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International Accreditation of Healthcare Facilities

Standards › Standard 9 › Plans and templates

Plan · FLD-PLN-004 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 9.8

At a glance

  • Infections are watched for each day through the surveillance register (HOS-REG-005).
  • A suspected outbreak is reported to the field unit lead within 24 hours.
  • Isolation, cohorting and PPE steps are set out for each outbreak type.
  • The plan is rehearsed each year.
  • Stop and get help straight away if: an outbreak is not reported or isolated, or the plan has never been rehearsed.

1. Purpose

To find and respond to outbreaks in crowded, temporary settings (9.8).

2. Scope

Applies to Clinical and support staff in the hospital
Locations All wards, clinics and departments of the facility
When Whenever the activity described is carried out
Does not apply to Activities covered by another document listed in section 15

3. Definitions

Term Meaning
Clinical lead The doctor or nurse in charge of the area at the time

4. Background

Crowded, temporary settings spread infection quickly. Infection control must be practised, and outbreaks found and reported through a defined route.

5. Responsibilities

Role Responsibility Competence
Infection control lead Watches the register and leads the response Clinician
Field unit lead Approves isolation and reporting Clinician

6. Materials and equipment

Item Requirement Condition
Records and forms named in this document Current version Checked before use

7. Safety

8. Before you start

9. Procedure

Step 1. Watch.

  • Record infections daily in HOS-REG-005 and look for clusters.

Key point: Watched every day.

Step 2. Report.

  • Report a suspected outbreak to the field unit lead within 24 hours, and to the health authority.

Key point: Within 24 hours.

Step 3. Respond.

  • Isolate, cohort and apply PPE steps as set out for the outbreak type, and rehearse each year.

Key point: Set steps, practised.

10. Decision points

11. Special situations

Situation Action
Out of hours Follow the same steps. Use the on-call contact on the wall of the area.

12. Escalation

13. Monitoring

Measure Target Frequency Owner If not met
Suspected outbreaks reported within 24 hours 100% Each event Infection control lead Escalate to the coordinating authority

14. Records

Record Kept in Retention
Record named in this document Patient record or the area file the period set by the facility’s records policy years

15. Training

16. Related documents

ID Title Use
HOS-SOP-014 Healthcare-associated infection surveillance and response (existing, reused) Procedure
HOS-REG-005 Healthcare-associated infection surveillance register (existing, reused) Register

17. Evidence

Reference Note
E-009 Based on the Sphere Handbook, Humanitarian Charter and Minimum Standards in Humanitarian Response (2018).
E-006 ASF Policy Framework v1.2. Adapted.
E-009 ASF Expert Committee consensus.

18. Change history

Version Date What changed Approval
1.0 the date of approval First version set Expert Committee approval

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