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1 Chief Nursing Officer Directrate Dr Margaret McGuire, Acting Chief Nursing Officer abcdefghijklmnpqrstu T: F: E: NHS Bard Chief Executives cc Chief Medical Officer cc Directrs f Public Health cc Executive Lead Healthcare Assciated Infectin cc Medical Directrs cc Nurse Directrs cc Infectin Cntrl Managers cc Carmel Sheriff cc Gerge McLachlan cc Marin MacKay cc HAI Task Frce 14 December 2009 Dear Chief Executive HEALTHCARE ASSOCIATED INFECTION (HAI) - REPORTING OF INCIDENTS AND OUTBREAKS AND NOROVIRUS GUIDANCE Further t the letter sent t yu dated 19 February 2009 detailing the prcedures fr the reprting f incidents and utbreaks t the Scttish Gvernment Health Department (SGHD), I am writing t re-emphasise the imprtance f the infrmatin cntained within that letter and t prvide yu with updated infrmatin regarding the revisin f the Watt Risk Matrix and the key cntacts in SGHD. In additin, I wuld like t highlight the publicatin f revised guidance n the management f Nrvirus infectin. Watt Risk Matrix Revisin Health Prtectin Sctland n behalf f the HAI Task Frce has c-rdinated a review f the Watt Risk Matrix (2002), which included cnsultatin with all NHS Bards. The purpse f the Watt Risk Matrix (V2 2009) knwn as the Hspital Infectin Investigatin Advisry Tl [HIIAT]) [Appendix 1] is t prvide NHS Bards with a standard tl fr assessing the severity f an incident r utbreak and facilitate effective cmmunicatins and cnsistency acrss Bards. The enclsed revised Matrix reflects the cmments received and is being issued under cver f this letter t NHS Bards fr immediate implementatin. 1

2 In the event f an incident r utbreak ccurring yu are required t assess the severity f the situatin against the criteria detailed in the HIIAT (Watt Risk Matrix V2 2009). It is essential that yu seek immediate supprt and specialist advice frm Health Prtectin Sctland fr incidents and utbreaks categrised as Amber r Red and that yu infrm the SGHD. This will ensure yu receive the apprpriate supprt required t manage the situatin and establish cmmunicatin channels with senir fficials in the SGHD. It shuld be nted that fr incidents and utbreaks categrised as Amber, the minimum f a hlding press statement shuld be prepared and a practive press statement released fr thse categrised as Red. All hlding and practive press statements shuld be shared with Health Prtectin Sctland and SGHD prir t release t facilitate cnsistency f messaging. Patients and relatives shuld als, wherever pssible, be infrmed f incidents r utbreaks befre press releases are issued. A HAI Incident and Outbreak reprting template [Appendix 2] is enclsed fr yur attentin. This template shuld be cmpleted and frwarded t Health Prtectin Sctland and SGHD at the time f reprting an incident r utbreak; and is the minimum infrmatin we wuld expect t be prvided at the time f reprting. I shuld be grateful if yu wuld ensure that all Senir Managers, including the Infectin Cntrl Manager, Infectin Cntrl Team, Executive Lead fr HAI and Public Health and the Health Prtectin Team are advised f the requirement t immediately infrm the SGHD and Health Prtectin Sctland f incidents and utbreaks f infectin categrised as Amber r Red using the key cntacts detailed belw. Scttish Gvernment key cntacts Mnday Friday ( ) excluding Public Hlidays Name E mail Tel number Carl Fraser, Nurse Carl.fraser@sctland.gsi.gv.uk Advisr HAI, HAI Plicy Unit Dr Lrna Willcks, Lrna.willcks@sctland.gsi.gv.uk Medical Advisr HAI, HAI Plicy Unit Kevin Hanln, Head HAI Kevin.hanln@sctland.gsi.gv.uk Plicy Unit Callum Percy, Lead HAI Callum.percy@sctland.gsi.gv.uk Perfrmance Management, HAI Plicy Unit Carmel Sheriff, Reginal Perfrmance Manager, (West Bards) Carmel.sheriff@sctland.gsi.gv.uk Gerge McLachlan, Gerge.mclachlan@sctland.gsi.gv.uk Reginal Perfrmance Manager, (East Bards) 2

3 Scttish Gvernment key cntacts ut f hurs including Public Hlidays Name Telephne number Chief Medical Officer Team Cmmunicatins Team Nrvirus Guidance In 2004 a Nrvirus aide memire was published by the Scttish Centre fr Infectin and Envirnmental Health (nw knwn as Health Prtectin Sctland) and issued t NHSSctland. In supprt f the HAI Task Frce Delivery Plan, the aide memire has been reviewed and updated by the Hspital Outbreak Advisry Grup (hsted by Health Prtectin Sctland). The updated Nrvirus guidance is nw available n the Health Prtectin Sctland website at: I als enclse a cpy f the relevant dcuments fr yur attentin [Appendix 3]. It is expected that all NHS Bards will nw review their Nrvirus plicy and ensure the detail within the revised guidance is fully reflected in lcal plicies. Yurs sincerely Dr Margaret McGuire Acting Chief Nursing Officer 3

4 Hspital Infectin Incident Assessment (HIIA) Tl (Watt Risk Matrix Replacement) Objective: T prvide all thse wh manage and need t knw abut hspital infectin incidents with a simple impact assessment tl. Step 1 Assess the infectin impact n: Patients, Services, Public Health and Public Anxiety as Minr, Mderate r Majr Patients Services Public Health Public Anxiety* Minr Only minr interventinal supprt needed as a cnsequence f the incident. N, r nly very shrt term clsure f clinical area(s) with minr impact n any ther service. N, r nly minr implicatins fr public health. N significant increased anxiety r cncern anticipated. N mrtality. Mderate Patients require mderate interventinal supprt, but n Shrt term clsure(s) having mderate impact n sme Mderate implicatins, i.e. there is a mderate risk f nly Increased cncern and r anxiety anticipated. mrtality as a cnsequence f the incident. services, e.g. multiple wards clsed r ITU clsed. mderate impact infectins t ther persns. Majr Life threatening illness r death as a cnsequence f the incident in ne r mre patient. Significant disruptin and impact n services, e.g. hspital clsures fr any perid f time. Significant implicatins fr public health, i.e. there is a mderate r majr risk f majr infectin t smene else. Alarm within at least sme areas f the cmmunity anticipated. Step 2 Calculate the Impact: All Minr = GREEN; 3 Minr and 1 Mderate = GREEN; N Majr and 2-4 Mderate = AMBER; Any Majr = RED; Step 3 Take actins in line with HIIA Tl clur GREEN AMBER RED Manage within the NHS Bard. Lg n SHORS if an utbreak. Infrm CPHM. Reprt t SGHD. Engage with CPHM. Lg n SHORS and reprt t HPS if an utbreak Ask HPS fr supprt if required** Cnsider issuing press statement (prepare hlding statement)*** Reprt t SGHD. Engage with CPHM. Reprt t HPS** Lg n SHORS if an utbreak Issue press statement*** * Public Anxiety: If a press statement was released tday summarising the situatin what wuld be the likely impact n public anxiety. **Cnsider thers wh may be f assistance in managing hspital infectin incidents: Fd Standards Agency, Scttish Envirnmental Prtectin Agency (SEPA), Water Authrity, Dental Public Health Cnsultant, Health and Safety Executive, etc. *** As far as is practicable, patients and relatives shuld be infrmed f an incident prir t press statement release. All press statements shuld be shared with SGHD and Health Prtectin Sctland. HPS: December

