Communicable Disease: Enteric Outbreak

Policy number:  IC - 25

Effective date:  September 2002

Last revision date:  September 2022

On this page

1. Background
2. Purpose
3. Policy
4. Procedure
5. References

1. Background

Registered staff will identify Resident’s with sign and symptoms of enteric infections and document infections on the “Monthly Resident Infection Control Surveillance Report”, as per policy. A potential outbreak, will be declared when there is one lab confirmed case of any enteric virus; facility enteric outbreak plans will be implemented. A enteric outbreak, will be identified by 2 cases of enteric illness with like symptoms or 2 cases above the baseline occurring within 48hrs on the same unit and again the facility enteric outbreak contingency plan will be implemented.

2. Purpose

Residents in a long-term care home are susceptible hosts for enteric outbreaks for a number of reasons associated with ageing; e.g., declines in natural barriers, immune system changes, debilitated status, organ deficits, multiple chronic diseases, nutritional factors and delays in recognizing infections.

All enteric outbreaks shall be reported to the Local Health Unit by the IPAC Coordinator or Designate. Rapid response to suspected food-borne enteric disease outbreak will serve to minimize the impact to ensure that all staff are aware of their responsibilities and specific tasks.

3. Policy

To provide information on enteric illness to manage infections within the home.

To provide direction for staff to ensure rapid response to enteric disease outbreak and to minimize the impact to residents, families, visitors, volunteers and staff.

To provide information to key personnel to assist with prompt infection control activities to reduce the spread of infection, assist with determining the source (s) of infection and to determine the specific pathogen related to an outbreak.

4. Procedure

The 13 items in the procedure for communicable disease: Outbreak will be carried out.

Initiate enteric precautions, as follows:

Nursing Department:

• The Registered Nurse in the affected area will follow the Outbreak Checklist.
• Residents are required to cohort.
• Staffing cohorting is implemented. 
• Requisition extra juices from dietary.
• Requisition extra linen and isolation bags from laundry.
• Have all departments refer to their own manuals for procedures to follow.
• Documentation of outbreak, line listing.
• Documentation of cases to include: names, locations, symptoms, date of onset, lab investigations, number and results, isolation procedures, duration of symptoms, outcome.
• Ensure staff and Resident's utilize hand-washing techniques.
• Acquire extra supplies (hand gel, masks, gowns, gloves, goggles / shields).
• Collect random stools samples [minor outbreak (3) cases – obtain specimens from all 3 Residents; major outbreak only 10 different specimens from different Residents need to be collected or as directed by Public Health. Collect 12 hours prior to planned pick-up, if it is a weekend or holiday unless arrangement made with Public Health for weekend/holiday collection. Stool Specimen collection kits, are provided by Public Health. Place the stickers from the kit code numbers on each of the containers and the fourth one on the outside of the collection bag. Refer to policy for transporting specimen collection to prevent cross contamination.
• Resident appointments that are non-urgent are to be rescheduled. (Affected unit(s) only)
• Implement cohort nursing; follow staffing guidelines policy if Norovirus is determined to be the cause of the outbreak.

Activation Department:

• Outings, special events and programs may need to be cancelled. Decision to be made by Program Supervisor and Infection Control Officer / designate / DON.
• Residents in isolation may need to receive visits or receive room activities once they begin to improve but are still communicable.

Dietary Department:

• Explicit instruction and specific training in personal hygiene and sanitary food handling will be given to staff (see Nutritional Department Manual).
• Previously collected food samples from the previous 72 hours prior to notification of the outbreak must be sent/given to the Public Health Inspector for testing if they requested. (The previous 72 hours prior to the outbreak of food samples must be available for Public Health if requested – please do not discard any food samples once an outbreak has been declared until released by the infection Control Officer/designate).
• If staff are symptomatic, they are to follow the procedure for employee health and see their doctor.
• Disposable dishes will only be initiated upon the request of the Dietary supervisor / delegate.
• Ensure adequate supply of ginger-ale and other clear fluids are on hand.
• Ensure to follow routine and additional precautions when completing daily tasks (i.e., hand hygiene, donning and doffing, etc.).

