Guidelines for the Management of Norovirus Outbreaks in Acute and Community Health and Social Care Settings Stakeholder Consultation Response Form The accompanying draft document is not complete. However, the Working Party values your contribution at this stage. All responses will be fully considered and logged. The Response Log will contain every suggestion submitted within each response and the decision of the Working Party in relation to each point. The Response Log will be available to stakeholders to view on request. For hospitals, the guidelines are a departure from the present practice of early ward closure. They focus on the preservation of patient safety whilst maintaining organisational activity and the segregation of patients within the minimal clinical spaces (eg bays) commensurate with effective Infection Prevention and Control. A separate section deals with the management of norovirus outbreaks in the residential and nursing home sector. Please note that the published guidelines will be supported by a web-based resource which will contain the underlying evidence base and various materials including information sheets, signage, triage forms and other items. Instructions to Respondents 1. Only organisational responses (not responses from individuals) are invited. 2. Please cascade the draft document through your organisation and collate responses into this Response Form. 3. Type your responses into the most appropriate field below. If you are unsure which field to use for a response, simply choose one. Every response will be considered whichever field is used. 4. The fields are expandable and there is no prescribed limit to the amount of text you can type. 5. You do not have to respond to every field. 6. In order to ensure you do not lose your work, it is advisable to type into a saved copy of this Response Form and to attach the saved copy to your e-mail when submitting your response. 7. Remember to save the document before attaching to your e-mail which should be sent to noroguide@yahoo.co.uk 8. The closing date for receipt of responses is 1700 hrs Tuesday 31 May 2011
PLEASE STATE YOUR ORGANIS ATION (PLEASE TYPE IN THE BOX IMMEDIATELY BELOW) Royal College of Nursing ORGANIS ATIONAL PREPAREDNESS The Royal College supports the need for organisations to consider norovirus outbreak preparedness a key activity as part of winter/emergency planning. Many organisations will already have major outbreak plans present. This is not recognised in the guidance and how this guidance interacts with existing policies should be considered in order to save duplication in the workplace. This section of the draft guidance does not reflect the need to ensure laboratories and ICT's are sufficiently staffed or resourced in order to support the surveillance and management of any potential outbreak. DEFINING THE START OF AN OUTBREAK DEFINING THE END OF AN OUTBREAK ACTIONS TO BE TAKEN WHEN AN OUTBREAK IS SUSPECTED Whilst patient symptoms are included, there is no mention of the need to investigate staff sickness. The presence of staff affected with symptoms at an early stage can be crucial for early effective management of outbreaks. The ICT are not responsible for the collection of specimens, ward managers or their deputies are. The emphasis for responsibility should be changed to clinical staff not the ICT who holds an advisory role
ACTIONS TO BE TAKEN WHEN AN OUTBREAK IS DECLARED Ward Close ward or bay to admissions this option to only close a bay should only be taken on advice from the ICT. Placing this statement without the caveat could result in conflict between ICT s and others who wish to keep as many beds as possible open. Assuming an outbreak has been declared, the closure of a bay only does not appear to be appropriate. Place patients within the ward - this sentance does not make sense and further explanation is required. All patients in hspitals will be placed in wards unless in out-patient settings. Healthcare workers - it is not possible to ensure all HCW's are symptom free. The emphasis should be placed on staff being encouraged to be accurate and timely in reporting symptoms and for staff to be made to submit specimens if symptomatic within 24hours of symptoms appearing. Staff should be given a clear definition of when to return to work. PPE - there is no evidence to support the use of face protection in norovirus outbreak control and this action could result in increased anxiety for patients and extra costs with no benefit to organisations. Environment many organisations routinely use chlorine dioxide for disinfection of the environment. This point should be further considered as the introduction of one specific chemical agent only could cause issues should an outbreak occur as staff may not be trained in the use of chlorine agents. Waste management - this is not inlcuded and should be Staff breaks (comfort and food breaks) - the guidance does not stipulate where staff should take their breaks. There is often a challenge between meeting the neeeds of staff and preventing the spread of infection to staff by allowing eating on the ward. This should be considered and guidance offered. Maintenance of safe staffing levels - this is not inlcuded in the guidance and should be placed as a management responsibility. The guidance should also offer best practice advice re the use of agency/locum staff and how they operate Single sex accommodation p.8 may not be possible to achieve all requirements during an outbreak ACTIONS TO BE TAKEN WHEN AN OUTBREAK IS OVER Terminal cleaning should be defined as different organisations use different terminology e.g. deep cleans, outbreak cleans When an outbreak is over (page7, page 16) is defined in the document as when terminal cleaning is complete. This may not be the case as sometimes cases occur after terminal cleaning is complete and it may become clear the outbreak is not infact over. This should be clarified as 'when there have been no new cases... and when terminal cleaning has been completed' The document does not stipulate who has responsibility for declaring the outbreak is over- this should be clarified. The role of the DIPC (where used) is not included and should be. Excretion of norovirus in stools not all patients will have formed stools due to underlying medical conditions. The guidance should provide advice for the management of these patients who may shed the virus longer than those who are capable of forming formed stools.