5 SCOTTISH GOVERNMENT HEALTH DEPARTMENT HAI INCIDENT AND OUTBREAK REPORTING TEMPLATE NHS Bard: Date & time: Cntact details: Name : Designatin : Phne : Healthcare facility name & type Specialty (e.g. ITU, rthpaedics): Number f beds Type f incident (e.g. infectin, including rganism, decntaminatin): Number f patients affected: symptmatic: cnfirmed: dead: Number f staff affected: symptmatic: cnfirmed: Dead: Additinal clinical infrmatin n cases: Facility pen r clsed, including date f clsure and re-pening: Date incident/utbreak identified: What is the impact n healthcare delivery? Nil Detail infectin preventin and cntrl in place: Status f incident as per Watt Matrix (revised Hspital Infectin Incident Assessment Tl [HIIAT] Dec 09): Health Prtectin Sctland infrmed/invlved: Infectin Cntrl Manager infrmed/invlved: Planned / hlding press release shared with Health prtectin Sctland and Scttish Gvernment Health Department: Date and time f next Incident Management/Outbreak Cntrl meeting: Date and time next expected update: Cmments: SGHD HAI TEAM DEC 2009

6 NOROVIRUS OUTBREAK: CONTROL MEASURES & PRACTICAL CONSIDERATIONS FOR OPTIMAL PATIENT SAFETY AND SERVICE CONTINUATION IN HOSPITALS What is the purpse f this dcument? Wh is this dcument fr? When and hw shuld it be used? Can it be adapted? Abut this dcument This dcument prvides backgrund infrmatin n nrvirus utbreaks in hspitals and details hw t minimise the risk f nrvirus utbreaks becming widespread thrughut a hspital by specifying the cntrl measures required. It prvides the ratinale fr the required cntrl measures. It is accmpanied by a single sheet Nrvirus Outbreak Daily Checklist/Nrvirus Outbreak Data Recrd, and a single sheet n decisin making fr healthcare wrkers called: Is it an utbreak? It is hped that cmbined these dcuments prvide a useful set f tls t help ICTs in their effrts t minimise the risk and t cntrl nrvirus utbreaks in hspitals. The dcument is primarily fr Infectin Cntrl Teams but can be used by anyne invlved in nrvirus utbreaks in hspitals. As there is the ptential fr nrvirus utbreaks in any hspital clinical area, Infectin Cntrl Teams (ICTs) shuld: Cnsider adapting the dcument fr lcal use. Advise HCWs where nrvirus utbreak tls can be accessed lcally. Advcate use f nrvirus cntrl tls when nrvirus utbreaks ccur r when data suggests that nrvirus utbreaks are likely. Intrduce new HCWs t the available nrvirus tls and encurage them t read and use them. It can be adapted lcally by the additin f supplementary infrmatin r lcal cntact details and by the use f sub-sectins f the dcument. Issue date: December 2009 Review date: June Cmments t NSS.HPSinfectincntrl@nhs.net Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 1 f 31

7 This nrvirus tl The parts f this Nrvirus Tl are presented in a simple, easily readable frmat. Mre detailed and mre technical literature reviews which underpin this dcument will be available n-line after the initial review perid. The value f prmpt ward clsures during nrvirus utbreaks Nrvirus utbreaks frequently affect hspitals when they are at their busiest, i.e. during winter mnths. This is when there is an increase in emergency admissins and cnsequently reduced bed availability as well as fewer suitably lcated beds. The decisin f whether t clse a ward and further reduce the number f beds available during these times is smetimes difficult; hwever, the evidence in the literature shws that early clsure is the best decisin fr patient safety and service cntinuatin. Early clsure can reduce the number f patients and healthcare wrkers affected and the duratin f clsure. The benefits f early clsure f a ward due t suspected nrvirus were explred during a study t mnitr utbreaks f gastrenteritis in 3 hspital systems (Lpman et al 2004). These researchers fund a statistically significant difference in the duratin f clsure when wards were rapidly clsed (within 3 days) t new admissins, cmpared t wards clsed after 4 days. The mean duratin f clsure was almst halved 7.9 days vs days p The cst f utbreaks f gastrenteritis in the NHS in England the mst frequent cause f which is nrvirus - was estimated t be 115m ( csts). Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 2 f 31

8 Index 1. Objectives fr effective nrvirus management in hspitals General infrmatin abut nrviruses in hspitals Why nrviruses cause utbreaks in hspitals settings Nrvirus Outbreak Schematic and Management Nrvirus Cntrl Measures (Single Ward) Nrvirus Management - Patient Care Measures Escalatin Plan Additinal Cntrl Measures when nrvirus utbreaks are cntinuing r are spreading Other practical cnsideratins fr clinical and infectin cntrl teams Lcal Nrvirus Outbreak Summary Reprt Pssible summary fr annual reprt n nrvirus utbreaks Systems t minimise the risk, the duratin and transmissin f nrvirus utbreaks within hspital settings Useful surces f infrmatin and references Appendix I - Is it an utbreak? Appendix II Nrvirus Outbreak Daily Checklist/Nrvirus Outbreak Data Recrd Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 3 f 31

9 1. Objectives fr effective nrvirus management in hspitals As nrvirus infectin cnfers nly shrt term immunity and nrviruses spread very effectively in hspitals and the cmmunity, preventing all nrvirus utbreaks in hspitals is impssible. Hwever, what is pssible is t minimise the risk f nrvirus utbreaks, and when they ccur t limit their impact and the disruptin f nrmal hspital services. The bjectives fr effective nrvirus management in hspitals can therefre be summed up as fllws: T reduce the risk f nrvirus utbreaks by: Being alert t the risk f individual patients ptentially having nrvirus; Identifying prmptly thse symptmatic patients that culd be infectius; Caring fr symptmatic patients away frm asymptmatic patients; Making visitrs and thers aware f the situatin, and that they shuld nt visit hspitals if they have gastrintestinal symptms suggestive f an infectin; Prmting and cmplying with Standard Infectin Cntrl Precautins during all clinical care, and using Transmissin Based Precautins when a persn is knwn r suspected t have an infectin caused by a specific agent. T reduce the impact f nrvirus utbreaks by: Clinical staff being alert t the pssibility f nrvirus in their patients; Infrming the ICT if 2 r mre patients develp nrvirus symptms (see case definitins); Fllwing ICT advice and instigating and cmplying with apprved Nrvirus Cntrl Measures; Clinical, management and infectin cntrl prfessinals wrking tgether as a team t reduce the impact f nrvirus n clinical services. Making patients, staff and visitrs aware f the situatin and asking fr their cmpliance with cntrl measures. Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 4 f 31

