Norovirus and Diarrhoea and Vomiting Management Policy HH(1)/IC/608/16 Previous document(s) being replaced Location Policy No Policy Name

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1 Norovirus and Diarrhoea and Vomiting Management Policy HH(1)/IC/608/16 Previous document(s) being replaced Location Policy No Policy Name HHFT HH(1)/IC/608/13 Diarrhoea & Vomiting Outbreak Management Policy Document Summary This policy provides guidance on the management of outbreaks of vomiting and/or diarrhoea within Hampshire Hospitals NHS Foundation Trust. Norovirus is the most common cause of outbreaks of gastroenteritis within the healthcare setting however there are other causes and this policy will therefore apply to all viral gastroenteritis s. This policy should be used by all staff to ensure that patients with suspected infectious diarrhoea and/or vomiting are assessed promptly, isolated and managed accordingly to reduce the risk of transmission to patients, visitors, staff and the healthcare environment and to minimise disruption to essential services. Ownership Author Hazel Gray Job Title Lead Infection Prevention and Control Nurse Document Type Level Level 1 Trustwide Related Documents Document Details Standard Precautions (incorporating Personal Protective Equipment) Policy Learning and Development Policy Environmental Cleaning Policy Reporting, Managing and Learning From Incidents Policy (Including the investigation of Serious Incidents Requiring Investigation and Being Open) Isolation of Infection and Antibiotic Resistant Organisms Policy Waste Management Policy Theatre Cleaning Standard Operating Procedure Clostridium difficile infection (CDI): Prevention, Treatment and Control Policy Relevant Standards CQC Outcome Outcome 8 NHSLA Standard N/A Equality Impact Completed by Lorraine Amos Assessment Date Completed 10 November 2016 Final Document Approval Committee Policy Approval Group Date Approved 26 September 2016 Other Specialist Committee(s) Infection Prevention and Control Committee committee(s) Date Recommended 19 September 2016 recommending approval Final Document Committee Executive Committee Ratification Date Ratified 29 September 2016 Authorisation Authoriser Mary Edwards Job Title Chief Executive Signature Date Authorised 11 November 2016 Dissemination Target Audience All Trust Staff Dissemination and Implementation Plan Page 1 of 49

2 Action Owner Due by Publicise detail of new document via Intranet and Midweek message Communication to all Senior Managers to advise publication of policy The policy will be available on the intranet and web site IPCT and Communication Team BNHH Healthcare Library BNHH Healthcare Library and Communication Team Within 1 week of publication On publication Within 1 week of authorisation Review Expiry date 29 September 2019 Review date 29 July 2019 Document Control Document Amendments Version No. Details Key amendments to note By whom Date 1 Review of harmonised HHFT policy New addition of HICPAC 2011 guidance New guidance on de isolation of symptomatic patients New guidance on bay/ward closures Addition of staff, visitor, and patient information leaflets Terminal cleaning guidance Addition of isolation priorities Amendment to Diarrhoea and/or Vomiting Risk Assessment Equality Impact Assessment Part 2 recognition of impact of isolation 2 Review of HHFT policy Additional guidance on the isolation of symptomatic and positive patients Amended guidance to the frequency of cleaning required for symptomatic patients Amended guidance to the cleaning required in Theatres when carrying out procedures on positive and/or symptomatic patients Additional guidance for staff that experience symptoms of Diarrhoea and/or Vomiting Additional guidance on actions to be taken by non infected visitors to reduce the risk of onward transmission D&V risk assessment form Director of the Day (DoD) to chair outbreak meetings Linda Swanson May 2013 Andrea Bullard May 2016 Page 2 of 49

3 Contents 1. Introduction Purpose Scope Explanation of Terms Duties Incubation Period, Signs/Symptoms and Side Effects Clinical Treatment of Norovirus Initial Assessment of Patients Testing for Norovirus Laboratory Results Infection Prevention and Control Management of Suspected/Confirmed Cases Ward/Unit Closure Isolation Options for the Symptomatic Patient Symptomatic Staff Discharging Patients during an Outbreak of Norovirus Defining the Start of a Period of Increased Incidence (PII)/Outbreak Actions to be taken during a Period of Increased Incidence (PII) Actions to be taken when an Outbreak is Declared Terms of Reference of the Outbreak Control Group (OCG) Members of the OCG and their Infection Control responsibilities during an Outbreak Defining the End of an Outbreak/Period of Increased Incidence Actions to be Taken When an Outbreak is Over Stakeholders Engaged During Consultation Dissemination and Implementation Training Monitoring Compliance with the Document References Associated Documentation Page 3 of 49

4 29. Contributors Appendix A Equality Impact Assessment Tool Appendix B Common Infections that Cause Diarrhoea and/or Vomiting and their Management Appendix C Diarrhoea and/or Vomiting Risk Assessment Form Appendix D Management of the Patient with Diarrhoea and/or Vomiting Appendix E Bristol Stool Chart Appendix F Isolation Priorities Appendix G Outbreak Control Measures Appendix H Terminal Cleaning Appendix I Staff Information Leaflet on Norovirus Appendix J Patient/Visitor Information Leaflet on Norovirus Appendix K Discharging Patients during Outbreaks of Norovirus Page 4 of 49

5 1. Introduction Gastroenteritis is a symptom of infection by many different bacterial, viral and parasitic enteric agents. Vomiting and diarrhoea is often accompanied by other clinical signs and symptoms including fever, dehydration and electrolyte imbalance. The micro organisms that cause gastro intestinal infection are mainly spread from person to person via the faecal oral route. Micro organisms transmitted by food (e.g. Salmonella, Escherichia coli (E.coli) can be spread to others by cross infection. In outbreaks of food borne illness, cross infection may cause what are described as secondary cases of infection, occurring several days after the main outbreak. Norovirus (also known as small round structured viruses, Norwalk, or the winter vomiting disease) is a highly infectious virus particularly in enclosed settings such as hospitals, schools, nursing homes and cruise ships. It is more prominent during the winter months, but can occur at any time of year. It is readily spread from person to person through aerosol inhalation and environmental contamination from vomiting and diarrhoea. Norovirus is the commonest cause of outbreaks of infectious gastroenteritis in hospitals, and is estimated to cost the NHS in excess of 100 million per annum, affecng approximately 1 million people each year in the UK, and causing major disruption to important and essential services (HICPAC 2011). Recent evidence suggests that implementation of robust infection prevention and control strategies may help to prevent prolonged ward/departmental closures, reduce disruption to essential services, reduce transmission of the infection and maximise the organisations ability to deliver appropriate care to patients safely and effectively (Norovirus Working Party 2011). It is essential that infection control is seen as an organisational responsibility and priority, that adequate isolation facilities and resources are provided, and that appropriate infection control staff and support services are available. Organisational preparedness is therefore essential in the management of Norovirus. Larger clinical units with a higher throughput of patients have been demonstrated as having increased rates of gastroenteritis. It is therefore essential that every opportunity is taken within plans for new builds and renovations to maximise the ability to control outbreaks with the provision of easily segregated clinical areas, bays with doors, and adequate provision of single en suite accommodation (Norovirus Working Party 2011). For further information regarding common infections that cause diarrhoea and/or vomiting and their management please see Appendix B. Page 5 of 49

6 2. Purpose To provide Trust staff with guidance for effective management of patients suffering from gastroenteritis and the prevention of transmission to other patients, staff, visitors and contamination of the environment. 3. Scope This policy and procedure will be applied fairly and consistently to all employees and service users regardless of their protected characteristics as defined by the Equality Act 2010 namely, age, disability, gender reassignment, race, religion or belief, gender, sexual orientation, marriage or civil partnership, pregnancy and maternity. For employees this policy also applies irrespective of length of service, whether full or part time or employed under a permanent or a fixed term contract, irrespective of job role or seniority within the organisation. Where an employee or service user has difficulty in communicating, whether verbally or in writing, arrangements will be put in place as necessary to ensure that the processes to be followed are understood and that the individual is not disadvantaged during the application of this policy. In line with the Equality Act 2010, the Trust will make reasonable adjustments to the processes to be followed where not doing so would disadvantage an individual with a disability during the application of this policy. This policy complements professional and ethical guidelines and the Nursing and Midwifery Council (NMC) Code of Professional Conduct (NMC 2015). 4. Explanation of Terms Enteric agents Intestinal Gastroenteritis Inflammation of the gastrointestinal tract involving both the stomach and the small intestine resulting in some combination of diarrhoea, vomiting abdominal pain, and stomach cramps Gastroenteritides organisms that may cause gastroenteritis Micro organism an organism of microscopic size Norovirus a very small contagious virus which causes the stomach or intestines or both to get inflamed (acute gastroenteritis) leading to symptoms of stomach pain, nausea, and diarrhea and vomiting. Diarrhoea using the Bristol Stool and Bowel Chart an episode of Type 6 or Type 7 stool (see Appendix E) Page 6 of 49

