Diarrhoea and Vomiting (Infection Prevention and Control Policy: Appendix 13)

Transcription

1 SH CP 21 Diarrhoea and Vomiting (Infection Prevention and Control Policy: Appendix 13) This Appendix must be read in conjunction with the Infection Prevention and Control Policy Version: 3 Summary: Keywords (minimum of 5): (To assist policy search engine) Target Audience: The Health Act (2008) stipulates that NHS bodies must, in relation to preventing and controlling the risk of Health Care Associated Infections (HCAI) have in place core policies. This document provides staff with clear guidelines on the actions they must take in order to manage case/s of diarrhoea and vomiting within the community. Implementation of this policy will contribute to the achievement of compliance with the Health Act (2008) Diarrhoea, vomiting, outbreak, isolation, norovirus, Bristol Stool chart, ward closure All staff of all disciplines, Non-Executive Directors, Volunteers, Governors and Contractors Next Review Date: April 2022 Approved & Ratified by: IP&C Group Date of meeting: 15 Date issued: Author: Accountable Executive Lead: Joanne Williams, Infection Prevention & Control Nurse Director of Nursing and Allied Health Professionals 1

2 Version Control Change Record Date Author Version Page Reason for Change Mary Pilgrim & 2 1 Review due to updated version Louise Piper Mary Pilgrim & Louise Piper 2 9 & 27 Technical Amendment - Infected linen bag change of outer bag cover from red to white Angela Roberts 2 27 Technical Amendment - Appendix 13.6 terminal clean of isolation room has been strengthened to include advice on radiator cleaning and separate instruction is now available for microfibre and mop and bucket cleaning Ann Hammond 2 Ward Outbreak Pack page 8 and 9 & Jo Williams 3 4 yearly review Technical Amendment to Outbreak Pack on page 8 IP&CT contact details amendment and of risk of infection poster added. Amendments made to pages 9 and 18 of actual policy re ward closure and risk of infection posters Reviewers/contributors Name Position Version Reviewed & Date IP& C Group members April 2014 IP&C Team April 2014 Liz Taylor Modern Matron, Children s Division, SHFT April 2014 Carol Cleary TQtwentyone April 2014 Sarah Underwood Ward Manager, Rowan ward, Petersfield Hospital April 2014 Angela Wilson Ward Manager, Sultan ward, GWMH April 2014 Julie Redman Modern Matron, The Becton Centre, Barton-on-Sea April 2014 Shelley Mason Modern Matron, Parklands Hospital, Aldermaston Road, April 2014 Basingstoke Toni Scammell Modern Matron, SE, SHFT (GWMH & Petersfield Hospitals) April 2014 Brian Murtagh Modern Matron for Hampshire and Southampton April 2014 Tim Coupland Head of Nursing, AHP & Quality Mental Health Division April 2014 Jacky Hunt Lead IP&C Nurse July 2018 V3 Louise Piper IPC Nurse Dr Mark Jackson Consultant Respiratory Physician July 2018 V3 Vanessa Lawrence Antimicrobial Pharmacist July July 2018 V32018 V3 Joanne Williams IP&C Nurse (SW) July 2018 V3 Helen Neary Associate Director of Nursing & AHP July 2018 V3 Gray Weedon Team Manager, Learning Disabilities July 2018 V3 Sarah Leonard Head of Nursing & Quality July 2018 V3 Vivienne O Connor Nurse Facilitator Infection Prevention & Primary Care July 2018 V3 (WHCCG) Naomi Payne Health Protection Nurse July 2018 V3 Scott Jones Facilities and Estaes Deputy Director July 2018 V3 Louise Jones Senior HR Manager Best Practice Development July 2018V3 2

3 Contents Page 1. Introduction 4 2. Definitions 4 3. Process 6 4. Training References 14 Appendices: Appendix 1: Infection Control Action Card Diarhoea and Vomiting outbreak 15 Appendix 2: Ward Outbreak Pack 16 Appendix 3: Disease and/or infective agent and clinical features 29 Appendix 4: Daily cleaning procedure for a single isolation room/bed space Appendix 5: Infectious terminal clean of isolation room / bay Microfibre cleaning method Mop and bucket cleaning method Appendix 6: Decontamination of Air Mattresses 45 Appendix 7: Clostridium difficile fact sheet 46 Apppendix 8: Gastroenteritis fact sheet 48 Appendix 9: Personal Protective Equipment for relatives and visitors 50 3

4 Diarrhoea and Vomiting 1. Introduction 1.1 For a quick reference guide to managing a potential outbreak please refer to Appendix 1 Infection Control Action Card Diarrhoea and Vomiting of this document which outlines the key actions to follow. 1.2 This appendix to the overarching Infection Prevention and Control Policy has been developed to provide a practical document to equip all care staff in the Trust with necessary information on the recognition, management and treatment of outbreaks and/or incidents of diarrhoea and vomiting in inpatient and community settings. Appropriate management of the patient(s) presenting with symptoms of infectious diarrhoea is paramount to reducing the incidence of an outbreak. The two main causes of an outbreak of diarrhoea and/or vomiting in a care setting are either Clostridium difficile and/or gastro-enteritis due to small round structured viruses such as Norovirus (2.14). Another cause for consideration is food poisoning and a food history should always be obtained and investigated for possible links. 2. Definitions 2.1 Norovirus which causes diarrhoea and vomiting, is one of the most common stomach bugs in the UK. It's also called the winter vomiting bug because it's more common in winter, although you can catch it at any time of the year. 2.2 Clostridium difficile is an anaerobic, gram positive spore forming Bacillus that can cause an infection in the gut (refer to Appendix 7 of this document clostridium difficile fact sheet). 2.3 Cohort nursing a group of patients with a disease or infection who are separated from patients who do not harbour the disease or infection and who are nursed in a geographically distinct area e.g. bay. 2.3 Confirmed outbreak results from laboratory specimens to identify cause of symptoms and/or pattern of outbreak which suggests transmission of infection 2.4 Decant Ward if two or more wards are affected by a norovirus outbreak, in the later stages of the outbreak there may be value in moving all affected patients and recovered patients to one ward to allow earlier cleaning and re-opening of an empty ward. (HPA 2011 Guidelines for the management of norovirus outbreaks) 2.5 Diarrhoea frequent episodes of loose stools type 6/7 (see ward outbreak pack, Appendix 2, Stool Chart, page 29 of this document) this implies more than 3 episodes per day or more than is usually experienced by the symptomatic person. 2.6 Environmental Contamination the area around the patient is contaminated with microbes capable of causing infection, e.g. norovirus infectivity can last for 48 hours after resolution of symptoms. Contaminated hands can transfer norovirus sequentially to up to seven clean surfaces. (HPA 2012 Guidelines for the management of norovirus outbreaks). Soft furnishings should be steam cleaned or laundered. Soiling with vomit should ideally be cleaned to a radius of two metres and people taken out of the area until it is done. (Working party of former PHLS Advisory Committee on GI Infections 2004). 2.7 Exclusion Rule staff should be excluded from the workplace for 48 hours after all symptoms of diarrhoea and/or vomiting have ceased. 4

5 Symptomatic patients are required to be clear of symptoms for 48 hours prior to being deemed fully recovered. For further advice on an individual basis please contact the IPCT 2.8 Hand Hygiene before and after each patient contact, after environmental contact and when moving between clean and dirty sites on the same patient World Health Organisation (WHO 2009) Five moments for Hand Hygiene (refer to Hand Hygiene Appendix 6 Infection Prevention and Control Policy). 2.9 Infectious diarrhoea - can be caused by many organisms including Escherichia coli sp, Salmonella sp, Shigella sp, Campylobacter sp, rotavirus to name but a few. Other causes of diarrhoea to consider are Clostridium difficle (bacteria) and Norovirus (viral diarrhoea), (refer to Appendix 3 of this document for further details) Isolation room a single room often with its own hand washing and toilet facilities Major Outbreak an outbreak may be classed MAJOR after consideration of its complexity, the number of people affected, the pathogenicity of the organism involved, the potential for transmission and any other unusual or exceptional features. The DIPC (Director of Infection Prevention and Control) or CCDC (Consultant of Communicable Disease Control) will make this decision. A significant number of cases of diarrhoea and vomiting involving several wards at the same site may be classed a major outbreak (refer to Outbreak of Infection & Major Outbreak Appendix 8 Infection Prevention and Control Policy) 2.12 Outbreak of diarrhoea and/or vomiting when two or more patients present with the same symptoms of diarrhoea and/or vomiting not associated with any underlying clinical condition in the same clinical setting. May also be used to refer to a local cluster of cases Outbreak resolved - an outbreak will be considered to be over when there has been a period of 48 hours after the resolution of vomiting and/or diarrhoea in the last known case and at least 72 hours after the presentation of the last new case. Often there can be a small number of patients with persistent symptoms these will be isolated or cohorted in order to facilitate the return to normal activity Small round structured virus (SRSV e.g. Norovirus or Rotavirus). - Norwalk - like virus, are the most common causes of outbreaks in hospitals and can also cause outbreaks in other settings such as schools, hotels, residential and nursing homes and cruise ships (HPA 2011 Guidelines for the management of norovirus outbreaks). (Refer to Appendix 8 of this document gastroenteritis fact sheet) Serious Incident (SI) an episode that requires reporting and investigating in view of Patient Safety and Quality. Any ward closure is classified as an SI Serious Incident Panel - a panel involving all parties to investigate the outbreak and put in place an action plan for future learning Ward/ Service closure if a ward/unit is closed due to an outbreak of diarrhoea and/or vomiting it will be considered a Serious Incident (SI) and will require a report on the Trust reporting system by ward staff Ward Outbreak Pack this is a separate pack of instructions to be used as an aide memoire to the local management of the outbreak and includes closure signs and checklists etc (inpatient areas only) please see Appendix 2 of this document. 5