10 2. General infrmatin abut nrviruses in hspitals Abut nrviruses and nrvirus infectin Nrviruses Clinical manifestatins Strain variatin/ virulence Incubatin perid Infectius dse Duratin f illness Perid f infectivity Diagnsis Severity f illness Patient supprt Nrviruses are nn-envelped viruses which belng t the Caliciviridae grup f viruses. Frmer names fr this grup f viruses include Nrwalklike viruses, winter vmiting disease, and Small Rund Structured Viruses. Nrviruses cause gastrintestinal infectin which is characterised by: acute nset f nn-bldy watery diarrhea with r withut vmiting which if present is ften prjectile. Als present may be: abdminal cramps, myalgia, headache, malaise and a lw grade fever may be present in up t 50% f cases. Recent reprts have highlighted that nrviruses have many sertypes which may express differences in virulence and pathgenicity. In particular, the GII.4 nrvirus strain has gained imprtance in utbreaks invlving institutins, with increased transmissibility and virulence ver mre cmmn UK strains, resulting in excess expected mrtality and mrbidity rates amngst affected patients. Fr further infrmatin: (Harris et al., 2008, Said et al., 2008). Usually hurs. Median 33 hurs. Reprted as early as 10 hrs pst expsure. Very small, between virus particles. Nrvirus gastrintestinal symptms usually reslve within 2-3 days but 40% f patients can still be symptmatic at 4 days. Patients (and staff) shuld be cnsidered infectius whilst they are symptmatic and until they are free f symptms fr 48 hurs r stls have returned fr 48 hurs t their nrmal (pre-infectin) pattern. Nrviruses can be detected in stls even after symptms have reslved and stls have returned t nrmal. The impact f this n crsstransmissin is unknwn. Nrvirus shuld be suspected in any patient wh develps diarrhea with r withut vmiting withut ther bvius cause (See definitins). NB If suspecting nrvirus, e.g. during a pssible utbreak, infrm the ICT as well as the labratry as virlgy testing fr nrvirus is nt rutinely dne n all faecal samples. Usually self-limiting and cnsidered mild, hwever, mrtality as a cnsequence f nrvirus can ccur and is recgnised in the literature. Mre vulnerable patients, e.g. elderly and immuncmprmised patients are at higher risk f severe illness. Nrvirus infectin can cause rapid dehydratin particularly in elderly patients. Therefre symptmatic patients shuld have their fluid balance Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 5 f 31

11 Abut nrviruses and nrvirus infectin Mde f transmissin Envirnmental survivability mnitred and receive rehydratin as necessary. Assuming bacterial, e.g. Clstridium difficile, causes have been ruled ut, anti-emetics may help symptmatic patients. Cntact via the Faecal-Oral rute and airbrne via inhalatin fllwed by ingestin f nrvirus-cntaminated aerslised vmit. Direct Cntact Faecal matter n hands put in muth. Cnsumptin f faecally cntaminated fd r water. Indirect Cntact Hands cme int cntact with cntaminated equipment r cntaminated surfaces and subsequently tuch the muth. Airbrne Patients with prjectile vmiting can disseminate large quantities f virus laden aersls which can cntaminate extensive areas f the ward envirnment. Crss-transmissin can then ccur when patients and staff inhale and subsequently ingest these virus laden aersls, r cnsume fd n which these aersls have landed. NB 30mls f vmit may cntain up t 30,000,000 virus particles. Nrviruses can survive: On any surface fr at least a week. On fds in a refrigeratr fr up t 10 days. Freezing indefinitely. Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 6 f 31

12 Definitins f nrvirus cases and nrvirus utbreaks Definitins (cases) Pssible Nrvirus Infectin Case: A persn (patient r staff) wh, within a 24 hur perid has, 3 r mre episdes f nn-bldy diarrhea*, OR, 2 r mre episdes f vmiting, withut having any ther bvius cause fr symptms. Cnfirmed Nrvirus Infectin Case: A persn (patient r staff) wh, within a 24 hur perid has, 3 r mre episdes f nn-bldy diarrhea*, OR, 2 r mre episdes f vmiting, withut having any ther bvius cause fr symptms AND wh has tested psitive fr nrvirus in RT-PCR. Definitins (utbreak) Please nte: Persns wh have had Clstridium difficile txin detected in their faeces (r been diagnsed with Clstridium difficile infectin by ther methds) shuld NOT be excluded as nrvirus cases. Persns wh have been diagnsed with ther gastrintestinal infectins shuld be excluded as nrvirus cases. *Des nt include lse stls induced by laxatives r enemas. In the absence f ther causes, prjectile vmiting is diagnstic f nrvirus. Pssible Outbreak - 2 r mre Pssible Nrvirus Infectin cases in a single care unit, e.g. ward. Cnfirmed Outbreak 1 r mre Cnfirmed Nrvirus Infectin cases in a single care unit, e.g. ward. Cncurrent utbreaks f nrvirus & Clstridium difficile infectin Interactins between Clstridium difficile and nrvirus have nt been investigated fully, and it is unknwn whether Clstridium difficile infectin may augment the pathgenesis f nrvirus infectins r vice versa. In this situatin bth events shuld be investigated and managed as separate but cncurrent events. This can als apply t ther gastr-intestinal pathgens but Clstridium difficile infectin is mentined as it is the ther main cmmn hspital gastrintestinal pathgen. Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 7 f 31

