CP101 Policy for the Management and Control of Diarrhoea ... · PDF filePOLICY FOR THE...

Authorities Document Control Information

Author: Dr ParnabyConsultant Microbiologist

Type: Policy

Sponsor: Members of the Infection Prevention & Control Committee

Scope: Major

Reference: CP101Issue Number: 2

Date July 2011 Status: Published

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POLICY FOR THE MANAGEMENT AND CONTROL OF DIARRHOEA AND VOMITING (NOROVIRUS) INFECTIONS


Author: Dr R ParnabyConsultant Microbiologist

Type: Policy

Sponsor: Paula Shobbrook,Director of Infection Prevention and Control

Scope: Major

Trust Reference Number:

CP101

Reviewer(s): Infection Prevention & Control Committee

Issue Number: 2

Approval body:

Policy Approval Group Status: Published

Effective Date: July 2011Review Date: July 2014Disposal Date: 2034

Document Authorisation Control

Prepared By:Dr ParnabyConsultant Microbiologist

Authorised OfficerChris Gordon Acting Chief Executive

Signature: Signature:

Winchester & Eastleigh Healthcare NHS TrustPOLICY FOR THE MANAGEMENT AND CONTROL OF

DIARRHOEA AND VOMITING (NOROVIRUS) INFECTIONS



Type: Policy


Scope: Major



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DOCUMENT CONTROL

Document AmendmentsNumber Details By Whom Date1 Reformatted into Trust format to meet NHSLA

standards with added notes to training, compliance, Trust policy references, and roles

Steven Jennings Divisional Governance Lead

6 June 2008

2 3 yearly review IPC Team (lead author Sue Dailly)

February 2011

Review TimetableDate Reason By Whom Date

Completed2011 3 year review Sue Dailly Lead

Nurse Infection Prevention & Control Team

July 2011

2014 3 year review IPC team

Distribution ListNo Title1 All employees via the Winchester and Eastleigh Healthcare NHS

Trust Intranet2 The public via Winchester and Eastleigh Healthcare NHS Trust

Website

RELATED TRUST POLICIES

OP001 Policy for Management of Controlled DocumentsCP073 Hand hygiene PolicyCP008 Incident Management & Reporting Policy Including the Management of Serious Untoward IncidentsCP076 Policy for the Standard Precautions and PPE (Personal Protection Equipment)CP030 Overarching Decontamination PolicyCP077 - Policy for Ward Closure due to an Infection Control Issue





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CP021 Surveillance Policy (includes reporting of healthcare associated infections to the Health Protection agency)CP033 (NP 14) Policy for Standards for Record Keeping by Nurses and Midwives CP071 Major Outbreak PlanCP022 Isolation and Infectious Diseases Policy





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Contents

Section Title Page1 Purpose 52 Scope 53 Roles and Responsibilities 54 Introduction 65 Signs and Symptoms 76 Transmission 77 Diagnosis 78 Patient Management and Treatment 89 Documentation 9

10 Stool Samples 1011 Isolation 1112 Hand hygiene 1213 Personal Protective Clothing 1214 Movement of Affected Patients 1215 Environmental cleaning 1416 Visitors 1417 Staff 1518 Ward Closure 1619 Outbreak Control Group 1620 Monitoring Compliance and Effectiveness 1721 Major Outbreak Control 1722 Training Implications 1823 References 18

Appendix 1 Diarrhoea & Vomiting Action Plan for Wards 19

Appendix 2 NHS South Central Top 10 tips to help prevent outbreaks of Norovirus 21

Appendix 3 Equality Impact Assessment Tool 26

Winchester & Eastleigh Healthcare NHS TrustPOLICY FOR THE MANAGEMENT AND CONTROL OF DIARRHOEA AND

VOMITING (NOROVIRUS) INFECTIONS



Type: Policy


Scope: Major



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1 PURPOSE

1.1 This policy has been developed to provide a practical document to equip all healthcare staff at Winchester & Eastleigh Healthcare NHS Trust (WEHCT) with the necessary information on the recognition, management and treatment of outbreaks of diarrhoea and vomiting such as Norovirus.

2 SCOPE

2.1 This policy extends to cover all WEHCT NHS Trust staff. This policy will also apply to honorary contract holders and staff employed by other organisations who work with the WEHCT NHS Trust patients and for the Trusts’ other staff.

2.2 This policy complements professional and ethical guidelines and the Nursing and Midwifery Council (NMC) Code of Professional Conduct (NMC 2009).

2.3 Infection prevention and control is the responsibility of ALL staff associated with patient care. A high standard of infection prevention and control is required on ALL wards and units, although the level of risk may vary. It is an important part of total patient care.

2.4 It is essential that infection prevention and control is seen as an organisational responsibility and priority, that adequate isolation facilities and resources are provided, and that appropriate infection control staff and support services are available.

2.5 This policy is ratified in line with OP001 Trusts Policy for the Management of Controlled Documents (2007).

3 ROLES AND RESPONSIBILITIES

3.1 The Chief Executive (CEO) has overall responsibility for ensuring the Trust has appropriate strategies, policies and procedures in place to ensure the Trust continues to work to best practice and complies with all legislation. The CEO has overall responsibility for the provision of adequate funding to meet the increased costs of outbreaks of Norovirus and adequate isolation facilities to enable national guidance on the control of Noroviruses to be implemented.