7 Spores organisms which are resistant structures capable of surviving for extended periods of time in unfavourable conditions Immunocompromised a state in which a person s immune systems ability to fight infection is compromised Terminal Cleaning a final level of cleaning used in health care environments required to help control the spread of infection. The level of cleaning required to denote the end of an outbreak prior to re opening of wards/affected areas Epidemiology the study of patterns, analysis, cause and effects of disease within a given population Period of Increased Incidence (PII) defined as two or more cases of hospital acquired infection within 28 days linked by epidemiology e.g. two cases on the same ward, bay or unit Outbreak defined as two or more cases of hospital acquired infection linked by epidemiology and declared by the DIPC/On call Consultant Microbiologist usually following discussion with the IPCT if further spread of the same infection is suspected e.g. with Norovirus a PII becomes an Outbreak if more than one bay is affected on the same ward 5. Duties 5.1 Postholders The Chief Executive (CE) has overall responsibility for the strategic and operational management of the Trust ensuring there are appropriate strategies and policies in place to ensure the Trust continues to work to best practice and complies with all relevant legislation in relation to this policy. The Director of Infection Prevention and Control (DIPC) is the Trust Director responsible to the board for the delivery of IPC standards. The DIPC will be responsible for defining the beginning and end of an outbreak. In the absence of the DIPC the outbreak responsibilities will be undertaken by the On Call Consultant Microbiologist. The Director of Nursing/Chief Operating Officer will ensure that the Divisional Directors take clinical ownership of the policy. The Director of the Day (DoD) is responsible for convening the Outbreak Control Group (OCG) as required. The Divisional Operational Directors will ensure that all healthcare workers comply with this policy and that all healthcare workers attend mandatory infection prevention and control training. They are responsible for ensuring adequate facilities and resources are available to adhere to this policy. Page 7 of 49

8 The Clinical Matrons/Service Managers/Leads (CSM) will ensure that a printed copy of this policy is available in all of their areas. They will ensure that all healthcare workers comply with this policy and that all healthcare workers attend mandatory infection prevention and control training. Managers are responsible for ensuring that staff are allocated to duties in either affected or non affected areas of the ward but not both unless completely unavoidable. The Laboratory Manager will oversee the laboratory testing and ensure results are reported in a timely manner and will be represented at the Outbreak Control Group. They are responsible for ensuring adequate laboratory resource and provision of service during an outbreak period. All Trust employees will comply with this policy and inform the Infection Prevention and Control Team about any issues or concerns relating to the policy. All staff will attend mandatory Infection Prevention and Control training annually. Infection control is the responsibility of ALL staff associated with patient care. A high standard of infection control is required on ALL wards and units, although the level of risk may vary. It is an important part of total patient care. 5.2 Groups The Outbreak Control Group (OCG) will oversee the timely management and instigation of any necessary measures to aid control of the outbreak. The Infection Prevention and Control Team (IPCT) will act as a resource for information and support. They will provide education in relation to this policy which includes mandatory training. They will monitor the implementation of this policy via audit within clinical areas and be responsible for regularly reviewing and updating it. The Health4Work department will act as a resource for information, and support and consult with managers, the Infection Prevention and Control Team and healthcare workers regarding the use of personal protective equipment. They will report positive results to staff members in a timely manner. The Health and Safety Team will act as a resource for information, and support and consult with managers, the Infection Prevention and Control Team and healthcare workers regarding the use of personal protective equipment. The Site Teams will act as a resource for information and support and consult with managers, the IPCT, Consultant Microbiologists and healthcare workers regarding implementation of this policy. 6. Incubation Period, Signs/Symptoms and Side Effects The period from when you are infected to when you start to show symptoms of Norovirus (known as the incubation period) usually lasts hours. During this time, you may be Page 8 of 49

9 infectious to other people and will continue to be infectious up to 48 hours after symptoms stop. Although Norovirus can affect anybody, some groups of people pose a higher risk of spread of the infection. These include people who have difficulty in implementing good personal hygiene, staff who may have direct contact with infectious material and are involved in serving food to susceptible patients, and food handlers whose work involves touching unwrapped food to be eaten raw or without further cooking. The virus is very small and is highly contagious, being easily spread by contact with an infected persons stool/vomit and/or contaminated environment/food/drink. The virus is spread via the faecal oral route. The virus is shed in the faeces and/or vomit of an affected person and may live on surfaces or objects touched by that person for several days. From these surfaces the virus may be transferred to another person and ingested. Although Norovirus is not technically airborne, inadvertent ingestion may occur in those who are in close proximity to symptomatic infected patients. Signs/Symptoms Norovirus is characterised by often sudden onset of symptoms of vomiting and/or diarrhoea. Some people may also have: a raised temperature (over 38C/100.4F) headaches stomach cramps aching limbs Norovirus is usually self limiting with most people making a full recovery within a couple of days. Immunity to Norovirus is very short lived, typically lasting up to a few weeks, consequently re infection is common (HICPAC 2011). Norovirus has no specific cure, and cannot be treated with antibiotics. Side Effects Dehydration is the most notable possible side effect of Norovirus, particularly in those who are elderly, poorly nourished, in the very young, and in those whose illnesses or conditions render them more vulnerable to the effects of dehydration. Apart from the risk of dehydration, the illness is not generally dangerous and there are usually no long lasting effects from having Norovirus, with most people making a full recovery within a couple of days. If diarrhoea persists for 7 days or more, or worsens in nature it is advised that the patient be re assessed by clinicians and alternative causes of diarrhoea considered and investigated promptly. Page 9 of 49

10 7. Clinical Treatment of Norovirus The mainstay of the clinical treatment of Norovirus is the avoidance or correction of dehydration. These measures are particularly important in the elderly and in those who may have underlying conditions or illnesses which render them more vulnerable to the effects of dehydration. This may be achieved through any standard oral rehydration regime in patients who can tolerate oral fluids, plus or minus the use of rehydration compounds such as Dioralyte. For those who cannot tolerate oral fluids or preparations, administration of appropriate fluids either subcutaneously or intravenously is indicated as an early supportive measure (HICPAC 2011). Rehydration should be carried out in the community where possible, with specialist outreach teams established to administer this treatment and thereby avoid admission of the patient to hospital solely for this purpose (HICPAC 2011). Use of Anti Emetic Drugs These are not recommended routinely for Norovirus positive cases unless the patient has profuse vomiting and their case is discussed with the consultant microbiologist. Use of Anti Diarrhoeal Drugs These are not recommended routinely but some doctors find them useful in cases where other causes of diarrhoea have been excluded and the case discussed with a consultant microbiologist. They can be dangerous in some conditions such as Clostridium difficile, and may also mask the infectivity of patients. 8. Initial Assessment of Patients Careful clinical assessment of the causes of vomiting or diarrhoea is important. Even in an outbreak there will be patients who have diarrhoea and/or vomiting due to other underlying pathologies. An initial assessment of patients with diarrhoea must be undertaken immediately symptoms commence using the Trust s Diarrhoea and/or Vomiting Risk Assessment algorithm. Please see Appendix C. Any patient admitted with diarrhoea and/or vomiting should be admitted into a single room with en suite facilities and standard isolation measures should be put into place to allow for a full assessment of their condition. Any patient who commences diarrhoea and/or vomiting whilst already an inpatient should be transferred into a single room with en suite facilities to allow for a full assessment of their condition. It is the onset of symptoms of diarrhoea and/or vomiting which necessitates the need for isolation of the patient, laboratory results should not be awaited to determine whether isolation is necessary. Please see Appendix D Management of the Patient with Diarrhoea and/or Vomiting. Page 10 of 49