13 3. Why nrviruses cause utbreaks in hspitals settings The reasns nrviruses are a challenge in hspitals settings: The infectius dse fr nrvirus is very lw. There are multiple rutes f transmissin. There are a variety f nrviruses and infectin with ne strain des nt cnfer immunity frm ther strains. Immunity fllwing infectin with nrvirus des nt last lng. The attack rate the number f peple wh get infected is high average 50% f thse expsed. It is easy fr frequently tuched sites t becme cntaminated - can be as high as 24%. Nrvirus can survive fr days n any surface including expsed fd. Peple may be infectius befre being symptmatic and nce asymptmatic may still excrete nrvirus in their stls. Nrvirus symptms start very quickly, and if they start with prjectile vmiting then many peple can be expsed and thereby becme infectius withut warning. It is smetimes difficult t identify cases and t differentiate between cases and nn-cases during an utbreak, i.e. patients wh have diarrhea but wh dn t have nrvirus, therefre early identificatin f an utbreak can be prblematic. Hspitals have high bed ccupancy rates and fr efficiency f clinical services, patients are ften mved between wards this means there is a high ptential t transmit the virus t ther care settings befre it is recgnised that patients culd be infectius. Sme healthcare wrkers (HCWs), e.g. medical staff and physitherapists, wrk in bth nrvirus affected and nrvirus unaffected areas. These HCWs can transmit the virus t unaffected clinical areas n their hands. Effective hand hygiene alne, i.e. withut additinal cntrl measures, is insufficient t prevent crss-infectin. Patients with cmplex cnditins may be admitted with symptms f ne disease whilst als incubating nrvirus gastrenteritis. This can delay recgnitin and instigatin f infectin cntrl precautins. Nrvirus utbreaks are mst cmmn during winter mnths when the health service is stretched by excess winter admissins. Mdelling studies suggest there can be a cntinuatin f nrvirus utbreaks when wards have a nrmal patient turn ver ( days). Lng term care wards with a patient stay >20 days can expect the utbreak t stp withut endemic cntinuatin. (Vanderpas et al., 2009) Ward clsures althugh preventing new patients frm acquiring nrvirus within the ward can pse a different patient risk by delaying admissins and essential healthcare interventins. There is always a patient safety risk-balance t be struck hwever, early identificatin and effective actins will reduce the duratin f any utbreak, its ptential t spread t ther wards and areas and prvide the best ptin fr patient safety. Standard cleaning regimens using detergents alne are ineffective against nrviruses. Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 8 f 31

14 Institutinal crss-transmissin risk factrs that increase the risk f nrvirus utbreaks Admissin f (identified r unidentified) infectius patients t pen ward areas. Inapprpriate admissin f infectius patients wh culd be managed at hme. Inability t immediately islate patients wh develp symptms. Multiple transfers f patients within units. Unrecgnised infectius patients can be transferred t several wards within a 24 hur perid and cnsequently utbreaks culd arise in all these wards. Symptmatic infectius visitrs may visit clinical areas. Failure t send faecal specimens prmptly fr virus detectin. Delays in recgnising pssible utbreaks and cntacting infectin cntrl teams. Delays in instituting r errrs in perfrming Nrvirus Cntrl Measures. Healthcare wrkers remaining n duty whilst symptmatic. Patients mst at risk are mre frequently in the medical receiving wards and wards with a high prprtin f elderly patients. Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 9 f 31

15 4. Nrvirus Outbreak Schematic and Management The schematic verleaf shws the prgress that a nrvirus utbreak in a single ward is expected t fllw. That is if there are 2 r mre suspected cases, the clinical team shuld d ABC: Alert the ICT prmptly, Be up t date with the details f patients that meet the suspect nrvirus case definitin and start C, Cntact precautins fr symptmatic patients. The ICT shuld assess the situatin and determine if there is a need t clse the ward and start Nrvirus Cntrl Measures, undertake an impact assessment using the Hspital Infectin Incident Assessment Tl (HIIAT) [Watt Risk Matrix replacement], lead n cmmunicatins with a pre agreed team f stakehlders and ask fr faecal specimens t be cllected. Until the utbreak is declared ver the ICT and clinical team shuld undertake a daily assessment and daily cmmunicatin f these assessments. In additin the ICT shuld wrk with the clinical team t start preparatin fr repening the ward. The management must be kept up t date with the likely repening timetable. If hwever, the utbreak situatin deterirates the ICT will determine if an escalatin plan is required. Befre repening the ward a terminal clean will be dne after repening, the clinical and ICTs need t remain mindful f the pssibility f nrvirus utbreaks reigniting. As single-ward nrvirus utbreaks are frequently assessed as HIIAT Green, efficient ICTs can manage utbreaks withut frmal Outbreak Cntrl Cmmittees prvided: there is agreement frm management, there are clear, apprved systems and cmmunicatins, and there is an agreed lcal escalatin trigger. It must always be remembered that nrvirus utbreaks affecting patients and staff in hspital wards can, if prly managed, easily and rapidly escalate t cause the clsure f the hspital t nn-emergency admissins. Therefre there needs t be careful management f the nrvirus situatin especially when there are 2 r mre wards clsed at any ne time in a hspital. Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 10 f 31

16 Nrvirus Outbreak Schematic Nrvirus Outbreak Suspected 2 r mre suspect nrvirus cases* Alert the Infectin Cntrl Team Be up t date with the details f patients & staff wh are symptmatic Cntact Precautins fr all affected + send faecal specimens ICT assessment is it an utbreak? If n, stp. Initial Nrvirus Actins Clse the ward t admissins and transfers HIIAT assessment (Watt Risk Matrix replacement) Cmmunicate patients, ward staff, utbreak cmms plan, & visitrs Cllect faecal samples frm symptmatic patients (& staff) Start Nrvirus Cntrl Measures Daily Assessments and Cmmunicatin f these Assessments Are Nrvirus Cntrl Measures being fllwed? Are patients being mnitred fr dehydratin (stl and fluid balance charts) and rehydrated as necessary? Has the Nrvirus Outbreak Data Recrd (number f new cases [staff and patients], ttal symptmatic cases, and new micrbilgy results) been updated? Is the situatin deterirating mre cases, mre severe cases, ther wards affected HIIAT assessment changing? If the situatin is deterirating, is a nrvirus escalatin plan required? Is the current Patient Placement within the ward ptimal fr patient safety and ptimal fr the preparatin f the ward re-pening? Is it sensible t pre bk terminal cleaning tday? Have repening criteria been met 48 hurs since last new case and 48 hurs since last vmiting r diarrhea? Deply nrvirus Escalatin Plan if utbreak is spreading t ther wards r nt stpping in a single ward after 7 days clsure. Terminal clean with 1000ppm available chlrine and then repen NB As symptm free cases can still excrete nrvirus fr many days, and any remaining envirnmental cntaminatin will nt be visible, healthcare wrkers must remain alert t the pssibility f the utbreak reigniting. *Pssible Nrvirus Case Definitin: A persn wh, within a 24 hur perid has, 3 r mre episdes f nn-bldy diarrhea, OR, 2 r mre episdes f vmiting, withut having any ther bvius cause fr symptms (Diarrhea - des nt include lse stls induced by laxatives r enemas). Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 11 f 31