6 3. Process 3.1 The management of diarrhoea and/or vomiting requires commitment and adherence from the Trust and all staff involved. The effect on a patient and/or member of staff involved in an incident and/or outbreak of this kind can be far reaching. Therefore the management of the situation should be advised by the Infection Prevention and Control Team and supported by the key personnel in the Trust responsible for the patient stay and their holistic care 3.2 Methods of Transmission of Infection - transmission of organisms, which cause diarrhoea and/or vomiting, is mainly by the faecal-oral route (unwashed hands after visiting the toilet and handling patient s soiled clothing, bed linen etc). Some organisms are spread by direct contact or through aerosoled viruses in vomit droplets. Widespread environmental contamination during bouts of diarrhoea and/or vomiting occurs. Food borne illness can occur directly through environmental contamination as above and also ingestion. 3.3 Local Management of Diarrhoea and Vomiting within the Trust Key recommendations: Clinicians (doctors and nurses) should apply the following mnemonic protocol (SIGHT) when managing suspected potentially infectious diarrhoea (DH Clostridium difficile infection 2013). S I G H T Suspect that a case may be infective where there is no clear alternative cause for diarrhoea Isolate the patient and consult the infection control team (IPCT) while determining the cause of the diarrhoea Gloves and aprons must be used for all contacts with the patient and the environment Hand washing with soap and water should be carried out before and after each contact with the patient and the patient s environment Test the stool for toxin (Clostridium difficile) or viral studies for Norovirus, by sending a specimen immediately Please note: Persons who have had a Clostridium difficile toxin detected or been diagnosed with Clostridium difficile by other methods should NOT be excluded as norovirus cases. (HPA 2011 Guidelines for the management of norovirus outbreaks). Local Standards: Strategic approach to prevention and control of outbreaks of D&V. When a patient develops unexpected/unexplained diarrhoea and/or vomiting an immediate nursing assessment is required Strict adherence to infection prevention and control measures including hand washing using soap and water, use of personal protective equipment (PPE). Anti-bacterial hand gel should not be used during an outbreak unless it is the specific anti-viral gel used in special areas such as Mental Health due to the lack of identified clinical hand wash facilities. (All gels are ineffective if hands are visibly soiled) Use of dedicated equipment and thorough decontamination of equipment/the environment must be observed by all staff Bed management that ensures patient safety within in-patient facilities while responding to operational needs The provision to isolate/cohort large numbers of affected patients while allowing 6

7 operational capability Timely appropriate information to staff, patient and public including specific posters/leaflets for patients and relatives at entrances to affected area. Risk assessment at patient gateways to hospital admissions and transfer, e.g. MAU (Medical Assessment Unit) Multi-disciplinary approach to outbreak management An early regional Trust wide warning system Ward closure to be recorded on Safeguard as a SI also reported to Public Health England (PHE) for National Surveillance Multidisciplinary management of affected staff ensuring appropriate work exclusion and timely return to work (48 hour rule) which may lead to a restriction of staff e.g. agency/bank staff. Ensure all staff (including bank and agency) who have been exposed to an outbreak situation are not transferred/moved to non-affected areas to work and remain in the area for the duration of their shift. Daily communication is required during an outbreak with the ward/unit representative, Infection Prevention and Control Team and facilities management. If a face to face meeting is not possible Trust teleconferencing facilities may be used. Visitor restriction may be required Communication Team may need to be informed due to possible Press coverage. 3.4 Communication - It is important that everyone is aware of the infection prevention and control precautions that need to be in place to manage D&V. Appropriate/relevant staff involved in patient care/interventions must be informed of the potential risks of the patient s infective diarrhoea. In addition to this, daily outbreak updates are available from the Infection Prevention and Control Team. Patients should be provided with an explanation and information regarding their diagnosis and treatment; this is the responsibility of the nursing and medical team providing care (Appendices 7 and 8 of this document). 3.5 Outbreak management Please print a copy of the outbreak pack (Appendix 2), this will guide you through the actions you need to manage on a daily basis. Immediate Action Community Hospital and Mental Health Settings (refer to Appendix 1 of this document Infecton Control Action Card) The Ward/Clinical Manager or deputy (Nurse in charge) will coordinate the initial response to the outbreak in consultation with the Infection Prevention and Control Team (IPCT) This will involve: Informing the IPCT immediately by telephone during core hours. Outside these periods the on call Modern Matron/Manager should be informed. 7

8 Set up daily communications between IPCT and the unit ward managers Informing Facilities Management to provide continuity of cleaning. This is to: a) provide reassurance that an enhanced clean is taking place daily and an infectious terminal clean when situation is resolved b) ensure levels of cleaning are increased in cases of infection and/or colonisation when a suspected or known pathogen can survive in the environment. Environmental contamination may contribute to the spread of infection (sp1 epic ) Identifying whether there is an alternative reason for diarrhoea and/or vomiting, such as an underlying disease or medication. All patients and staff presenting with symptoms having their details and symptom history recorded on the outbreak reporting form (available in the ward outbreak pack, Appendix 2). Staff must be made aware of the 48 hour rule which means that they must remain off duty for 48 hours after their last known symptom to reduce the risk of transmission to others on their return to work. Staff should always maintain excellent hand hygiene. Closure of the bay/ward The decision to close the ward will be made by the IP&C Team with the ward manager. The DIPC and Professional lead will subsequently be informed. Arranging stool specimens to be taken from all symptomatic individuals, for definitions of diarrhoea please refer to the Stool Chart (available in Ward Outbreak Pack, Appendix 2 of this document). The stool must be type 5 or 7 and take up the shape of the container. If samples are contaminated with urine they can still be processed. The laboratory should be asked for a viral screen on all samples, this should be also identified on the specimen request form e.g. Stool for viral studies/ Clostridium difficile screen. Up to a maximum of six specimens of faeces from the group of affected patients should be submitted for Norovirus detection in the first instance. (HPA 2012 Guidelines for the management of norovirus outbreaks) NB stool samples collected over a weekend should be sent to the local Laboratory by taxi, so they are not delayed. Instigate the Ward Outbreak Pack (Appendix 2) including risk of infection and ward closure posters at all entrances/ward reporting form etc. Ensure orange bags are available for the disposal of clinical waste and to replace tiger stream bags during the outbreak period. Ensure safe disposal of linen to include use of alginate bags (as per manufacturer s guidance) as well as white outer bags. Please make sure that the bags are not overfilled as this will reduce the risk of cross infection. Relay all relevant information concerning affected patients during subsequent change over of clinical staff and include the status of the ward i.e. open or closed. This is aimed at preventing complications such as dehydration. Escalate outbreak information to microbiologist/laboratory for results and advice. (Usually undertaken by IPCN). Hand Hygiene as a minimum hands should be washed with soap and water at the start and end of clinical duties, when hands are visibly soiled or potentially contaminated, following removal of gloves and before and after any clinical intervention, (refer to Hand Hygiene Appendix 6 IP&C Policy). 8

9 3.6 Isolation Symptomatic patients should be nursed in isolation where possible to minimise transmission. If there are insufficient isolation facilities, then affected patient(s) should be cohort nursed together. (HPA 2012 Guidelines for the management of norovirus outbreaks) Avoid cohort nursing individuals with diarrhoea of different aetiologies (causes or diagnosis). Always care for patients who are symptomatic and C.difficile toxin positive of C.difficle carriers in a side room. If this is not possible please contact the IPC Team The clinical needs of the patient are of paramount importance if neither a single room or cohort nursing is available then single bed barrier nursing with strictly enforced source isolation must be adhered too following discussion with IP&C Team only. Risk assessment prior to isolation must be undertaken, e.g. risk of falls, confusion etc. Be aware that patients may present with similar symptoms but may in fact be identified as having different aetiologies (Clostridium difficile or norovirus) Priority Service users with viral gastroenteritis / diarrhoea order 1 Single room or cubicle within the specialty, ensuite- toilet if possible or a dedicated commode 2 To a cohort nursing area refer to Isolation - Appendix 9 of the Infection Prevention and Control Policy 3 A single bed isolation area close to a clinical washbasin within an existing bay. Strict source isolation nursing MUST be enforced refer to Isolation procedure (viral diarrhoea) and discussion with IP&C Team 4 Consider reverse barrier nursing if minority of service users are affected, removing immunocompromised non affected service users into side rooms 3.7 Patient Admission/Movement and Transfers Prior to admission/transfer of a patient the following questions should be considered: Is the patient known to be currently suffering from diarrhoea and/or vomiting? Has the patient had a history of diarrhoea and/or vomiting in the past? Has the patient come from a known outbreak/infectious care setting Has the patient recently had an inpatient stay in a healthcare institution? Has the patient an existing contributing condition that may present with diarrhoea and/or vomiting? Has the patient been prescribed antibiotics? Has the patient an alternative method of feeding, e.g. PEG, Naso-gastric tube? Has the patient provided a recent stool specimen? Has the patient a known history of Clostridium difficile, with a positive stool in the past 28 days? Consider food poisoning if patient/patient shows symptoms within 3 days of admission and of duration of more than 3 days? Has the patient been prescribed any laxatives? Is there an accurate documentation and reporting of symptoms, fluid balance and bowel movements? Does the Nurse in charge have an in-depth knowledge of the patient involved in the outbreak so as to be able provide a comprehensive update on a daily basis? If any informal patients wish to go on leave, staff are required to escort them to the reception area of the building and then to collect them on their return. Any informal patients who are 9