11 9. Testing for Norovirus If Norovirus is clinically suspected then a member of the Infection Prevention and Control Team (IPCT)/Consultant Microbiologist/Site Team/ should be informed immediately. This will allow for prompt isolation, testing and management of patients and their potential contacts. Laboratory services will be informed by the IPCT/Consultant Microbiologist/Site Team that Norovirus testing will be required. Norovirus can be detected via either stool or vomit samples. Stool samples are the preferred method of detection. Vomit samples should be sent in the absence of diarrhoea and where Norovirus is clinically suspected. It is important that consideration is given to the patient s right to consent or refuse testing for Norovirus. The provision of a clear explanation from nursing/clinical staff as to why testing is required can be beneficial in helping the patient come to an informed decision regarding testing. A stool sample must be sent immediately symptoms of type 6/7 stools on the Bristol Stool and Bowel Chart (see Appendix E) are present and infection is suspected. Stool samples can still be sent if contaminated by urine or taken from an incontinence pad/sheet as this will not usually affect the results. Anti diarrhoeal medication should not be prescribed to relieve symptoms as this may prolong the period of infectivity. Vomit samples must be sent immediately symptoms of vomiting commence and in the absence of a stool specimen when Norovirus is clinically suspected. It is important that the sample is collected and that staff ensure that the sample has left the clinical area and is transported to the microbiology laboratory as soon as possible to allow for timely results. This is the responsibility of the person collecting the sample. Failure to ensure that the sample has left the clinical area can cause extensive delays in testing and obtaining results, leading to potential operational issues within the Trust and potential disruption to services. 10. Laboratory Results During times of heightened Norovirus activity, and especially during Period of Increased Incidences (PIIs), negative test results will allow lifting of restrictions more rapidly, and enable optimal use of scarce isolation facilities, and a return to normal operational duties. Laboratory testing for Norovirus will be instigated by the IPCT in liaison with the Laboratory Manager and DIPC/Consultant Microbiologist and will be based upon epidemiology of affected patients, increased Norovirus activity within the community/hospital setting, and where patients have been admitted with diarrhoea and/or vomiting where alternative, non infectious causes cannot be confidently diagnosed. Page 11 of 49

12 Collection of samples is paramount in aiding decision making amongst the organisation and enabling timely progression of patient care. Collection of samples is the responsibility of the nurse in charge. Ensuring that sample results are obtained is the responsibility of the requesting/collecting person. A Norovirus result is either positive or negative. It is not necessary to test for clearance of Norovirus. Norovirus clearance is dictated by the absence of clinical symptoms for 48 hours or more. During normal office hours results will be telephoned through to the IPCT/Consultant Microbiologist/Site Team/ward by laboratory staff. It is the receiving person s responsibility to ensure that these results are communicated to the appropriate people. Out of hours results will be telephoned through to the Site Team/wards/IPCT/Consultant Microbiologist as appropriate by laboratory staff. It is the receiving person s responsibility to ensure that these results are communicated to the appropriate people. 11. Infection Prevention and Control Management of Suspected/Confirmed Cases Isolation of symptomatic cases remains one of the most important and effective infection prevention and control measures in limiting the spread of suspected/confirmed Norovirus. Whilst it is recognised that isolation may have an impact on the psychological wellbeing of a patient, this can be greatly reduced by the provision of timely information detailing the reasons why isolation is necessary, measures being used to manage/treat the infection, and how long isolation nursing is anticipated. This information should be provided verbally by the nursing staff/responsible clinicians/ipct. Information leaflets should also be provided to both the patients and their relatives, ensuring that confidentiality is maintained at all times. Please see Appendix J Patient/Visitor Information Leaflet on Norovirus. The isolation of symptomatic inpatients within single rooms and bays as opposed to the early closure of complete wards is now recommended (HICPAC 2011) as it allows flexibility of response and the early terminal cleaning and re opening of affected subward areas. Patients should only be transferred for investigations and interventions that cannot be safely delayed clinically. Ward staff must ensure that the receiving area has been notified of the infection risk. Receiving areas must ensure that the patient does not use waiting areas with other patients. If urgent investigations and interventions are required, they must proceed with careful management of the patient and a deep clean area of the area after the patient s investigation must be carried out. Only when there is evidence of a failure of containment within all available singleoccupancy rooms and bays should whole ward closure be considered. In order to Page 12 of 49

13 maintain necessary clinical services as much as possible and to reduce interruption to vital services it is recommended that healthcare organisations undertake a local riskassessed approach to the closure of entire areas to admissions/transfers during outbreaks. The IPCT/DIPC/Consultant Microbiologist/Clinical Matron/Service Manager (CSM) are best placed to undertake this risk assessment. Ward/unit closure is not recommended providing the following criteria can be met: Symptomatic persons can be physically segregated from the non symptomatic patients into single rooms with en suite facilities or cohort bays with doors Levels of staffing are such that successful cohort nursing can be undertaken to allow for one group of staff to attend to symptomatic patients only, and another group of staff to attend to asymptomatic patients only Staff working in closed and adjacent non closed areas have been trained on the importance of preserving efficient segregation of these areas for patients, staff and visitors. 12. Ward/Unit Closure Ward/unit closure will be required where there is clear evidence that the outbreak is uncontrolled, with further spread of Norovirus evident despite the introduction of isolation/cohort nursing and the implementation of infection prevention and control measures. This assessment will be made by the IPCT in consultation with the DIPC/Consultant Microbiologist and the CSM of the affected area. Ward closure can only be authorised by the DIPC/Consultant Microbiologist. Closure refers to the restriction of incoming and outgoing personnel, equipment, materials (including patient notes) to an unavoidable minimum. The fewer times that the portal of a closed area is crossed, the less is the risk of transmission of virus and further spread to other areas. Patients should only be transferred for investigations and interventions that cannot be safely delayed clinically. Ward staff must ensure that the receiving area has been notified of the infection risk. Receiving areas must ensure that the patient does not use waiting areas with other patients. If urgent investigations and interventions are required, they must proceed with careful management of the patient and a deep clean area of the area after the patient s investigation must be carried out. There should be an obvious boundary between open and closed areas to signal to everyone that restricted access is in place. This boundary should consist of doors and high visibility signage. There should be provision of hand hygiene facilities at each boundary. These may be mobile units if permanent facilities are not available. All non essential personnel should be prohibited from entering the closed area. This includes non essential social visitors of patients. Page 13 of 49

14 Admissions to a closed area should be restricted to patients who are known to have been exposed to Norovirus, whether potentially incubating, symptomatic or recovered. Closed areas should, ideally, be self contained with hand washing facilities and en suite toilet facilities. The use of commodes and communal toilets may increase the risk of spread in an outbreak and this should be mitigated by the implementation of an intensive and frequent cleaning schedule. Dedicated nursing and healthcare staff should be assigned to closed areas for each work shift. If this is not possible, thorough application of personal IPC measures as described in local policies are essential. These measures include the use of PPE such as plastic aprons, gloves, masks and rigorous attention to hand hygiene with soap and warm water. Staff should also have access to eye and face protection if there is a risk of a body fluid splash into the face. Staff should be reminded that gloved hands that have been used to clean up spillages of body fluids can themselves be a vehicle for further contamination and that these items should be disposed of as infectious waste (orange waste stream) and the hands cleansed with soap and warm water at the earliest opportunity. Please also see Appendix D Management of the Patient with Diarrhoea and/or Vomiting 13. Isolation Options for the Symptomatic Patient Any patient with suspected/confirmed Norovirus is a high priority for isolation. See Isolation Priorities Table Appendix F. A single room with en suite facilities on the ward which the patient developed symptoms is always the preferred option for isolating the patient suspected/confirmed with Norovirus (Norovirus Working Party 2011). All attempts must be made to ensure that this level of isolation is achievable, including the provision of extra nursing staff if necessary to ensure the safety and well being of the patient being cared for in isolation. Failure to isolate must be recorded as an incident by completing a Datix form. Isolation with standard precautions in place should be maintained for a minimum period of 48 hours following cessation of symptoms. Isolation door should remain closed at all times with clear signage depicting that isolation nursing is in progress. In those patients whom are immunocompromised consideration should be given to extending the period of isolation with standard precautions as these patients are at increased risk of relapse, and can experience protracted episodes of diarrhoea with prolonged viral shedding into the environment. De isolation of this patient group should be based upon clinical judgement by the clinicians responsible for the patients care, and the IPCT/DIPC/Consultant Microbiologist (HICPAC 2011). Page 14 of 49