3.2 Line managers

3.3 Are responsible for ensuring this policy is accessible for all staff and that they have read and understood the content. Line mangers are responsible for ensuring any changes in practice are implemented, and any further training needs identified and addressed. Ward managers are to assist with the root

Winchester & Eastleigh Healthcare NHS TrustPOLICY FOR THE MANAGEMENT AND CONTROL OF DIARRHOEA

AND VOMITING (NOROVIRUS) INFECTIONS



Type: Policy


Scope: Major



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cause analysis which will be carried out following a ward closure or death due to Norovirus (see section 20.4).

3.4 All staff

3.5 All staff must ensure that their practice follows the current policies. Information regarding the failure to comply with the policy (e.g. lack of training, inadequate equipment) must be reported to the line manger and the incident reporting system used where appropriate.

3.6 Infection Prevention & Control Team (IPC team)

3.7 The Infection Prevention & Control Team (IPCT) have a responsibility to offer advice to healthcare staff on treatment and isolation requirements. The team will collate data and share this within the Trust via the Infection Prevention & Control Committee (IPCC) and the Infection Prevention & Control divisional leads and link practitioners (IPCLPs).

4 INTRODUCTION

4.1 Small round structured viruses (SRSVs e.g. norovirus), are the most common cause of outbreaks of gastro-enteritis in hospitals and can also cause outbreaks in other settings such as schools, nursing homes and cruise ships. Hospital outbreaks often lead to ward closure and major disruption in hospital activity. Outbreaks can affect both patients and staff, sometimes with attack rates in excess of 50%. For this reason, staff shortages can be severe, particularly if several wards are involved at the same time.

4.2 The disease was historically known as the “winter vomiting disease” due to its seasonality and typical symptoms. However in recent years this typical pattern has changed and outbreaks have occurred throughout the year. In a recent study the Health Protection Agency (HPA), have showed that variants to the virus emerge frequently and become the predominant circulating strain which in turn is later replaced by a new variant. Large numbers of contacts can therefore be affected as immunity to the illness is not long-lasting.

4.3 Norovirus infections are usually associated with relatively mild and short lived symptoms and affected individuals in the community rarely seek medical attention. However outbreaks involving patients and staff in hospitals can have a significant impact on hospital activities ranging from ward closures and delays in the admission and discharge of patients. It is therefore essential that cases are detected early and isolated appropriately to prevent spread and major outbreaks. These viruses are relatively resistant to alcohol gel so soap and water must be used when washing hands.





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5 SIGNS AND SYMPTOMS

5.1 The average incubation period for norovirus associated gastro-enteritis is 12-48 hours. Patients cared for in bays where other patients have symptomatic Norovirus may have an extended incubation period and develop symptoms after 48 hours of contact with a source of the virus.

5.2 The illness is characterized by a sudden acute onset of:

Vomiting (may be projectile) Watery diarrhoea and abdominal cramps Nausea

5.3 In addition headache, myalgia, fever and malaise are common. Some or all of the above symptoms may be present.

5.4 Symptoms last between one and three days and recovery is usually rapid. The frequency of the symptoms can vary with some patients having just 2-3 episodes of diarrhoea or vomiting, rather than the expected frequent episodes, this depend on the circulating virus at the time of the outbreak. In some cases the duration of symptoms may be longer.

5.5 Dehydration is the most common complication and patients may require replacement fluids.

6 TRANSMISSION

6.1 Noroviruses are highly contagious with as few as 10 -100 virus particles thought to be sufficient to cause infection. Noroviruses are transmitted primarily through the faecal –oral route either by person to person spread or via contaminated food or water. In addition noroviruses can be spread via aerosol dissemination of infected particles following vomiting.

6.2 Transmission can also occur through hand transfer of the virus to the oral mucosa following contact with environmental surfaces, fomites and equipment which have been contaminated with either faeces or vomit.

7 DIAGNOSIS

7.1 Diagnosis of norovirus infection can often be made on clinical grounds from their characteristic features. However the infection can also be confirmed following testing of a stool sample.

7.2 When an outbreak is suspected, it is imperative to initiate infection prevention and control measures immediately without waiting for virological confirmation from stool testing.





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8 PATIENT MANAGEMENT AND TREATMENT

8.1 Treatment

8.2 Currently there is no effective antiviral treatment for noroviruses. It is a self limiting illness which will usually cease within a few days. It is important to ensure prompt fluid replacement to prevent dehydration and its complications.

8.3 There is a sample patient, relatives and carer’s information leaflet available on the intranet, ref 308 “Norovirus”. Copies of this leaflet are available from the IPC team.

8.4 What to do if you suspect there is an outbreak?

8.5 If you have 2 or more cases of unexplained diarrhoea and / or vomiting or nausea on your ward, either staff or patients, you may be at the start of an outbreak. It is the responsibility of the nurse in charge to contact the Infection Prevention & Control Team (IPC Team) on ext 4483 or 5170 immediately for further advice. (See Appendix 1).

8.6 Out of hours and during the weekend the nurse in charge must discuss this with the on-call Consultant Microbiologist or night site coordinator and either email the Infection Prevention & Control Nurses (IPCNs) via their generic email address or leave a message on their answer-phone (x5170) so they can follow up on the next working day. See 8.9 below for a provisional decision on ward closure.

