HPS Norovirus Outbreak Guidance Season

Transcription

1 HPS Nrvirus Outbreak Guidance Seasn Preparedness, cntrl measures & practical cnsideratins fr ptimal patient safety and service cntinuatin in hspitals NB Abut a mnth t g is week 37 Versin.1 Seasns and page 1 f 40

2 Cntents 1. Objectives fr effective nrvirus management in hspitals T reduce the risk f nrvirus utbreaks T reduce the impact f nrvirus utbreaks General infrmatin abut nrviruses in hspitals Abut nrviruses and nrvirus infectin Definitins f nrvirus cases and nrvirus utbreaks: Why nrviruses cause utbreaks in hspitals settings The reasns nrviruses are a challenge in hspitals settings: Institutinal risk factrs that increase the nrvirus utbreak risk The Nrvirus Year fcussing n preparedness Lcal NHS Bard Preparedness Plans fr ptimal preparedness Nrvirus Outbreak Schematic and Management Nrvirus Cntrl Measures (Single Ward) Risk Assessment fr Ward r Bay Clsures Discharges Transfers Healthcare Wrkers (HCWs) Knwledge management Immediate Risk Reductin Specimens Hand hygiene Persnal Prtective Equipment (PPE) Decntaminatin f the Envirnment Decntaminatin f spillages f faeces r vmit Laundry Visitrs & Temprary Suspensin f Visiting Daily Patient Placement & Bed Management Terminal cleaning Repening the ward by bays Nrvirus Management - Patient Care Measures Escalatin Plan Additinal Cntrl Measures when nrvirus utbreaks are cntinuing r are spreading Investigatins t identify what is causing the nrvirus escalatin r failing t stp an utbreak: Escalatin Plan When Nrvirus Cntrl Measures cannt be applied Other practical cnsideratins fr clinical and infectin cntrl teams Lcal Nrvirus Outbreak Summary Reprt Versin.1 Seasns and page 2 f 40

3 8.1. Pssible summary fr annual reprt n nrvirus utbreaks Useful surces f infrmatin and references Appendix I - Is it an utbreak? A decisin tree t help clinical staff Appendix II Nrvirus Outbreak Daily Checklist/Nrvirus Outbreak Data Recrd Appendix III Algrithm fr Ward r Bay Clsure Appendix IV Algrithm fr Ward r Bay Re-pening Appendix V Temprary Suspensin f Visiting (TSV) Checklist Appendix VI - Key TSV messages NHS bards may cnsider useful Tweet infgraphics available The algrithms n pages 36 & 37 were prduced fr a Wrking Party s revisin f the Chadwick et al 2000 Guidelines: Guidelines fr the Management f Nrvirus Outbreak in Acute and Cmmunity Health and Scial Care Settings. 2 Versin.1 Seasns and page 3 f 40

4 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 incidence f nrvirus utbreaks, and when they ccur t limit their impact and the disruptin f nrmal healthcare services. The bjectives fr effective nrvirus management in hspitals can therefre be summed up as fllws: 1.1. T reduce the risk f nrvirus utbreaks By: Planning and preparing fr nrvirus utbreaks every year. 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 nn-expsed patient. 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 Infectin Preventin and Cntrl Team (IPCT) if 2 r mre patients develp nrvirus symptms (see case definitins). Fllwing IPCT 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. Versin.1 Seasns and page 4 f 40

5 2. General infrmatin abut nrviruses in hspitals 2.1. 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 Nrviruses are nn-envelped viruses which belng t the Caliciviridae grup f viruses. Frmer names fr this grup f viruses include Nrwalk-like viruses, winter vmiting disease, and Small Rund Structured Viruses. Nrviruses cause gastrintestinal infectin which is characterised by: acute nset f nn-bldy watery diarrhea and/r 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: 3;4 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 symptm free 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 crss-transmissin is unknwn. Immuncmprmised patients can excrete the virus fr cnsiderable perids f time. 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 IPCT as well as the labratry as virlgy testing fr nrvirus is nt rutinely dne n all faecal samples. Usually self-limiting and cnsidered mild. Mrtality as a cnsequence f nrvirus can ccur and des ccur, particularly in elderly patients with c-mrbidities. Versin.1 Seasns and page 5 f 40

6 Patient supprt Mdes f transmissin Nrvirus infectin can cause rapid dehydratin particularly in elderly patients. Therefre symptmatic patients shuld have their fluid balance mnitred and receive rehydratin as necessary. Assuming bacterial causes, e.g. C. difficile, 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 Hands cme int cntact with faecal matter and subsequently tuch the muth. Indirect Cntact Hands cme int cntact with cntaminated equipment r cntaminated surfaces and subsequently tuch the muth. Cnsumptin f faecally cntaminated fd r water. Airbrne Disseminatin 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. Flushing lidless tilets is als cnsidered t be a means f cntaminating the surrunding envirnment. NB 30mls f vmit may cntain up t 30,000,000 virus particles. 1 gram f faeces can cntain up t 5 billin infectius dses f nrvirus 1. Envirnmental survivability Nrviruses can survive: On any surface fr at least a week. On fds in a refrigeratr fr up t 10 days. Freezing indefinitely. Versin.1 Seasns and page 6 f 40

7 2.2. Definitins f nrvirus cases and nrvirus utbreaks: Definitins (cases/expsed and nn-expsed persns) Pssible Nrvirus Case: A persn (patient r staff) wh, within a 24 hur perid has, 3 r mre episdes f nn-bldy diarrhea*, AND/OR, 2 r mre episdes f vmiting, withut having any ther bvius cause fr symptms. Cnfirmed Nrvirus Case: A persn (patient r staff) wh, within a 24 hur perid has, 3 r mre episdes f nn-bldy diarrhea*, AND/OR, 2 r mre episdes f vmiting, withut having any ther bvius cause fr symptms AND wh has tested psitive fr nrvirus. Expsed asymptmatic patients Patients wh have been expsed t a symptmatic pssible r cnfirmed nrvirus case by being in the same rm as pssible r cnfirmed cases and whse last expsure was within the past 48 hurs. Nn-expsed patients Patients wh, within the past 48 hurs, have nt been cared fr, r been in the same rm as a pssible r cnfirmed nrvirus case, in hspital r a care hme 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. Definitins (utbreak) 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. The IPCT may assess patients as pssible cases based n the verall presentatin f an utbreak. Versin.1 Seasns and page 7 f 40