10 experiencing symptoms are requested to remain on the ward to prevent the spread of infection to the wider hospital. All discussions with the patient should be documented in their record. Where patients need to attend departments for essential lifesaving investigations the receiving area should be notified of the patient s D&V status in advance of transfer, and arrangements should be put in place to minimise the contact with other patients. Staff should follow standard precautions whilst in contact with the patient. Arrangements for transfer to other healthcare facilities, e.g. hospitals, should include notification of the individual s D&V status, as appropriate and be made following advice from the Infection Prevention and Control Team. (Refer to Admission, Discharge and Transfer Policy) Non-essential treatments e.g. visits to physiotherapy gyms, OT assessments should be postponed until the patient is symptom free for 48 hours Staff who are transferring patients who require an enhanced level of care must ensure that: The receiving area is aware of the patient s D&V status If the patient is being moved to another ward/unit the receiving area has the appropriate level of isolation nursing available If the patient is on antibiotics and/or stool charts these MUST be sent with the patient. Portering staff who are transferring patients should wear appropriate PPE (gloves and/or aprons depending on contact risk) only when in contact with patient; however they MUST cleanse their hands before and after the job using soap and water. The patient is transferred to a clean bed with clean linen or if a trolley or chair is used this must be cleaned with detergent followed by a chlorine based disinfectant e.g. Actichlor Plus solution that contains both components before being used on another patient. Ambulance staff MUST adhere to their own policy. 3.8 During the Patients Stay The patient: Must be actively encouraged to keep the bed space free from clutter to enable cleaning to be carried out to a high standard. Must be discouraged from keeping open food stuff at bedside. Must be actively encouraged to inform nursing staff of bowel movements to ensure the accurate recording of a stool chart and provide a stool specimen (stool specimen forms should indicate if viral and/or bacterial screen is required). Must be actively encouraged to observe good hand hygiene at every opportunity preferably with soap and water. Must be encouraged to follow instructions from healthcare staff to limit any cross transmission e.g. this may include the restriction on staff movement between clinical areas. If compliant and not detrimental to mental health the patient must remain in isolation as advised by IP&C team. If identified as Clostridium difficile positive must be encouraged to wash using soap and water as alcohol gel is not affective against spores. (Appendix 15 of the IP&C Policy). The staff. Personal Protective Equipment (PPE) should be worn by staff carrying out clinical care or 10

11 cleaning of the environment/equipment (gloves and/or aprons depending on the task/risk), (refer to Appendix 9 of this document). Patient s water jugs should be renewed by staff as required ensuring that one member of the team remains in the infected bay and is supported to deliver meal trays and/or jugs by a member who presides in the unaffected area. Hand washing with a liquid soap should be undertaken before and after patient contact by staff and following removal of PPE. The nurse in charge of the shift is to ensure documentation of patients stool history is accurate and up to date. The visitor Visitors should be restricted and children of school age should be discouraged for the duration of the outbreak because of the risk of sudden symptoms developing without warning in school. (HPA 2012 Guidelines for the management of norovirus outbreaks) Signage should be on display to inform visitors if there is an outbreak or ward closure. 3.9 Surgical Interventions Every effort should be made to eliminate D&V before surgery if this is not possible then the following strategy must be adopted D&V patients should be scheduled for surgery (only if lifesaving) for further advice consult the Infection Prevention and Control Team. Bathe/shower the patient with antiseptic detergent e.g. chlorhexidene gluconate 4% prior to surgery to reduce risk of transmission. All theatre surfaces in contact with the patient should be decontaminated post operation according to theatre policy D&V patients in recovery must be segregated wherever feasible and nursed by dedicated staff adhering to isolation procedures At the end of every operating session the table and any other equipment must be cleaned using detergent solution, followed by hypochlorite solution (Actichlor plus) and dried Patient Discharge D&V patients should be discharged promptly from hospital when their clinical condition allows. The General Practitioner and other healthcare agencies, including if appropriate, Community Infection Prevention and Control Teams (IPCT), involved in the patient s care should be informed. D&V patients will not normally require special treatment after discharge from hospital. If a treatment course needs to be completed in particular circumstances the IPCT team should advise about this. If the patient is discharged to a residential care facility the medical and/or nursing staff should be informed in advance. The patient should be 48 hours free from symptoms in order to reduce the risk to the other residents of transmission of infection. However, discharge to a home (nursing or residential) known to be affected by an outbreak at the time of discharge should not be delayed providing the home can safely meet the individual s needs. Those that have been exposed but are not symptomatic maybe discharged only on the advice of the local Public Health England office or IPCT (Infection Prevention and Control Team). Carers must be alerted to the risk of diarrhoea and/or vomiting infection. If visiting in a care facility or clients own home and they themselves have been symptomatic they should be discouraged from contact until 48 hours clear. 11

12 3.11 Deceased Patient The Infection Prevention and Control precautions for handling the deceased patients are the same as those used in life. Any lesions should be covered with impermeable dressings. Black body bags may be used as part of general practice in accordance with standard precautions for all patients. There is a negligible risk to mortuary staff and/or undertakers, provided standard precautions are employed. It is not necessary to inform the mortuary that the patient had D&V. (Refer to the Care of the Deceased Patient Appendix 19 Infection Prevention and Control Policy) 3.12 Visitors During an outbreak of gastroenteritis, the service manager in consultation with the IPCT should advise restricted visiting. Visitors should therefore be advised of the situation and warned that they may be at risk of illness. This should occur prior to them entering the ward in order that they can make an informed decision to visit. All visitors should be encouraged to wash their hands with soap and water when visiting Staff Movement Due to the risk of cross contamination (even if correct personal protective equipment (PPE) has been used) staff movement from one clinical area to another must be avoided wherever possible for the duration of the shift. Ideally staff working in an outbreak area should remain there for the duration of the outbreak, although it is recognised this may be difficult for housekeeper and facilities staff as they are frequently expected to work across more than one clinical area. Consideration should be given to pregnant staff who should avoid working in a closed unit/ward until the causative organism is identified and following advice from Occupational Health. Other staff including doctors, physiotherapists, radiographers and social workers can continue to work in unaffected and affected areas, however outbreak areas should be visited last if necessary and meticulous hand hygiene should be undertaken and appropriate PPE worn Patient(s) in the Community (e.g. Supported Living) with Diarrhoea and Vomiting These patients are under the care of their own General Practitioners who should be advised of the patient s debility if the symptoms are severe as well as review any current medications. Members of healthcare staff who work with the affected patients must adopt Standard Infection Control Precautions particularly in regards to hand hygiene. Patients and carers in these settings should have the importance of hand hygiene and all other precautions explained. Patients in the community who are symptomatic should not attend community day care clinics / facilities until 48 hours after their symptoms have resolved Patients who are symptomatic must be encouraged to stay out of the kitchen and not be involved in food handling and/or preparation. Patients must be encouraged to stay in their own bedrooms if possible while symptomatic. During the outbreak enhanced daily cleaning of bedrooms and bathrooms should be undertaken Patient(s) Community Respite Facilities Unless clinically imperative patients who have symptoms should not be admitted for respite care until 48 hours after symptoms have resolved. However, if symptomatic patients require admission they should be admitted into an isolation room and all precautions taken Cleaning in the Environment and Equipment The management of the environment and equipment should be considered as central to minimising the spread of D&V. Cleaning regimens for isolation facilities should focus on 12

13 removal of dust and infectious organisms from frequently touched surfaces as dust contains spores and harmful organisms, therefore dust must be kept to a minimum. firstly, the management of the occupied facility secondly, terminal clean of the facility after the discharge of the patient or resolution of the outbreak.(a sign off sheet should be kept as evidence that a terminal clean has been carried out after discharge of the patient or at the end of the outbreak - refer to Appendix 5 of this document) When there is diarrhoea or vomiting present within a supported living home, a chlorine cleaning product is necessary to clean the affected areas, in particular toilets and bathrooms. Detergent alone is not sufficient to clean. 1) Household bleach needs to be diluted as per manufacturer s instructions to avoid personal injury (Domestos or equivalent may be the only product available so can be used as required). 2) Patient equipment e.g. wheelchairs, hoists, slings, sphygmomanometer cuffs etc. should be capable of being decontaminated before use by other patients, or should be single patient use and discarded as clinical waste at the end of the period of usage Routine Cleaning of the Occupied Facility (refer to Appendix 4 of this document) Instruments or equipment (e.g. sphygmomanometers, stethoscopes, lifting slings, and physiotherapy exercise machines) should preferably be single patient use, or designated for D&V Patients, these should be cleaned daily with detergent and chlorine containing solution e.g. Actichlor plus. Multiple-patient use items should be decontaminated appropriately before use on another patient in accordance with Trust policy or manufacturer s instructions e.g. toilets, commodes etc. It is essential that clutter around the bed space is kept to a minimum to aid good nursing practice and facilitate cleaning. Stains, soiling, food residue etc. should be removed with a detergent solution disinfectants on their own do not clean Enhanced daily clean, lockers, over-bed tables and chairs should be cleaned daily with detergent and a chlorine based disinfectant e.g. Actichlor plus. The mattress and bed frame should be wiped over daily with detergent. If the admission is more than two weeks wherever possible the patient should be given a clean bed and the current bed thoroughly cleaned with detergent. In some settings where isolation of the affected patient cannot be managed i.e. in Adult mental health settings, the IP&C team will recommend that communal areas are included in the daily clean with Actichlor plus. In addition healthcare workers will be advised to clean commonly touched objects e.g. door handles and light switches at least twice daily with Clinell sanitising wipes InfectiousTerminal Cleaning on Patient/Inpatient Discharge following resolution of the outbreak/transfer/death (refer to Appendix 5 of this document) Enhanced levels of cleaning requiring additional time to enable the removal of all reservoirs of dust, e.g. ventilation ducts, radiators, equipment etc. are required. Infected diarrhoea patient areas should be cleaned after the patient s discharge according to Trust policy, this includes; (refer to Appendix 5 for cleaning schedule checklist sign off sheet). * Steam cleaning is highly effective in the removal of organic matter but may not inactivate norovirus. Therefore hypochlorite disinfection is still required for areas which have been previously steam cleaned. Disposable cloths should be used for each bed space. (HPA 2012 Guidelines for the management of norovirus outbreaks). 13