THE IPC MANAGEMENT OF SUSPECTED AND CONFIRMED CAS ES Whilst the RCN is supportive of maintaining services as much as possible, the Royal College is very concerned at the emphasis placed on cohorting and closure of bays during the observation period which allows an accurate assessment of the situation to occur. The guidance fails to recognise the need to moitor staff sickness and without this no decision regarding cohorting or bay closure could be made. The infectiousness of norovirus and the inability to ensure dedicated staff could see spread of infection which otherwise could have been prevented if early closure was implemented. The RCN suggestes that if this issue is to be a major part of the guidance (as reflected in the intorduction) that clear and definative guidance is issued indicating the circumstances under which cohorting or closuere of bays can be implemented. A flow chart may be of use. All decisions regarding closure and how this decison was reached, together with any objections if present should be documented carefully to support a debrief of actions following the outbreak. Role of the ICT - this should be strengthened as an advisory capacity and the role of the DIPC in decision making regarding closure or opening of clinical areas must be inlcuded. The roles of all those involved should be stipulated e.g. bed management, management, occupational health, ICT's, matrons, ward managers etc. The change of advice to close only bays and not wards appears to be on the basis of expedience and not evidence. Whilst it is clear that in some circumstances this may be possible, there is considerable variation in what is defined as a bay and where the bay is. A bay which is opposite the main ward entrance is more problematic than a bay at the end of the ward with little traffic. Bays with en-suites are also easier to close. In areas with patients who are particularly vulnerable to infection e.g. immunity compromised, closure to admissions to reduce the exposure of new patients who would have a more significant illness if they contracted norovirus would be preferable. Single room nursing RCN members have expressed concern at the precedence given to norovirus over such cases as measles or open TB. Further consideration should be given to decision making based on review of the patient and possible cause of symptoms. Cohort nursing there is currently no national guidance on this method of managing patients. The guidance refers to the training of staff in this area however in the absence of national definitions and guidance this is unlikely to be uniform and create variation in standards this should be considered further. An additional point refers to night staff where there traditionally less staff available and cohorting could be impracticle on a 24 hour basis due to this. The RCN supports the non-use of norovirus isolation wards. Page 9. zipped plastic sheets to form a barrier. The RCN is not aware of their use with the exception of building work to prevent dust control. Has it been tested to ensure it is not a hanging risk? How is it cleaned? What is required to fix it to walls/ceiling? This should not be included in the guidance. Dedicated healthcare staff guidance should be included on how these staff can be deployed after their shift in an outbreak area and whether restrictions apply to working elsewhere as a result of exposure.