15 Please read in conjunction with the Standard Precautions (incorporating Personal Protective Equipment) Policy. Please also see Appendix D Management of the Patient with Diarrhoea and/or Vomiting 14. Symptomatic Staff Please see Appendix G for staff considerations. 15. Discharging Patients during an Outbreak of Norovirus Please see Appendix K for Discharging Patients during an Outbreak of Norovirus 16. Defining the Start of a Period of Increased Incidence (PII)/Outbreak Laboratory confirmation is not always necessary in order to define the start of a PII/outbreak, and definition may be based on clinical presentation of cases. However, laboratory confirmation is invaluable in establishing the cause of outbreak and aiding epidemiological surveillance. Prior to the instigation of a full organisational approach to an outbreak, there is often a preliminary period in which a small number of undiagnosed symptomatic patients may or may not herald a Norovirus outbreak. These cases will be managed as a PII which signifies increased surveillance, increased interaction between the IPCT, affected clinical area/s, site team/relevant managers and laboratory services. Defining the start of an outbreak/pii serves two purposes. helps to establish trigger points for the activation of organisational responses helps to establish trigger points for epidemiological surveillance and data collection An outbreak/pii is defined as two or more cases linked epidemiologically and should trigger both actions above. Declaration of a PII may be either formally or informally made by the DIPC/IPCT via communication of the situation to the relevant managers/site teams and clinicians. 17. Actions to be taken during a Period of Increased Incidence (PII) Even during an outbreak of Norovirus careful assessment of the causes of vomiting and/or diarrhoea should continue as there will be patients who have diarrhoea and/or vomiting due to other underlying pathologies. During a PII of diarrhoea and/or vomiting, affected patients should still be isolated in single rooms, or cohort nursed in bays. At this stage, there is no need to call a formal outbreak control meeting although the IPCT should alert appropriate managers and clinicians to the potential for an outbreak. Page 15 of 49

16 IPC surveillance, interventions and communications with the ward staff should be intensified during this period. The ward staff in liaison with the IPCT should ensure that faeces/vomitus specimens from active cases are collected without delay and are sent to the laboratory for testing for Norovirus detection, bacterial culture and, if appropriate, Clostridium difficile tests. Microbiological analysis of stool specimens associated with potential outbreaks must be available on a seven days a week basis. The turnaround time for non culture analysis to provision of a telephoned or electronically transmitted result should be within the same day or, at most, 24 hours in order to minimise bed closures and to aid patient management. 18. Actions to be taken when an Outbreak is Declared Declaration of an outbreak is made at a point in the evolution of a suspected outbreak at which there is a significant risk of IPC demands outstripping available resources and affecting operational ability. The IPCT is best placed to assess when this point is reached in any given circumstances in consultation with the DIPC/Consultant Microbiologist, with an outbreak being declared formally by the DIPC/IPCT. For ward/affected area outbreak control measures/actions please see Appendix G Outbreak Control Measures In order to oversee the timely management and instigation of any necessary measures to aid control of the outbreak, an outbreak control group (OCG) will be formed by the DIPC. Membership of the OCG should comprise: Director of the Day (Chair) DIPC (deputy chair if required) Infection Prevention and Control Nurse with responsibility for the affected area Medical Director or designate Consultant in Communicable Disease Control if required (CCDC) Consultant(s) from the affected area(s) Senior nurse(s) or midwife(s) from the affected area(s) Divisional Operational Director of affected area(s) (deputy chair if required) Consultant Microbiologist Health4Work Doctor/Nurse Communications representative Facilities Manager Site Co ordinator/lead Head of HR (if required) Head of Support Services (if required) Secretarial Assistance Other representatives may be co opted e.g. Pharmacy/Procurement Page 16 of 49

17 N.B. some members of the group may represent a number of roles. 19. Terms of Reference of the Outbreak Control Group (OCG) Once an outbreak has been identified the functions of the OCG are: To agree on a working case definition for outbreak management To agree and co ordinate policy decisions on the investigation and control of the outbreak and to ensure they are implemented To take all necessary steps to ensure optimal continuing clinical care of all patients (affected or unaffected) during the outbreak To take all necessary steps to ensure the well being and safety of staff involved To assess the resource implications of outbreak management, and how these will be met e.g. additional supplies and clerical staff To agree arrangements for providing information to patients relatives and visitors if required (Appendix J) To meet on a regular basis as considered necessary by the DIPC/IPCT to review progress on outbreak investigation and control To define the end of the outbreak and evaluate its management To inform the Risk and Compliance Manager To prepare a report for submission to the Trust Infection Prevention and Control Committee and Divisional Governance Board as necessary 20. Members of the OCG and their Infection Control responsibilities during an Outbreak Infection Prevention and Control Team Identify possible PII/outbreak and report to DIPC/Consultant Microbiologist Identify an Infection Prevention and Control Nurse to provide leadership at ward level, co ordinate outbreak management, and ensure that consistency of advice is provided throughout the outbreak Institute outbreak control measures Ensure the provision of bay/ward signage Advise on Trust wide signage required Monitor that outbreak control measures are consistently implemented Collect relevant patient/staff information from ward/clinics or other affected areas and keep an up to date electronic record of affected areas/patients Collect all laboratory information Collate and continually review evidence to confirm incident and plot its course, reporting this to the DIPC and OCG Enlist the assistance of the Health4Work staff if required for the co ordination of staff screening if deemed necessary Report to DIPC Monitor and advise ward staff on the care of patients DIPC Define the beginning and end of an outbreak Page 17 of 49

18 Co ordinate all control measures Inform and liaise with: o Clinicians in affected area o Ward manager o Divisional Operational Director o Medical director o CCDC o Chief Executive Discuss with Divisional Directors whether a Serious Incident Requiring Investigation (SIRI) is required in accordance with the Reporting, Managing and Learning From Incidents Policy (Including the investigation of Serious Incidents Requiring Investigation and Being Open) Director of the Day Convene Outbreak Control Group Chair outbreak meetings Advise OCG on current status of outbreak Advise OCG on infection control procedures CCDC Consult with the DIPC and help to institute the Trust Infectious Incident and Outbreak Plan Advise the OCG on further epidemiological aspects of outbreak investigation Inform and liaise with the Local Authority Environmental Health Department as necessary Inform Director of Public Health Medicine as necessary Inform CDSC as necessary Liaise with Risk Management Be available for consultation during the outbreak Clinical Consultant Advise OCG on aspects relating to clinical care of patients Relay OCG instructions to medical team involved Keep medical staffing requirements under review Consultant Microbiologist Advise OCG on further microbiological aspects of the investigation Arrange for microbiological analysis of specimens and report results to OCG Advise on the beginning and end of an outbreak Communications Department To provide robust local communication channels between agencies both internally and externally To provide timely communication to external agencies such as General Practitioners (GP) surgeries, ambulance control and local press to limit admissions from the community where possible To provide timely communication to the general public regarding restrictions in visiting Senior nursing/midwifery Ensure that information from the OCG is communicated to ward level in a timely manner manager of affected Ensure that the affected ward/area is collating data on Page 18 of 49

19 wards/areas affected patients/staff on a daily basis Identify any supportive measures that may be required by the ward/area during the outbreak All meetings of the OCG will have clear agendas; minutes and action notes will be produced. Members of the IPCT will be responsible for providing status reports at each meeting for OCG deliberation. Where an outbreak involves the community, the CCDC may take the lead role. 21. Defining the End of an Outbreak/Period of Increased Incidence The end of an outbreak is defined as either: 48 hours after the resolution of vomiting and/or diarrhoea in the last known active case. This is also the point at which terminal cleaning will have been completed. An outbreak cannot be declared over until terminal cleaning of the affected area has been completed in whole. Please see Appendix H Terminal Cleaning. For epidemiological surveillance the end of an outbreak is defined as no new cases recognised within the previous 7 days. There is often a small number of patients who may persist with symptoms of Norovirus. It is advisable to segregate those patients within the ward/area in order to facilitate a return to normal activity. This can be achieved by moving symptomatic patients into single rooms with en suite facilities or cohort nursing in a bay with doors. Terminal cleaning of a ward should commence once any symptomatic patient is successfully isolated. 22. Actions to be Taken When an Outbreak is Over It is the completion of terminal cleaning that serves as the definition of the end of the outbreak for IPC purposes. There is often uncertainty at this early stage, with a small number of patients experiencing protracted episodes of symptoms (especially diarrhoea) and it may be difficult to ascribe those symptoms to Norovirus with any confidence. Such patients should be placed in single occupancy rooms if possible and terminal cleaning of bays and general ward areas may then proceed. The IPCT should inform the wider managerial team and the local health protection organisations of the successful completion of terminal cleaning and unrestricted activity may then resume. Vigilance should be maintained during the immediate period following the recommencement of unrestricted activity because there is a risk of re emergence of the outbreak at that time. Page 19 of 49