14 Additionally there should be planned, periodic and thorough cleaning of the whole ward, including bedding, soft furnishings and curtains 3.19 Defining the end of an outbreak This also serves two purposes which, again, may have two different approaches: a) Declaration of the end of an outbreak for Infection Prevention and Control (IPC) The definition is usually set, on the basis of experience, as 48hr after the resolution of vomiting and/or diarrhoea in the last known case and at least 72hr after the initial onset of the last new case. This is also the point at which terminal cleaning has been completed. Often, there are a small number of patients with persistent symptoms and it is advisable to segregate those patients in order to facilitate a return to normal activity. Symptomatic patients may be moved into single rooms or otherwise within a cohort away from the area to be cleaned. There is thought to be little risk of prolonged airborne persistence of virus and terminal cleaning of an area such as a ward can commence immediately after the removal of the symptomatic patients. b) Epidemiological surveillance. The end of an outbreak is defined as no new cases recognised within the previous 7 days. (HPA Guidelines 2011). 4. Training: Refer to Training Needs Analysis (TNA) in IP&C Policy 5. References Department of Health (2013) Clostriduim Difficile infection: Guidance on management and treatment 15 th June 2013 Epic 3 :National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England H.P.Loveday, JA Wilson, RJ Pratt, M Golsorki, A Tingle, A Bak, J Browne, J Prieto, M Wilcox Healthcare Commission 2005: Management, prevention and surveillance of Clostridium difficile Health Protection Agency, (November 2011) (Updated March 2012): Guidelines for the Management of norovirus outbreaks in acute and community health and social care settings Health Protection Scotland, 2013: HPS Norovirus Outbreak Guidance Preparedness, control measures & practical considerations for optimal patient safety and service continuation in hospitals. Version 2 September 2013 Working Party of former PHLS Advisory Committee on GI Infections 2004: Preventing person to person spread following gastrointestinal infections: guidelines for public health physicians and environmental health officers. Communicable Disease and Public Health vol7 no 4 pages World Health Organisation (2009) WHO Guidelines on Hand Hygiene in Healthcare - First Global Patient Safety Challenge Clean Care is safe care Public health England (Feb 2017) Clostridium Difficle: guidance data and analysis Published July 2014 updated Feb 2017 NICE (2017) National institute for Health & Care Excellence) Diarrhoea and Vomiting in children overview. Updated 3 rd April

15 Appendix 1: Infection Control Action Card Diarrhoea and Vomitting Infection Control Action Card Diarrhoea and Vomiting Outbreak Inform relevant parties of the D&V outbreak If two or more patients develop unexpected/unexplained diarrhoea and/or vomiting, this must be considered to be a possible outbreak inform relevant parties of the D&V outbreak e.g. Infection control, bed manager, domestics etc. Follow Trust Policy Follow Infection Prevention advice and Trust Policy. Standard Precautions and effective hand washing are essential. Care of Patients with symptoms Document all newly symptomatic patients on the daily D & V outbreak sheet. Obtain a faecal specimen from all affected patients. Maintain an accurate record of their intake/output and particularly bowel habits (using the Bristol stool Chart in outbreak pack) Restrict access to all non-essential staff Clearly display Outbreak notice at entrance to ward (please see outbreak pack). Teaching rounds should not take place. Essential staff should continue to visit the ward (e.g. physios, OTs, phlebotomists, social care managers). Other staff numbers, including bank and agency staff, should be kept to a minimum. Nursing and health care assistants should not work in other clinical areas. Provide information and advice to visitors Visitors must decide if they wish to visit, but staff must ensure they are aware of the outbreak and the risk of acquiring infection. Discourage non-essential visits and wherever possible, exclude children from visiting. Request that visitors do not visit other patients on the ward or elsewhere in the hospital. Visitors symptomatic in the previous 48 hours should not visit. Provide patients and visitors with information leaflets. Show visitors how to carry out effective hand hygiene using soap and water. Management of staff with symptoms Affected staff must remain off duty until clear of symptoms for 48 hours. A stool specimen should be sent to the laboratory, to be reported to Occupational Health (OH Assist). Ensure that the ward has adequate supplies of essential items Ensure that the ward has adequate supplies of consumables e.g. bedpans, linen, PPE, hand hygiene agent, chlorine-releasing cleaning agent, wipes etc. Implement & maintain enhanced levels of environmental cleaning and disinfection Implement enhanced environmental cleaning with chlorine-releasing agent. Reduce clutter around bed and chair areas to facilitate cleaning. Ensure patients own food, including fruit, is stored away inside their locker. Vacuuming/buffing should not take place on affected wards during an outbreak. Curtains should be changed prior to re-opening an area / when an isolation room/bed space is vacated. 15

16 Appendix 2: Ward Outbreak Pack Ward Outbreak Pack To be used in the event of an outbreak of suspected viral diarrhoea Infection Prevention and Control Team Contact Details: Jacky Hunt, IPCN (North/NE): Joanne Williams, IPCN (LNFH & West): Louise Piper IPCN (SE): Michelle Cook IPCN (Mid Hants) Ann Hammond, Team Secretary: or

17 Contents Check list for staff actions Out of hours instruction Ward instructions Hand hygiene trolley for visitors (if applicable) Poster to inform staff and visitors that there is a risk of infection on the ward due to an outbreak Poster to inform staff and visitors of flu outbreak and/or diarrhoea & vomiting outbreak Hand hygiene poster to be displayed at ward entrances Alert Isolation poster Bristol stool chart Ward reporting form Specimen request form (example) Example of specimen request form 17

18 CHECK LIST: This is an aide de memoire to help you Action Signature Inform: Infection Prevention & Control Team - see contact details on front page Ward manager/modern matron, bleep holder or site manager of situation Housekeepers/Domestics on the ward commence enhanced regime Inform all non-clinical staff of the outbreak Complete ward reporting form (master supplied with pack) If ward is closed, Safeguard ward closure - staff to report situation on Safeguard as a SIRI (Serious Incident Requiring Investigation) Patients: If sufficient siderooms/cubicles isolate in these siderooms/cubicles If more than one patient vomits with no known cause they should be isolated to prevent aerosol spread If insufficient cubicles cohort nurse to try and contain the problem. Commence stool charts on all affected patients plus fluid input and output charts Collect specimens for microbiological assessment request viral studies MC&S and C diff. Staff must state suspected outbreak on laboratory form. Carry out a review of affected Patients/patients, assess alternative reasons for diarrhoea :- 1. Antibiotics 2. Underlying disease 3. Medication e.g. aperients, diagnostic tests 4. Normal bowel habit for patient 5. Change of diet 6. Anxiety/stress 7. Admitted from a known outbreak setting 8. Known history of C diff positive stool in the last 28 days Medical review of patient(s) to assess whether medical cause of symptoms Supplies: Ascertain that ward has sufficient supplies to ensure enteric precautions. If not order immediately including linen, gloves, aprons hand washing towels etc Ensure there are sufficient commodes if applicable Ward: Ensure connecting doors are shut and display signs to prevent excess movement through the ward/unit (supplied with pack) Set up hand hygiene trolley to be placed at ward entrances (posters supplied with pack) Actively encourage all visitors to use the alcohol gel on entry and wash with soap and water before leaving Staff: Re-iterate the importance of strict hand hygiene Inform Occupational Health department if staff are involved Inform affected staff that they should not return to work until 48 hours after symptoms have subsided For further advice PLEASE RING Infection Prevention and Control Team NB : Post outbreak If a ward closure (not a single room and/or bay) has occurred then the outbreak has to be reported on Safeguard as a SIRI (Serious Incident Requiring Investigation). Following the resolution of the outbreak a SIRI panel will meet to discuss the management of the outbreak and produce an action plan as and if required of learning points for all. 18

19 Infection Prevention and Control- Out of Hour s Diarrhoea and Vomiting 1. If there are 2 or more cases of unexplained diarrhoea and/or vomiting within a care facility this may be considered the start of an outbreak. Action required Ward to implement their outbreak pack Close the affected bay to admissions and transfers. Once a bay is closed do not move patients (symptomatic or asymptomatic) from the bay. Do not discharge patients from affected bay to nursing or residential homes patients can be discharged to their own homes if clinically well enough Commence enhanced daily cleaning with chlorine and detergent inform housekeeping. Obtain stool samples and request MC&S and Viral screening 2. If you cannot isolate symptomatic patients in a side room or cohort bay OR if you have 50% or more of inpatients affected, close the entire ward to admissions and contact the IP&C team on the next working day. No patients should ideally be admitted into a ward once it has been closed for infection control reasons. AMH: There may be occasions when a decision is needed to admit a patient into a closed ward as their health condition outweighs the risk of infection eg within adult mental health. A decision to admit into a closed ward can only be taken following careful risk assessment on the understanding that there are no other inpatient beds available in other inpatient facilities. PATIENT TRANSFERS: No patient should be accepted for admission from a ward which is currently closed for infection control reasons. Patients can be transferred from wards with closed bays, on the understanding that the patient is not currently in the closed bay and has not been exposed to anyone in the closed bay. 3. If clostridium difficile is suspected rather than viral gastroenteritis (eg patient has only diarrhoea and no vomiting, is over 65 years of age and may have had antibiotics) OR the patient has just been admitted (so might have food poisoning rather than viral gastroenteritis) then isolate the affected patient in a side room and clean any bay bed space with Actichlor plus and change the curtains. Continue to admit into the bay once cleaning has been complete. If a side room is not available on your own ward, consider transferring to a side room on other wards with the same hospital. 4. Staff who have symptoms of vomiting or diarrhoea must refrain from duty until symptom free for 48 hours 5. Please refer to the full Management of Diarrhoea and Vomiting Policy on the intranet / internet. (SH CP 21) 6. Please phone and leave a message for the IP&C Nurse for the area who will follow this up on the next working day. Jacky Hunt North Hampshire Joanne Williams SW Hampshire Louise Piper SE Hampshire Michelle Cook Mid Hampshire 19

