Policies,Clinical,UW Health Clinical,Infection Control

Investigation of a Potential Epidemic (4.1.5)

Investigation of a Potential Epidemic (4.1.5) - Policies, Clinical, UW Health Clinical, Infection Control


Policy Title: Investigation of a Potential Epidemic within UW Health
Policy Number: 4.1.5
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: January 21, 2016


To provide direction for uniform and complete investigation of suspected epidemics of healthcare-associated
infections in patients and/or employees in both inpatient and outpatient settings of UW Health. Epidemiologic
investigation may be initiated for any infections w hich appear to be above endemic levels or w hich involve
organisms of epidemiologic signif icance.


A. The Infection Control Committee shall have ultimate responsibility for investigating epidemics and
developing policies aimed at preventing and controlling healthcare-associated infections w ithin UW Health. If
an epidemic is suspected, the Hospital Epidemiologist w ill direct the investigation. In the absence of the
Hospital Epidemiologist, the staff physician on the Infectious Disease consult service w ill direct the
investigation. For epidemics affecting employees, the Medical Director of Employee Health Service (EHS),
or designee, w ill also participate in the investigation.
B. Affected University of Wisconsin students (those w ith clinical illness, or w ho have been exposed to the
epidemic agent) w ill be referred to University Health Service (UHS) for appropriate follow -up. The
appropriate faculty responsible for affected students from other schools (e.g., Deans of students of Madison
College, Edgew ood) w ill be notif ied in order to facilitate follow -up of these individuals. Protected health
information w ill not be divulged to the sponsoring institution of an affected student unless w ritten permission
to do so is obtained from the affected individual w ith the UW Health Authorization for Release of Medical
Information form.
C. If a delay in follow -up of students through UHS or their respective educational institution is anticipated and
could compromise the health of the affected student, EHS w ill provide initial follow -up, including prophylaxis
or treatment as needed. The student w ill then be referred to UHS or their respective educational institution
for subsequent follow -up.
D. The State and Local Departments of Health w ill be apprised of the epidemic if it involves a reportable
disease or any disease w ith signif icant community impact.
E. If circumstances w arrant (e.g., unusually large number of patients or staff affected, unusually virulent
organism involved, bioterrorism suspected, etc.), the Hospital Epidemiologist or his/her designee w ill
contact the Administrator on Call to coordinate activation of the Emergency Operations Plan for Infectious
Disease and Special Pathogen events.


A. The Hospital Epidemiologist, or in his/her absence, the staff physician on the Infectious Disease consult
service, w ill be notif ied immediately upon recognition of a potential epidemic. Methods of identifying
increased incidence of specif ic infections include, but are not limited to:
i. Automated surveillance program results/alerts review ed by Infection Control Department staff.
ii. Routine healthcare-associated infection surveillance performed by Infection Control Department
iii. Communicable Disease reports generated by Infection Control Department staff.
iv. Notif ication of Infection Control Practitioners (ICPs) of relevant laboratory results by Clinical
Laboratory staff or State Laboratory of Hygiene staff.
v. Information received by Infection Control Practitioners from UW Health clinical personnel or state or
local public health department personnel.
B. Infection Control Practitioners w ill initiate steps to prevent further transmission, based on information
available at that time. As more information becomes available, control measures may need to be updated or
expanded, and these may include, but are not limited to:
i. Isolation of potentially infectious patients.
ii. Quarantine of exposed patients during the incubation period.
iii. Exclusion of ill or exposed healthcare w orkers from duty.
iv. Coordinating prophylaxis or treatment of affected patients or staff.
v. Cohorting of patients and staff.

