Control of Infectious Diseases (CID) On-Call Responsibilities and Documentation

  1. Policy

Category: Control of Infectious Diseases
Subject: Control of Infectious Diseases (CID) On-Call Responsibilities and Documentation
Division: Health Protection Division
Policy Number: CA.82.01.111
Effective Date: October 20, 2016

POLICY STATEMENT

It is the policy of Wellington-Dufferin-Guelph Public Health (WDGPH) to be available on a 24/7 basis to review reports of, and respond to, infectious diseases of public health importance, in accordance with the Health Protection and Promotion Act, (HPPA) and the Infectious Disease Protocol (as current), and Ontario Public Health Standards.

Staff will investigate reports of sporadic cases and outbreaks of infectious diseases of public health importance or any clusters of unusual/unexpected illness within local populations received after hours, on weekends, or holidays.  A   review of cases/outbreaks will be completed immediately on all reports and investigated accordingly based on level of urgency. Refer to policy CA.82.01.104 and procedure CA.82.02.104 Reportable Disease Follow-Up/Outbreak Control During Office Hours and On-Call and the disease specific protocols and guidance documents as needed to determine the level of urgency required for on-call follow-up.

All incoming communication received outside of regular business hours via the on-call General Program PHI (GP PHI) or the on-call Manager will be documented on the on-call log summary in Excelicare in order to ensure all communications are followed-up as applicable, and can be audited for quality assurance. The on-call log in Excelicare does not replace the standard documentation that should be done for all actions a staff member performs during on-call. It is a means to track that all afterhours calls are responded to in a timely way.

SCOPE

This policy applies to the Control of Infectious Disease program Public Health Nurses and Public Health Inspectors, CID Manager, CID Supervisor, and on-call Manager.

DEFINITIONS

Communication – Any phone call or email received directly or indirectly from the on-call GP PHI or the on-call Manager.

Infectious Diseases of Public Health Importance – Include, but are not limited to, those specified reportable diseases as set out by Regulation 559/91 (as amended) under the Health Protection and Promotion Act, and include zoonotic diseases and emerging infectious diseases. Follow-up is directed under 

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Corresponding Procedure:  CA.82.02.111 Control of Infectious Diseases (CID) On-Call Responsibilities and Documentation
CA.31.02.411 Infectious Diseases Program/On-call Management of Bloodborne Exposures Guidance Document
CA.50.01/02.102 Documentation Practices
CA.82.01/02.104 Reportable Disease Follow-Up/Outbreak Control During Office Hours and On-Call
CA.82.02.104 Appendix B: Reportable Diseases Coded List.CA.86.01/02.103 Notebook Documentation
CA.86.01/02.105 Documentation
CA.86.01/02.107 Documentation of Rough Notes
CID Desktop Reference for Excelicare
Control of Gastroenteritis Outbreaks in Long-Term Care Homes (MOHLTC, as current)
A Guide to the Control of Respiratory Infection Outbreaks in Long-Term Care Homes (MOHLTC, as current)
Health Protection and Promotion Act
(Regulation 559/91)
Ontario Public Health Standards (Ministry of Health and Long-Term Care; Toronto, ON. Queen’s Printer for Ontario, 2008). Retrieved August 4, 2009 from:
http://www.health.gov.on.ca/english/providers/program/pubhealth/oph_stan…
ophs/progstds/pdfs/ophs_2008.pdf
Infectious Diseases Protocol, 2009 (Ministry of Health and Long-Term Care; Toronto, ON. Queen’s Printer for Ontario, 2009). Retrieved August 4, 2009 from:
http://www.health.gov.on.ca/english/providers/program/pubhealth/oph_stan…
ophs/progstds/protocols/id_protocol_09.pdf.

CONTACT FOR INQUIRIES

Manager, Control of Infectious Diseases 

APPROVED BY

Director, Health Protection    


Procedure 

Category: Control of Infectious Diseases
Subject: Control of Infectious Diseases (CID) On-Call Responsibilities and Documentation
Division: Health Protection Division
Procedure Number: CA.82.01.111
Effective Date: October 20, 2016

PROCEDURE

General Responsibilities

  1. The on-call staff will ensure that the on-call BlackBerry and laptop are fully charged and operable prior to each on-call shift, and update the on-call laptop with current on-call folder structure located in the CID_Excelicare (\data-fs) (Y:).
  2. The staff will ensure that they are only using an encrypted laptop and memory stick from home to access policies, procedures, medical directives, and Control of Infectious Diseases (CID) reports on the reportable disease fax line as well as for communication. All access codes will be kept in a separate location away from the on-call kit, laptop and Blackberry.
  3.  An on-call schedule for the week normally starting on Friday at 16:30 hours and finishing the following Thursday  at 23:00 hours will be distributed to the team on-call for the week by the CID Program Assistant or designate on Friday afternoons by 16:30. Any new advisories or bulletins will be attached to the on-call schedule for the week.
  4. The staff must be within two hours of the nearest WDGPH office at all times during the on-call shift.
  5. The staff must ensure that strict attention is given to maintaining client confidentiality when following cases/outbreaks during on-call hours (e.g. case follow-up should not be conducted at public venues where one cannot ensure privacy).
  6. Messages received on the on-call Blackberry must be acknowledged (by an email response to the on-call Manager and/or the on-call General Program PHI (GP PHI)) within 15 minutes of receiving, and follow-up initiated as soon as possible. Messages are to be followed up according to CA.82.01/02.104 Reportable Disease Follow-up/Outbreak Control During Office Hours and On-call A copy is also located in the on-call kit, laptop, memory stick and on-call folder structure
  7. The staff will check the Reportable Disease secured fax line a minimum of two times per day on weekends and holidays and once during weeknights towards the end of the on-call shift. Reports are to be followed up according to CA.82.01.104 and CA.82.02.104 Reportable Disease Follow-up/Outbreak Control During Office Hours and On-call. A resource to record faxes is available.
  8. Please note: All Clinical Services related reportable diseases can be left for Clinical Services follow-up. For MBTA applications, follow-up must be initiated as soon as received (refer to guidance document CA.31.02.411 Infectious Diseases Program/On-Call Management of Bloodborne Exposures.
  9. A general update must be provided to the entire CID team regarding any case management done during on-call hours. Cases started during on-call hours must be referred to the appropriate office for ongoing case management on the next business day and Excelicare/iPHIS numbers forwarded to the designated CID team member, manager, and supervisor in a timely fashion.
  10. The staff will update the Manager on-call and copy the CID Manager/Supervisor regularly via email regarding case management during on-call shift. Medical Officer of Health (MOH) is to be consulted as needed for on-call case management. Prior to calling the MOH, discuss with on-call Manager as to who should call the MOH with case details.
  11. Completed on-call timesheets (CA.30.01.121) are to be forwarded to the CID Manager or Supervisor for approval.  Once approved, the CID Manager or Supervisor will forward the timesheet to Human Resources.