20 WARD/SERVICE INSTRUCTIONS Remove exposed fruit/food/non-covered liquids and unwrapped sweets from bed tables and the tops of lockers as these items can easily be contaminated. Reducing the clutter will aid cleaning and this should include the whole ward e.g. nurses station and reception area Consider patients diet to reduce foods/liquids that may increase symptoms e.g. fruit juice, vegetables. Limit visiting to reduce risk of transmission to visitors especially the very young and elderly who are more vulnerable to infection. Ask visitors with symptoms not to visit until symptom free for at least 48 hours Request visitors do not visit other patients on the ward or elsewhere within the hospital(s) Involve the domestic/housekeeping staff - include them in a daily update on the situation. Increase the level of cleaning of the patient s bed area.(enhanced cleaning). Reduce clutter especially around the bed and chair area, this will facilitate cleaning thus reducing environmental contamination. Good communication to all members of the multidisciplinary team staff that need to come on your ward often get forgotten. Wherever possible cohort nurse as this will help reduce transmission. Ask people not to sit on the patients beds 20

21 Hand Hygiene Trolley A trolley should be placed at each ward/unit entrance (where deemed safe to do so ) and should be clearly identified by enclosed hand hygiene poster reminding staff and visitors to clean their hands with alcohol hand gel on entering and leaving the area. A further trolley should be placed outside a side room/bay Contents of this trolley should be:- a pump action alcohol gel if a wall mounted dispenser is not available in the immediate vicinity gloves in a variety of sizes yellow plastic aprons are required for close clinical contact in outbreak situation. A FOOT OPERATED LIDDED sac holder WITH A ORANGE CLINICAL WASTE SACK should be placed next to the trolley for disposal of gloves and aprons. BUT these should have been removed and disposed of within the patient areas and hands washed as per Infection Control guidelines 21

22 IMPORTANT NOTICE Risk of Infection Due to outbreak of viral diarrhea Please speak to nurse in charge before visiting 22

23 INFECTION PREVENTION ALERT All visitors must use alcohol sanitising foam on arrival FLU SYMPTOMS? If you have flu symptoms do not visit until your symptoms have resolved (usually 5-7 days). DIARRHOEA & VOMITING? If you have diarrhoea and vomiting symptoms do not visit. Please stay away until you have been symptom free for at least 48 hours. 23

24 HELP US TO PREVENT THE SPREAD OF INFECTION Please clean your hands with alcohol gel or liquid soap and water on entering and leaving our ward area 24

25 ALERT INFECTION CONTROL PRECAUTIONS ALL STAFF MUST Remove white coats, arms bare from elbows down Decontaminate hands before entering and leaving the room Wear single-use apron and gloves when dealing with blood / body fluids and / or direct service user contact Discard protective clothing in room in an orange bag Wash hands after removing gloves Unless advised, masks are not required VISITORS Speak to the nurse in charge before entering room Use alcohol hand rub before entering and wash hands with soap and water before leaving the room The use of gloves, aprons and masks is not routinely necessary PLEASE ENSURE THE DOOR REMAINS CLOSED AT ALL TIMES (if safe to do so) Contact IPCT for further advice protecting patients,staff and visitors 25

26 Patient Name: Hospital Number: Stool Chart Date Time Type Description Specimen sent Initials 26

27 WARD REPORTING FORM Please record number of episodes and continue to complete fluid and stool charts Date.. Ward. D = Diarrhoea V = Vomiting Use one sheet per day starting from midnight till midnight the following day (24 hour reporting) - Please tally the number of episodes of D and V Patient Name Bay Number of Episodes Midnight - Midnight the following day D V Date stool sample sent Result 27

28 Specimen request form: example of request for D&V Please complete as outlined in Italics below Hosp Code Requesting consultant/gp code Specimen STOOL type/site Date taken Ward/surg code Time taken Copy to code(s) MICROBIOLOGY REQUESTS ONLY CLINICAL DETAILS (including antibiotic treatment) Diarrhoea & vomiting Suspected outbreak (List antibiotics over past 2 weeks) Hospital No Surname Forename Sex Lab No Date of Birth GP patient No Address Tests required: (please complete as outlined below) MC&S Norovirus Adenovirus Rotavirus C.diff tox 28

29 Appendix 3: Disease and/or infective agent and clinical features table Disease and/or infective agent and clinical features Small round structured virus e.g. norovirus (diarrhoea and/or vomiting) Transmission Faecal oral (hand to mouth following direct contact with faeces and /or vomit). Secondary faecal oral spread from infected cases Droplet from aerosols from vomit Contact with contaminated gloves, shared clinical equipment and the environment Unwashed healthcare worker s hands Guidance and Isolation Isolate for 48 hours from the last episode of diarrhoea and/or vomiting Staff members who are symptomatic should stay at home for 48 hours from the last episode of diarrhoea and/or vomiting Collect patient/patient stool specimens ASAP for virology Staff stool specimens should be sent via GP ONLY if requested by Occupational Health or Infection Prevention and Control Team Rotavirus As above As above Hepatitis A Hepatitis E Faecal oral which includes patient to patient spread. Infected food handlers with poor personal hand hygiene Contaminated water and food especially shellfish Contaminated drugs and needle sharing equipment in illicit drug users Faecal oral person to person spread. Contaminated water and food Isolate for one week after the onset of jaundice or in the absence of jaundice until 10 days after the onset of first symptoms. Report cases to the local Public Health England (PHE) This period maybe extended following advice from Infection Prevention and Control Team Isolate for duration of symptoms. This period maybe extended following advice from Infection Prevention and Control Team Observe strict hand hygiene

30 Disease and/or infective agent and clinical features Campylobacter (symptoms include profuse diarrhoea, malaise, abdominal pain and sometimes vomiting). Transmission Undercooked meat especially poultry. Cross contamination from raw to cooked food. Food contaminated by unwashed hands and contaminated utensils Person to person spread Guidance and Isolation Isolate for 48 hours from the last episode of diarrhoea and/or vomiting This period maybe extended following advice from Infection Prevention and Control Team Collect food history Affected persons should not prepare or handle food for others until symptom free for at least 48 hours. Report all cases to PHE Eschericha coli (E.coli) gastroenteritis, causing diarrhoea and vomiting Ingestion of contaminated food and/or water. Faecal oral Contaminated hands of infected cases. Contaminated equipment Isolate for 48 hours from the last episode of diarrhoea and/or vomiting. Collect food history Notify the local PHE Listeria Salmonella (vomiting, diarrhoea and fever). Ingestion of contaminated dairy products, meat based products, seafood and vegetable based products. Ingestion of contaminated cooked food by raw food or inadequate cooking temperatures. Eggs, red and white meats, dairy products Person to person spread does not occur except during neonatal period Notify the local PHE Antibiotic therapy should be guided by a microbiologist Isolate for 48 hours from the last episode of diarrhoea and/or vomiting Food handlers should not return to work until cleared by Occupational Health Report to PHE Typhoid Fever (Salmonella typhi) The infectious Ingestion of food and water contaminated by faeces Faecal oral person to person spread Isolate for 48 hours from the last episode of diarrhoea. 30

31 Disease and/or infective agent and clinical features period lasts as long as bacilli are present in the stool. Cryptospoidiosis gastroenteritis (Protozoan parasite causes watery or mucoid diarrhoea). Diarrhoea (unknown cause) Bacillus cereus Giardiasis (A protozoan parasite that causes diarrhoea and cramps). Transmission Guidance and Isolation Unwashed hands of asymptomatic carriers Antibiotic therapy guidance from microbiologist Obtain travel history Exclude affected food handlers until six negative stool specimens taken at 2 week intervals, commencing 2 weeks after completion of antibiotics. Exclude Healthcare workers who are not food handlers until 3 negative stool specimens taken at 2 week intervals, commencing 2 weeks after completion of antibiotics. Report to PHE Ingestion of contaminated water, food and milk. Isolate for 48 hours from the last episode of Faecal oral spread diarrhoea Aerosol or droplet spread can occur Sexual partners Faecal oral person to person spread Isolate for 48 hours from the last episode of diarrhoea and/or vomiting Contaminated cooked food, mainly rice dishes, Isolate for 48 hours from the last episode of occasionally other source such as pasta, meat, diarrhoea and/or vomiting vegetable dishes, dairy products and sauces. Report to PHE Faecal oral spread of the cysts and by ingestion of Isolate for 48 hours from the last episode of the cysts from contaminated food and water diarrhoea Report to local PHE Antibiotic therapy should be guided by a microbiologist Gastroenteritis Faecal oral route Isolate for 48 hours from the last episode of diarrhoea and/or vomiting Cholera Vibrio cholera (Cases usually admitted to infectious Faecal oral route Contaminated food and water Isolation for the duration of the illness which can cease following two consecutive negative stools 31