20 23. Stakeholders Engaged During Consultation Stakeholder Date of Consultation Infection Prevention and Control (Lead Infection Prevention & Control 12/08/2016 Nurse) Health and Safety (Health and Safety Advisor) 12/08/2016 Safeguarding (Trust Safeguarding Lead) 12/08/2016 Information Governance (Information Governance Manager) 12/08/2016 Assistant Risk and Compliance Manager (Risk and Compliance) 12/08/2016 Divisional Directors and Divisional Directors (Operational) 12/08/2016 Equality and Diversity Lead (Equality & Diversity) 12/08/2016 Head of Health4Work 12/08/2016 Infection Prevention and Control Committee 12/08/2016 Consultant Microbiologists 12/08/2016 Clinical Matrons/Service Managers/Leads 12/08/2016 Operational Service Managers 12/08/2016 Facilities Managers 12/08/2016 Laboratory Manager 12/08/ Dissemination and Implementation Action(s) Publicise detail of new document via Intranet and Midweek message Communication to all Senior Managers to advise publication of policy The policy will be available on the intranet and web site Owner IPCT and Communication Team BNHH Healthcare Library BNHH Healthcare Library and Communication Team 25. Training Individuals in the Trust should receive annual infection prevention and control training to ensure they are aware of their responsibilities. Education and Training will be provided in accordance with the Trust Training Needs Analysis (Learning and Development Policy). 26. Monitoring Compliance with the Document NHSLA Minimum requirements A. Effectiveness of policy Requirement Reviewed by Infection Prevention and Control Method of Monitoring Frequency of Review Committee where Monitoring is Reported to Audit of outbreak Annual Infection Prevention and Control Page 20 of 49

21 Team Committee 27. References MacCannell T, Umscheid CA, Agarwal RK, Lee I, Kuntz G,and Stevenson KB, Guideline on the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings. HICPAC Guideline. Infection Control Hospital Epidemiology October; 32(10). pp: Guideline 2011.pdf Accessed 26/09/2016 Norovirus Working Party, Guidelines for the Management of Norovirus Outbreaks in Acute and Community Health and Social Care Settings. HPA. managing outbreaks in acuteand community health and social care settings Accessed 26/09/2016 Guidance from other organisations Centres for Disease Control and Prevention, Updated Norovirus Outbreak Management and Disease Prevention Guidelines. CDC. Accessed 26/09/2016 Nursing and Midwifery Council (NMC) Code of Professional Conduct (NMC Accessed 26/09/ Associated Documentation Standard Precautions (incorporating Personal Protective Equipment) Policy Environmental Cleaning Policy Learning and Development Policy Reporting, Managing and Learning from Incidents Policy (Including the investigation of Serious Incidents Requiring Investigation and Being Open) Isolation of Infection and Antibiotic Resistant Organisms Policy Waste Management Policy Theatre Cleaning Standard operating procedure (SOP) Clostridium difficile infection (CDI): Prevention, Treatment and Control Policy 29. Contributors Contributor Job Title Infection Prevention and Control Nurse Contributor Name Andrea Bullard Page 21 of 49

22 Appendix A Equality Impact Assessment Tool To be completed by the Policy Author at the development stage of the policy and before consultation. Part 1 should be forwarded to an Equality Analysis Lead (list available on the Document Control Trust Intranet page) for sign off and any comments from them considered and addressed before seeking final approval of the policy. Document Title: Norovirus and Diarrhoea and Vomiting Management Policy PART 1 Policy Author to complete and forward on to an EA Lead for sign off 1. Could the application of this document have a detrimental equality impact on individuals with any of the following protected characteristics? (See Note 1) Yes/No /NA a Age No b Disability No c Gender reassignment No d Race No e Religion or belief No f Sex No g Sexual orientation No h Marriage & civil partnership No i Pregnancy and maternity No Summarise the equality and diversity related elements within the policy 2. If Yes to question 1, do you consider the detrimental impact to be valid, justifiable and lawful? If so, please explain your reasoning. It is recognised that isolation may have an adverse psychological impact on a person and may affect their freedom of liberty. However isolation is still considered the most effective measure in limiting the spread of infectious diseases/ organisms and is therefore considered a necessary intervention 3. Specify with which, if any, individuals and groups you have consulted in reaching your decision. Page 22 of 49

23 Document Title: Norovirus and Diarrhoea and Vomiting Management Policy PART 2 Equality Analysis Lead to complete and forward back to the Policy Author Provide a brief summary of the potential impact of the policy and whether sufficient consideration has been given to the Equality Duty. 1. Is this document recommended for publication? Y / N If yes go to question 3 if No complete number 2 below. 2. This document is not recommended for publication because: A Amendments are suggested as follows: B A more detailed equality analysis should be undertaken as follows: C Other (please specify) 3. Specify with which, if any, individuals and groups you have consulted in reaching your decision. Name: Lorraine Amos Job Title: Pathology Business Manager Date: 10/11/2016 PART 3 Policy Author to complete on receipt of part 2 and before forwarding for final policy approval 1. I have reviewed the Part 2 assessment and have made the necessary amendments to the policy. If you have answered no, please explain why not Name: Hazel Gray Job Title: Lead Infection Control Nurse Date: 10/11/2016 Note 1 Under the terms of the Equality Act 2010 s public sector Equality Duty, the Trust has a legal responsibility to think about the following three aims of the Equality Duty as part of our decision making and policy development. Eliminate unlawful discrimination, harassment and victimisation; Advance equality of opportunity between people who share a protected characteristic and people who do not share it; and Foster good relations between people who share a protected characteristic and people who do not share it. Page 23 of 49

24 Appendix B Common Infections that Cause Diarrhoea and/or Vomiting and their Management This list is not exhaustive but gives examples of micro organisms which cause gastrointestinal infections. All cases of unexplained diarrhoea and/or vomiting should be reported to the Infection Prevention and Control Nurse. Disease and/or infective agent and clinical features Small round structured virus (diarrhoea and/or vomiting) Norovirus Transmission Faecal oral (hand to mouth following direct contact with faeces and/or vomit). Secondary faecal oral spread from infected cases. Indirect spread after environmental contamination by vomitis. Droplet from aerosols from vomit. Contact with contaminated gloves, shared clinical equipment and the environment. Unwashed Healthcare Worker s hands. Rotavirus As above As above Hepatitis A Faecal oral which includes patient to patient spread. Infected food handlers with poor personal hygiene. Contaminated water and food especially shellfish. Contaminated drugs and needle sharing equipment in illicit drug users. Hepatitis E Faecal oral person to person spread. 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 stool specimens ASAP for Norovirus testing. Staff stool specimens should be sent via Health4Work or their GP. 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 Centre (PHE) Isolate for 48 hours from the last episode of Page 24 of 49

25 Escherichia coli (E.coli) gastroenteritis Causing diarrhoea and vomiting Campylobacter (symptoms include profuse diarrhoea malaise, abdominal pain and sometimes vomiting) Salmonella (vomiting, diarrhoea and fever) Typhoid fever (Salmonella typhi) The infectious period lasts as long as bacilli are present in stool. Contaminated water and food. Ingestion of contaminated food and/ or water. Faecal oral. Contaminated hands of infected cases. Contaminated equipment. Undercooked meat especially poultry. Cross contamination from raw to cooked food. Food contaminated by unwashed hands and contaminated utensils. Person to person spread can occur. Ingestion of contaminated cooked food by raw food or inadequate cooking temperatures. Eggs, red and white meats, dairy products. Faecal oral spread. Ingestion of food and water contaminated by faeces. Faecal oral person to person spread. Unwashed hands of asymptomatic carriers. diarrhoea Observe strict hand hygiene. Report to the local PHE Centre Isolate for 48 hours from the last episode of diarrhoea Collect food history. Notify the local PHE Centre Isolate for 48 hours from the last episode of diarrhoea 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 Centre Isolate for 48 hours from the last episode of diarrhoea Food handlers should not return to work until cleared by Health4Work. Report to PHE Centre. Isolation precautions for duration of illness and until stools are normal. Antibiotic therapy guidance from microbiologist. Obtain travel history. Exclude affected food handlers until cleared by PHE Exclude HCWS who are not food handlers until 3 negative stool specimens taken at 2 Page 25 of 49