8.7 There are several different actions which must be taken, some according to the number of patients who are affected, but isolation of cases on the same ward and prevention of transfers from the ward are both critical. Further, the Consultant Microbiologist will make a decision as to whether to close or partially close the ward to admissions to bring the situation under rapid control. Early discussion is key as every situation is different. Examples of requirements for control are as follows:

a. Move symptomatic patients into side rooms, close the bay for 48 hours, consider other patients in that bay as contacts and monitor for development of diarrhoea and / or vomiting. Review this with the IPC team.

b. If numbers exceed side room capacity, cohort nurse, symptomatic patients and their contacts. Patients with a positive Clostridrium difficile result must not be cohort nursed with patients with diarrhoea due to another cause. Patients with Clostridium difficile should be moved to the cohort ward (Victoria Ward or other ward if so designated in the future).

c. Send specimens on all affected cases to the Microbiology laboratory.





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d. Stop all transfers to other wards.e. Monitor all unaffected patients for symptom development and affected

patients for frequency of symptoms. Keep a symptom chart on each patient and update on each shift.

f. Close one or more bays as necessary.g. Close the whole ward.

8.8 The Consultant Microbiologist is the ONLY person with designated responsibility to close and open a ward because of infection. Please refer to the Ward Closure policy and Major Outbreak Plan for further information.

8.9 If incidents of diarrhoea and/or vomiting occur during the night, ward staff and

night coordinator can make a provisional decision to close the bay or ward and institute barrier nursing, aiming to collect diarrhoeal samples and then contacting the microbiologist or IPCNs in the morning for follow up action.

8.10 The nurse in charge must inform the site coordinator that there is a problem on their ward with diarrhoea / vomiting/ nausea. The site coordinator must discuss with the IPC Team what action needs to be taken.

8.11 The IPCT will visit the ward daily or more often if required to assess the situation and set an action plan for the next 24 hours. On a Friday an action plan will be set for the weekend or Bank Holiday period. This action plan will be verbally discussed with the nurse in charge of the ward and the site coordinator. In addition a generic email will be sent out each day from the IPCT to all staff on the outbreak contact list to help ensure all relevant staff, including the Occupational Health Department, are kept fully informed with the latest information. Unexpected events that occur over the weekend or Bank Holiday should be discussed with the Consultant Microbiologist on call by the site coordinator or on call manager. IPCNs will aim to visit or contact the wards at the weekend when outbreaks are affecting several wards within the Trust.

9.0 Documentation

9.1 Once an outbreak is suspected the IPCT will ask the ward staff to complete a daily record sheet for all symptomatic patients. (See intranet for copies – diarrhoea and vomiting outbreaks – data collection form). Patients are most infectious during the early stages when diarrhoea / vomiting is profuse. Accurate documentation on all symptomatic patients is vital in order for the IPCT to make an accurate assessment of the infection and plan the correct course of action. The following information is necessary for all symptomatic patients:

i. Name; first and surnamesii. Position in ward; state bed number and bay or single room





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iii. Frequency; please state the number of times the patient has an episode of either diarrhoea or vomiting. The data collection form is downloadable from the intranet and to be used daily (one sheet per day).

iv. Data should also be collected on patients who are nauseous. It will not be necessary to close an area if no vomiting or diarrhoea develops but nausea may be an early symptom of infective gastro-enteritis.

9.2 It is the responsibility of the nurse in charge to ensure that accurate documentation is maintained on all symptomatic patients throughout the duration of the outbreak, as per CP033 (NP 14) Policy for Standards for Record Keeping by Nurses and Midwives

10 Stool Samples10.1 Please take a stool sample from every patient who has diarrhoea. If the

sample is contaminated with urine it can still be sent. Faeces scraped off the sheet or incontinence pad can also be used if you are unable to obtain a sample from a bedpan. The sample should contain the runniest part of the sample. All samples which are liquid will be tested for Clostridium difficile. During unsocial hours diarrhoeal samples can be collected for testing during the day after discussion with a consultant microbiologist.

10.2 Stool testing for norovirus is carried out if an outbreak is suspected. It is important that a representative number of patients provide samples and these are sent to the laboratory as soon as possible. Never wait for positive results before implementing infection control precautions and outbreak control measures. Viral gastroenteritis is most infectious in the early stages.

10.3 The IPCT will co-ordinate with the microbiology laboratory to ensure a relevant sample of affected patients receives norovirus testing. The current hospital laboratory test may confirm some patients have norovirus, but if the samples are all negative they will be sent to another hospital laboratory for further investigation. This molecular test may become available locally in the future. Confirmation of norovirus often is not known until the outbreak is either resolving or has resolved if the samples have to be sent to another hospital. For financial reasons, once a ward has confirmed norovirus, it is not usual practice to continue to test new patients with the same symptoms during an on-going outbreak on that ward.

10.4 The IPCT will provide the microbiology laboratory with the HPA epidemiological outbreak log number to link the outbreak samples which may be referred for typing, to the particular outbreak or ward closure which has been reported by the IPCT as part of the national enhanced surveillance programme for norovirus.





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11. Isolation

11.1 Depending on the number of symptomatic patients involved, he/she/they will either be nursed in single rooms, or cohort nursed in a bay. Some patients cannot be moved to a side room as this would place them in an ‘unsafe’ environment. For example patients who are at falls risk, are confused or under the Mental Health Act. Consideration must be taken of patients’ clinical and psychological needs when assessing where to place patients during an outbreak of diarrhoea and vomiting. Please refer to the CP022 Isolation Policy for further information.

11.2 If necessary the whole ward will be closed to admissions, transfers and discharges except to the patient’s own home.