8 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. Minimum criteria fr a bay t be used fr a nrvirus bay clsure ptin A ward bay used fr a nrvirus bay clsure shuld have clsable drs, wash-hand basin and tilet facilities which are nt shared by patients wh d nt have symptms. IPCT risk assessment cnfirming suitability. Versin.1 Seasns and page 8 f 40

9 3. Why nrviruses cause utbreaks in hspitals settings 3.1. 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 and wrapped fd items. 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 crssinfectin. 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 5. 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. Bay clsures are implemented t reduce this risk withut prlnging the utbreak. Bay clsures are being used increasingly in Sctland withut prlngatin f utbreaks. Standard cleaning regimens using neutral detergent alne are ineffective against nrviruses. Versin.1 Seasns and page 9 f 40

10 3.2. Institutinal risk factrs that increase the nrvirus utbreak risk Admissin f (identified r unidentified) infectius patients t pen ward areas. Inapprpriate admissin f symptmatic 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 IPCTs. 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. Versin.1 Seasns and page 10 f 40

11 4. The Nrvirus Year fcussing n preparedness As nrvirus utbreaks happen in almst every hspital every year mainly ver the winter perid - IPCTs shuld ensure their systems are ptimally prepared t identify and manage nrvirus utbreaks. This wrk shuld be cmplementary with the HPS nrvirus preparedness and actins listed belw. Mnth HPS Activity Cntinuus activity August September Publish HPS Annual Nrvirus Seasn evaluatin reprt Prepare and issue HPS nrvirus tracker, nrvirus diary Re-issue mdified guidance (if necessary) Prepare natinal key cmmunicatins fr winter preparedness and the cming seasn Review cmmunicatin strategy Week 37 Alert NHS Bards: Abut 1 mnth t Nrvirus Implement Nrvirus/Winter Planning preparedness plans Remind f any changes in HPS Nrvirus Guidance Take part in the winter planning events 1. Weekly HPS Nrvirus Pint Prevalence. 2. Aut searching f the literature using fllwing terms: Nrvirus and Outbreak and Hspital r Nscmial r Care Hme r Lng Term Care Facility. Octber Alert NHS Bards and SGHSCD when nrvirus seasn begins 3. Review f identified Nvember Clse mnitring and feedback f any new infrmatin n the presentatin f nrvirus fr the current seasn Prepare key messages fr hliday perid literature fr need t mdify guidance. December Release key messages fr hliday perid January Onging mnitring f seasn February Onging mnitring f seasn March Initial evaluatin f seasn data April Prepare fr NHSSctland seasn evaluatin Based n review f the evidence and if required, mdify HPS Nrvirus Guidance changes and send t HOAG and then t the service fr apprval May Meet with natinal winter planning t agree key dates fr cming seasn NHSSctland nrvirus seasn evaluatin. June NHSSctland nrvirus seasn evaluatin cmplete. Take part in Winter Review meeting/winter planning. July Send nrvirus seasn evaluatin t HOAG. Versin.1 Seasns and page 11 f 40

12 4.1. Lcal NHS Bard Preparedness Plans fr ptimal preparedness Out f seasn and preseasn activity Educatin and training Cnsider any changes in Nrvirus Management and mdify teaching prgrammes if necessary. Identify all thse wh need educatin/training befre the next seasn and prepare/plan prgrammes. Prvide, with thers, the educatin and training n nrvirus, e.g. clinical skills n the ward, self-directed learning, r frmal sessins. Create a cmmn purpse - a teams apprach - by agreeing/cnsidering Hw best t wrk with the lcal HPT t share preparedness and ptimise systems t reduce nrvirus impact in hspitals and care hmes. Cnfirm hw the IPCT will perate at times f multiple ward clsures r ver the hliday perid t ensure there is IPCT resilience. The cmmunicatins plans during the nrvirus seasn, wh will get what messages when. What surveillance data will be kept, hw this data will be shared and fed back including the frequency f updates. The ut-f-hurs staffing, cmmunicatin, reprting and mde f apprval f a ward r bay clsure. Hw actins will change if the escalatin plan is required. Cnfirm which clinical areas, if any, culd use a Bay Clsure Optin if the utbreak presentatin is limited t a single bay r manageable area. Explain this t the ward managers invlved. Develping a pre-ccupatin with failure apprach Visit the receiving areas when patients with nrvirus symptms are mst likely t enter the hspital first and make sure that staff in these areas are aware f what t d t minimise the risk f an utbreak. Identify the clinical areas that are mst vulnerable t nrvirus utbreaks and make sure that staff in these vulnerable clinical areas are aware that their assessments and patient placements can have utbreak ptential. Cnfirm that staff in these clinical areas are aware f what t d when patients arrive with symptms f nrvirus r are being transferred frm areas where peple may have nrvirus symptms. Have available back up plans fr when there is n single rm accmmdatin t care fr an individual patient with nrvirus symptms. Fr every utbreak ward r bay clsure have a plan f what assessments and checks will be made daily by the IPCT. Versin.1 Seasns and page 12 f 40