32 Disease and/or infective agent and clinical features diseases unit). Staphylococcus aureus Food poisoning Transmission Skin flora and infections in food handlers of cooked food that has then been stored at room temperature and eaten cold Exclude food handlers with septic lesions Faecal oral route Contaminated food Guidance and Isolation taken at hour intervals Report to the local PHE Isolate for 48 hours Shigella Including bacillary dysentery Isolate for 48 hours from the last episode of diarrhoea Clinicians should report to PHE Clostridium perfringens Contaminated food No person to person spread Clinicians should report to PHE Clostridium difficile Diarrhoeal infection is often triggered by the use of Isolate until asymptomatic for 48 hours and until (A gram- positive anaerobic bacillus antibiotics stools are normal. This period maybe extended that produces toxins). Direct patient to patient spread by faecal oral following advice from Infection Prevention and Clinical manifestations include route Control Team abdominal pain, fever and profuse Unwashed hands of health care workers Collect stool samples for C. difficile foul smelling diarrhoea (HCW) toxins Transferred on contaminated equipment Treat with oral antibiotics as (including healthcare equipment). recommended by a microbiologist Contaminated environment Use chlorine releasing disinfectant to Lack of prudent antibiotic prescribing reduce spores in the environment Mandatory reporting of case to the Department of Health by the Trust 32

33 Appendix 4: Daily Cleaning Procedure for a Isolation Room/Bed Space Before starting -Report to the clinical staff to receive any special instructions In the cleaning room, wearing gloves make up chlorine solution by adding one tablet of chlorine releasing agent e.g. Actichlor plus to 1 litre of cold water. When the tablet has fully dissolved, dose cloths and mops as per microfibre, set up on trolley in yellow buckets. Only personnel trained in the use of chlorine releasing agent e.g. Actichlor Plus should use this product. Collect all materials and equipment eg hand towels, toilet rolls, soap, pre-dosed yellow microfibre cloths and pre-dosed yellow microfibre mops, high dusting tool Park the trolley outside the room within reach of the door, do not take it inside the room Clean hands outside of the room before you go in Put on disposable yellow apron over uniform & disposable gloves before entering the room (discuss with nursing staff if any additional protective clothing is required). Collect up the dosed yellow microfibre cloths you require and yellow microfibre mop. Enter room. Prop up your mop in the furthest corner away from the door ready for use. Take in your yellow cloths into the room Open the window. NB at least one yellow cloth will be required for the isolation room and a further two for any ensuite. Pick up any large items of rubbish & place in orange bag, including locker bag Once detergent and chlorine containing agent eg Actichlor Plus tablets have dissolved in damp dusting bucket, use a yellow cloth to damp dust all surfaces e.g. bed locker, bed frames, table tops, chairs, window ledges and bed lamp. The chlorine releasing solutions must be changed when it becomes visibly dirty. The solution should be freshly made for use for each room, and thrown away, down the sluice after each cleaning session Clean all window ledges and skirting boards Wipe down all doors and handles, paying particular attention to vents. Discard yellow cloth into orange bag. Dry all surfaces using disposable paper and discard after use into orange bag. Clean sink, splash backs, mirror and all fixtures and fittings with clean yellow cloth and detergent and chlorine containing agent e.g. Actichlor Plus solution If en-suite present, using your bucket for en-suite cleaning to thoroughly clean shower cubicle with yellow cloth and chlorine releasing solution eg Actichlor Plus, paying attention to shower head, tiles and shower tray 33

34 Wipe and replenish paper towel, soap and toilet paper dispenser (if appropriate) Using a yellow disposable cloth, thoroughly clean toilet using clean to dirty method. Ensure you rinse your yellow cloth regularly Discard used cloths into orange waste bag. Dry mop the floor working from the furthest point towards the door. Alternatively an (exhaust filtered) vacuum cleaner can be used. Wipe the casing of the vacuum cleaner with a Clinell sanitising wipe, after vacuuming before moving to another room If floor not carpeted wet mop the floor working from the furthest point towards the door. Display floor signs. Leave room and shut door Go directly (whilst still wearing your aprons and gloves) to the sluice area. Empty floor buckets, damp dusting bucket and en-suite bucket in sluice /cleaning cupboard sink (never use a hand washing sink or a sink in the isolation room) Wash the bucket with detergent and water and rinse and dry the bucket whilst in the sluice/or if applicable decontaminate in a ward washer disinfector Remove mop heads and send for laundry in a plastic bag Store mop handle and buckets in the cleaning cupboard or isolation room Remove disposable gloves and apron whilst still in the sluice and thoroughly wash hands using soap and water, in the hand washing sink. 34

35 Appendix 5: Infectious Terminal Clean of Isolation room/bay Microfibre cleaning method Site:.. Ward/Dept:. Room number/name:. Date requested: Time requested: Requested by:. Requirement to remove radiator covers prior to terminal cleaning Remove if:- Ward closure due to infection (e.g. D&V, MRSA, FLU outbreak) Single case of Clostridium difficile and C.diff carrier case if advised by IPCT On request of IPCT as part of management of a resistant organism Removal not required if:- Bay closures due to infection e.g. D&V Single case of resistant organism e.g. MRSA or ESBL Actions Y N Signature Radiator cleaning if covers removed:- Estates department to be contacted in advance of infectious terminal cleaning by the nurse in charge to remove radiator covers. Estates helpline telephone number: (Mon - Fri 08:30 5pm) Arrange the date and time to coincide with terminal cleaning. Estates department to replace radiator covers when infectious terminal cleaning process completed. Cleaning of radiators: Outside & Inside (if required) Facility staff to clean using a damp disposable cloth soaked in detergent and chlorine containing solution (e.g. Actichlor Plus). Nursing staff Responsibility (ideally nursing tasks to be completed prior to housekeeping tasks) Actions Y N Signature The patient must have vacated the bed space before cleaning commences. Wash hands before entering the isolation area. Put on single use gloves and yellow apron before entering the isolation area. Ensure good ventilation. The room or area should be cleared of miscellaneous items (e.g. discard magazines, used toiletries into an orange hazardous waste bag). Remove all linen from bed and place in an alginate bag, followed by infectious outer laundry bag, and tie securely. All disposable fittings and single use medical devices should be disposed of into an orange hazardous waste bag, e.g. oxygen tubing, suction tubing & suction drainage bags.

36 All reusable medical equipment must be decontaminated according to manufacturer s instructions. Following decontamination, remove the equipment from the area. Cleaning: Use a detergent and chlorine containing solution eg Actichlor Plus, 1000ppm. Ensure tablets are dissolved before using. Always ensure good ventilation and correct personal protective clothing is worn when handling the chlorine releasing solution. (Refer to Actichlor Plus dilution poster for the general environment and for cleaning up any blood spillage). Actichlor Plus BS Actichlor Plus GE Solution Only SoutherSouthern Health NHS If commode or raised toilet seat present, thoroughly clean all areas with a detergent and chlorine solution, rinse and then dry. Thoroughly wipe the mattress, upper bed frame, bed head, bed rails, and plastic pillow cover with detergent and chlorine solution eg Actichlor Plus and dry with disposable paper towels. Discard paper towels into orange hazardous waste bag. Ensure good ventilation whilst cleaning within the room. Clean the patient wash bowl if non-disposable with detergent and chlorine solution e.g. Actichlor Plus and dry with disposable paper towels. If bedside entertainment system present, remove headset earpiece covers and discard into orange hazardous waste bag. Arrange for cleaning and replacement earpieces. Name of nurse (print): Date completed: Time: Signature: Housekeeping Staff Responsibility (Ideally nursing tasks should be completed prior to housekeeping tasks) Housekeeping Team to use detergent and chlorine containing agent eg Actichlor Plus 1000ppm for all cleaning tasks during this procedure. Actions Y N Signature Before starting: report to clinical staff to receive any specific instructions. Make up Chlorine based disinfectant solution: In the cleaning room, prepare all equipment needed. Wearing gloves and aprons make up a chlorine solution by adding one tablet of Chlorine releasing agent e.g. Actichlor Plus to one litre of cold water. When the tablet has fully dissolved, dose cloths and mops as per microfibre set up on trolley in yellow buckets. NB: Only personnel trained in use of Chlorine releasing agent e.g. Actichlor Plus, should use this product. Collect all materials and equipment: e.g. hand towels, toilet rolls, soap, pre-dosed yellow microfibre cloths or disposables & pre-dosed yellow microfibre mops, high dusting tool. 36