17 5. Nrvirus Cntrl Measures (Single Ward) Hw and when the Infectin Cntrl Team (ICT) is alerted t the pssibility f an utbreak is shwn as a schematic in Is it a Pssible Nrvirus Outbreak? Appendix I. Nrvirus Cntrl Measures shuld be deplyed n the advice f the ICT. NB The Nrvirus Outbreak Daily Checklist and Data Recrd enables HCWs t keep an up t date recrd f thse affected by the utbreak and that the cntrl measures are in place Appendix II. Admissins Clse the ward t admissins. The ward drs shuld be kept clsed and an apprved ntice shuld be placed n the dr indicating that within the ward there is a suspected nrvirus utbreak, r utbreak f diarrhea and vmiting. Exemptin: In exceptinal situatins the risk t an individual patient f nrvirus acquisitin will be less than the risk f nn-admissin. In such exceptinal events, when alternative pssible accmmdatin fr the patient has been excluded, the patient can be admitted t a clsed ward, but the patient and r relative must be infrmed f their persnal nrvirus risk. Such events shuld be recrded n the NHS bard s Risk Register as a risk t the patient. Discharges Patients may be discharged t their hmes prvided their relatives are aware f the nrvirus situatin in the ward, the persnal risk t themselves and hw this risk can be minimised, e.g. hand hygiene, washing f persnal laundry and, nrvirus infrmatin is prvided. (Discharges t nursing hmes r discharge f patients with a scial care packages, i.e. where carers will visit the symptmatic patient and ther asymptmatic patients shuld be treated as transfers). Patients shuld be advised that if symptms develp they shuld infrm their GP f the situatin in the ward. Transfers Avid transferring any patient t ther hspitals/clinical areas/nursing hmes unless there is a clinical pririty. (If there is a clinical pririty t mve a patient the receiving clinical area must be fully infrmed f the nrvirus situatin in the transferring ward and the patient shuld be islated n arrival in the receiving ward even if asymptmatic). Cntact Precautins still need t be deplyed in the receiving clinical area. Healthcare Wrkers: Healthcare wrkers (HCWs) shuld be aware f their duty t stay ff wrk when they have symptms f gastrintestinal infectin (reprting sickness is als mandatry). Send HCWs with gastrintestinal symptms ff duty; d nt allw them t return t wrk until they are symptm free fr 48 hurs. HCWs shuld cntact their Occupatinal Health Dept fr advice. As far as is pssible: Allcate staff fr the duratin f the utbreak t care fr either cases r nn cases. D nt allcate staff n the affected wards t wrk n unaffected wards. (Cnsider bank and agency staff as peple wh culd Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 12 f 31

18 Knwledge management Immediate Risk Reductin inadvertently spread this infectin thrughut the hspital). D nt allcate staff frm unaffected areas t wrk in the affected wards unless they are t remain there fr the duratin f the clsure. Unless deemed clinically necessary, nn-essential staff shuld avid visiting Clsed Wards r at the very least avid the symptmatic patients. Infrm everyne wh needs t knw abut the clsed status f the ward including: Bed Management, ICT, General Management, Cnsultants, Health Prtectin Team, etc., etc. There shuld be lcal agreement n wh gets daily updates during nrvirus utbreaks. Have in place a system f at least daily updating via t this grup. (See Suggested Nrvirus Cmmunicatin frmats t be included). Ensure all HCWs in the area are aware f hw nrvirus can be transmitted and their rle in minimising the risks t patients and t preparing the ward fr repening. Cue cards listing the rles f different prfessinals during an utbreak may help reduce errrs f missin and cnfusin. Prvide patients and their visitrs with ral and written infrmatin regarding the nrvirus utbreak. If ward pantries r kitchens have drs, these shuld be clsed and kept clsed. Identify and advise n the discarding f fd thrughut the ward which may have been cntaminated by nrvirus cntaminated aersls (frm prjectile vmit), e.g. fruit r sweets n patient lckers, pen butter dishes in pantries. Avid the subsequent expsure f fd in the ward, n bed-tables and lckers and in pantries / kitchens. As cleaning alne is ineffective at remving nrvirus, and can actually result in the transfer f the virus thrughut the envirnment, in-use, and ready-fr-next-patient-use equipment shuld be cnsidered cntaminated with nrvirus, therefre: Clean and disinfect all cmmdes and frequently tuched surfaces with a detergent and 1000 ppm available chlrine (av. cl.) Review ward equipment and remve any equipment that cannt be effectively decntaminated, e.g. damaged cmmdes r chairs with trn seat cverings. Avid expsing equipment t airbrne nrvirus cntaminatin wherever pssible, e.g. cnsider cvering pen dispsables items with plastic sheets. Stp using fans in the ward areas. Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 13 f 31

19 Specimens Send faecal specimens frm symptmatic patients (and staff) fr culture, Clstridium difficile txin testing and fr virlgy. [Staff specimens t be sent with return label fr Occupatinal Health Dept.] Use a Nrvirus Outbreak Data Recrd t keep track f the patients that are and have been symptmatic, their symptms, specimens that have been sent and the results that have been received. Patient Placement & Bed Patient placement decisins during a nrvirus utbreak require lcal infectin cntrl and clinical team assessment f the ptins with the least risk fr all the patients. Management The variables that will assist the ICT and clinical team in making patient placement decisins with the best ptins fr patient safety include: the number f symptmatic patients, the number f patients wh are vmiting, the ward layut (cubicles, beds per bays r nightingale ward areas), the availability f cmmdes, hand hygiene facilities, tilets and en suite facilities, the sex mix n the ward, the vulnerability f patients wh are nt currently affected, current ccupancy rate and the duratin f symptms. The fllwing are guidelines: Patients wh are vmiting pse mst risk if pssible islate these patients in a single rm and keep the dr clsed. If there are mre symptmatic patients than available cubicles, chrt nurse symptmatic patients tgether in bays. D nt mve patients if it places asymptmatic patients at risk f expsure. As the number f patients decreases it may be that ne r tw patients remain symptmatic lnger than thers. When available, these symptmatic patients can be mved int single rms t further reduce spread, and aid cntainment f nrvirus. Patient placement assessments shuld be dne n a daily basis. Empty Beds: As patients are discharged, the linen n the beds shuld be remved and the bed, bed table and lcker cleaned with neutral detergent and water and then dried. These beds shuld nt be re-made until the terminal clean cmmences. During the terminal clean, all empty beds shuld be re-cleaned and the bed cleaning prcess shuld included 1000ppm av. cl. After the terminal cleaning has been cmpleted, the beds can then be remade. The ratinale fr this is that nrviruses culd survive fr up t a week n cleaned beds and n clean bed linen, and als t prevent the need fr the duble use f hypchlrite slutin. Create clean bays as patients are discharged, try t create clean bay areas, where patients can be admitted t first nce the ward is repened. Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 14 f 31