26 Cryptosporidiosis gastroenteritis (Protozoan parasite causes watery or mucoid diarrhoea) Ingestion of contaminated water, food and milk. Faecal oral spread. Aerosol or droplet spread can occur. Sexual partners Staphylococcus aureus Ingestion of food containing staphylococcal enterotoxin, the source can be from HCW hand. Contaminated food stored at ambient temperature. Bacillus cereus Contaminated food stored at ambient temperature. Diarrhoea (unknown cause) Faecal oral person to person spread. Giardiasis (A protozoan parasite that causes diarrhoea and cramps) Faecal oral spread of the cysts and by ingestion of the cysts from contaminated food and water. week intervals, commencing 2 weeks after completion of antibiotics. Report to PHE Centre. Isolation precautions for the duration of illness. Standard precautions (person to person spread does not occur) As above Stool and isolation precautions for 48 hours post symptoms. Isolate for 48 hours from the last episode of diarrhoea Report to the local PHE Centre Antibiotic therapy should be guided by a microbiologist. Consider testing all household contacts. Gastroenteritis Faecal oral route. Stool and isolation precautions for 48 hours post symptoms Cholera Vibrio cholera (Cases are normally admitted to an infectious diseases unit) Faecal oral spread. Contaminated water and uncooked seafood. Stool precautions and isolation for the duration of illness and following two consecutive negative stools taken at hour intervals. Page 26 of 49

27 Shigella including bacillary dysentery Clostridium difficile (A grampositive anaerobic bacillus that produces toxins). Clinical manifestations include abdominal pain, fever and profuse foul smelling diarrhoea (See Clostridium difficile infection (CDI): Prevention, Treatment and Control Policy) Clostridium perfringens (A2 strains can survive normal cooking) Faecal oral route. Contaminated food. Highly infectious organism Diarrhoeal infection is usually triggered by the use of antibiotics. Direct patient to patient spread by faecal oral route. Unwashed hands of healthcare workers (HCW) Transferred on contaminated equipment (including healthcare equipment). Contaminated environment. Lack of prudent antibiotic prescribing. Ingestion of contaminated food (e.g. undercooked minced beef). Inadequately reheated food and food kept warm at temperatures C. Stool and isolation precautions for 48 hours from the last episode of diarrhoea Clinicians should report to the local PHE Centre Isolate with stool precautions for duration of stay. Collect stool samples for C.difficile toxins. Treat with oral antibiotics as recommended by a microbiologist. Use Actichlor Plus disinfection to reduce spores in the environment. Clean room/bay three times daily Mandatory reporting to PHE for all cases aged 2+ years that meet the reporting criteria Isolate for 48 hours from the last episode of diarrhoea Report to the local PHE Centre. Page 27 of 49

28 Appendix C Diarrhoea and/or Vomiting Risk Assessment Form Printable version of this document is available on the intranet: Forms Infection Control Patient with diarrhoea Bristol Stool Chart type 6 7 stools Patient has vomiting, concerned about Norovirus? Yes Is it for a long standing medical condition that cannot be stopped? Is the patient on laxatives? No Action: Send stool sample Isolate within 2 hours No Do not send a sample to the laboratory Yes Action: Send vomit sample Isolate in a side room No Is the diarrhoea due to constipation or is it confirmed overflow? Yes If unable to isolate inform site team date and time If unable to obtain specimen reason why? Isolate bay that patient came out of until results available Yes Action: Treat for constipation no need to isolate No Action: Stop the laxatives and review in 24 hrs DO NOT SEND SPECIMENS WHILE THE PATIENT IS ON LAXATIVES C. difficile positivecommence C. difficile care pathway Action: Update EPR for patient review tomorrow C. difficile negative consider other causes of diarrhoea and discuss isolation requirements with infection control nurses Assessment done by Designation Date: Time Page 28 of 49

29 MANAGING SUSPECTED POTENTIALLY INFECTIOUS DIARRHOEA 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 with the Infection Prevention and Control Team (IPCT) while determining the cause of the diarrhoea GLOVES AND APRONS must be used for all contacts with the patient and their 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 by sending a specimen immediately Actions to take in case of a laboratory confirmed diagnosis C. difficile (See Clostridium difficile infection (CDI): Prevention, Treatment and Control Policy) Salmonella/ Campylobacter/ Shigella/ E.coli 0157 Norovirus/ Rotavirus/ Adenovirus If a patient is in a bay when positive result is known once the patient is isolated, the whole bay will need to close and be deep cleaned and HPV decontaminated before re opening C. difficile Integrated Care Pathway must be commenced immediately Medical team must: Undertake medical review within 4 hours, record severity assessment within 4 hours; commencement antibiotic treatment within 4 hours; complete C. difficile care pathway within 24 hours Patients with C. difficile must remain in isolation and barrier nursed until discharge or assessed by the IPCT Re testing should be discussed with Infection Prevention and Control Team/Microbiologists Side room must be deep cleaned and HPV decontaminated prior to re use Laboratory confirmed must remain in isolation and barrier nursed until 48 hours after the last symptom These are notifiable diseases and the Medical team needs to inform Public Health England Side room must be deep cleaned and HPV decontaminated prior to re use Laboratory confirmed must remain in isolation and barrier nursed on base ward until 48 hours after the last symptom Confirmed cases must not be moved to other wards to reduce spread of outbreak to other areas Contacts must be isolated/cohort barrier nursed and observed for signs and symptoms for 48 hours after last exposure to positive patient Side room/bay must be deep cleaned and HPV decontaminated prior to re use Page 29 of 49

30 Appendix D Management of the Patient with Diarrhoea and/or Vomiting The creation of short term Norovirus isolation wards is not recommended because, unless these wards are part of the routine configuration of the hospital, there may be an unacceptable safety risk to patients as a result of suboptimal management of their other medical conditions. The routine transfer of patients into an isolation ward does not prevent or even reduce the continuing outbreak on the original wards. Individual Case in a Ward Bay Any patient admitted to hospital with diarrhoea and/or vomiting and any patient whom develops diarrhoea and/or vomiting whilst an in patient must be assessed promptly by nursing staff/clinicians to attempt to identify the cause of the diarrhoea and/or vomiting. See Appendix G Diarrhoea Algorithm. Norovirus should be suspected if: There is confirmed/suspected Norovirus within the community and/or the hospital The patients close household contacts/family members have the same symptoms or have recently had the same symptoms The patient has been in contact with any other individuals (either in the workplace, school etc) who had symptoms of diarrhoea and/or vomiting Other people in contact with the patient develop the same symptoms e.g other patients/staff members If Norovirus is clinically suspected please follow guidance below Individual Case of Suspected/Confirmed Norovirus in a Ward Bay. If the patient has diarrhoea of unknown origin i.e. is not on laxatives; not considered part of an underlying condition, or where there is uncertainty in assessment then they need to be isolated in a single room with ensuite facilities. See Appendix G Diarrhoea Algorithm It is the onset of diarrhoea and/or vomiting which determines that the patient should be isolated. Do not wait for a positive diagnosis of a named bacteria or virus before deciding to isolate a symptomatic patient. Prompt action can prevent transmission to other patients and prevent bay/ ward closure. If en suite facilities are not available the isolation room must have a designated commode/ toilet for the use of that patient only. An isolation sign must be placed on the door to inform all entrants that isolation precautions are required. The need for isolation and precautions required must be explained to the patient and relatives ensuring that confidentiality is maintained at all times. Page 30 of 49