Policy Title: Investigation of a Potential Epidemic w ithin UWHC
Policy Number: 4.1.5

vi. Use of additional barriers (e.g., glove use for all patient contact).
vii. Use of higher level surface disinfectants or more aggressive cleaning protocols.
viii. Confiscation of patient care devices or products suspected as fomites (e.g., endoscopes) or
infection sources (e.g., intrinsically contaminated solutions).
ix. Prohibiting use of reprocessing equipment w hen disinfection/sterilization failure is suspected.
C. If employees are involved, EHS personnel must be contacted immediately.
D. The Hospital Epidemiologist, and in the case of employee exposure, the Medical Directors of EHS (or
designee), w ill determine w hether the situation poses a threat to the health of other patients and employees
and w arrants immediate investigation.
E. The Hospital Epidemiologist may elect to call an emergency meeting of the entire Infection Control
Committee if the epidemic appears to be large, is caused by a particularly virulent organism, could represent
bioterrorism, or if far reaching decisions have to be made.
F. To expedite the investigation, the situation w ill be discussed in periodic emergency meetings of the
Executive Committee of the Infection Control Committee (the Hospital Epidemiologist and Infection Control
Practitioners). EHS personnel, the Clinical Laboratory Directors, Microbiology Laboratory Directors, and the
Administration representative on the Infection Control Committee w ill also participate, w hen indicated.
G. The disciplines w hich need to be included in immediate planning and action w ill be determined by the
Hospital Epidemiologist at the outset. These may include any or all of the follow ing:
i. Infection Control Committee members.
ii. Attending staff and house off icers caring for the involved patients.
iii. The Nurse Managers of affected patient care units.
iv. Clinic Managers of affected ambulatory locations.
v. Senior Vice President, Chief Nursing Officer and Patient Care Services, or designee.
vi. Senior Vice President, Chief Medical Officer
vii. EHS Medical Directors and Clinical Nurse Manager.
viii. Medical or Administrative Directors of the Clinical Laboratory.
ix. State Laboratory of Hygiene personnel.
x. University Health Service personnel.
xi. Appropriate faculty of affected non-University of Wisconsin students.
xii. Pharmacy personnel.
xiii. Emergency Department and Urgent care personnel.
xiv. UW Health Administrator On Call (AOC).
xv. Directors and Managers of ancillary services departments (e.g., Environmental Services, Culinary
Service, Plant Engineering).
xvi. Wisconsin Division of Health personnel and/or Local Health Department personnel.
xvii. Public Affairs personnel.
xviii. Human Resources personnel.
xix. Workers' Compensation Manager.
xx. Risk Management.
xxi. Director, Life Safety.
H. The Hospital Epidemiologist (or designee) may call an immediate meeting of such individuals and disciplines
in order to:
i. Clarify the nature and extent of the potential problem.
ii. Discuss proposed investigative steps.
iii. Determine the case definition and establish exact criteria for selection of patients and personnel for
possible epidemiologic studies.
iv. Determine and assign exact responsibility of each department (e.g., determine w ho w ill collect and
record appropriate data).
v. Anticipate questions that may arise and develop consistent answ ers to those questions. Specif ic
individuals w ill be designated as resource people w ho w ill be available to answ er queries and keep
personnel and media outlets informed as necessary.
vi. The need for informational materials such as disease fact sheets or drug information, and the
appropriate groups to target such information to, w ill be considered at this time and responsibility
for obtaining or generating such material assigned.
a. Informational materials may be selected from existing sources (e.g., Centers for Disease
Control and Prevention fact sheets), if appropriate.
b. Informational materials may need to be created internally, w ith input from content experts,
based upon the educational needs and target audiences determined by the members of

Policy Title: Investigation of a Potential Epidemic w ithin UWHC
Policy Number: 4.1.5

