Outbreak leads to 70% absentee rate

Norovirus event brings pandemic lessons

Imagine a communitywide outbreak so pervasive that employees fell ill at work, 40% called in sick, and even the chief nursing executive pitched in to work as a staff nurse.

"Within 24 hours, we had a 70% absentee rate in med-surg," says Shannon Akers, LPN, employee health nurse and infection control assistant at Missouri Baptist Hospital — Sullivan. "From there, the absentees just kept coming."

This scenario sounds like one from a pandemic influenza drill — but it was a real-life episode of norovirus at Missouri Baptist Sullivan, a rural hospital about 70 miles from St. Louis. Missouri Baptist — Sullivan, part of BJC Healthcare, is a small hospital with just 75 beds and a daily census of about 16 in its medical/surgical unit. It serves about 20,000 patients a day in its emergency department and has about 500 employees. The 2006 norovirus outbreak at the facility illustrated how vulnerable all facilities are to the spread of infection and how an easily transmissible infectious disease can affect the hospital's operations, Akers says. She presented information about the outbreak at the annual conference of the Association of Occupational Health Professionals in Healthcare in late September.

Before this outbreak, the threat of a pandemic "seemed very distant and far away," she says. "I just never felt we were going to be impacted by anything big. I have definitely changed my mind about that. I don't think we're sheltered from anything."

The hospital ultimately controlled the outbreak through rigorous adherence to hand hygiene and infection control precautions. But the lessons learned from the outbreak still are shaping the hospital's employee health policies and pandemic planning, Akers says.

Akers vividly remembers when the outbreak began. The hospital's infection control specialist was checking into reports of influenza in the community and found out about cases of gastroenteritis at the local high school. That was the first warning sign.

Noroviruses, also known as Norwalk-like viruses, are highly contagious; exposure to as few as 10 virus particles can lead to infection, according to the Centers for Disease Control and Prevention. It is spread through fecal contamination of food or water or through environmental or fomite contamination.

In Missouri, norovirus had affected about half the passengers on a cruise ship on the Mississippi River. But it also had traveled along the interstates and moved through the state from other sources. Monica Clonts, RN, communicable disease nurse at the Crawford County Health Department in Steelville, MO, who had worked with Missouri Baptist, says "It's highly contagious. We just watched it creep its way across the state."

With norovirus, symptoms can appear within 12 hours of exposure. Although the hospital employees were greatly affected by the virus, only six patients, in the geropsychiatric unit, contracted norovirus from a hospital-based transmission. "We attribute that to the enormous commitment our employees showed to patient safety," says Akers. "It was the employees who contained this. We're very proud of them."

To contain the outbreak, environmental service workers scrubbed the hospital clean with bleach — twice. Health care workers were meticulous about hand hygiene. Anyone with symptoms was instructed to stay home, and ill employees were told to stay home for 72 hours after the symptoms subsided.

Weaknesses in planning

The outbreak pointed out weaknesses in the hospital's emergency planning, says Akers. "What this showed us was that we were deficient in offering our employees options," she says. "We don't have a day care [center]. We didn't have staff properly cross-trained. If there was an emergency in a department, there wouldn't be anyone to replace them. Those are areas that we're looking at to improve."

During the outbreak, employees received spot training to enable them to work in different departments. However, the hospital is gearing up for more cross-training. Akers and her colleagues are also taking a closer look at how to provide day care and meet other employee needs during an emergency. The hospital also monitors spikes and trends in employee absences.

Communication is key

Communication with the health department also was a key to controlling an infectious disease that had spread throughout the community. The health department tracks trends in gastrointestinal and respiratory illnesses. "It was a group effort to get this investigated and contained," says Clonts, who noted that the relationship between the hospital and the health department grew stronger as a result of the outbreak.

It took about 30 days to control the hospital outbreak, and the norovirus eventually died out in the community. "It's my understanding that it just kept moving down the highway," says Akers.