THE ROLE OF THE LABORATORY AVOIDANCE OF ADMIS S ION The implementation of a hospital norovirus admissions policy another policy is not needed, this should be included in the ICT policy on the management of norovirus CLINICAL TREATMENT OF NOROVIRUS PATIENT DIS CHARGE
Page 18 Residents discharged from hospital. Does this mean hospitals have to contact HPA every time they want to discharge a patient to a nursing/residential home. The Noro tool kit does not stipulate this In box 4 on discharge, members recommend that a 4th point is made such as Discharge or Transfers to another hospital or community-based institution of asymptomatic exposed patients should be delayed 72 hours (included in incubation period for Norovirus). Page.11 - Patient discharge to own homes may need to be on risk assessment basis rather than at any time CLEANING OF THE ENVIRONMENT Page 12 box 5 the guidance is confusing as it indicates that disposable cleaning materials should be used and then refers to laundering microfibers. Page 12 box 5 cleaning should include toilets and commodes & patient call bells. Page 12 box 5 Is there national colour coding for PPE as this implies? Page 12. Steam cleaning is mentioned frequently and I assume a member of the panel has an interest in this. Is there any evidence that steam cleaning is effective in controlling norovirus outbreaks? The implication at the bottom of the page Therefore hypochlorite disinfection is still required for areas which have been previously steam cleaned. Would imply that it is not effective so what is the benefit? Page 13 ultra heated dry steam cleaning is again promoted as effective although this time in conjunction with microfiber. This is confusing as elsewhere the document mentions disposables. Impractical Page 14 Steam cleaning is suggested for upholstered furniture and bed mattresses. Can I assume that the panel have taken into account the potential to aerosolise during steam cleaning and the potential for transmission to the cleaners and patients in the surrounding areas? I suggest if this method is used that this should be done away from patient areas. Page 14 Steam cleaning is again promoted to avoid the problems associated with the bleaching effect of Chlorine. A better solution is to have robust cleanable fabrics and furniture. Page 14 the implication from the bullet points is that if microfiber is not compatible to chlorine that organisations should switch to disposable microfiber or traditional cloths. A disposable cloth which is disposed of after use would be preferable to a traditional cloth which may be rinsed out and reused. Page 12 After cleaning disinfect with 1000ppm soduim hypochlorite - refer to comments above re only using clhlorin agents. Additionally, the use of a 2 step method over a combination product needs to be evidence based. A 2 step method is very time consuming and a drain on stretched cleaning services. VIS ITORS
Why are we asking visitors to stay away 72hours symptom free and staff 48hours (p.15)? Page 14 Non essential visitors. Good idea to restrict newspaper vendors etc but it is important that alternative arrangements are made to promote complance with the policy and not create psychological issues with patients. STAFF CONSIDERATIONS Page 15 Colour coded scrubs and aprons this will only add to confusion in some organisations where there is already a plethora of coloured scrubs in areas. COMMUNICATIONS THE MANAGEMENT OF OUTBREAKS IN NURSING AND RESIDENTIAL HOMES (Comments may also be typed into the above fields)
Page 16. The role of the GP is not clear. Page 17 specialised steam cleaning is recommended again and I wonder how practical this is in nursing and residential homes when they often have carpet cleaning systems already available. Page 18 the exclusion time for visitors to nursing homes is 48 hours but in hospitals (page 14) 72 hours is required why is there a difference? Page 18 why are notices in nursing homes too intrusive and how else are they going to ensure people know on entering that there is an outbreak? Page 18 Prevention of hospital admissions there is no mention of the role of the GP. Page 18 Residents discharged from hospital it should not be mandatory to seek permission from the HPA to discharge patients who are symptom free back to nursing homes. This will cause delays and we already have good relationships with many homes. In some instances it would be helpful to have the HPA support. APPENDIX 3 - ALGORITHM GENERAL COMMENTS
There is nothing about mental health- this is notoriously difficult due to wandering etc.. so would be helpful when trying to justify to board and senior managers why wards have been closed or managed in a certain way. clarity on the incubation period of norovirus is required as 48-72 hours is frequently quoted meaning organisatins may be tempted to use 48 hours as the maximum rather than the minimum. RCN members susggest a cautionary note should be placed at the bottom of page 18 about discharged resistant s clothing / possessions needing to be handled with caution and treated as potentially a source of re-infection / poses a risk of cross infection.