37 Park cleaning trolley outside: Within reach of the door. Do not take the trolley inside the room. Clean hands before entering the isolation area. PPE: Put on single use gloves and yellow apron before entering the isolation area (discuss with nursing staff if any additional PPE is required). Ensure good ventilation e.g. open a window Remove dirty curtains: Place into an alginate bag, then outer infectious linen stream bag. Damp dust: Using the pre-dosed yellow micro fibre 8 sided cloth technique. Clean all horizontal surfaces from:- High to low Clean to dirty Top to bottom Far end of room to the door Damp dust: Using the pre-dosed yellow micro fibre 8 sided cloth technique. High Dust - Damp dust all areas to hand height level regularly rinsing cloth, allow to air dry. Bedside Lamp - Extend the lamp, damp dust all areas, return to original position, allow to air dry. Hand held nurse call device, careful to clean around idented button, allow to air dry. Bedside Locker - Thoroughly clean all areas inside and outside, and allow to air dry. Bedside Table - Thoroughly clean all areas of table top, underside & stand, allow to air dry. Bedside Chair - Thoroughly clean all wipeable areas of chair seat, back, top, underside and legs, allow to air dry. Bed Frame (below top frame) - Raise bed and thoroughly clean all areas of underside and stand areas working from the top to the bottom, allow to air dry. Window Ledges - Damp dust all areas, and allow to air dry. All Doors, Door Handles & Door Vents - Thoroughly clean all areas paying attention to hand contact surfaces, allow to air dry. Skirting Boards - Damp dust all areas, allow to air dry. Clinical Hand Wash Sink, Taps & Splash Back Use two cloths one for taps and dispensers the other for the basin. Taps should be cleaned first before the rest of the CHWB (ref HTM 04: ). Tiles -Thoroughly clean the area working from the outside inwards, Allow to air dry. Mirrors - Thoroughly clean the area then dry and buff with a second cloth/disposable paper towel to remove any smears. Bathroom facilities/ En Suite: Using a fresh cloth, clean the basin and shower cubicle paying attention to taps, shower heads, tiles and shower tray. For any wash hand basins: Use two cloths one for taps and dispensers the other for the basin Taps should be cleaned first before the rest of the CHWB (ref HTM 04: ) Clean the areas working from the outside inwards, allow to air dry. 37

38 Shower Cubicle, Shower Tray & Wall Tiles/Cladding (if present) - Thoroughly clean the area working from shower head/hose/controls outwards to the tiles and tray, allow to air dry. Hand Towel, soap & Toilet Roll Dispensers - Damp dust all areas, allow to air dry. Replacement Consumables - Replenish hand soap, toilet roll, paper hand towels and opened packets of Clinell wipes. (No need to replace hand towels or toilet rolls that are in an enclosed dispenser, just clean/wipe over the external container). Throw away toilet brushes. Toilet & Toilet Seat - Flush then apply descaler if required. Using a fresh yellow microfibre cloth thoroughly clean all areas with a chlorine releasing solution eg Actichlor plus, working from the highest point to the lowest and from the outside inwards (clean to dirty method), scrub toilet bowl and finish with toilet seat and a final flush. Damp dust: Using the pre-dosed yellow micro fibre 8 sided cloth technique. Floors Hard floors: Damp mop (using yellow mop heads or disposable), working from the furthest point to the door. Display floor signs. Soft floors: Vacuum debris using an exhaust filtered vacuum cleaner then carpeted floors / any rugs to be steam cleaned. Soft furnishings e.g. chairs or sofas: Steam clean any non wipeable surfaces within the room. Discard all disposable cleaning cloths / mop heads into the orange bag for infectious waste. Ensure used microfibre cloths and mop heads have been placed into linen bags directly on the cleaning trolley ready for laundry. Waste Bin/Bags Pick up any items of rubbish e.g. locker bag, discard in orange waste bag. Remove Orange healthcare waste bags, and clean the bin. Replace waste bags as appropriate in the lidded bins for the next patient. Before leaving the room: Remove PPE and discard into orange waste bag. Swan neck tie and secure orange bag with ward identification tape. Thoroughly clean hands with soap and water Close door as you leave the room. Outside of room: Clean hands with alcohol sanitizer Store mop handle and buckets in the cleaning cupboard Place microfibre laundry bags into dedicated washing machine, on hot wash Take orange waste bag to storage area Replace curtains with clean ones, if no available curtains please discuss steam cleaning with the IPCT before the infectious terminal clean commences. Blinds - Clean /Steam / Actichlor blinds as appropriate. 38

39 Comments from housekeeping staff Comments from nursing staff On completion of the Terminal Clean please sign the box below confirming that you are satisfied with the standard of cleanliness. Ward Manager/shift leader Housekeeping supervisor Name: (print) Date completed: Time: Name: (print) Date completed: Time: Signature: Signature: Retain copies of this form:- 1. The person requesting final isolation clean must ensure that a copy is to be retained on the ward 2. One copy to be retained by Housekeeping 39

40 Appendix 5: Infectious Terminal Clean of Isolation room/bay Mop and Bucket cleaning method Site:.. Ward/Dept:. Room number/name:. Date requested: Time requested: Requested by:. Requirement to remove radiator covers prior to terminal cleaning Remove if:- Ward closure due to infection (e.g. D&V, MRSA, FLU outbreak) Single case of Clostridium difficile and C. diff carrier case if advised by IPCT On request of IPCT as part of management of a resistant organism Removal not required if:- Bay closures due to infection e.g. D&V Single case of resistant organism e.g. MRSA or ESBL Actions Y N Signature Radiator cleaning if covers removed:- Estates department to be contacted in advance of infectious terminal cleaning by the nurse in charge to remove radiator covers. Estates helpline telephone number: (Mon - Fri 08:30 5pm) Arrange the date and time to coincide with terminal cleaning. Estates department to replace radiator covers when infectious terminal cleaning process completed. Cleaning of radiators: Outside and inside (if required) Facility staff to clean using a damp disposable cloth soaked in detergent and chlorine containing solution (e.g. Actichlor Plus). Nursing staff Responsibility (ideally nursing tasks to be completed prior to housekeeping tasks) Actions Y N Signature The patient must have vacated the bed space before cleaning commences. Wash hands before entering the isolation area. Put on single use gloves and yellow apron before entering the isolation area. Ensure good ventilation e.g. open a window The room or area should be cleared of miscellaneous items (e.g. discard magazines, used toiletries into an orange hazardous waste bag). Remove all linen from bed and place in an alginate bag, followed by infectious outer laundry bag, and tie securely. All disposable fittings and single use medical devices must be disposed of into an orange hazardous waste bag, e.g. oxygen tubing, suction tubing & suction drainage bags. 40

41 All reusable medical equipment must be decontaminated according to manufacturer s instructions. Following decontamination, remove the equipment from the area. Actions Y N Signature Cleaning: Use a detergent and chlorine containing solution eg Actichlor Plus 1000ppm, Ensure tablets are dissolved before using. Always ensure good ventilation and correct personal protective clothing is worn when handling the chlorine releasing solution. (Refer to Actichlor Plus dilution poster for the general environment and for cleaning up any blood spillage). Actichlor Plus BS Actichlor Plus GE Solution Only SoutherSouthern Health NHS If commode or raised toilet seat present, thoroughly clean all areas with a detergent and chlorine solution, rinse and then dry. Thoroughly wipe the mattress, upper bed frame, bed head, bed rails, and plastic pillow cover with detergent and chlorine solution eg Actichlor Plus and dry with disposable paper towels. Discard paper towels into orange hazardous waste bag. Ensure good ventilation whilst cleaning within the room. Clean the patient wash bowl if non-disposable with detergent and chlorine solution e.g. Actichlor Plus and dry with disposable paper towels. If bedside entertainment system present, remove headset earpiece covers and discard into orange hazardous waste bag. Arrange for cleaning and replacement earpieces. Name of nurse (print): Date completed: Time: Signature: Housekeeping Staff Responsibility (ideally nursing tasks should be completed prior to housekeeping tasks) Housekeeping Team to use detergent and chlorine containing agent eg Actichlor Plus 1000ppm for all cleaning tasks during this procedure. Ensure tablets are dissolved before using. Always ensure good ventilation and correct personal protective clothing is worn when handling the chlorine releasing solution. (Refer to Actichlor Plus dilution poster for the general environment and for cleaning up any blood spillage). Actions Y N Signature Prepare all equipment needed. Park cleaning trolley outside infection room/bay. Wash hands before entering the isolation area. Put on single use gloves and yellow apron before entering the isolation area (discuss with nursing staff if any additional PPE is required). Ensure good ventilation. Whilst the chlorine containing tablets are dissolving, remove dirty curtains, place into alginate then outer infectious laundry bag. 41

42 Actions Y N Signature Use a detergent and chlorine containing solution eg Actichlor Plus, clean the following using a yellow disposable cloth and damp dusting bucket: High Dust - Damp dust all areas to hand height level regularly rinsing cloth, allow to air dry. Bedside Lamp - Extend the lamp, damp dust all areas, return to original position, allow to air dry. Hand held nurse call device, be careful to clean around idented button. Bedside Locker - Thoroughly clean all areas inside and outside, and allow to air dry. Bedside Table - Thoroughly clean all areas of table top, underside and stand area regularly rinsing cloth, allow to air dry. Bedside Chair - Thoroughly clean all wipeable areas of chair seat, back top, underside and legs, allow to air dry. Bed Frame (below top frame) - Raise bed and thoroughly clean all areas of underside and stand areas working from the top to the bottom, regularly rinsing cloth, allow to air dry. Window Ledges - Damp dust all areas, and allow to air dry. All Doors, Door Handles & Door Vents - Thoroughly clean all areas paying attention to hand contact surfaces, regularly rinsing cloth, allow to air dry. Skirting Boards - Damp dust all areas, allow to air dry. Clinical Hand Wash Sink, Taps & Splash Back Use two cloths one for taps and dispensers the other for the basin. Taps should be cleaned first before the rest of the CHWB (ref HTM 04: ) Tiles -Thoroughly clean the area working from the outside inwards, allow to air dry. Mirrors - Thoroughly clean the area then dry and buff with a second cloth/disposable paper towel to remove any smears. Bathroom facilities/ En Suite, use detergent and chlorine releasing solution contained in the Ensuite Cleaning Bucket and disposable yellow cloths and clean taps & splash back tiles thoroughly. Clean the area working from the outside inwards, regularly rinsing cloth, allow to air dry. For any wash hand basins: Use two cloths one for taps and dispensers the other for the basin. Clean the areas working from the outside inwards, allow to air dry. Taps should be cleaned first before the rest of the CHWB (ref HTM 04: ) Shower Cubicle, Shower Tray & Wall Tiles/Cladding (if present) - Thoroughly clean the area working from shower head/hose/controls outwards to the tiles and tray, allow to air dry. Hand Towel & Toilet Roll Dispensers: Damp dust all areas, allow to air dry. (No need to replace hand towels or towel rolls that are in an enclosed dispenser, just clean/wipe over the external container). Throw away toilet brushes into infectious waste stream bag. Actions Y N Signature Toilet & Toilet Seat - Flush then apply descaler if required, thoroughly clean all areas using a yellow cloth and chlorine releasing solution eg Actichlor plus, working from the highest point 42