the multidisciplinary meeting.
vii. If a meeting is called, minutes of the meeting including w ritten documentation of the assigned
responsibilities w ill be generated and retained by Infection Control.
I. Any major decisions involving large numbers of patients or personnel, or considerable expense, such as
closing a unit to admissions, w ill be made in conjunction w ith the Hospital Epidemiologist, investigating
personnel, attending staff and Administration.
J. The Hospital Epidemiologist (or designee) has primary authority to assess the need for additional resources
as part of a w ider institutional response and to direct the Administrator on Call (or designee) to activate the
Emergency Operations Plan for Infectious Disease and Special Pathogen events
K. If prophylaxis (immunoprophylaxis or chemoprophylaxis) or therapeutic medications are required for
employees, the EHS Medical Directors or Hospital Epidemiologist w ill be responsible for prescribing these
i. All necessary prophylaxis or therapeutic medications for employees w ill be administered through a
UW Health pharmacy, or if practicable through the employee's local pharmacy, at no expense to
the employee.
ii. Prophylaxis regimens requiring injection w ill be provided through EHS or the Emergency
Department w hen EHS is closed.
iii. Affected employees w ill be informed of the need for prophylaxis or therapeutic medication.
Pharmacy, EHS or Emergency Department personnel w ho dispense or administer these agents w ill
provide relevant drug information to include contraindications, potential side effects and drug
iv. If a delay is anticipated in coordinating appropriate medical follow -up w ith UHS for affected UW
students, or through the administrator of the schools of affected non-UW students (see II.B. and
II.C.), initial follow -up w ill be provided by EHS, w ith provision of prophylaxis or therapeutic
medications follow ing the same stipulations listed in this section.
L. If prophylaxis or therapeutic medications are required for affected patients, Infection Control personnel w ill
notify the medical staf f caring for these patients of this need, and w ill also convey to them the recommended
prophylactic regimen as determined by the Hospital Epidemiologist, or designee. Infectious Disease staff w ill
provide consultation to medical staff caring for affected patients regarding therapeutic medication or
alternative prophylactic regimens, as needed.
M. Department Managers, Clinical Directors of Nursing or Clinical Nurse Managers may be requested to notify
their respective employees of the epidemic situation. Managers may be asked to assist w ith facilitating the
collection of specimens from employees and/or patients for laboratory analysis as part of the epidemiologic
N. The Workers' Compensation Coordinator w ill be apprised in w riting by EHS of all potentially exposed or
infected personnel to avoid any problems w ith Workers' Compensation or hazardous duty status coverage.
O. The potential for anxiety, fear or even panic on the part of employees, patients or families should be
anticipated and dealt w ith by fully informed personnel.
i. The persons identif ied by the Hospital Epidemiologist or designee to serve as informational
resources (see III.H.v.) w ill have primary responsibility for promulgating accurate and relevant
information for employees, visitors and patients.
ii. The release of information to the new s media w ill be coordinated w ith the Hospital Epidemiologist
(or designee), Public Affairs and Administration.
iii. Interdisciplinary meetings may be held to review new developments, inform involved personnel of
the progress of the investigation, and to answ er questions.
P. The State Division of Health w ill be apprised of the epidemic by the Infection Control Department if it
involves a reportable disease or any disease w ith signif icant community impact.
Q. At the conclusion of the epidemiologic investigation, after analysis of all data is complete and the situation is
fully clarif ied, the Infection Control Department w ill generate a formal w ritten report and w ill disseminate it to
the involved departments. It may be appropriate to distribute interim reports during the investigation, if it is
R. After the investigation is completed, all aspects of the investigation w ill be critically review ed by the Infection
Control Committee to identify problems w hich can be averted in the future.


Author: Infection Control Practitioner
Senior Management Sponsor: Sr. VP, Patient Care Services and CNO

Policy Title: Investigation of a Potential Epidemic w ithin UWHC
Policy Number: 4.1.5

Approval committees: Infection Control Committee; UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: December 21, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospital and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.


Jeff Grossman, MD
UW Health CEO

Teresa Neely

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee


-UWHC Administrative policy #13.04, Communicable Disease Reporting
-UW Health clinical policy #4.1.6, Communicable Disease Exposure Response
-UWHC Administrative policy #4.13, Using and Disclosing (or Releasing) Protected Health Information

Version: Revision
Next Revision Due: January 21, 2019
Formerly Know n as: Hospital Administrative policy #13.11