13 Cmmunicatins check Make sure patient infrmatin leaflets are available t cver relevant tpic areas are up t date, sufficient in supply and available in key areas, e.g. accident and emergency, medical receiving, medical and elderly care wards. Prepare/check grups fr nrvirus updates. Be ready fr the Abut 1 mnth t g at week 37. Have cpies f the Stay at Hme leaflet available and the e-banner n the bard web page. Wrk with yur cmmunicatins team n the utility and apprpriateness f tweets during peak seasn Reviewing and preparing any mdificatins t lcal guidance and escalatin plan/hiiat clur classificatins Cnsider if there is a need t mdify either the lcal guidance r dcumentatin. If required, cnsider hw t infrm thse wh need t implement the guidance f any changes t the Nrvirus Cntrl Measures. Make sure Nrvirus Cntrl Measures are still available n all wards. If facilities have changed ver the year cnsider what impact this culd have n the escalatin plan. Cnfirm the IPCT are clear n the arrangements in the escalatin plan fr the cming seasn When the seasn starts Alert Healthcare Wrkers (HCWs) that the seasn has started and remind them again f hw t access the IPCT and lcal guidance. Keep key HCWs updated thrughut the year with details f hw the nrvirus seasn is prgressing and the implicatins fr practice. Maintain an up-t-date recrd f any ward clsures and implicatins. Start regular cmmunicatins as planned including using the Safety Briefs fr updates n lcal and natinal nrvirus activity. IPCT presence at bed management meetings. Pst ward clsures have a lcal debrief t learn hw such an utbreak might have been prevented, r cntrl measures instigated earlier. Cntinuusly review the success r therwise f a Bay Clsure Optin. Mdify strategy if bay clsures are prlnging utbreaks. Plan t ensure there is ICPT resilience during the hliday perid, i.e. there is IPCN cver fr nrvirus especially when there are multiple ward clsures After the Seasn Have a lcal NHS Bard seasn debrief include the HPT if cnsidered apprpriate. Take part in the HPS natinal nrvirus evaluatin. Determine what went well and what needs t change t imprve systems fr next seasn. Versin.1 Seasns and page 13 f 40

14 5. 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 IPCT 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 IPCT shuld assess the situatin and determine if there is a need t clse a bed bay r the ward and start Nrvirus Cntrl Measures, lead n cmmunicatins with a pre-agreed team f stakehlders and ask fr faecal specimens t be cllected. If the ward is clsed, the HIIAT shuld be undertaken t determine if the situatin is HIIAT amber r red. Until the utbreak is declared ver the IPCT and clinical team shuld undertake a daily utbreak assessment and daily cmmunicatin f these assessments. Outbreak assessments include bth the effectiveness f cntrl measure implementatin and whether the number f persns affected is increasing r decreasing. In additin the IPCT shuld wrk with the clinical team t start preparatin fr repening the bed bay r ward. The management team must be kept up-t-date with the likely repening timetable. If hwever, the utbreak situatin deterirates the IPCT will determine if an escalatin plan is required. Befre repening bed bay(s) r ward, a terminal clean will be dne after repening, the clinical and IPCTs need t remain mindful f the pssibility f nrvirus utbreaks restarting. It must 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. Careful management f the nrvirus situatin is therefre required especially when there are 2 r mre wards clsed at any ne time n a hspital site. Versin.1 Seasns and page 14 f 40

15 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 IPCT assessment is it an utbreak? If n, stp. Initial Nrvirus Actins Assess fr (Bay r Ward) clsure t admissins and transfers Perfrm HIIAT assessment Cmmunicate patients, ward staff, utbreak cmms plan & visitrs Cllect faecal samples frm symptmatic patients (& staff) Start Nrvirus Cntrl Measures Cnsider the benefits f a Temprary Suspensin f Visiting (See TSV Checklist) 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 bed bay(s) r 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? Cnsider Deplying Nrvirus Escalatin Plan if utbreak is spreading t ther wards r nt waning in a single ward after 7 days clsure. Terminal clean use a detergent slutin then disinfect with 1000ppm available chlrine (r use a cmbined detergent/disinfectant prduct) 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: Nn-bldy diarrhea** ( 3 episdes f lse stl), r vmiting ( 2 episdes in 24 hurs) withut ther reasn, r, bth diarrhea** and vmiting. **Diarrhea - des nt include lse stls induced by laxatives r enemas. Versin.1 Seasns and page 15 f 40

16 6. Nrvirus Cntrl Measures (Single Ward) Hw and when the IPCT is alerted t the pssibility f an utbreak is shwn as a schematic in Appendix I Is it a Pssible Nrvirus Outbreak?. Nrvirus Cntrl Measures shuld be deplyed n the advice f the IPCT. 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. At the height f the nrvirus seasn, sme success in preventing multiple ward clsures had been achieved by applying nrvirus decntaminatin t wards that are nt affected. This can be cnsidered as a measure aimed at preventing the clsure f wards Risk Assessment fr Ward r Bay Clsures The IPCT will undertake a risk assessment f a pssible nrvirus utbreak and determine whether there shuld be cmplete r partial restrictin f admissins/transfers. An algrithm shwing hw such an assessment can be made is prvided (Appendix III). Any prpsed clsure will be made knwn t the ward staff, bed management and general management. Fllwing a clinical risk assessment, the bay drs t all bays shuld be clsed, and where pssible fans remved, t further reduce airbrne disseminatin f the virus. A bay clsure ptin shuld be used t chrt nrvirus symptmatic cases whilst minimising the risk f expsing thers. Bay sharing f categries f patients shuld be as fllws: Patients categries in the Pssible Sharing Optins bay Bay cntains a mixture f If sufficient single rms are available, islate case(s) in a single symptmatic pssible r rm(s) leaving expsed asymptmatic patients in the clsed bay cnfirmed nrvirus cases D nt mve ut expsed asymptmatic patients t share a bay with and expsed asymptmatic nn-expsed patients patients If expsed asymptmatic patients have been discharged r are in alternative accmmdatin (but nt with nn-expsed patients), ther pssible r cnfirmed cases culd be mved in t share the bay. Bay cntains expsed D nt mve in symptmatic pssible r cnfirmed cases asymptmatic patients Can share accmmdatin with nn-expsed patients if it is >=48hurs since the expsed asymptmatic patients last expsure t a pssible r cnfirmed case * Bay cntains nn-expsed Can share accmmdatin with ther nn-expsed patients patients Can share accmmdatin with expsed asymptmatic patients if >=48hurs since their last expsure t a pssible r cnfirmed case * Versin.1 Seasns and page 16 f 40

