Appendix H: Infection Prevention and Control Guideline for Flexible Gastrointestinal Endoscopy and Flexible Bronchoscopy – Guideline for outbreak investigation

APPENDIX H – Guideline for Outbreak Investigation Related to Endoscopic Procedures^{Footnote 90 Footnote 172 Footnote 174 Footnote 205}

The steps below may be done simultaneously and do not always follow the order listed.

1. Identify the duration and nature of exposure (identify microorganism(s) of concern).
2. Identify which scope, and/or scope accessories were used and quarantine if necessary.
3. Notify all involved personnel (e.g., infection prevention and control, endoscopy director and nurse manager, administration, microbiology, clinical department heads, communications department and family MDs).
4. Advise laboratory to save all relevant patient and endoscope isolates.
5. Identify and count cases or exposures.
   1. Create a case definition.
   2. Develop a patient line listing: sort according to the procedure, endoscope used, and chronological order in which accessories are used.
   3. Perform chart review of cases for risk factors related to suspect procedure(s) or other known risk factors for the infection under consideration; if review indicates endoscopy-related infection, perform retrospective chart review of all patients undergoing the procedure(s) for linked cases of post-endoscopy infection.
6. Tabulate and orient the data in terms of time, place, and person.
7. If indicated, perform environmental sampling of endoscopes, rinse water, fluid from automated endoscope reprocessor (AER) and other relevant items (e.g., water bottles, I.V. sedatives). Save environmental isolates and compare with patient isolates to determine strain relatedness.
8. Formulate hypothesis for suspected outbreak.
9. Implement control and preventive measures.
10. Evaluate epidemiological data on the strength of causal association.
11. Initiate surveillance for new cases as well as continued microbiologic culturing of endoscopy equipment.
12. Re-evaluate specific control and preventive measures and revise if necessary.
13. Communicate findings.
    1. Notify local public health and the Public Health Agency of Canada if there are public health implications.
    2. Prepare written reports for administration, involved department heads, and other requesting authorities.
    3. Provide information and debriefing sessions to involved personnel.
    4. Notify the communications department and advise if patient follow-up is required.
14. Assess risk to the patient.
15. Develop plan for patient follow-up (only if required).
    1. Organize a small notification team.
    2. Develop a telephone script, contact letters, and fact sheets for patients and physicians (family and attending).
    3. Initiate telephone contact with the patient followed by written confirmation with fact sheet.
    4. Provide information to the patient regarding required blood work and arrangement for follow-up testing if necessary.
    5. Notify diagnostic laboratory if a large volume of tests is necessary; may be advantageous if lab requisitions for required tests are filled out for each patient and faxed/delivered to lab.
    6. Plan for managing patients who test positive.