11.3 Patients who have to be moved to another ward due to their clinical condition e.g. ITU must be isolated and barrier nursed until symptom free for at least 48 hours but ideally 72 hours. The sending ward must inform the receiving ward and ensure adequate facilities are provided.

11.4 The nurse in charge must ensure that a sign is placed on the door of the isolation room or affected bay alerting all staff and visitors that this is an isolation area. If the whole ward is closed a sign should be placed on the door at the entrance to the ward informing staff and visitors of the situation and asking them to report to the nurse in charge before seeing a patient.

11.5 The affected bay or ward should be closed to all new admissions or transfers unless approved by the consultant microbiologist. If the clinical condition of a patient dictates that their treatment requires them to be admitted to a ward closed with diarrhoea and vomiting, the admitting medical team have a responsibility to inform the patient of the ward status and also document in the patient’s notes that their clinical condition outweighs their risk of entering a ward which is currently closed due to diarrhoea and vomiting.

11.6 When a patient has had no diarrhoea or vomiting for 72 hours they are deemed no longer infectious. A ‘closed’ bay can be re-opened when there have been no new cases and all affected patients have been asymptomatic for 72 hours. When a whole ward has been closed, bays may be opened gradually towards the end of the outbreak. Bays can only be re-opened when there have been no new cases and all affected patients have been asymptomatic for 72 hours. All areas must be deep cleaned or ideally decontaminated using hydrogen peroxide technology (Bioquell®) before opening, please refer to section 15.0 on environmental cleaning. The decision to re-open an infected ward can only be made by the consultant microbiologist. In some circumstances the Consultant Microbiologist may reduce the 72 hour limit to 48 hours but this decision cannot be taken without





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his/her advice and agreement. If appropriate the Consultant Microbiologist will seek advice from the HPA.

11.7 All linen from isolation areas should be treated as infected linen and disposed off as per the infected linen policy.

12 Hand Hygiene

12.1 The hands of healthcare staff can provide the vehicle for the transmission of this infection. Furthermore a lack of hand hygiene among healthcare staff is a well recognised problem nationally. It is therefore essential that all staff wash their hands when required using the correct hand washing technique to help reduce the risk of transmission, as per CP073 Hand hygiene Policy. A

12.2 Alcohol gel is not effective against these viruses and therefore hands must be washed with soap and water before and after every patient contact and after contact with potentially infectious equipment, furnishings or other fomites. Please refer to CP073 Hand hygiene Policy for further details.

12.3 Wearing gloves do not obviate the need to wash hands.

12.4 Patients must be provided with the opportunity to wash their hands or use hand wipes after each toileting episode and also before each meal. Hand washing with soap and water is always preferable.

13 Personal Protective Clothing

13.1All staff must put on a yellow plastic apron and non-sterile gloves before entering an affected bay or side room. These should be removed and hands washed with soap and water before leaving the room or bay. Any failure to comply with the wearing of protective clothing and hand washing during an outbreak should be notified to the ward manager and the IPC team. Failure of compliance may constitute a clinical incident. Outbreaks of D&V can be contained if all staff follow these instructions. Refer to the CP076 Policy for the Standard Precautions and PPE (Personal Protection Equipment) for guidance.

13.2 There is currently no evidence to justify the wearing of face masks routinely for either patients or staff.

14 Movement of Affected Patients

14.1If a patient is symptomatic, his/her visit to another department should be delayed unless clinically urgent, as it will be distressing for the patient if an episode of diarrhoea or vomiting occurs during transit. Furthermore this will also unnecessarily expose more contacts to the infection and may result in





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the contamination of equipment e.g. radiological scanners. Alternatives should be considered such as portable X-ray. If clinically urgent the investigation or treatment should be discussed with the appropriate department in advance so that appropriate precautions can be undertaken.

14.2 Asymptomatic patients in a closed bay maybe able to visit other departments for tests etc. It is the responsibility of the nurse in charge of the ward to ensure that the receiving department is informed about the status of the patient, so they can ensure their visit is brief.

14.3 Patients in a closed bay or ward who require surgery should have their requirements discussed on a case by case basis between microbiologist, anaesthetist and surgeon. This will depend on clinical urgency as in 14.1.

14.4 Asymptomatic patients requiring social work / care home assessment can have their assessment carried out in a day room or another room off the affected ward so as to reduce the delay in discharge.

14.5 When Kingfisher ward or another satellite ward e.g. Melbury Lodge has norovirus there need to be contingency plans of where these patients will be accommodated if they are clinically too unwell to be accommodated on Kingfisher ward. The affected ward must discuss with the site coordinator, A/E, EMAU and the admitting doctor that the patient either has norovirus or is a contact prior to transfer to the RHCH site.

14.6 What to do if a visit to another department is essential for clinical care

14.7 Symptomatic and asymptomatic patients must not be transferred to other wards. However if the patient needs to be transferred to another ward for clinical reasons, this must be discussed with the IPCT on an individual basis, and they must be isolated for at least 72 hours following their transfer or until symptom free for 72 hours. Individual patients may be transferred to another ward to enable them to be isolated. However the nurse in charge or the bed manager must discuss this with the IPCT before the transfer takes place.

14.8 Affected patients must not be discharged to nursing or residential homes until they have been clear of symptoms for more than 72 hours. If their discharge is planned within this period it is the responsibility of the nurse in charge to contact the nursing or residential home to discuss their discharge arrangements. The local HPU may advise that a 48 hour interval is acceptable.