17 *Cnfirm nging decntaminatin f expsed asymptmatic patient envirnments prir t sharing accmmdatin with nn-expsed patients. Patients and staff shuld be chrted, i.e. staff shuld be allcated t care fr cases that are expsed r nn-expsed. 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. Patients shuld be advised that if symptms develp after discharge, they shuld infrm their GP f the situatin in the ward. (Discharges t care hmes r discharge f patients with scial care packages, i.e. where carers will visit the symptmatic patient and ther asymptmatic patients, shuld als be treated as transfers) Transfers Avid transferring any patient frm a clsed ward r bay t ther hspitals/clinical areas/care 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 used in the receiving clinical area Healthcare Wrkers (HCWs) As far as it is pssible fr the duratin f the utbreak: Allcate HCWs t care fr either cases and expsed patients, r nn expsed patients (i.e. allcate staff t affected bays r nn-affected bays). D nt allcate staff n the affected wards/bays t wrk n unaffected wards. (Cnsider bank and agency staff as peple wh culd inadvertently spread this infectin thrughut the hspital). D nt allcate staff frm unaffected wards areas t wrk in the clsed wards r clsed bays unless they are t remain s allcated fr the duratin f the clsure. If staff cannt be allcated t specific chrt areas, the ward may nt be suitable fr bay clsure. HCWs shuld be aware f their duty t stay ff wrk when they have symptms f gastrintestinal infectin (reprting sickness is als mandatry). Versin.1 Seasns and page 17 f 40

18 HCWs with gastrintestinal symptms shuld be sent ff duty and nt allwed t return t wrk until they are symptm free fr 48 hurs. HCWs shuld cntact their Occupatinal Health Department fr advice. Unless deemed clinically necessary, nn-essential staff (e.g. physitherapists, ccupatinal therapists) shuld avid visiting clsed wards r clsed bays r at the very least avid the symptmatic patients. Cnsideratin shuld be given t stpping medical students entering clsed wards Knwledge management Infrm everyne wh needs t knw abut the clsed status f the ward/r bay including: Bed Management, IPCT, General Management, Cnsultants, Health Prtectin Team, 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. 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 Immediate Risk Reductin If ward pantries r kitchens have drs, these shuld be clsed and kept clsed. Identify and advise the discarding f fd (wrapped and unwrapped) 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/kitchen. 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, tilets and frequently tuched surfaces with a neutral 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. NB These shuld nt be present even in a nnutbreak situatin. Avid expsing equipment t airbrne nrvirus cntaminatin wherever pssible, e.g. cnsider cvering pen dispsables items with plastic sheets. As far as is pssible stp using fans in the ward areas t further reduce airbrne disseminatin f the nrvirus. Versin.1 Seasns and page 18 f 40

19 6.7. Specimens Send faecal specimens frm symptmatic patients (and staff) fr culture, C. 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. Appendix II Hand hygiene 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 keybards and at the nurses statin, therefre: D nt use alchl based hand rubs (ABHR) alne fr rutine decntaminatin f hands when there is an utbreak f gastr-intestinal infectin. Perfrm hand hygiene using liquid sap and warm water. ABHRs can be used after a hand wash with liquid sap and warm water prir t perfrming an aseptic technique (Mment 3) Persnal Prtective Equipment (PPE) 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 wrn t minimise the risk f splash cntaminatin and inhalatin f nrvirus and subsequent ingestin. Discard PPE waste as Healthcare (including Clinical) Waste Decntaminatin f the Envirnment Increasing the hurs available fr cleaning f the ward is a key cnsideratin fr the IPCT t advise n. Cnsideratin shuld be given as t hw frequently cleaning shuld be dne based n the utbreak presentatin and ward layut. Versin.1 Seasns and page 19 f 40

20 Cleaning using wet clths can be a means f transferring the virus thrughut the ward. The IPCT 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. Fr each patient bed space a single use dispsable clth shuld be used. Wherever pssible the cleaning with a detergent and warm water shuld be fllwed with 1,000 ppm av cl r cmbined chlrine/detergent based prduct. NB In rder t prevent further transmissin and als t prtect thse wh have nt been expsed the entire ward area shuld be decntaminated by cleaning fllwed by 1,000 ppm av cl r cmbined chlrine/detergent based prduct. Nt just a clsed bay. NB nt mving staff between affected and nn-affected clinical areas applies t dmestic staff Decntaminatin f spillages f faeces r vmit Wear Persnal Prtective Equipment glves, aprn (and surgical mask if there is a risk f splashing). Requirements: healthcare waste bag, spill kit r wet and dry paper twels, fresh slutin f 1,000 ppm av cl. 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 neutral detergent (applicatin f a disinfectant t faeces/r vmit will inactivate it). Disinfect the area with 1,000 ppm av cl 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 and dry Laundry During an utbreak all laundry cming frm a ward r bay which is clsed shuld be cnsidered ptentially cntaminated and discarded directly int alginate bags and then subsequently re-bagged Visitrs & Temprary Suspensin f Visiting 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. Versin.1 Seasns and page 20 f 40

21 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. If mre wards are clsed cnsider the restricting visitrs t ther areas f the hspital. Temprary suspensin f visiting (TSV): A TSV may be cnsidered necessary t reduce the risk f the nrvirus utbreak spreading thrughut a ward r part f a hspital. NB Extract frm a SIRN funded research prject by Glasgw Calednian University f current patients visitrs and a randm representative sample f the public (n = 522) Survey results shwed the majrity (84.6%) indicated that verall the pssible benefits f clsing a hspital ward r care hme t visitrs during a winter vmiting bug utbreak are greater than the pssible disadvantages. Cnversely, the majrity disagreed that a TSV is wrng as it ignres peple s rights t have cntact with family and friends. Advice n cmmunicating this t visitrs is available frm HPS. [Lead Authr Kay Currie: Prject title: The acceptability f suspended hspital visiting during nrvirus utbreaks: perceptins f service users, clinical staff and the wider public.] Daily Patient Placement & Bed Management Patient placement assessments shuld be dne n a daily basis. Patient placement decisins during a nrvirus utbreak require lcal IPCT and clinical team assessment f the ptins with the least risk fr all the patients. The variables that will assist the IPCT and clinical team in making patient placement decisins with the best ptins fr patient safety include: the number f symptmatic pssible r cnfirmed cases, 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 single rms, chrt nurse symptmatic patients tgether in bed bays. (Fllw 6.1). - D nt mve patients if it places unexpsed asymptmatic patients at risk f expsure. - As the number f cases 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 r int a bed bay(s) t further reduce spread, and aid cntainment f nrvirus. Versin.1 Seasns and page 21 f 40

