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Issue link: https://eguideline.guidelinecentral.com/i/921497
11 A.4. Legal, Ethical, and Regulatory Requirements 1. Federal, accrediting, state, and local/regional bodies set requirements/standards pertinent to infectious diseases outbreaks, which may change or be updated due to anticipated, occurring, or past outbreaks. Requirements should be identified in the facility's EMP, which should incorporate: a. Public health structures that influence delivery of care during an outbreak investigation and/or declared public health emergency b. Regulations that influence delivery of care around facility and emerging pathogen outbreaks, as well as declared public health emergencies. 2. e facility should ensure Hospital Legal Counsel (or equivalent) as part of the HICS structure. 3. e facility's Ethics Committee (or equivalent) should be involved in EMP and EOP reviews, especially when plans deviate from accepted standards of clinical care. 4. e facility should be aware of its state's crisis standards of care (CSC) guidance when outbreaks limit the resources needed to provide the usual standard of care. B. Roles and Responsibilities of the Healthcare Epidemiologist in Facility and Emerging Pathogen Outbreaks B.1. Leadership Role of the HE in Incident Management 1. e HE should be versed and trained in basic HICS response. 2. In most facilities, the HE serves as the medical-technical specialist in domains relevant to infection prevention and control and infectious diseases within HICS when the system is being utilized. 3. e HE should ensure that liability coverage is provided for the duties undertaken based on his/her role in HICS. B.2. Activities and Responsibilities of the HE in Incident Management 1. e HE should provide input into the facility's EMP and the four phases of incident management as they relate to infectious diseases and infection prevention and control: preparedness, mitigation, response, and recovery. 2. e HE should be involved in the development, maintenance, and evaluation of a facility's EOP as it relates to infectious diseases outbreaks. 3. e HE should ensure that the hospital systematically monitors local, federal, and international public health advisories and alerts of emerging pathogens. 4. e HE should ensure the existence of, or help develop when needed, a hospital-wide surveillance program that accurately and rapidly identifies exposed and infected patients and healthcare personnel (HCP), including protocols for reporting these individuals to infection prevention and control staff. 5. e HE should interpret advisories/alerts and surveillance data to identify when the healthcare facility is faced with a potential or actual outbreak, and report this information to the Emergency Program Manager, Incident Commander, and/or appropriate leadership as established by the facility. 6. e HE should have access to contact information for, and have working knowledge of, stakeholders' roles in responding to a facility or emerging pathogen outbreak.