14.9 Affected patients may be discharged to their own homes once they are deemed fit for discharge.





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15 Environmental Cleaning

15.1 Whilst a bay or ward is closed during an outbreak, the area must be cleaned twice daily with both detergent and chlorine e.g. Actichlor Plus®. Frequently used areas such as toilet areas should be cleaned at least twice daily and more frequently should the need arise. It is the responsibility of the nurse in charge to inform the housekeeping staff of requirements for their ward.

15.2 Bays and wards can be re-opened 72 (see 11.5) hours after the last symptomatic episode but this maybe reduced to 48 hours if a risk assessment suggests this is appropriate. This decision will be made by the Consultant Microbiologist. Before opening, all areas on the ward must receive a deep clean. This involves cleaning all surfaces with both detergent and chlorine e.g. Actichlor Plus® (a combined detergent and chlorine bleach agent), paying particular attention to frequently touched objects such as call bells, light switches, door handles, taps and toilets.

15.3 Disposable curtains must be changed when visibly soiled and when a bay is ‘deep cleaned’ at the end of an outbreak. All window curtains must be changed as part of the deep clean process and washed at a temperature of at least 60°C or dry cleaned.

15.4 Healthcare staff should wear the appropriate PPE when undertaking the deep clean and must have received training in the use of chlorine based agents. Refer to the CP076 Policy for the Standard Precautions and PPE (Personal Protection Equipment) for guidance.

15.5 Nursing staff are responsible for ensuring that all equipment is cleaned with detergent and chlorine e.g. Actichlor Plus®, in-between each patient and also as part of the deep cleaning process before the ward re-opens. Refer to the CP030 Disinfection, decontamination of hospital equipment policy for guidance.

16 Visitors

16.1 Friends and family must be informed that the ward or bay is currently closed because of diarrhoea and vomiting. They should be asked to postpone their visit or, if essential for personal reasons to make the visit as short as possible. No food should be brought in from outside. Visitors should also be asked to wash their hands with soap and water on entering and before leaving the ward and to refrain from sitting on the bed whilst visiting. Visitors can be given the patient, relatives and carers leaflet 083 “Norovirus” which is available from the IPC team. In some circumstances the ward may be completely closed to visitors.





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16.2 Posters will be placed at the entrances to the hospital and in the car park to There will also be clear signage outside each closed ward including the use of large free standing banners.

16.3 If the outbreak affects several wards or it is felt to be helpful, the communications department will arrange for a press release to local papers and radio stations, advising people not to visit patients unless necessary.

17 STAFF

17.1Symptomatic staffAny member of staff who becomes symptomatic whilst on duty must be sent home as soon as possible. Any person who becomes symptomatic at home must inform their ward manager by telephone. It is the responsibility of symptomatic staff to provide a stool sample to rule out other causes of diarrhoea. Staff must not return to work until they have been symptom free for at least 48 hours and have also returned to normal eating and drinking habits for 24 hours prior to return.

17.2 Staff can contact the Occupational Health department for specific advice e.g. for advice about returning to work.

17.3 Responsibilities of the ward staff

17.4 To ensure all members of staff on duty are aware which bays or side rooms are infected and what precautions are required. Whenever possible, allocate staff to either infected or non-infected areas.

17.5 To record every episode of diarrhoea and vomiting on a daily record sheet.

17.6 To take a stool sample from every symptomatic patient. NB sample does not have to be a ‘clean’ sample.

17.7 To promptly update the IPCT if changes in the situation occur.

17.8 To inform all visitors to the ward that there is an outbreak and advise them which precautions are required.

17.9 To ensure all healthcare staff wear protective clothing when entering an affected bay or side room. Any failure to comply with these precautions must be reported to the ward manager and if necessary to the IPCT for advice. Refer to CP076 Policy for the Standard Precautions and PPE (Personal Protection Equipment).

17.10 To ensure that correct hand hygiene measures are carried out by patients and their visitors. Visitors should be discouraged from visiting until all





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patients in the bay are symptom free, not just the person they are planning to visit. If visitors choose to visit a closed bay they should wear gloves and aprons and wash their hands before entering and leaving. If other patients in the same ward are symptomatic, again the visit should be deferred.

17.11 To ensure there are adequate stocks of gloves, aprons, linen, disposable bedpans and vomit bowls.

17.12 To ensure that any member of staff affected must be sent home immediately.

17.13 Visiting staff e.g. Occupational Therapists (OT), Physiotherapists and Social Workers

17.14 If the patient is symptomatic and the visit is not urgent they should delay the visit. If the visit is essential, gloves and aprons should be worn and make the visit as brief as possible. Hands must be washed with soap and water once PPE has been removed. Visits to the affected ward should be made at the end of the shift. If the visiting therapist has to work on an affected ward and then carry out home visits he/she should wear scrubs whilst on the ward and wear uniform for the home visit. Staff must not sit on the bed but use the chairs provided for visitors. Notes, x-rays and other equipment should not be placed on the bed.

Once a patient has recovered from diarrhoea / vomiting their rehabilitation and therapies should recommence. The patient can leave the ward or visit the OT kitchen area when 48 hours symptom free.

17.15 Bank & Agency staff

17.16 Where possible bank staff should only work on an affected ward or non affected ward but not on both. Bank staff can work on a ward affected by diarrhoea and vomiting BUT cannot move straight to another ward without first ideally showering and at a minimum changing their uniforms. If avoidable, staff should work on unaffected wards first then the affected ward.