22 - Even thugh an entire ward has been clsed it may be repened bay-by-bay, n the advice and risk assessment f the IPCT See: Repening the ward by bays. Empty Beds in clsed bays r wards: 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. Create clean bays as patients are discharged, try t create clean bed bay areas, where patients can be admitted t first nce the ward/bay is repened. See: Repening the ward by bays Terminal cleaning During the terminal clean, all empty beds shuld be re-cleaned and the bed cleaning prcess shuld include 1,000ppm av. cl. r with a cmbined chlrine/detergent based prduct. 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. 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 IPCT. The IPCT 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). Terminal cleans shuld invlve a change f curtains in bays where cases have been cared fr. (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 where cases have been nursed 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. Thrughly clean and then disinfect all surfaces with a neutral detergent and 1,000 ppm av cl. r use a cmbined chlrine/detergent based prduct. Once the decntaminatin prcedures are cmplete the curtains can be re-hung and the beds remade Repening the ward by bays Althugh an entire ward may have been clsed t admissins, as the utbreak wanes the clsed ward can be repened bay-by-bay prvided: Versin.1 Seasns and page 22 f 40

23 The bays are free f symptmatic patients (48 hurs) and there have been n new cases fr 48 hurs, r The bays have becme empty f all patients, AND The bay has been deep cleaned, AND Staffing and remaining patient placements/facilities and assessments enable the IPCT t cnfirm it wuld be safe t d s. T ensure that a bay clsure ptin and a repening the ward by bays, ptin des prlng utbreaks, data n the duratin f restricted admissins, type f clsure (bay r ward) and bed days lst shuld be cllated fr all wards where there are restricted admissins. This assessment culd be dne using a Nrvirus diary. Repening f a ward can cmmence when: The ward has been terminally cleaned t the satisfactin f the ward manager and IPCT 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 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 & Relatives Ensure all patients and relatives are aware f the situatin regarding 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. Versin.1 Seasns and page 23 f 40

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. Smetimes the number f patients arriving int hspital with symptms f nrvirus can trigger multiple utbreaks and the need fr the Escalatin Plan t be triggered 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: Restricted admissins (bed bay r ward clsures) have remained clsed t admissins and transfers All n-duty staff are asymptmatic Visitrs are asymptmatic There is cntrl f ward traffic. Review and seek reassurance n the fllwing infectin cntrl indicatrs: Ward cleaning including ward cleaning recrds Ward cleanliness including safe patient envirnment audit data Hand hygiene practices undertake hand hygiene audits Determine if there have been any admissins t a clsed ward(s). Determine if 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. Versin.1 Seasns and page 24 f 40

25 7.2. Escalatin Plan When Nrvirus Cntrl Measures cannt be applied Expand the Outbreak Cntrl Team (OCT) managing the nrvirus utbreak(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 OCT t mnitr the success f the decisins they make regarding utbreak management. (This can be dne frm the HPS Nrvirus Tracker). Mnitr the nrvirus situatin in the cmmunity by using the HPS Nrvirus Pint Prevalence data this may help the decisin making. The OCT 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. Undertake an asset assessment f all ward facilities pssibly available fr recnfiguring wards. 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. (This may include amalgamatin f symptmatic cases in a single ward t allw deep cleaning and repening f sme areas mre quickly). 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. Ensure that accident and emergency departments have advice leaflets fr patients presenting with symptms suggestive f nrvirus wh d nt require admissin. Cnsider cmmunicating with GPs t ensure awareness f the situatin within care hmes/hspitals and t avid any unnecessary admissins. 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. Prmte hand hygiene by all HCWs and visitrs. Ensure cleanliness is as specified by the IPCT. Cnsider extending the ward clsure time t 72 hurs after last vmit/diarrhea episde. Cnsider temprarily switching hspital wide, detergent t a hypchlrite agent fr standard cleaning in nn-utbreak wards t cver duratin f utbreak. Cnsider asking HPS fr advice. Cntinue t assess the impact f the utbreak using the HIIAT and reprt nwards as required. Versin.1 Seasns and page 25 f 40

26 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 clsing the hspital, r areas f the hspital, t all but essential visitrs, i.e. a Temprary Suspensin f Visiting (TSV). If this is cnsidered necessary, agree befre restricting visitrs, the criteria wuld fr returning t nrmal visiting. Befre clsing the hspital t all but essential visitrs ensure cmmunicatins internally and externally (public, media, HPS and SGHSCD). Wherever pssible advise visitrs abut the restrictins befre they arrive fr visiting. HPS has prduced advice n cmmunicating a TSV t patients, staff and visitrs. NB Maintain effective cmmunicatins: patients, staff, visitrs, cmmunity, HPS, SGHSCD Other practical cnsideratins fr clinical and infectin cntrl teams Once the clsed ward has re-pened ward staff shuld: Admit patients t empty terminally cleaned 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. IPCTs: shuld be alert t warnings f increases in nrvirus activity thrugh the HPS weekly Mnday Prevalence and NHS 24 exceedance reprts. Advise medical receiving teams when the nrvirus risk is high. Bed Management Liaisn and IPCTs: 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. Hspital IPCTs and Health Prtectin Teams (HPTs): shuld cmmunicate effectively t share infrmatin n lcal clsures due t nrvirus. Versin.1 Seasns and page 26 f 40

27 8. Lcal Nrvirus Outbreak Summary Reprt Belw is a simple summary reprt frmat cmpletin f which will enable IPCTs 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 IPCT Initial HIIAT assessment Pssible Nrvirus Infectin Case: A persn (patient r staff) wh, within a 24 hur perid has, 3 r mre episdes f nn-bldy diarrhea*, AND/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*, AND/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 Admissin restrictins Bay Clsure frm / / t / / Bed days lst 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 nn-affected 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 bed bay(s)/ward, repening f the ward against IPCT advice, transfer f staff t ther nn-affected wards? Was there an event recgnised which culd have started the utbreak, e.g. transfer frm anther Ward Clsure frm / / t / / Estimate: Versin.1 Seasns and page 27 f 40

28 area if s culd this have been anticipated and averted? What went well? What actins/systems culd be imprved? 8.1. Pssible summary fr annual reprt n nrvirus utbreaks The table belw prvides IPCTs 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 Number f bay clsures that did lead t full ward clsure Number f full ward clsures Average duratin f bed bay(s) clsure 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 Versin.1 Seasns and page 28 f 40