20 Envirnment Cleaning Hand hygiene Persnal Prtective Equipment (PPE) Cleaning using wet clths can be a means f transferring the virus thrughut the ward. The ICT shuld be assured that the methds f cleaning, the intensity f cleaning and the rute f cleaning unaffected t affected areas is ptimal t minimise the risk f nging transmissin f nrviruses. Dmestic staff shuld therefre reprt t the nurse in charge every mrning fr any additinal r change t cleaning regimens. Increasing the hurs available fr cleaning f the ward is a key cnsideratin fr the infectin cntrl team t advise n. Fr each patient bed space single-use dispsable clths shuld be used. Wherever pssible the cleaning shuld be fllwed with a chlrine based slutin 1,000 ppm av cl r cmbined chlrine/detergent based prduct. Steam cleaning is an excellent methd f remving rganic matter. There is n evidence at present t suggest it is sufficient t destry nrviruses. Therefre after steam cleaning disinfectin with 1000 ppm av cl is still necessary. NB nt mving staff between affected and nn-affected clinical areas als applies t dmestic staff. Hands are a key, but nt the nly, means f transmitting nrvirus within the ward. As nrvirus remains viable n surfaces that are tuched fr several days, HCWs must be mindful that hands can and will transfer the virus. In additin, hands can and will be cntaminated with the virus during rutine activities like tuching drs, tuching key bards and at the nurses statin, therefre: D nt use alchl based hand gel fr rutine decntaminatin f hands when there is an utbreak f gastr-intestinal infectin. Decntaminate hands with liquid sap and warm water. Alchl based hand gel alne may be used during nrvirus utbreaks t decntaminate hands as an intermediate step in an aseptic prcedure. Use Persnal Prtective Equipment (PPE) glves and aprns t prevent persnal cntaminatin with bdy fluids. HCWs must be mindful that anyne wearing glves and an aprn and cming int cntact with spillages r cntaminated surfaces can disseminate nrvirus by glve cntact n clean surfaces. On remval f PPE hands must be washed with liquid sap and warm water. As per Standard Infectin Cntrl Precautins, during any prcedure, where there is a risk f splash, e.g. when decntaminating spillages f faeces r vmit, in additin t glves and aprn, a surgical mask may be Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 15 f 31

21 wrn t minimise the risk f splash cntaminatin and inhalatin f nrvirus and subsequent ingestin. (See next sectin). Discard PPE waste as Healthcare Waste. Decntaminatin f Wear Persnal Prtective Equipment glves, aprn. A surgical mask may prevent inhalatin f cntaminated aersls during this prcedure. spillages f faeces r Requirements: healthcare waste bag, wet and dry paper twels, fresh slutin f 1000 ppm av cl. vmit Use dry r wet paper twels t remve all vmit r faeces and discard immediately int healthcare waste bag. Clean the area using fresh dispsable paper twels and a general purpse detergent (applicatin f a disinfectant t faeces will inactivate it). Apply 1000 ppm av cl t the area where the spillage ccurred fllwing the manufacturer s instructins fr surface disinfectin. Dry the area thrughly. Discard all dispsables including glves and aprn immediately int healthcare waste bag and then wash hands with liquid sap and warm water. Laundry During an utbreak all laundry cming frm a ward which is clsed shuld be cnsidered ptentially cntaminated and discarded directly int alginate bags and then subsequently re-bagged. Visitrs There shuld be an apprved ntice n the ward dr t first alert visitrs t the pssibility f a nrvirus, r diarrhea and vmiting, utbreak. The ntice shuld advise visitrs t perfrm hand hygiene, i.e. n entering the ward, n leaving the ward and nt t put fingers in their muth r cnsume fd r drink whilst in the ward. These messages shuld be reinfrced t visitrs by a member f the ward team. Visitrs shuld fr their wn safety be advised: T reduce the number f visits whilst the utbreak lasts. Nt t visit if they themselves are suffering frm an infectin and until they are 48 hurs symptm free. That children shuld nt visit the ward during an utbreak. That they shuld nt visit peple in ther wards. Terminal cleaning The terminal clean can start when the 48 hur perid f n new cases and n nrvirus symptms is cmpleted. When terminal cleaning cmmences shuld be pre-agreed with the ICT. The ICT shuld prvide a ward with a terminal clean prcedure that specifies nt just hw things shuld be cleaned, disinfected r dispsed f and dried, but als the rder in which this shuld be dne. (There shuld be clear agreement n wh des what with regard t the terminal clean tasks). Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 16 f 31

22 Re-pening the ward criteria Terminal cleans shuld invlve a change f curtains. (Pre bking in advance a planned curtain change may als reduce time t re-pening). Again the rder f curtain change within the terminal clean prcedure shuld be specified. Ideally the rder shuld be as fllws: Remve all curtains this can be dne as the beds r bays becme empty. Remve all bed linen frm unccupied beds this can be dne as the beds becme empty. Decntaminate all care equipment in line with manufacturer s instructins. Wherever pssible use thermal decntaminatin. Then thrughly clean and then disinfect all surfaces with a detergent and 1000 ppm av cl. Once the decntaminatin prcedures are cmplete then clean curtains can be re-hung and the beds re-made. The ward has been terminally cleaned t the satisfactin f the ward manager and ICT and, There have been n new cases f Pssible nrvirus fr 48 hurs and, There has been n vmiting r diarrhea fr a full 48 hurs which is cnsidered t be caused by nrvirus. Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 17 f 31

23 6. Nrvirus Management - Patient Care Measures Patient care Cmmence all symptmatic patients n a stl and fluid balance chart t mnitr fr pssible dehydratin. Reprt t medical staff if any patient s clinical cnditin suggests rehydratin may be necessary. Patients & Ensure all patients and relatives are aware f the situatin regarding Relatives the utbreak and what they can d t prevent additinal persnal risk. Prvide written infrmatin, e.g. hw t wash persnal laundry, hw t wash hands, restricting visitrs during an utbreak. Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 18 f 31