31 De isolation is usually possible once the patient has ceased symptoms of diarrhoea and/or vomiting for 48 hours. If Norovrius is suspected the isolation room will require terminal cleaning including the use of HPV cleaning prior to being released back into the bed stock. Individual Case of Suspected/Confirmed Norovirus in a Ward Bay A single room with en suite facilities is always the preferred option for isolating the patient suspected/confirmed with Norovirus (Norovirus Working Party 2011). All attempts must be made to ensure that this level of isolation is achievable, including the provision of extra nursing staff if necessary to ensure the safety and well being of the patient being cared for in isolation. Failure to isolate must be recorded as an incident by completing a Datix form. Where Norovirus is suspected and in order to restrict potential transmission throughout various wards/departments within the hospital all attempts must be made to accommodate the symptomatic patient in an en suite room on the ward on which they initially commenced symptoms. In order to accommodate this it may be necessary to transfer those non exposed, unaffected patients occupying the wards en suite rooms to other ward isolation rooms. The nature of the patient transfer must be communicated by the nurse in charge of the transferring ward to the nurse in charge of the receiving ward/area so that they may take any necessary precautions. The Site Co ordinator/ IPCT/Duty Consultant Microbiologist must be consulted where patient moves off of an area suspected to have Norovirus is identified as necessary. The period of isolation will extend until the patient has ceased symptoms of diarrhoea and/or vomiting for 48 hours or more and a terminal clean has been performed. See Appendix E Terminal Cleaning. During the isolation period it is advised that a minimum of three times per day cleaning of high touch surfaces is carried out using an Actichlor Plus solution at a strength of 1000 ppm. See Appendix F Daily Housekeeping Management of Norovirus Isolation Areas. In order to reduce the environmental load of Norovirus spores and prevent re infection of the patient, it is advised that all efforts are made to deep clean the patients environment with an Actichlor Plus solution at a strength of 1000 ppm once the patient has been asymptomatic for 48 hours or more. Once the patient is discharged from that environment terminal cleaning will be required prior to releasing the room for any further patient occupation. See Appendix E Terminal Cleaning. If the patient suspected/confirmed with Norovirus is deemed too clinically unstable to move by the responsible clinician then a risk assessment to keep the patient in a Page 31 of 49

32 bay/open unit must be performed by the clinicians, the IPCT, the Clinical Matron/Service Lead (CSM) for the area and the ward manager. In this situation the bay will be closed to further admissions/transfers except urgent clinical transfers. Patients may be discharged home from the closed bay. Patients may not be discharged to other care settings from the closed bay until all affected patients are clear of symptoms for 48 hours or more, and the whole bay has had a terminal clean. See Appendix E Terminal Cleaning. During the isolation period it is advised that a minimum of twice daily cleaning of high touch surfaces is carried out using an Actichlor Plus solution at a strength of 1000 ppm. See Appendix F Daily Housekeeping Management of Norovirus Isolation Areas. The bay may only be de isolated and released for further patient occupation/transfer once all affected patients are clear of symptoms for 48 hours or more, and the whole bay has had a terminal clean. See Appendix E Terminal Cleaning. Two or More Cases in a Ward Bay If ward accommodation allows all symptomatic patients should be nursed in single rooms with en suite facilities. All attempts must be made to ensure that this level of isolation is achievable as a priority. In order to restrict potential transmission throughout various wards/departments within the hospital, single room isolation should be on the ward where the patient/s initially commence symptoms. In order to accommodate this it may be necessary to transfer those non exposed, unaffected patients occupying the wards en suite rooms to other ward isolation rooms. The nature of the patient transfer must be communicated by the nurse in charge of the transferring ward to the nurse in charge of the receiving ward/area so that they may take any necessary precautions. The Site Coordinator/IPCT/Duty Consultant Microbiologist must be consulted where patient moves off ward are identified as necessary. If single room isolation is not achievable then the bay must be closed to admissions/transfers except urgent clinical transfers, when the suspected/confirmed infectious nature of the patient/s must be clearly communicated to the nurse in charge of the receiving ward/area to enable necessary precautions to be instigated. Patients may be discharged home from the closed bay. Patients may not be discharged to other care settings from the closed bay until all affected patients are clear of symptoms for 48 hours or more, and the whole bay has had a terminal clean. In order to expedite discharge to other care facilities such as nursing/residential homes consideration may be give to transferring a non symptomatic contact patient from an Page 32 of 49

33 affected bay into a single isolation room providing this isolation room is on the same ward. Once the patient has been successfully isolated and has developed no symptoms within a 48 hour period the patient may then be discharged to the care facility, providing that the whole ward has not closed in the interim. Clinical Procedures/Investigations Where Norovirus is suspected/confirmed and in order to restrict potential transmission throughout various wards/departments within the hospital only clinically necessary/ urgent off ward investigations should occur Where possible all attempts must be made to carry out investigations on the ward, but necessary urgent clinical procedures/investigations should not be delayed for those suspected/confirmed of Norovirus. Where urgent off ward procedures are required the following criteria must be met: Where possible the suspected/confirmed patient should be 48 hours clear of symptoms of Norovirus. Where the patient is coming from a closed affected bay/ward even if they are asymptomatic they should be treated as if a positive case. The nurse in charge of the receiving area should be informed of the patient s suspected/confirmed infectious status by the nurse in charge of the patient s care so that any necessary measures may be taken. The patient should be put last on the procedure list allowing for the theatre/ procedure room to be cleaned thoroughly afterwards. The patient should not be left in any waiting areas but should be called down for the procedure and taken into the theatre/procedure room directly upon transfer. They should be recovered in the theatre/procedure room and then transferred directly back to the ward. Theatre staff must wear personal protective equipment whilst tending to the patient. The theatre/procedure room must be deep cleaned as per the Theatre Cleaning Standard operating procedure (SOP) providing the patient has not had any symptoms of diarrhoea and/or vomiting whilst having the procedure. If the patient has had any symptoms of diarrhoea and/or vomiting whilst in the procedure room, the deep clean must be followed by an HPV clean. See Appendix H for Terminal Cleaning See Appendix K for Discharging Patients during Norovirus Outbreaks Page 33 of 49

34 Appendix E Bristol Stool Chart Page 34 of 49

35 Appendix F Isolation Priorities HIGH Do not remove from isolation without prior discussion with duty Microbiologist/IPCT Diarrhoea and/or vomiting of unknown origin Suspected/confirmed Norovirus Suspected/confirmed C.difficile Suspected/confirmed Pulmonary TB including MDRTB. Possible MDRTB must be discussed immediately with the duty microbiologist Suspected/confirmed Chicken pox/ Shingles/ Measles MRSA in sputum/ exudating wound/mrsa skin shedder/high Mupricin resistance/ MRSA 16 or 18 E.coli 0157/Shigella/ Salmonella Norwegian scabies Pandemic influenza Viral haemorrhagic fever possible cases must be discussed with the duty microbiologist immediately Invasive Group A Strep Carbapenemase producing Enterobacteriaceae (CPE) Candida aurius MEDIUM ESBL/AMPC/Acinetobacter GRE RSV/Influenza Mumps Meningitis with cough (isolation for 24 hours IVABX) Strep A/Strep G on high risk areas (isolation for first 24 hours of IVABX) Open weeping TB lesions to skin LOW MRSA 15 or 16 post full screen and on Mupiricin Meningitis (undiagnosed or meningococc al) no cough Strep A/G (after 24 hours IVABX) Scabies (isolate until first treatment completed) NB: MRSA 16 & 18 strains can be more resistant to antibiotics and also resistant to Mupiricin 5 and 200, due to the resistancy of the strain these patients cannot be placed in an open bay or with any other MRSA positive patient. Page 35 of 49

36 Appendix G Outbreak Control Measures Ward Close affected bay(s) to admissions and transfers Keep doors to single occupancy room(s) and bay(s) closed at all times Place signage on the door(s) informing all visitors of the closed status and restricting visits to essential staff and essential social visitors only Place patients within the ward for the optimal safety of all patients Commence data collection of all patients within the ward/bay highlighting those whom are symptomatic Ensure that provision of necessary ward stock levels are adequate Prepare for reopening by planning the earliest date for a terminal clean Ensure that all affected patients are closely monitored for signs of dehydration Ward Managers Ensure all staff are aware of the Norovirus situation and how Norovirus is transmitted Ensure that staff information leaflets (Appendix I) are available in staff rest areas Ensure all staff are aware of the work exclusion policy and the need to go off duty at first symptoms Ensure that all staff are aware that they will be required to send in a sample of either diarrhoea or vomit for testing for Norovirus with results to be directed to Health4Work Ensure that a responsible person is charged with daily data collection of all patients within the ward/area identifying all ward patients but clearly defining patients who are symptomatic. Allocate staff to duties in either affected or non affected areas of the ward but not both unless completely unavoidable (e.g. therapists) Ensure that there is provision of information leaflets for all affected patients and visitors with advice on the outbreak and the control measures they should adopt Advise visitors of the personal risk and how they might reduce this risk Ensure that visitors are aware that they should not visit if they have signs/symptoms of Norovirus until they are at least 48 hours clear of symptoms Maintain an up to date record of all staff with symptoms, liaising with Health4Work where necessary Monitor all affected patients for signs of dehydration and correct as necessary Hand Hygiene Ensure adequate provision of hand hygiene facilities including soap, paper towels, disposal bins. Alcohol gel is ineffective in killing Norovirus soap and water is the recommended product of choice Ensure that hand hygiene is performed upon removal of any PPE worn Ensure that hand hygiene continues to be performed using the 5 Moments for Hand Hygiene approach Encourage and assist patients with hand hygiene Page 36 of 49