29 9. Useful surces f infrmatin and references (1) Hall AJ. Nrviruses: the perfect human pathgens? J Infect Dis 2012 Jun;205(11): (2) Health Prtectin Agency, British Infectin Assciatin, Healthcare Infectin Sciety, Infectin Preventin Sciety, Natinal Cncern fr Healthcare Infectins, NHS Cnfederatin. Guidelines fr the management f nrvirus utbreaks in acute and cmmunity health and scial care settings. Health Prtectin Agency 2012 March [cited 2012 Feb 15];Available frm: URL: (3) Harris JP, Edmunds WJ, Pebdy R, Brwn DW, Lpman BA. Deaths frm nrvirus amng the elderly, England and Wales. Emerg Infect Dis 2008;14(10): (4) Said MA, Perl TM, Sears CL. Healthcare epidemilgy: gastrintestinal flu: nrvirus in health care and lng-term care facilities. Clin Infect Dis 2008 Nv 1;47(9): (5) Vanderpas J, Luis J, Reynders M, Mascart G, Vandenberg O. Mathematical mdel fr the cntrl f nscmial nrvirus. J Hsp Infect 2009 Mar;71(3): Versin.1 Seasns and page 29 f 40

30 Appendix I - Is it an utbreak? A decisin tree t help clinical staff Outbreaks can start abruptly and spread quickly t minimise their impact n patients and the hspital they must be recgnised, reprted and cntrlled very swiftly. This flw chart will help yu make the right decisin. A patient develps diarrhea and/r vmiting. An infectius cause is pssible is it part f an utbreak? Is there anyne else n the ward (patient r staff) with diarrhea r vmiting? Islate symptmatic patient in a single rm with the dr clsed t reduce risk f crsstransmissin. Yes N Are tw r mre f these Nrvirus Outbreak markers present? Symptm nset was sudden Vmiting is prjectile Diarrhea is watery and nt bld stained. Symptmatic patients have nt had laxatives r enemas within past 48hrs. Negative stl fr C. diff, Salmnella, E. cli O157, Cryptspridium, Shigella, and Campylbacter. (But dn t wait fr results befre reprting a suspected utbreak). Nt an utbreak (yet) Islate the patient. Start cntact precautins. Send a stl sample t bacterilgy and virlgy. Be extra vigilant fr ther patients r staff develping symptms Cntinue t mnitr the patients cnditin. Send symptmatic staff hme. Yes N Likely t be a Nrvirus Outbreak Alert the Infectin Preventin & Cntrl Team (IPCT) Islate the patient Send a stl sample t bacterilgy and virlgy. Cntact precautins fr all symptmatic patients, send symptmatic staff hme. Start Nrvirus Outbreak Data Recrd fr all symptmatic cases. Lcal IPCT Cntact Number xxx xxxx Less likely t be Nrvirus Islate the patient(s) if pssible. Use cntact precautins. Send stl samples fr culture. Cnsider ther causes f diarrhea such as antibitics, laxatives, cnstipatin, fd related, etc. Call the IPCT if yu are cncerned r if the situatin changes. Seasn Versin.1 Seasns and page 30 f 40

31 cnsideratins fr ptimal patient safety and service cntinuatin in hspitals Appendix II Nrvirus Outbreak Daily Checklist/Nrvirus Outbreak Data Recrd Hspital Ward: IPCT infrmed Shift/day date: Ward/bay(s) clsed t admissins and transfers until 48 hurs after last new case and 48 hurs after last diarrhea/vmit. The ICD may based n specific epidemilgical data extend the clsure time. Ward / side-rm / bay drs are clsed; there is an apprved ntice n the ward dr advising visitrs what t d. IPCT and Ward team t cnsider the need fr a Temprary Suspensin f Visiting (TSV) *If required fllw Checklist All Healthcare Wrkers (HCWs) n the ward are: Aware f the status f the ward and hw nrvirus is transmitted. Nrvirus symptm free. Allcated if pssible t care fr either affected r nn-affected areas f the ward including agency and bank staff. All patients (and relatives) n the ward are aware f the nrvirus situatin and have been given infrmatin leaflets n nrvirus and the need fr hand hygiene, and safe handling f persnal laundry. All patients with symptms f nrvirus have been assessed tday fr symptm severity and assessed fr signs f pssible dehydratin (Stl and Fluid Balance charts). Nrvirus Outbreak Data Recrd (verleaf) The utbreak data cllectin recrd has been updated including any new cases, the symptms patients are experiencing tday and labratry data. (Stl samples have been requested frm all symptmatic patients). Patient Placement Assessment: A patient placement assessment and any advised / suggested mves have been made. Persnal Prtective Equipment (PPE) glves, aprn, surgical (mask/visr if risk f facial cntaminatin with aersls). There are sufficient supplies f PPE in the ward PPE is used fr single tasks, nce remved hand washing is perfrmed using liquid sap and warm water. PPE is used befre cntact with the patient r the patient s immediate envirnment r befre any dirty task. Hand hygiene is being carried ut with liquid sap and warm water this can be fllwed by alchl based hand rub. Versin.1 Seasns and page 31 f 40

32 cnsideratins fr ptimal patient safety and service cntinuatin in hspitals Hand hygiene: Patients are encuraged and given assistance t perfrm hand hygiene befre meals and after attending the tilet. Envirnment: There is increased cleaning f the envirnment including frequently tuched surfaces, with neutral detergent and 1,000ppm av cl. [Cleaning recrds are up t date.] Envirnment: There is n wrapped r unwrapped fd in the clinical ward area even if unexpsed all fruit shuld be washed befre eating. Equipment: Where pssible single patient use equipment is used and cmmunal patient equipment avided. All reusable equipment is decntaminated after use. There are sufficient ther sundries fr effective cntrl measure implementatin. Linen: Whilst the ward remains clsed, categrise all discarded linen as infected. Spillages: All faecal and vmit spillages are decntaminated by staff wearing PPE. The spillage is remved with paper twels, and then the area is decntaminated with an agent cntaining 1,000 ppm av cl. All waste arising is discarded as healthcare waste. PPE is then remved and hands washed with liquid sap and warm water. Advice and Guidance: HCWs have access t, and fllw NHS Bard guidance n: The decntaminatin f bdy fluid spills, equipment, sft-furnishings What t d if unifrms becme cntaminated. Tday the IPCT has made an assessment f the cntinuing need fr ward clsure. The earliest pssible date fr repening has been cmmunicated t the clinical team, bed management staff and t thse listed in the Outbreak Plicy. In preparatin fr repening empty beds have been cleaned but left unmade. In preparatin fr repening the curtains in empty rms have been taken dwn. In preparatin fr repening cnsider requirement fr pre-bking a terminal clean and curtain change. Befre repening: a terminal clean has been perfrmed fllwing IPCT recmmendatin and the hspital prcedure. n/a n/a Versin.1 Seasns and page 32 f 40