24 7. Escalatin Plan Additinal Cntrl Measures when nrvirus utbreaks are cntinuing r are spreading When Nrvirus Cntrl Measures fail t stp an utbreak, r the utbreak spreads t ther areas f a hspital there are likely t be ne f tw reasns fr this: The Nrvirus Cntrl Measures have nt been applied crrectly (inability t implement r failure t cmply). The Nrvirus Cntrl Measures are insufficient t prevent utbreaks r utbreak cntinuatin. Given the abve, the Escalatin Plan fcuses n finding ut, if pssible, what is causing the escalatin r failing t stp the utbreak. Investigatins t identify what is causing the nrvirus escalatin r failing t stp an utbreak: Have the cntrl measures been implemented crrectly? Lk fr evidence that: The ward has remained clsed t admissins and transfers. All n-duty staff are asymptmatic. Visitrs are asymptmatic. There is cntrl f ward traffic. Review: Ward cleaning recrd. Ward audit data. Ward hand hygiene data. Observe practices n the wards Has there been a reintrductin thrugh the admissin f symptmatic patients, symptmatic healthcare wrkers r visitrs t the ward? Is there data t suggest that there are high levels f nrvirus infectin in the cmmunity? (See HPS weekly Nrvirus Pint Prevalence data and NHS 24 data). If the situatin is a failure t apply Nrvirus Cntrl Measures effectively, when there are the resurces and facilities t apply them crrectly, then every effrt shuld be made t instigate and rigrusly apply the Nrvirus Cntrl Measures. If the situatin is being caused by a failure t apply the Nrvirus Cntrl Measures because they can t be applied at present, e.g. emergency admissins requiring hspital accmmdatin and clsed wards being the nly accmmdatin ptin, the Escalatin Plan may assist in gaining cntrl f the situatin: Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 19 f 31

25 Escalatin Plan - When Nrvirus Cntrl Measures cannt be applied Expand the Outbreak Cntrl Team Managing the Nrvirus Outbreak(s). Get tgether a high level utbreak cntrl team including: bed management, general management, risk management, infectin cntrl, ccupatinal health and clinical services. Prduce and update an epi curve f all new cases in each ward each day and an verall epi curve f all new cases in all wards. This will enable Outbreak Cntrl Team t mnitr the success f the decisins they make regarding utbreak management. The grup shuld meet at least daily t mnitr the changing impact f nrvirus n the hspital, its staff and patients and t assess the success r therwise f their actins. Mnitr the nrvirus situatin in the cmmunity by using the HPS Nrvirus Pint Prevalence data this may help the decisin making. Undertake an asset assessment f all ward facilities pssibly available fr recnfiguring. Cnsider all ptins fr pssible ward cnfiguratins that wuld ease pressure and the number f empty beds in clsed wards. Agree ward cnfiguratins fr ptimal patient safety and ptimal maintenance f services. Liaise with neighburing NHS Bards if this culd help the lcal situatin. T reduce the number f clsed wards, cnsider pening a ward fr all patients with diarrhea n admissin and patients with pssible r cnfirmed nrvirus infectin. Cnsider creating a ward fr patients admitted withut diarrhea - deep clean pre use. If patients are presenting t Accident and Emergency with symptms nly suggestive f nrvirus, cnsider prviding advice in the department regarding what t d t reduce symptms and impact rather than admitting ptentially infectius patients. Prvide public messages thrugh the media abut nt cming t hspital if symptmatic, r nt visiting mre than ne ward at a time, and generally what t d t reduce spread if peple get diarrhea / vmiting in the cmmunity. Cnsider whether staff wh are returning frm being n sick leave due t nrvirus culd wrk in nrvirus affected wards rather than in wards that have nt yet been affected. Medical staff and thse wh wrk in bth affected and nn-affected wards shuld cnsider hw they can best wrk s that they reduce the ptential fr crss-transmissin, i.e. can these staff wrk nly in affected r unaffected areas until the situatin is ver? Medical staff t prmte 100% hand hygiene cmpliance. Cnsider extending the ward clsure time t 72 hurs after last vmit/diarrhea episde. Cnsider asking HPS fr advice. Cntinue t assess the impact f the utbreak using the HIIAT (Watt Risk Matrix replacement) and reprt nwards as required. Cnsider restricting all but essential visitrs if the situatin is being exacerbated by visitrs with symptms attending the hspital. NB Maintain effective cmmunicatins: patients, staff, visitrs, cmmunity, HPS, SHGD. Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 20 f 31

26 8. Other practical cnsideratins fr clinical and infectin cntrl teams Once the clsed ward has re-pened ward staff shuld: Admit patients t clean bay areas first. Be alert t the pssibility f the utbreak reigniting and be ready t re-institute cntrl measures. Cntinue t prvide additinal cleaning advice t dmestic staff. ICTs shuld be alert t warnings f increases in nrvirus activity thrugh the HPS weekly Mnday Prevalence and NHS 24 excedence reprts. Advise medical receiving teams when the nrvirus risk is high. Bed Management Liaisn and Infectin Cntrl Teams: must wrk clsely tgether t ensure ptimal patient safety fr all patients. Early cmmunicatins and pre-planning f re-pening shuld assist in reducing the impact f nrvirus utbreaks. Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 21 f 31

27 9. Lcal Nrvirus Outbreak Summary Reprt Belw is a simple summary reprt frmat cmpletin f which will enable ICTs t swiftly write a reprt and assess its recgnitin, its impact and its management. Hspital Directrate / department Ward Case definitin Date first case Date reprted t ICT Initial HIIAT assessment (WRM) Date ward clsed Date ward pened Days f clsure Did the HIIAT (WRM replacement) increase during the utbreak? Was an escalatin plan required? Did virlgy cnfirm the utbreak? Ttal number f patient cases with symptms? (attack rate if pssible) Ttal number f staff cases What were the cnsequences t the affected patients? (e.g. any patients requiring intravenus rehydratin due t nrvirus causing dehydratin) What were the cnsequences t the nnaffected patients, e.g. delays in admissins? Cnsequences t ther areas f the hspital? Was there any nn-cmpliance with guidance, e.g. admissins t clsed ward, repening f the ward against ICT advice, transfer f staff t ther nn-affected wards? Pssible Nrvirus Infectin Case: A persn (patient r staff) wh, within a 24 hur perid has, 3 r mre episdes f nnbldy diarrhea*, OR, 2 r mre episdes f vmiting, withut having any ther bvius cause fr symptms. Cnfirmed Nrvirus Infectin Case: A persn (patient r staff) wh, within a 24 hur perid has, 3 r mre episdes f nnbldy diarrhea*, OR, 2 r mre episdes f vmiting, withut having any ther bvius cause fr symptms AND wh has tested psitive fr nrvirus in RT-PCR. Green, Amber, Red Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 22 f 31

28 Was there an event recgnised which culd have started the utbreak, e.g. transfer frm anther area if s culd this have been anticipated and averted? What went well? What actins / systems culd be imprved? 10. Pssible summary fr annual reprt n nrvirus utbreaks The table belw prvides ICTs with a frmat that culd be used in their annual infectin cntrl reprts f lcal surveillance f Nrvirus utbreaks. It may help in determining the epidemilgy and t summarise impact and perfrmance cmpliance. Ttal number f utbreaks by directrate Ttal number f patients affected Ttal number f staff affected Average duratin f ward clsure Assessment f what went well during utbreaks Assessment f what did nt g well during utbreaks Identified system changes that culd reduce risk f nrvirus utbreaks Any nn-cmpliance with infectin cntrl advice during utbreaks Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 23 f 31