Housekeeping, Laundry, Maintenance Departments:

See PIDAC's Best Practices for Environmental Cleaning for Prevention and Control of Infections

• Ensure that specific responsibilities are understood (department manual)
• Additional cleaning on the affected unit will need to be implemented
• Increase cleaning of high-touch surfaces such as, but not limited to: keypads, doorknobs, handrails, tables, bathroom faucets and grab bars in the bathroom
• Isolation of linen will occur where deemed necessary by nursing staff, follow policy regarding handling of isolation linen and garbage in ill Resident rooms
• If reverse isolation is necessary, the isolation cart outside of the unit will contain necessary isolation supplies, gowns, gloves, eye protection and masks
• Keep units supplied with disinfecting products, and other supplies
• Laundry should mask when sorting contaminated linens and donning of protective eyewear is recommended

Infection Control Committee Members During an Enteric Outbreak:

• Attend meeting at the first reporting of a suspected outbreak as well as any meetings that are further requested by the IPAC Coordinator
  • Refer to the IC-60 Policy for more details

Administrator / Designate:

• Reviews progress reports from Committee / designate and reports to General Manager and Council
• Acts as spokesperson to the media, visitors, family, Auxiliary, volunteers

Directing of Nursing / Designate:

• Receives information from Nursing Staff regarding outbreak
• Communicate progress and decisions to the Administrator, Committee, nursing team, Residents and other departments
• Notifies the Ministry of Health and completes outbreak notification (or designate)
• Notifies LHIN & Hospital of Outbreak
• Update Infection Control message on voicemail system
• Liaises PHD during outbreak period in absence of Infection Control Officer

IPAC Measures:

• Receives information from Nursing Staff regarding outbreak
• Reinforce implementation of Contact Precautions as soon as possible for all residents at onset of unexplained diarrhea
• Dedicate equipment to residents with Enteric Symptoms
• Clean entire unit with sporicidal disinfectant, including resident care equipment, high-touch items at nursing stations, carts (medication, isolation) and other areas touched by health care providers
• Remove and launder all curtains (privacy, shower) when visibly soiled and on discharge / transfer cleaning
• Audit compliance with IPAC Self-Assessment Tool on a weekly basis, and regularly with hand hygiene, routing practices, additional precautions and environmental cleaning

Visitors:

Visitors should receive instruction on the importance and proper technique for hand hygiene. Visitors who provide care for a patient/ resident, or who have significant contact with the patient/ resident’s immediate environment, should follow the same precautions as health care providers. Visitors must not use the patient/ resident’s bathroom or go into other patient/ resident rooms or bed spaces. Visitors should be discouraged from eating or drinking in the room or bed space.

Patient Transfer:

After discharge, patients with CDI are not a risk for other family members, as person-to-person transmission within the home setting is rare. Good hand hygiene practices should always be exercised by the discharged patient and household members. Patients and their families should be instructed to clean their bathroom thoroughly using regular household cleaners. Educational tools for patients and family regarding proper hand hygiene and potential for CDI relapse should be considered.

New Admissions:

Take into consideration the burden of the enteric outbreak on the unit and the ability to cohort residents.

Discontinuation of Precautions:

Precautions for CDI should only be discontinued in consultation with Infection Prevention and Control. The following criteria are used when considering discontinuing precautions for CDI:

Patient / resident with suspected CDI:

Patients/ residents on Contact Precautions for suspected CDI may, after consultation with Infection Prevention and Control, have the precautions discontinued when two negative EIA toxin tests or one negative molecular test have been reported.

If CDI is still suspected, the clinician should evaluate the patient/ resident and consider other diagnostic modalities (e.g., colonoscopy/ sigmoidoscopy). Contact Precautions should be maintained until such evaluation has taken place or until CDI is otherwise ruled out.

Patient / resident with confirmed CDI:

Contact Precautions may be discontinued when the patient/ resident has had at least 48 hours without diarrhea (e.g., formed or normal stool for the individual).

Contact Precautions should be discontinued only in consultation with Infection Prevention and Control.

Re-testing for C. difficile is not necessary and is not recommended to determine when precautions may be discontinued.

Contact Precautions should not be discontinued until the room/bed space and bathroom have received terminal CDI cleaning with a sporicidal.

5. References

PIDAC: Routine Practices and Additional Precautions in All Health Care Settings | November, 2012

PIDAC: Best Practices for Environmental Cleaning for Prevention and Control of Infections | April 2018

PIDAC: Guide to IPAC Management of Suspected or Confirmed VHF in Acute Care | July 2019