33 cnsideratins fr ptimal patient safety and service cntinuatin in hspitals Ward: Pssible Nrvirus Infectin: 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: 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. Names numbers f all symptmatic patients (diarrhea and r vmiting) Tick if symptm present D = diarrhea Abx V = vmiting Y r N (Antibitics is abbreviated as [Abx]) Laxatives Specimen Pssible r / enemas Y r N date Cnfirmed* Other Inf Date(s) and Day * Des the patient meet the definitin f a Pssible r Cnfirmed case? Versin.1 Seasns and page 33 f 40

34 cnsideratins fr ptimal patient safety and service cntinuatin in hspitals Date (agree a time f day t be dne) N. f patients symptmatic N. f patients <48 hrs symptm free N. f empty beds N. f new HCWs ff duty with symptms N. f bays with symptmatic patients Cmment Versin.1 Seasns and page 34 f 40

35 Appendix III Algrithm fr Ward r Bay Clsure 2 r mre peple develp diarrhea and r vmiting Call the IPCT fr assessment Watching brief N IPCT assess utbreak as prbable? Yes Yes Mre cases? Open plan ward (i.e. withut clsable ward bays) N Pssible r cnfirmed cases cnfined t 1 bay?* N Pssible r cnfirmed cases in >1 bay? N Yes Clse bay Yes Yes N Mre cases utwith clsed bay(s)? Yes Clse affected bays N Manageable as multiple bay clsure? Yes Clse ward Manage as clsed bays N Mre cases utwith clsed bays? Await attainment f criteria fr repening ward/bay Yes Return t nrmal wrking * Pssible r cnfirmed nrvirus cases cnfined t 1 bay, means that these cases were in the same single bay when their symptms arse, and they are in the same single bay nw. It des nt mean that the additinal pssible r cnfirmed nrvirus cases have been mved frm separate bays t a single bay t facilitate a single-bay clsure. Fr a bay clsure ptin t be successful, it is imprtant that same categry patients are cared fr tgether in the same bay, i.e. all symptmatic pssible r cnfirmed cases tgether, r all expsed asymptmatic patients tgether, r all nn-expsed patients tgether. Als that, wherever pssible, staff are allcated t care fr specific patient/bay categries fr the duratin f restrictins. NB althugh nly a bay is clsed, the decntaminatin measures shuld apply t the entire ward. Expsed asymptmatic patients can remain in the same bay where expsure t the pssible r cnfirmed nrvirus cases ccurred, i.e. with pssible r cnfirmed cases. Expsed asymptmatic patients can be cared fr with nn-expsed patients if it is 48 hurs after their last expsure, and f curse, they have remained asymptmatic. Versin.1 Seasns and

36 Appendix IV Algrithm fr Ward r Bay Re-pening 1 r mre clsed bays within a ward and new cases are decreasing T reduce the number f affected bays the IPCT will: Undertake a daily ptimal patient placement assessment Amalgamate same patient categries* Use single rms Plan fr Terminal Clean fr individual bay r ward at the earliest pprtunity Liaise with bed management thrughut N Empty Bay, r a Bay with n new cases r pssible / cnfirmed cases have been asymptmatic fr 48 hurs? Yes IPCT t cnfirm staffing and ther patient placements / IPC practices and facilities indicate the clsed area is safe t Terminal Clean and repen Organise a Terminal Clean f the area and the pen maintaining vigilance fr utbreak reigniting *Amalgamating the same categry patients means caring fr patients that are: All symptmatic pssible r cnfirmed cases tgether r, all expsed asymptmatic** patients tgether, r all nn-expsed patients (nnexpsure in the ward, r within the past 48 hurs anywhere) tgether. D nt amalgamate expsed asymptmatic patients with nn-expsed patients unless it is 48 hurs after their last expsure, and f curse, they have remained asymptmatic. Expsed asymptmatic patients can remain in the same bay where expsure t the pssible r cnfirmed nrvirus cases ccurred, i.e. with pssible r cnfirmed cases, but shuld nt be expsed t new cases. ** Cnfirm nging decntaminatin f expsed asymptmatic patients envirnments prir t sharing accmmdatin with nn-expsed patients. See Decntaminatin f Envirnment and Decntaminatin f Spillages f Faeces r Vmit. Versin.1 Seasns and page 36 f 40

37 cnsideratins fr ptimal patient safety and service cntinuatin in hspitals Appendix V Temprary Suspensin f Visiting (TSV) Checklist Purpse: T prvide advice fr the Infectin Preventin and Cntrl Team (IPCT) and clinical team t cnsider and enable ptimal cmmunicatins befre, during and after a TSV is used. Befre the Temprary Suspensin f Visiting (TSV) starts A persn has been nminated t c-rdinate the TSV (see nte 1). The clinical areas where the TSV will be applied are cnfirmed. The criteria fr lifting the TSV are cnfirmed (see nte 2). A persn has been nminated t infrm the relevant management, HAI Executive lead and the CEO and t keep these peple updated. The staff in the affected clinical areas have been infrmed f when the TSV will start (see nte 3). The staff in the nn-affected areas including frnt f hspital staff have been infrmed that a TSV will be put in place, when it will start and arrangements fr liaisn with ward staff in event f queries. The persn in charge f infrming the patients is cnfirmed (see nte 4). The persn in charge f infrming the patients relatives is cnfirmed (see nte 5). Patients, relatives and staff have been infrmed befre public messaging is annunced. (The Bard cmmunicatins team are invlved in planning the annuncements (see nte 6)). The persn in charge f leading public cmmunicatins is cnfirmed. The key messages fr use during the TSV have been agreed (see TSV key messaging guidelines). During the TSV There is a daily review f the TSV (impact / feedback / cntinuing need / updating f public messaging). At least daily, the TSV c-rdinatr will cnsult with the cmmunicatins team, the IMT and clinical staff t agree nging messaging requirements. Clinical staff will prvide daily updates fr the patients. Clinical staff will prvide daily updates fr the relatives. The senir charge nurse and ward team will assist in ptimising patient/visitr cmmunicatins, e.g. ward phne, mbile phnes (where permitted). After the TSV has been lifted Issue a media release and web update thanking the public fr their c-peratin and reinfrce nging safety messaging (see nte 7). IPCTs and thers t assess the impact n the duratin and intensity f the utbreak and seek feedback frm the clinical areas and any self-generated public feedback: What wrked well What culd have wrked better D any f the messages need changed fr next time. * Cnsider the applicability fr the prepared tweets t aid with public cmmunicatins: See als: Tweet pictures Versin.1 Seasns and page 37 f 40

