Influx of Communicable Patients: Testing Surge Capacity with Community Outbreak of Norovirus

        Joan Finney, RN, BSN, CIC, Director, Infection Prevention and Epidemiology, Good Samaritan Hospital, Los Angeles, CA
        Issue: Noroviruses are a group of small round structured viruses that belong to the family Caliciviridae. Symptoms of illness are sudden onset of nausea, vomiting, diarrhea, and stomach cramping. Symptoms usually last 1 to 2 days. Outbreaks are frequent on cruise ships and in healthcare facilities. In the Fall of 2008 our Los Angeles area experienced a dramatic increase in outbreaks in community settings. During one outbreak associated with a major university campus our public health department reported 675 students or staff had symptoms of norovirus infection. Our hospital experienced a surge of communicable patients from this outbreak and used the activity to test our response capability.
        Project: Between Oct 2 - 8 our 12 bed ER received 41 symptomatic patients from the outbreak, with a peak of 25 on Oct 4. Nine required inpatient admission for treatment. The surge began late on a busy Friday night when IC staff and administrative staff coverage was limited. IC was contacted by cell phone and remotely directed these prevention and control strategies: 1) Patients cohorted in an overflow triage area; 2) Housekeeping staff sent to ED to clean gurneys, bathrooms, and high-touch surfaces with bleach solution; 3) Contact precautions and thorough hand washing; 4) Hourly phone conferences with bed control to identify open beds; 5) Fact sheets on norovirus faxed to all units; and 6) Specimen collection reviewed with nursing and lab.
        Results: ER staff followed policy with timely notification of IC. Proper cohorting and PPE were utilized. Housekeeping had stock of bleach solution and provided rapid cleaning. Cohorting on a single nursing unit was not achievable due to high census, and required patient placement in 4 different units. Separation of patients required more educational / supportive calls from IC to assure compliance with strategies. Public Health and IC communicated frequently to facilitate the outbreak investigation in the community. No secondary cases were identified in staff or patients.
        Lessons Learned: Just one month later a second wave of the outbreak brought 8 additional student/staff patients to the ER and our lessons learned in the Oct surge were utilized. To better prepare for future norovirus patients, our policy will be changed to require masks for staff who may have contact with aerosolized vomit. ER staff will have “vomit bags” available in their utility room. Bleach product will be located in ER for quick disinfection. Use of cell phones, PDAs and remote access to hospital data made IC support available from off site after hours. Surge response for this event was successful; however, it is important to continue to train for larger influx of communicable patients.