Agency staff are not permitted by the agency to work on a ward closed with diarrhoea / vomiting.

18 Ward closure – refer to CP077 - Policy for Ward Closure due to an Infection Control Issue.

19 Outbreak Control Group – refer to CP077 Ward Closure policy / CP071 Major Outbreak Plan.





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19.1The front reception desk must be kept up to date with which wards are closed or affected by diarrhoea/vomiting so they can advise visitors entering the hospital.

19.2 Switchboard must also be informed which wards are affected with diarrhoea / vomiting.

20 MONITORING COMPLIANCE AND EFFECTIVENESS

20.1 During the outbreak the IPCT will keep a record of the number of patients and staff that were affected and also how long a bay or ward was closed to admissions due to infection.

20.2 Every ward closure is reported internally (on Datix) and an outbreak as a Serious Incident Requiring Investigation (SIRI) in line with SIRI reporting guidance. These are then reported to the SHA and PCT commissioners or to any subsequent commissioning organisation, as required. Any ward closure due to suspected norovirus is also reported to the HPA via its electronic surveillance scheme. See CP021 Surveillance Policy for further details.

20.3 An outbreak is a clinical incident and should be reported as such by the ward manager or IPCT. Outbreaks may be subject to a Root Cause Analysis (RCA), to ensure lessons learnt can be disseminated throughout the organisation. See CP008 Incident Management & Reporting Policy including the Management of Serious Incidents Requiring Investigation for information.

20.4 After the outbreak has resolved the IPCT will assist or be responsible for writing a summary of the event including lessons to be learnt. This will be sent to the Patient Safety and Governance Committee or clinical risk co-ordinator for dissemination. If appropriate an incident review meeting will be held.

20.5 The IPC team will present a summary of the outbreak at the Infection Prevention & Control Committee and at divisional meetings so that any learning can take place.

20.6 After each outbreak the practices and procedures around handling the outbreak will be reviewed and any changes made and communicated.

21 MAJOR OUTBREAK CONTROL

21.1 If two are more wards are affected with the same symptoms concurrently, the major outbreak plan may be implemented. Please refer to CP071 Major Outbreak Plan for further information.





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22 TRAINING IMPLICATIONS

22.1 Infection Prevention and Control training on basic principles is part of the Trust wide mandatory training scheme for all staff and is monitored via attendance records.

22.2 Training is offered to all staff at induction.

22.3 Training is offered to all staff at their annual update.

22.4 Speciality based training is offered via divisional meetings on an ongoing basis.

22.5 The Infection Prevention & Control Link Practitioners participate in the specialist programme of ongoing training.

22.6 It is the responsibility of individuals and line managers to ensure attendance training. The Education and Training Department feed back non attendances to their respective line managers whose responsibility is to follow up non attendances and to ensure their subsequent attendance.

22.7 E-learning for infection control is an acceptable alternative on alternate years once face to face induction is completed. E-learning is accompanied by certification which can be used in evidence at appraisal.

23 REFERENCES

Health Protection Agency 2007 Newsletter 1. 1st July Health Protection Agency Network for the Detection and Characterisation of Noroviruses.

Infection Prevention Society (2011) Guidelines for the Management of Norovirus Outbreaks in Acute and Community Health and Social Care Settings (Draft May 2011): Bathgate: IPS

Nursing & Midwifery Council (2009) Record Keeping: Guidance for nurses and midwives. London: Nursing & Midwifery Council

Report of the Public Health Laboratory Service Viral Gastro Enteritis Working Group. (2000) Management of hospital outbreaks of gastro-enteritis due to small round structured viruses. Journal of Hospital Infection (2000) 45: 1-10.





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Appendix 11: Diarrhoea & Vomiting Action Plan for Wards

1.1 Contact the Infection Prevention & Control Team (IPCT) when there are 2 or more patients with unexplained episodes of diarrhoea and / or vomiting.

1.2 Move affected patients into a side room or into one bay if this is appropriate – if in doubt seek advice from the IPCT. The bay(s) should be closed to admissions – seek IPCT advice if in doubt.

1.3 Cohort nursing should be commenced if there are larger numbers of patients involved.

1.4 Take faecal specimens and label, ‘ward outbreak’. NB stool samples do not need to be ‘clean’.

1.5 It is important to record whether the specimens are from staff or from patients.

1.6 Ensure yellow plastic aprons and gloves are being used when entering all isolation areas on the ward. Following their removal staff must wash their hands with soap and water and not alcohol gel.

1.7 All linen should be treated as infected and disposed of into an alginate bag and then a red laundry bag.

1.8 Any staff that becomes ill should leave the ward immediately and go home.

1.9 Staff should not return to work until they have a formed stool, or are free from symptoms for 48 hours and are also eating and drinking for 24 hours.

1.10 Bank staff should not work on an affected ward and then go straight to an unaffected ward – ideally there should be an overnight break between changing wards, at a minimum they must change their uniform. Agency staff are not allowed by their Agency to work on wards affected by diarrhoea / vomiting.

1.11 Patients can only be discharged to their own home.

1.12 Patients must not be discharged to another institution such as a nursing or residential home.

1.13 Patients must not be transferred to another ward without permission from the IPCT.





Type: Policy


Scope: Major



Page 20 of 26

Appendix 1: 22: The Infection Prevention & Control Team responsibilities :

2.1 The IPC team will visit the affected ward each weekday or more often to collect information on the number of patients / staff affected and their signs and symptoms.