Lab Result Responsibilities

  1. When notification is received from the after-hours answering service that a laboratory, physician, or hospital is calling to report a communicable disease or lab result, the GP PHI or Manager on call will notify the CID team member on call. The GP PHI will give the caller’s contact information to the CID team member to call and take the report. During the period from 2300 hours to 0830 hours, there is no CID team member or GP PHI on call. The Manager on call must contact the reporting agency to collect the required information during this time.
  2. The staff will contact the lab, physician, or hospital and complete the Excelicare intake assessment where applicable.
  3. The staff will follow up with the Manager on call to advise the Manager on call of the significance of the report and/or advise of the need for consultation with the MOH for contact management and recommended prophylaxis. The staff will keep the Manager updated on the case management by phone or email.
  4. All information collected regarding the report of a communicable disease is confidential.  An electronic record will be created and maintained using Excelicare during case management of the reportable disease by the staff member.
  5. All cases of reportable diseases will be entered into iPHIS by the Data Entry Clerk the first business day following the date the report was received and additional case follow-up assigned to the appropriate person/office.

Documentation Responsibilities

  1. When communication is received by the on-call staff from the on-call GP PHI or the on-call manager, the staff will record the details of the communication on the on-call log summary in Excelicare, being sure to include:
  • Date and time of the communication received;
  • Reason for communication;
  • Who the communication was received from;
  • Brief summary of actions taken by the on-call CID team member;
  • Organizational and program procedures for documentation must be followed;
  • If the call requires new or ongoing case or outbreak management the Excelicare file number or outbreak number should be documented on the on-call summary log in Excelicare.

RESPONSIBILITIES

Management will:
  • Ensure all new staff are oriented to program (minimum three months) prior to being assigned on-call duties;
  • Orient staff to on-call policies and procedures;
  • Review policies and procedures on regular basis; and
  • Supply equipment needed to ensure on-call duties can be fulfilled.
CID Employees will:
  • Review and follow  this policy and procedure and related guidance documents;
  • Check all on-call IT equipment (BlackBerry and on-call laptop) on Friday before on-call begins at 4:30;
  • Update the on-call laptop with current on-call folder structure located in the CID Excelicare (\data-fs) (Y:);
  • Adhere to CA.82.01/02.104 Reportable Disease follow up/Outbreak Control During Office Hours and On-call for the management of lab reports/calls during on-call; and
  • Ensure client confidentiality is maintained at all times when completing on-call duties

DEFINITIONS

Cluster – Two or more epi-linked cases beyond a household/exposure site.

Outbreak – A greater than expected number of cases that are spacially and temporally linked above what is expected of people with an infectious disease that may be of public health concern.

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Corresponding Policy CA.82.01.111 Control of Infectious Diseases (CID) On-Call Responsibilities and Documentation
CA.30.01.121 On-Call Timesheets
CA.31.02.411 Infectious Diseases Program/On-call Management of Bloodborne Exposures Guidance Document
CA.50.01/02.102 Documentation Practices
CA.52.01.126 Confidentiality
CA.73.01/02.101 Mandatory Blood Testing Act, 2006
CA.82.01/02.104 Reportable Disease Follow-up/Outbreak Control During Office Hours and On-call
CA.86.01/02.103 Notebook Documentation
CA.86.01/02.105 Documentation
CA.86.01/02.107 Documentation of Rough Notes
CID Desktop Reference for Excelicare
Control of Gastroenteritis Outbreaks in Long-Term Care Homes
(MOHLTC,  as current)
A Guide to the Control of Respiratory Infection Outbreaks in Long-Term Care Homes (MOHLTC,  as current)
Health Protection and Promotion Act (Regulation 559/91)
Ontario Public Health Standards Ministry of Health and Long-Term Care; Toronto, ON. Queen’s Printer for Ontario, 2008. Retrieved August 4, 2009 from:
http://www.health.gov.on.ca/english/providers/program/pubhealth/oph_stan…
ophs/progstds/pdfs/ophs_2008.pdf
Infectious Diseases Protocol, 2009 Ministry of Health and Long-Term Care; Toronto, ON. Queen’s Printer for Ontario, 2009. Retrieved August 4, 2009 from:
http://www.health.gov.on.ca/english/providers/program/pubhealth/oph_stan…
ophs/progstds/protocols/id_protocol_09.pdf

CONTACT FOR INQUIRIES

Manager, Control of Infectious Diseases

APPROVED BY

Director, Health Protection