37 Personal Protective Equipment (PPE) Use gloves and apron for contact with the affected patient and/or their environment Ensure that gloves and aprons are single patient use only and are changed between each and every patient and between clean and dirty tasks Use a standard surgical mask when cleaning up any bodily fluids/disposing of bodily fluids Use eye shields/goggles where there is a risk of splashing to the eyes/face Dispose of any PPE into the infectious waste (orange) stream Environment Remove exposed foods, e.g. fruit bowls, and prohibit eating and drinking by staff within clinical areas Discourage communal foods e.g. boxes of biscuits/chocolates unless individually wrapped as many hands will access them Ensure that the environment is kept completely de cluttered to enable adequate cleaning Ensure that clinical areas are not over stocked as this may lead to large stock losses during the terminal cleaning phase Effective cleaning and removal of organic soiling using an Actichlor Plus 1:1000 ppm solution prior to disinfection is essential Ensure that all cleaning is carried out using an Actichlor Plus 1:1000 ppm solution. Do not use detergent wipes alone as they are ineffective in killing Norovirus spores. Intensify cleaning to twice daily using an Actichlor Plus 1:1000 ppm solution, ensuring affected areas are cleaned and disinfected. Toilets used by affected patients must be included in cleaning regimes Decontaminate frequently touched surfaces with an Actichlor Plus 1:1000 ppm solution Ensure that domestic staff wear appropriate PPE and follow standard infection control precautions. Use dedicated domestic staff where possible and avoid transfer of domestic staff to other areas unless they have been 48 hours clear of contact with an affected area and have not developed symptoms themselves On a ward with closed rooms clean from unaffected to affected areas, and within affected areas from least likely contaminated areas to most highly contaminated areas Use disposable cleaning cloths Dedicate reusable cleaning equipment to affected areas and thoroughly decontaminate between uses e.g. mop handles and buckets Pay particular attention to frequently touched surfaces such as bed tables, door handles, toilet flush handles and taps National and local colour coding for PPE and cleaning equipment should be adhered to, in order to avoid cross contamination Page 37 of 49

38 Equipment Use single patient use equipment wherever possible Segregate equipment where possible to ensure no cross over of equipment between affected/unaffected areas wherever possible Decontaminate all patient equipment immediately after use with an Actichlor Plus 1:1000 ppm solution Ensure that clean utility room equipment cupboard doors are kept closed to reduce the risk of environmental contamination and the need to dispose of multiple stock loads during the terminal cleaning phase Linen All linen should be discarded into the red soluble bags (alginate) and then placed into clear/white plastic bags Linen should be cleared away in a timely manner by portering staff and not allowed to accumulate All patient linen should be changed on a daily basis Linen should be bagged immediately in the patient care area and not left on flooring/chairs/lockers etc When making beds care should be taken not to shake out sheets thereby causing dissemination of any spores Linen should only be carried bagged, never loose Extra provision of linen may be required during an outbreak and it is the wards responsibility to request extra provision Spillages Ensure that gloves, aprons and masks are worn as standard, plus the addition of goggles/eye protection if risk of splashing to eyes/mucous membranes. Clean up spillages immediately Remove debris with paper towels disposed of in the infectious waste stream, and then decontaminate the area with an Actichlor Plus 1:10,000 ppm solution Discard all PPE in the infectious waste stream and wash hands with soap and water Staff Considerations The movement of all staff around the Trust whilst carrying out their daily duties is recognised as a risk to patients and staff in outbreak situations and must be kept to a minimum where possible. These staff must ensure they are following strict infection control precautions. Exclusion of symptomatic staff Affected staff members must be excluded from work until they have been symptom free for 48 hours or they have negative test results. Symptomatic staff must make all reasonable efforts to send in a sample for testing via their GP or via Health4Work. The sample must be marked appropriately to ensure that the results are sent to Health4Work and should not be sent via the clinical area. Bank and agency staff Page 38 of 49

39 The use of these in outbreak restricted areas should be kept to a minimum. Such staff working in affected areas should be advised of the risk of Norovirus transmission, the specific precautions that must be adhered to, and the importance of reporting any symptoms. 48 hours should be allowed before transferring staff who have worked in an affected area to other unaffected areas providing they are symptom free themselves. Visitor/Visiting Considerations The visitor who has Norovirus is a transmission risk and the visitor who does not have Norovirus is at risk of contracting it during a visit. The first is an obvious infection prevention and control hazard but the second is usually not. Restrictions on visiting are mainly intended to assist in outbreak control. Local decision by the outbreak management group should determine any visiting restrictions required. Visitors who have Vomiting and/or Diarrhoea Visitors who are symptomatic should not visit until at least 48h after the resolution of their last symptoms. All Other, Non infected Visitors Visits by children of school age should be discouraged for the duration of an outbreak because of the risk of sudden symptoms developing without warning in school. Adult visitors should be warned of the risk of contracting Norovirus and given advice in the form of an information leaflet. They should be discouraged from visiting other patients outside the outbreak restricted area unless the closed area is visited last. They must be educated the correct use of Personal Protective Equipment (PPE) and in appropriate use of hand hygiene. Extenuating Circumstances Visitors should be allowed in extenuating circumstances on the decision of the ward manager. Terminally ill patients, children, vulnerable adults and those for whom visiting is an essential part of recovery should be allowed visitors following daily risk assessment by the ward manager. Clinical and social judgement needs to be applied sensitively and compassionately whilst recognising the duty of care for the health and well being of all patients, staff and visitors. Those who have travelled a long distance, taken time off work, or in other ways have been significantly inconvenienced, may be allowed to visit patients on outbreak restricted areas provided that they observe IPC measures. Non essential visitors Visits from newspaper vendors, hairdressers, mobile libraries and similar should not be allowed within an outbreak restricted area until the outbreak is declared over and terminal cleaning successfully completed. However, provision of reading materials such as newspapers can be an important part of recovery and can be provided to patients in other ways which do not jeopardise outbreak control. Used reading materials should be disposed of as infectious waste and should not be shared between patients Page 39 of 49

40 Contractors Appropriate instructions should be given to contractors before they enter a closed area. However, only work that cannot be postponed until after re opening of the closed area should be allowed. Please see Appendix I for Staff Information Leaflet on Norovirus Please see Appendix J for Visitor Information Leaflet on Norovirus Page 40 of 49

41 Appendix H Terminal Cleaning Terminal cleaning is a pre requisite to ward/bay/single room re opening and return to normal bed stock. The IPCT, Clinical Matron/CSM and Ward Manager will advise the Domestic Manager/Supervisor that terminal cleaning will be required and the proposed date. Terminal cleaning will involve a whole ward/departmental approach It is recommended that unused disposable patient care items within the patient area are discarded Boxes of open gloves inside single rooms/bays discard whole box and contents Boxes of open gloves outside of single rooms/bays discard the first 5 layers of gloves and clean the outside packaging with the Actichlor Plus 1:1000 ppm solution Open packs of wipes etc discard the entire pack Medical equipment discard of any equipment in packaging which cannot be cleaned without breaching the sterility of the product Discard of paper notices laminated wipeable notices may be kept Remove window and privacy curtains and send for laundering Remove all linen including unused linen and send for laundering Decontaminate all equipment including beds/lockers/tables/ monitoring equipment/commodes/toilet seats using the Actichlor Plus 1:1000 ppm solution Steam clean any soft upholstery Complete terminal cleaning by cleaning all ward areas including dirty utility, clean utility, offices, patient areas with a Hydrogen Peroxide Vapour (HPV) cleaning system. Please read in conjunction with the Environmental Cleaning Policy Page 41 of 49

42 Which clean do you require on discharge? Page 42 of 49