29 11. Systems t minimise the risk, the duratin and transmissin f nrvirus utbreaks within hspital settings The sectin belw describes the behaviurs that need t be exhibited t minimise the risk f system errrs. Using these behaviurs the table describes the rganisatin and culture, current perating cnditins, safe acts and defences that will enable wards and hspitals t minimise the risk f nrvirus utbreaks (Reasn, 1990, Reasn, 2000, Weick et al., 1999). These behaviurs can be summed up as fllws: Knwing what t d - and when t d it - in respnse t events. Always wanting t make systems strnger and safer. Always being alert t hw systems culd g wrng. Nt taking the easiest answer, but lking critically at prblems fr the right answer. Recgnising the need fr - and asking fr - expert help whenever it is required. The rganisatin & culture t minimise utbreaks f nrvirus and identify them early if they ccur. The clinical team are aware that : Outbreaks f nrvirus can ccur at any time f the year, mst particularly in the winter mnths and that early signs f utbreaks can be easily missed. Missing early signs f utbreaks culd result in mre prlnged and mre widespread hspital utbreaks. They shuld send / request faecal specimens when patients develp diarrhea, and start Cntact Precautins immediately if an utbreak is suspected. They need t, as far as is pssible, maintain nrmal ward services and meet the existing needs f patients. They shuld alert the Infectin Cntrl Team as sn as an utbreak is suspected. N matter hw effective they are at implementing infectin preventin and cntrl (IPC) prcedures, they shuld always cnsider hw they can imprve their systems. The Clinical Team is attentive t: The pssibility f failure t cmply with plicies, prcedures and guidance, and cntinuusly reviews perfrmance and perfrmance data, e.g. time t send specimens frm patients with lse stls, r the time t reprt t the Infectin Cntrl Team (ICT) if an utbreak is suspected. Data suggesting that there is an increased risk f nrvirus utbreaks, e.g. when there are utbreaks in ther areas f the hspitals r in nearby cmmunities, r during higher risk perids. The clinical team always cnsiders that: Any patient wh vmits r has lse stls culd be the first (r anther) patient with nrvirus, therefre faecal specimens are sent early and the ICT is alerted at the earliest pssible sign f an utbreak. Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 24 f 31

30 Current Cnditins f Wrk The members f the clinical team, including dmestic and supprt staff, are encuraged t reprt symptmatic patients and identify the pssibility f an utbreak ccurring. The ICT is alerted at the earliest pprtunity. All pssible utbreaks are investigated. The Management supprts the clinical team s high-reliability apprach t minimising nrvirus utbreaks n the ward. There is a plicy which is fllwed NHS Bard Outbreak Plicy There are prcedures which are apprved, effective, tested, available, accessible, achievable and fllwed including: Sending specimens early frm patients with diarrhea (within 24hrs). Cmmencing cntact precautins if patients are cnsidered t be have infectins. When t call the ICT. Cmmunicatins plan during a nrvirus utbreak. Terminal clean f a nrvirus affected ward befre pening. A nrvirus infrmatin pack is available n the ward cntaining: Infrmatin fr patients/relatives available regarding: nrvirus, Outbreak, Laundry and Hand hygiene Nrvirus Outbreak Data Recrd cllectin sheet t maintain an up t date list f everyne wh is symptmatic (staff and patients) new cases, faecal specimens sent and specimen results. Nrvirus Outbreak Daily Checklist t ensure Nrvirus Cntrl Measures are in place. Ntice fr ward dr regarding clsure and advice fr visitrs. Clinical Team: There are sufficient HCWs n the ward wh knw hw t, and fllw all the Nrvirus Cntrl Measures. The Ward layut: Enables ptimal infectin preventin and cntrl t be practiced, e.g. gd hand hygiene facilities, available islatin rms and setting up f chrt rms. Ward Equipment: There is sufficient equipment and sundries t negate / minimise crss-transmissin risks. Equipment is single use r capable f being effectively decntaminated. The Infectin Cntrl Team are available fr: Prmpt (within the hur) review f a pssible nrvirus utbreak. Advice n deplyment f any infectin cntrl prcedure. Daily assessment f the cntinuing need fr Nrvirus Cntrl Measures Clinical Team, ICT and Management: An Outbreak Debrief Assessment is dne f every nrvirus utbreak, i.e. what went well, what culd have gne better, what systems if any need changed. Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 25 f 31

31 Safe acts Defences Management: Are invlved in supprting the clinical team in the deplyment f Nrvirus Cntrl Measures. The fllwing safe acts are bserved: Early sending f specimens frm patients (r staff) with symptms; Early referral t the ICT. Early instigatin and effective applicatin f Nrvirus Cntrl Measures. Mnitring f all symptmatic patients fr the need fr rehydratin therapy. Rutine use f Standard Infectin Cntrl Precautins including hand hygiene cmpliance by all healthcare wrkers at all times. Visitrs fllwing hand hygiene cntrl measures, and nt visiting the ward if symptmatic. T defend against nrvirus utbreaks: The labratry prvides a prmpt turnarund fr nrvirus testing. There is cmpliance with nrvirus cntrl precautins, e.g. ward clsures and nn-transfer f staff frm affected wards. There is an effective ICT. The epidemilgy f nrvirus utbreaks in hspitals is cntinuusly mnitred and data fed back t thse wh need t be alerted. 12. Useful surces f infrmatin and references Harris, J. P., Edmunds, W. J., Pebdy, R., Brwn, D. W. and Lpman, B. A. (2008) Deaths frm nrvirus amng the elderly, England and Wales, Emerg Infect Dis, 14, Reasn, J. (1990) Human Errr, Cambridge Univ Press. Reasn, J. (2000) Human errr: mdels and management, West J Med, 172, Said, M. A., Perl, T. M. and Sears, C. L. (2008) Healthcare epidemilgy: gastrintestinal flu: nrvirus in health care and lng-term care facilities, Clin Infect Dis, 47, Vanderpas, J., Luis, J., Reynders, M., Mascart, G. and Vandenberg, O. (2009) Mathematical mdel fr the cntrl f nscmial nrvirus, J Hsp Infect, 71, Weick, K., KM., S. and Obstfeld, D. (1999) Organizing fr high-reliability: prcesses f cllective mindfulness, Research in Organizatinal Behavir, 54, NB the full literature review used is available at: (web link t be inserted). Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 26 f 31

32 13. Appendix I - Is it an utbreak? Nrvirus Outbreak: Cntrl measures and practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals HPS: December 2009 page 27 f 31