2.2. Inform relevant departments each day as appropriate e.g. by sending out an –e-mail to all those on the outbreak list (senior manager, housekeeping, occupational health, nurse bank, supplies and laboratory staff).

2.3 Offer support and advice to ward staff and patients

2.4 Co-ordinate outbreak meetings, if required

2.5Liaise with site co-ordinators and support decision making processes at regular bed management meetings

2.6Disseminate “lessons learnt” from the review undertaken of an outbreak on its completion

2.7 Assist the communications department with press releases and wider communication as necessary.





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Scope: Major



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Appendix 2: Department of Health (2010) NHS South Central Top 10 tips to help prevent outbreaks of Norovirus (Document adopted from the HPA and NHS London Ten Top Tips). London: DoH

Ten Top Tips for CEO’s, Medical Director & Nursing Director1. Ensure you have a nominated individual responsible for the development and

implementation of your winter / surge plan, this should contain a section to manage an outbreak like Norovirus

2. Maintain high visibility in all clinical and management areas3. Ensure roles and responsibilities are clear for the escalation to executive team

to maintain leadership and control of a rapidly changing situation.4. Plan your escalation facilities, where will these be based, what will trigger their

opening and closure, and how they will be set up. Consider all external alternative providers (including private providers) if wards are closed for prolonged periods.

5. Develop communications plan to ensure engagement in the management of acute phase, rapid flow of prepared information and updates within the Trust and externally to partnership organisation and members of the public.

6. Develop staffing plans for staff sickness cover, staffing for escalation areas and alternative emergency pathways if wards are closed.

7. Develop plan for site lock down by the Trust Security team (or providers) if required, what will trigger this action.

8. Ensure a focus on business continuity detailing the financial implications for reductions in planned activity and increased emergency activity (specify what information must be collected during the adverse situation)

9. Ensure community escalation plans are in place, who are the key points of contact to trigger engagement and implementation.

10.Ensure escalation plans are in place for social services plans, who are the key points of contact to trigger engagement and implementation.

11.Ensure good communication links established with Executives in local acute trusts to share plans and support during extreme pressures.

12.Test your plan before it is required with table top scenario testing, involving key people and local partners

Document adopted from the HPA and NHS London Ten Top Tips

Top Ten Tips to help prevent outbreaks of NorovirusTen Top Tips for ward nurses1. Recognise patients with symptoms of diarrhoea and vomiting and institute

appropriate care plan and action (no matter how long the patient has been in hospital)

2. Isolate patients with diarrhoea in a side room immediately3. Always wear gloves and aprons for direct patient contact if they have vomiting

or diarrhoea, discard and wash hands before doing anything else.





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Page 22 of 26

4. Alcohol hand rub is not reliably effective against norovirus so wash your hands with soap and water after each contact with affected patients or their immediate environment

5. Discard all food from the surfaces of lockers. All patient food to be located INSIDE lockers. Staff food to be located in staff area only.

6. Inform the ward matron and IPCT as soon as possible when a patient on the ward has diarrhoea

7. If it appears there are 2 cases of vomiting or diarrhoea in the same bay/ward, inform the IPCT immediately (at 8am if overnight or the microbiologist on call at the weekend)

8. Diarrhoeal stool samples should be sent to the laboratory for processing immediately (virology requesting norovirus, microbiology requesting c&s and C. difficile toxin)

9. Ensure enhanced cleaning of ward and equipment (1% hypochlorite/ sporocidal agents/single use equipment where possible)

10. If you become unwell with diarrhoea or vomiting stay at home (or if it occurs in shift, inform senior and go home immediately) and do not return to work until 48 hours symptom free


Top Ten Tips to help prevent outbreaks of NorovirusTen Top Tips for infection prevention & control teams1. Ensure annual updates on infection prevention & control to all clinical staff

include the awareness and importance of diarrhoea management and other relevant policies (disseminate top ten tips).

2. When a ward team informs you of 2 or more cases of diarrhoea or vomiting on ward, attend ward and assess all pts for diarrhoea and vomiting on the same day and make a decision about bay or ward closure.

3. If you institute a bay or ward closure activate the incident/outbreak control policy

4. Post “restricted entry” and “infection control” signs on entrance and exit to inform visitors and healthcare staff (where possible assign a mobile hand washing unit to entrance/exits, if no sink already present)

5. Inform Bed Management team, Comms team, DIPC, local HPU, local PCT infection control lead

6. Ensure ward staff aware of policies and actions (Disseminate TOP TEN TIPS to appropriate groups)

7. Ensure laboratories aware of potential outbreak and requirements for testing8. Ensure cleaning staff aware of outbreak and know the expected cleaning

regimen; where necessary observe practice and perform audits9. Attend ward daily and perform appropriate surveillance (daily line list, daily epi-

curve, daily sitrep to pre-determined parties)10.When no new cases have occurred for at least 72 hours and all symptomatic or

exposed cases are isolated/ cohorted, deep clean and re-open the ward. Review the outbreak management and disseminate any lessons learnt from the outbreak throughout the hospital.





