration for the outbreak.
• tHE or designee will be responsible for communicating outbreak information to:
  The Chairman of the Hospital Epidemiology and Infection Control Committee
  The Director of the Microbiology Laboratory
  The Vice President for Medical Affairs
  The physician and/or nursing director and/or administrator responsible for the hospital area
  Occupational Health Services or University Health, if employees are involved
  Risk Management, if indicated
  Appropriate division of the local or state health department or other public health agency (CDC, EPA, FDA), if indicated
  Public Affairs
  Pharmacy (if involves prophylaxis or drug utilization)

2. Verify the Diagnosis and the Epidemic

Microbiology will provide support for microbiologic and/or serologic studies.

HEIC will evaluate previous hospital experiences with the organism or disease (rates where possible)

3. Identify cases and the population at risk
&
4. Collect risk information

HEIC will develop a working case definition
HEIC will create the Exposure Timeline to identify when patients and staff could have been exposed.
HEIC will determine criteria for exposure, and will generate a outbreak specific Exposure Worksheet.

For Staff: HEIC and/or the OIMT designee will identify exposed persons in a two step process

Step 1:
Determine those possibly exposed (using work assignment logs, etc.) based on duty assignment in the general geographical area of the index case during the exposure period.

Step 2:
Review list according to the criteria in the Exposure Worksheet. Categorize persons as "Not Exposed or "Exposed or Possibly Exposed"
complete individual exposure forms for those "Exposed/Possibly Exposed" - include the index case's name on the form.
refer to OHS for follow-up.
OHS will forward the completed form to HEIC.

Charges for employee:
Exposure to another patient or to a staff member - OHS.
Exposure to the employees' own family members or their visitors - their insurance.

For Patients: HEIC and/or the OIMT designee, the Infection Control staff and patient's physicians will determine the exposure status of each patient (in-house and discharged). This process should be carried out in three distinct steps.

Step 1: Who might have been exposed as a result of direct or indirect contact/exposure to the index case(s) during the exposure period.

Step 2: Fill out Exposure Forms including each patient potentially exposed. OIMT will make recommendations to the patient's physician. HEIC and medical teams will jointly contact discharged patients and their physicians

Step 3: HEIC will ensure that patients and their physicians are contacted by phone and follow-up letter. Patients will be asked to self report any disease.

Charges for patient:
Exposure to another patient or to a staff member-
HEIC 5-8384
pager 410-283-3855,
after hours: 410-283-3850.

Exposure to patients' own family members or visitors - their insurance.

Managers/Supervisors will be responsible to provide information (e.g., work schedules, home addresses, telephone numbers) in a timely manner as requested by HEIC.

HEIC will maintain a current computer database with demographic, exposure, treatment, and clinical status of involved staff members and patients. Data collected will be outbreak specific and will be determined by the OIMT. All employee data will be transferred to OHS in a timely fashion.

5. Tabulate the data in terms of time, place and person

tHE is responsible for consolidating and analyzing all data. HEIC staff will maintain the epidemic data and describe the scope and nature of the outbreak i.e. HEIC will create an exposure timeline, plot the epidemic curve, create spot maps of cases.

6. Collect specimens for laboratory analysis

tHE/OIMT will determine the need for laboratory testing or prophylaxis. If the OIMT is warranted, but is unable to convene in a timely fashion and the delay will seriously increase the scope of the outbreak, tHE will make immediate decisions.

7. Conduct environmental investigations

HEIC will be responsible for ordering any necessary environmental investigations. For example, cultures of equipment of rooms, air sampling. The tHE will communicate decisions regarding investigational needs.

8. Institute control measures

The tHE will be responsible for implementing the strategy for acute management of the outbreak.

HEIC staff will present intervention strategy options and their relative costs, and will make recommendations to tHE/OIMT.

The tHE will be responsible for assuring that diagnostic/therapeutic orders are signed.

The OIMT will designate the location for medical care of staff. In general this will be OHS (Houck 3).

Post Exposure Management Worksheets and Questions will be used by OHS or other designated personnel to determine if all necessary medical steps have been completed for each exposed person.

The Treatment/Testing Management Options will be used by the OIMT as the basis for testing or treating patients and staff members in a major outbreak is based on the most current epidemiological information available.

Pre-treatment testing of exposed individuals is usually unwarranted unless testing can be accomplished quickly and gives cost effective/low risk alternatives for treatment, confirms a clinical diagnosis, or prevents adverse outcomes from therapy

9. Formulate and tests hypothesis

HEIC will develop a presumptive hypothesis on which to initiate reasonable control measures.

10. Conduct additional systematic studies

HEIC is actively conducting studies to prevent nosocomial transmission. Whenever possible, lessons learned during acute outbreaks should be expanded upon and further tested in systematic studies.

11. Communicate the findings

The tHE will prepare the final report

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