38 cnsideratins fr ptimal patient safety and service cntinuatin in hspitals Ntes Nte 1: The Senir Charge Nurse, ward staff and a cmmunicatins representative will be included in all the decisins / discussins regarding the TSV Nte 2: Criteria fr lifting the TSV culd be: The TSV will be in place while the utbreak cntrl measures are in place within the wards r whilst the wards are clsed Nte 3: Ensure measures are in place during the TSV fr the management f patient clthing / washing. Cnsider using hspital nightwear fr the duratin f the TSV. Nte 4: Infrming the patients: the persn in charge shuld identify and make exemptins fr patients receiving end-f-life care r fr thse wh are critically ill. Fr these patients, visiting can cntinue as usual. In additin when patients are being admitted int a clsed ward where TSV is in place then a relative may be allwed t accmpany the patient t see they are settled and aid in the admissin prcess. Nte 5: Infrming the visitrs: Make every effrt t make cntact with the next f kin befre they leave fr visiting. Nte 6: There is a need fr flexibility in applying the TSV. This is nt a plicy which requires t be pliced it is abut supprting patients, public, relatives, staff t make their chices in minimising the risk t themselves and ther patients. Nte 7: Messaging when the TSV has been lifted: Thank the public thrugh the media and websites: Fr their c-peratin in helping t halt the spread f nrvirus in the hspitals Cnfirm again the need fr cntinued vigilance f the situatin thrughut the winter Reiterate messages abut nt visiting if they have symptms and nt t visit fr 48 hurs thereafter. Versin.1 Seasns and page 38 f 40

39 Appendix VI - Key TSV messages NHS bards may cnsider useful Temprary Suspensin f Visiting (TSV) during nrvirus utbreaks Pssible Key Messaging fr Bard Cmmunicatins in Cnsultatin with IPCTs Why there is t be a TSV It is fr verall patient safety t prevent the ptential fr further spread within the hspital. It is als t prevent the spread f nrvirus t visitrs. T help with patients privacy and t maintain their dignity at a time when many are experiencing distressing symptms. What is being requested? Relatives and friends are asked nt t visit specific clinical areas whilst utbreak cntrl measures are in place. The Bard is asking the public fr their c-peratin at this time. What is being dne t bring this matter t a speedy cnclusin? Everybdy is wrking very hard t stp nrvirus spreading in the hspital. Clinical staff are als wrking very hard t minimise any distress and discmfrt t patients (e.g. t ensure that frail / elderly patients d nt feel mre vulnerable) whilst there is nrvirus in the wards and a TSV in place. Hw lng will the TSV be in place fr? The IPCT will review the utbreak situatin daily and as sn as it is cnsidered that the risk f spreading nrvirus t ther areas f the hspital and visitrs has reduced the TSV will be lifted. What d the visitrs t thse areas nt invlved in the TSV need t knw? There is n restrictin n visitrs t unaffected areas apart frm the imprtant message abut nt cming t hspital if they have had vmiting and r diarrhea. Peple wh have been sick shuld be symptm free fr a full 48 hurs. Cnsider adding, nt just if they are r have been sick, but if anyne in their family has had symptms f nrvirus within the past 48hurs. (Why: because we knw that nrvirus symptms cme n very quickly withut any warning and it is pssible they may already be infected). Visitrs are asked t cmply with all hand hygiene messages and nly visit ne clinical area per visit. Further backgrund infrmatin that may be useful Research undertaken at Glasgw Calednian University, which sught the pinins f patients, visitrs and members f the public has shwn the majrity (84.6%) indicated that verall the pssible benefits f clsing a hspital ward r care hme t visitrs during a winter vmiting bug utbreak are greater than the pssible disadvantages. Cnversely, the majrity disagreed that a TSV is wrng as it ignres peple s rights t have cntact with family and friends. Advice n cmmunicating this t visitrs is available frm HPS. [Lead Authr Kay Currie: Prject title: The acceptability f suspended hspital visiting during nrvirus utbreaks: perceptins f service users, clinical staff and the wider public. Hw a TSV can help prevent nrvirus spreading? A TSV will reduce the number f peple wh are expsed t nrvirus during an utbreak and therefre the utbreak shuld be ver mre quickly. Versin.1 Seasns and page 39 f 40

40 Other general infrmatin t cnsider It remains f paramunt imprtance that all visitrs cmply with ward hand hygiene instructins. If a decisin t intrduce a TSV has been made and visiting is imminent, cnsider allwing visiting but infrm the visitrs that the TSV will be in place ging frward. Ask the visitrs t nt visit further whilst the utbreak measures are in place fr the reasns stated abve. (Ask visitrs nt t visit ther wards during this visit and t cmply with hand hygiene messages). Cnsider having frnt dr messaging which reinfrces the messages abve. Fr example shuld be mre n hspital switchbard, messages while peple wait n the phne (in place f music), prmpt and clear messaging n web site, radi, large psters ready in advance fr frnt dr. Whilst a TSV is in place cnsider having smene t answer enquiries at the frnt dr. (Make sure there are links t the NHS Infrm web site fr general inf n nrvirus) Cnsider adding the cntext it is peak seasn, ut f seasn exceptin. Tweet infgraphics available The tweet infgraphics belw are a small selectin f thse available fr use. Versin.1 Seasns and page 40 f 40