Infection Prevention and Control Strategies and Resources to Prepare for and Respond to Outbreaks

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September 16, 2024

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Information and resource links for current infectious disease outbreaks can be found on Red Book Online Outbreaks.

During a community outbreak, special procedures may be necessary in ambulatory settings to prevent transmission of the outbreak pathogen among staff, patients and their families/caregivers. While the exact measures necessary to prevent transmission will vary based on the characteristics of the outbreak pathogen, all ambulatory practices should develop education, resources, policies, and procedures now that will improve their ability to respond to a future infectious disease threat. These include:

Education

Modes of transmission: Educate staff on the modes of transmission and the appropriate personal protective equipment (PPE) to prevent the spread of specific infectious pathogens. Include possible outbreak scenarios to demonstrate how adherence to Infection Prevention and Control (IPC) practices can prevent both in-clinic and community transmission of infectious organisms that have outbreak potential. For further details, refer to CDC’s Clinical Syndromes or Conditions Warranting Empiric Transmission-Based Precautions in Addition to Standard Precautions.
Screening: Train schedulers and front office staff to screen patients before and upon arrival for communicable diseases. At all times, this should include “Have you recently been exposed to someone with a known or suspected infectious disease such as chicken pox or measles?”. For patients who have acute illness, this should include “Have you recently traveled? Where did you recently travel? ” During an outbreak, follow-up questions can be added based on the epidemiology of the outbreak, including whether there has been travel to an area that is known to be having a localized outbreak. This will facilitate discussion with clinician on patient placement (ie, immediate rooming, waiting in the car, or waiting in the common waiting area) and appropriate use of PPE by staff and patients. Consideration can be given to creating sick and well-waiting areas, if feasible, however, these must be monitored to ensure appropriate use.
Staff health: Educate staff on the modes of transmission and strategies to protect themselves from the spread of infection in the workplace. Ensure training covers specific ways to keep staff healthy during patient care (ie, use of PPE to prevent exposures, appropriate hand hygiene, and staff vaccination). Develop strategies to support staff during an outbreak or widespread community transmission of illness (eg, flexible schedules, childcare, and mental health supports). Although exclusion from work for the duration of any upper respiratory illness (URI) is preferred to prevent the spread of illness, staff absences can impact daily operations in the ambulatory setting. Adopting a unified approach for managing individuals with URIs is recommended which includes exclusion from work until the ill employee is afebrile for at least 24 hours without using antipyretics and there is improvement of symptoms. Precautions should be taken with an emphasis on hand hygiene before and after every patient contact and a well-fitting mask should be used when having direct patient contact. Personnel should be excluded from patient contact if they are unable to contain secretions or to control coughing and sneezing. For further guidance, refer to CDC’s Respiratory Virus Guidance. By avoiding an outbreak amongst your team, you will help maintain the staffing of your practice. Similarly, staff can pass infectious organisms they carry to patients.
Patient education: Provide educational resources to parents on self-care and promote well-being and healthy living through diet and exercise, household hygiene, and vaccination.

Policies & Procedures

Infection prevention and control policy for clinic visits: Ensure that your clinic’s ambulatory IPC policy includes all the following elements (Table 1).

Table 1: Elements of a comprehensive ambulatory IPC policy

Hand hygiene and respiratory hygiene for staff, patients, and visitors
Patient and visitor screening and appropriate patient placement
Sharps safety and safe injection practices
Appropriate application of standard precautions, including use of PPE and isolation for patients with possible infections due to certain high-risk pathogens
Cleaning and disinfection of the waiting room and clinical environments and instruments/devices
List of contacts for public health, local emergency rooms, and nearest high-level isolation facility

Plan for alternate clinic operations in outbreaks: Alternate strategies for clinic layout and operations are an essential element in preparing for a future outbreak. Cohorting sick patients or scheduling them to be seen at the end of the day can help limit in-clinic exposures. Similarly, scheduling vulnerable patients (eg, neonates and those with immunocompromising conditions) at the beginning of the day can also limit their risk of exposure. Identify alternative clinic flow patterns to isolate sick from well patients. During an outbreak, ambulatory settings must be able to continue to provide essential care to both infectious and noninfectious patients. Strategies to alter clinic operations during an outbreak are listed in Table 2.

Table 2: Strategies to alter clinic operations during an outbreak

Limit number of accompanying family members
Prescreen patients and the accompanying adult(s) before arrival
Encourage healthcare workers to perform daily “self-screen”
Identify a dedicated “sick entrance” or “wait in car” strategy if possible that can be used if needed
Consider immediate rooming for symptomatic patients, as possible
Position masks at clinic entrance to encourage use by families
Increase frequency of between-patient disinfection
If available, increase the number of air exchanges per hour to the maximum possible in your clinic’s HVAC system
If possible, use natural ventilation to dilute the concentration of airborne infectious particles by opening windows and doors
Conduct deep cleaning (or “terminal cleaning”) of waiting area, triage station, and all examination rooms at the end of each day and whenever visibly soiled
Conduct telehealth visits when possible

Partnership with public health: Identify a point of contact at your local public health department and establish a strategy to communicate. This should include how to report patients with suspected or documented infections related to an outbreak and other reportable diseases. Verify that your clinic has the most up-to-date reportable disease and conditions list for your state. Ensure that the clinic is receiving outbreak alerts from the CDC and local/state health departments such as through the Clinician Outreach and Communication Activity (COCA) and Healthcare Alert Network (HAN).
Partnerships with regional emergency departments and pediatric inpatient care units: Most regions have an identified high-level isolation facility for children who require hospitalization and are known or suspected to be infected with a pathogen that has been designated as high-risk by public health authorities. Other hospitals in the region will be designated frontline or assessment facilities. Understand the capabilities of facilities in your area and the appropriate point of contact.
Patient transfer: Establish a plan to transfer potentially contagious patients to the emergency department or hospital designated in your area to provide high-level isolation care.
Optimize vaccination rates: Develop a reminder and recall system for continual review of patient files and contact families to schedule appointments for children who are behind on immunizations (recall) or due soon (reminder).
High-risk patients: Many pathogens pose a greater risk for patients with specific underlying medical conditions. Create a report or flag system to quickly pull lists of patients known to be at increased risk (eg, immunocompromised, serious heart or lung disease, etc).

Clinic Resources

PPE and alcohol-based hand rub: Establish a minimum level of supply available on-hand for PPE and alcohol-based hand rub and identify vendors willing to increase delivery in the event of an outbreak. Tools are available from NIOSH to estimate how many days a PPE supply will last given current inventory levels and PPE burn rate
Respiratory hygiene station: Place a respiratory hygiene station that contains tissues, adult and child face masks, and alcohol-based hand rub at the clinic entry.
Signage: Develop and post instructional signs for families directing them on how to enter the facility, mask as needed and disclose acute illness symptoms.
Create alternate care delivery strategies: Establish telehealth capacity or alternative strategies (ie, drive thru clinics) to deliver healthcare services during an outbreak.

This content has been adapted from the following resource:

Infection Prevention and Control in Pediatric Ambulatory Settings | Pediatrics | American Academy of Pediatrics (aap.org)