43 to the lowest and from the outside inwards, scrub toilet bowl and finish with toilet seat and a final flush. Floors Remove debris using an exhaust filtered vacuum cleaner OR dry mop. Follow this with, wet mopping using a yellow handled mop and chlorine releasing agent eg Actichlor plus from the yellow mop bucket (dispose/launder mop heads after use). If areas are carpeted, steam clean carpet and launder any rugs. Soft furnishings e.g. chairs or sofas: Steam clean any non wipeable surfaces within the room. Waste: Discard all disposable cleaning cloths in the orange bag for infectious waste. Pick up any items of rubbish e.g. locker bags, discard into orange waste bag Remove orange waste bag to clean the bin. Replace waste bags as appropriate in the lidded bin for the next patient. Replacement Consumables - Replenish hand soap, toilet roll, hand towels and opened packets of Clinell wipes. (No need to replace hand towels or toilet rolls that are in an enclosed dispenser, just clean/wipe over the external container). Throw away toilet brushes. Before leaving the room: Remove PPE and discard into the orange waste bag. Swan neck tie and secure with ward identification tag / tape. Thoroughly clean hands with soap and water. Close door as you leave the room. Outside the room: Clean hands with alcohol sanitiser Store cleaned and dry cleaning trolley, mop handle and bucket in the cleaning cupboard. Take orange bag waste to storage area. Replace curtains with clean ones, if no available curtains please discuss steam cleaning with the IPCT before the Infectious terminal cleaning process.. Blinds Clean / Steam / Actichlor blinds as appropriate. Comments from housekeeping staff Comments from nursing staff 43

44 On completion of the Terminal Clean please sign the box below confirming that you are satisfied with the standard of cleanliness. Ward Manager/shift leader Housekeeping supervisor Name: (print) Date completed: Time: Name: (print) Date completed: Time: Signature: Signature: Retain copies of this form:- 1. The person requesting final isolation clean must ensure that a copy is to be retained on the ward 2. One copy to be retained by Housekeeping 44

45 Appendix 6: Decontamination of Air Mattresses (e.g. Nimbus, Alpha Xcell) 1 Remove all linen from the mattress into a laundry skip. 2 Put on disposable non-sterile gloves and plastic apron. 3 Decontamination of mattress cover (On discharge of a patient or if mattress visibly soiled) If no known infection risk : Start at head end of the mattress; wipe entire mattress cover using Clinell Sanitising Wipes. Discard used wipes into clinical waste bag p.p.m. If known infection risk ( e.g. from an isolation room): Start at head end of the mattress; wipe entire mattress cover using Actichlor plus solution (1000ppm of available chlorine) and a disposable cloth. Discard used cloths into clinical waste bag. If blood soiling of mattress cover: Apply a chlorine releasing agent (10,000ppm of av. Cl) e.g. Actichlor, directly to the blood for 3 minutes, then remove blood using disposable paper towels. Clean the area with Clinell wipes. Discard used towels and wipes directly into orange waste bag. If 10,000 p.p.m. large area is soiled with blood send for deep clean (see point 6). 4 Remove protective clothing, discard it into orange waste bag and wash hands. 5 Put on disposable non-sterile gloves and plastic apron. 6 Examine the mattress cover for rips, tears, then unzip the cover and check for breaching of the top cover. If rips or tears found in mattress cover or ingress (fluids/staining) visible inside mattress, arrange for a deep clean via Huntleigh Health Care by faxing the below details to fax your full name & contact number, mattress location address, your invoice address, state clearly deep clean required There will be a charge for this service 7 Wipe tubing, motor (compressor) and hanging bracket with a Clinell sanitising wipe. Discard used towels and wipes directly into orange waste bag. 8 Remove protective clothing, discard it into orange waste bag and wash hands. 45

46 Appendix 7: Clostridium difficile fact sheet information for patients, visitors and relatives Clostridium difficile fact sheet: Information for patients, visitors and relatives. What is Clostridium difficile (C. diff)? A germ (bacteria),which is present in the gut of approx 3% of healthy adults. It is more common in babies/infants, but rarely causes problems. People over the age of 65 are more susceptible to contracting infection. How do you catch it? It is possible for this infection to spread from person to person because C. diff spores are shed in the faeces they can survive for long periods of time in the environment (bedpans, toilets, surfaces etc.) and can be transported on hands and contaminated equipment. Clostridium difficile may be acquired by transferring the bacteria from contaminated hands or equipment to the mouth (faecal oral spread). In most healthy people the C. diff will not cause disease, however more vulnerable people particularly those whose normal gut bacteria have been disrupted by antibiotic treatment, may go on to develop C. diff infection. What are the symptoms? The effects of C. diff can vary from no symptoms to diarrhoea (mild to severe) and more unusually severe inflammation of the intestines which can cause death. Other symptoms can include fever, loss of appetite, nausea and abdominal pain or tenderness. You should report any diarrhoea and or vomiting to health care staff immediately. Who does this affect? Are some people more at risk? Advanced age, 80% of cases reported are in the over 65 age group. Those with a lowered immunity Those patients with underlying medical conditions Patients who have had long length of stay in healthcare settings Antibiotic treatment Repeated enemas and or gut surgery increases a person s risk. How is Clostridium difficile diagnosed? Initial diagnosis can be on the symptoms and patient history (e.g. previously taken a course of antibiotics). Followed up with carrying out laboratory testing of a faecal 46

47 specimen which shows the presence of the C. diff toxins, (poisons produced by the bacteria). How can it be treated? In most patients the C. diff can be treated with specific antibiotics. There is a relapse rate of 20 30% of patients; other treatments may be tried with the aim of re-establishing the balance of flora in the gut. Most cases make a full recovery. More complex cases, associated with other underlying medical conditions may have a more severe infection. Occasionally, infection in these circumstances may be life threatening. If I have Clostridium difficicle, what should I do to prevent the spread to others? In order to reduce the chance of spreading the infection to others it is advisable to wash hands with soap and water, especially after using the toilet/commode and before eating. Keep surfaces in bathrooms clean, using a household disinfectant e.g. bleach type agent, (bleach can dis-colour/damage certain fabrics use with caution) Encourage your visitors to wash their hands before they leave. How can hospitals prevent the spread of Clostridium difficile? Ensure antibiotics are used only when really necessary. Clinical staff will identify patients in the early stages of this disease and introduce enhanced infection control measures such as;- Isolation in a single room with en-suite or dedicated toilet/commode, which helps to limit the spread of infection. Clinical staff will wear disposable gloves and aprons when caring for infected patients Performing hand hygiene using soap and water prior to and after contact with the patient who has the infection. Clostridium difficile contamination should be removed from the environment by daily thorough cleaning using a chlorine based cleaning agent. Visitors will be asked to wear disposable aprons and gloves if participating in the care of their relatives. Additional infection control measures may be introduced for staff, patients and relatives if an outbreak (2 or more patients) with Clostridium difficile infection is suspected. Does somebody who has had a Clostridium difficile infection pose a risk to others after they have been discharged? There should be no restriction on the discharge or transfer of patients to other healthcare facilities when recovered from C. diff diarrhoea. Once recovered there is no clinical risk to others even though they continue to carry the organism in their gut provided they observe normal personal hygiene precautions e.g. hand washing with soap and water after using the toilet. 47

48 Appendix 8: Gastroenteritis caused by Norovirus and other viruses factsheet Gastroenteritis caused by Norovirus and other viruses factsheet. Information for patients, visitors and relatives. What is viral gastroenteritis? An infection of the gut (intestines) which usually causes vomiting and/or diarrhoea. It is most commonly caused by Norovirus, other small round structured viruses or Rotavirus. What is Norovirus? The most common cause of gastroenteritis (stomach bugs) also called winter vomiting virus or Norwalk-like virus. It is estimated that Norovirus affects between 600 thousand and a million people in the UK each year, most of these are people in their own homes. This virus is responsible for causing outbreaks of gastroenteritis in institutions like hospitals, residential/nursing homes, schools and cruise ships. How is viral gastroenteritis including Norovirus caught? Viral gastroenteritis is easily transmitted from one person to another. By contact with an infected person. By contact with surfaces or objects that have been contaminated with viral particles. By swallowing the virus dispersed in the air after someone has had projectile vomiting. By consuming food or water contaminated with viral particles Also rarely from raw or undercooked food, particularly shell fish, as this may be contaminated with raw sewage. Who is at risk of getting Norovirus or other viral gastroenteritis? It affects people of all ages. The very young and elderly should take extra care if infected, as dehydration is more common in these age groups. Outbreaks usually affect people who are in semi-closed environments, or where large numbers of people congregate for several days, providing an ideal environment for the spread of the disease. What are the symptoms? The following symptoms will usually begin around hours after becoming infected with gastroenteritis/norovirus:- Sudden onset of nausea followed by vomiting which may be projectile. Watery diarrhoea. 48