Type: Policy


Scope: Major



Page 23 of 26


Top Ten Tips to help prevent outbreaks of NorovirusTTT for bed management team1. Inform IPCT if you are aware of 2 or more cases of diarrhoea on a ward at any

one time2. Following IPCT or Microbiology advice close bay or ward as appropriate3. Inform Director of Ops/ Performance/Executive team of any problems

associated with ward or bay closures immediately (including A&E breaches etc)4. Do not move patients from affected bays or affected wards without consultation

with the IPCT (microbiology out-of-hours) unless urgent clinical need.5. Do not cohort symptomatic, incubating or unaffected patients without express

agreement of IPCT.6. Patients can be discharged to their own home once clinically stable and take

consideration of high risk home contacts7. Patients can only be discharged to a nursing home from an affected ward if the

nursing home is aware and able to institute appropriate infection control measures.

8. Attend incident (outbreak/sitrep) control meetings daily/as they occur9. Ensure you have a daily list of all affected bays and wards in the hospital10. if you become unwell with diarrhoea or vomiting stay at home (or if it occurs in

shift, inform senior and go home immediately) and do not return to work until 48 hours symptom free


Top Ten Tips to help prevent outbreaks of NorovirusTen Top Tips for DIPC (and on-call manager)1. Liaise closely with IPCT and ensure IPC leadership across organisation2. Ensure appropriate IPC policies (outbreak management, diarrhoea,

decontamination, staff health) in place across organisation and that they are audited yearly

3. Ensure IPCT appropriately resourced to carry out duties during incident/outbreak

4. Ensure that enhanced cleaning and decontamination is supported during outbreaks e.g. adequate staff, 1% hypochlorite, hydrogen peroxide

5. Ensure adequate laboratory support (both virology and microbiology) for specimen processing and administration during incidents/ outbreaks

6. Ensure adequate bed and operational management during outbreak7. Ensure that information is disseminated across the organisation in a timely

manner (minimum daily during outbreak)8. Ensure that the hospital has an external communications plan (for patients,

visitors, PCT, GPs, care homes, other hospitals etc)9. Ensure that the Executive Team are aware of incident/outbreak and any issues

brought to their attention10.Ensure the relevant data are collected for reporting to SHA/ Winter Planning

etc.





Type: Policy


Scope: Major



Page 24 of 26


Top Ten Tips to help prevent outbreaks of NorovirusTen Top Tips for Modern Matrons1. Ensure that your ward staff are aware of Diarrhoea and Vomiting/ Norovirus

policies and inform IPCT promptly (within 24 hours) of all cases2. Ensure adequate clinical care of patients with diarrhoea and vomiting (stool

charts, fluid intake)3. If outbreak is declared ensure IPCT advice is followed by all ward staff and

visitors (including specialists/clinicians etc.)4. Ensure enhanced ward cleaning commences and continues in a timely manner

(at least twice daily) during outbreak5. Restrict movement of ward/bank staff and allocate nursing staff to designated

affected and unaffected areas during outbreak where possible6. Discard all fruit and food items from ward area7. Consider use of scrubs for ward staff8. Restrict visiting to ward according to hospital policy9. Ensure AHPs/ medical staff visit ward/ designated areas last on rounds unless

patient requires urgent clinical review (and ensure that ward staff understand this)

10.Once outbreak is over, instigate ward deep clean (change all ward curtains, all linen items etc) and complete pre-opening checklist


Top Ten Tips to help prevent outbreaks of NorovirusTen Top Tips for Facility teams, Cleaners, and Housekeepers1. Ensure all staff working in clinical areas are aware of diarrhoea and vomiting

and related infection prevention and control policies2. Ensure all staff attend annual IPC update sessions (for external contractors

ensure they have appropriate yearly training in place)3. Ensure there is an enhanced cleaning policy for ward and rooms during an

outbreak 4. Ensure there is a policy for deep cleaning ward and individual rooms after

outbreak before ward re-opens5. Ensure all cleaning staff are aware of specific products to use during diarrhoea

outbreak (e.g. 1% hypochlorite and hydrogen peroxide)6. Cleaners working in affected wards or areas should not take cleaning

equipment to unaffected areas.7. No food or drink is to be consumed in affected areas by ward staff. Breaks and

meals should be in designated rest areas8. Alcohol hand rub is not reliably effective against norovirus so wash your hands

with soap and water after each contact with affected patients or their immediate environment

9. All waste from cleaning processes to be discarded as potentially infectious





Type: Policy


Scope: Major



Page 25 of 26

10. if you become unwell with diarrhoea or vomiting stay at home (or if it occurs in shift, inform senior and go home immediately) and do not return to work until 48 hours symptom free






Type: Policy


Scope: Major



Page 26 of 26

Appendix 3 - Equality Impact Assessment Tool

To be completed and attached to any controlled document when submitted to the appropriate committee for consideration and approval.

Yes/No Comments

1. Does the policy/guidance affect one group less or more favourably than another on the basis of:

Race NO

Ethnic origins (including gypsies and travellers)

NO

Nationality NO

Gender NO

Culture NO

Religion or belief NO

Sexual orientation including lesbian, gay and bisexual people

NO

Age NO

Disability - learning disabilities, physical disability, sensory impairment and mental health problems

NO

2. Is there any evidence that some groups are affected differently?

NO

3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

N/A

4. Is the impact of the policy/guidance likely to be negative?

NO

5. If so can the impact be avoided?

6. What alternatives are there to achieving the policy/guidance without the impact?

7. Can we reduce the impact by taking different action?

If you have identified a potential discriminatory impact of this procedural document, please refer it to the Board Secretary, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact the Compliance and Governance Manager: Telephone Number: 01962 825376

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