The Management of Diarrhoea and omiting Author(s) & Designation Lead Clinician if appropriate In consultation with To be read in association with Ratified by Julia Bloomfield, Infection Prevention and Control Nurse Mary Lewis, Director of Nursing and Director of Infection Prevention and Control Infection Prevention and Control Forum Hand Hygiene Policy Infection Control Isolation Policy Standard Infection Control Precautions Policy Decontamination Policy Policy for Spillage of Blood and other Bodily Fluids Cleaning Policy for Infected Clinical Areas Clostridium Difficile Policy Infection Prevention and Control Forum Re-issue/Ratification date July 2016 ersion 3 Review date July 2019 This policy supports compliance with the CQC 5 Domains: NHSLA Risk Management Standard(s): Safe Caring Effective Responsive Well Led If you require this document in a different format, please contact the Governance team on 01275 546831 1
Contents 1. Introduction 3 2. Purpose / Objective of the Document 3 3. Definition of Terms Used 3 4. Duties and Responsibilities 3 5. Gastrointestinal Infections 5 6. Routes of Transmission 6 7. Infection Control Precautions 6 8. Ward Outbreaks of Diarrhoea and omiting at North Somerset Community Hospital 9 9. Re-occurrence of symptoms 12 10. Monitoring of Compliance 12 11. Training 12 12. References 12 13. Appendices 13 Appendix 1 Information provided by the PHLS Advisory Committee on Gastrointestinal Infections 2004 14 Appendix 2 Infection Control Record Diarrhoea and omiting Outbreak (IPCT to complete) 17 Appendix 3 Outbreak Daily Record Sheet 19 Appendix 4 Key Points for North Somerset Community Hospital 24 Appendix 5 Outbreak Notification Poster for Ward Entrances 25 Appendix 6 Equality Impact Assessment 26 Type of Document Policy Policy Title Author Date ersion Ratifying Committee The Management of D& The Management of D& Suzanne Golding- Ellis Suzanne Golding- Ellis July 11 1 IPCF July 13 2 IPCF Policy The Management of D& Julia Bloomfield July 16 3 IPCF Page 2 of 28
1. Introduction Worldwide 1.7 million deaths occur from diarrhoeal disease annually (Damani 2012). Gastrointestinal infection can be caused by a variety of communicable diseases and infections, which gain entry by and affect the gastrointestinal tract. See appendix 1. Symptoms of gastrointestinal infection, which included diarrhoea and / or vomiting, are caused by the organisms themselves or by the toxins that they produce. Infectious intestinal disease affects as many as 1 in 5 members of the population each year. iral gastroenteritis has the ability to spread very quickly within a hospital/healthcare environment causing ward closures in some cases. The most common cause of diarrhoea and vomiting outbreaks in hospitals is from small round structured viruses (SRSs) such as norovirus. These viruses are more common during the winter months and affect both staff and patients. Symptoms tend to be acute but selflimiting and recovery normally takes places after about 72hrs. 2. Purpose / Objective of the Document The purpose of this policy is to provide the information that healthcare staff will require to recognise an outbreak of infection, at the earliest stage, and take the appropriate action required, when a patient is suspected of having viral gastroenteritis. Prompt and effective measures are essential in controlling the spread of infection between patients, staff and visitors. This policy applies to all staff providing direct care working within a health or social care setting including patients/clients own home. The policy applies to ALL healthcare workers, including medical staff, allied health professionals, support workers and nursing staff. 3. Definition of Terms Used Diarrhoea is defined as the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual). Frequent passing of formed stools is not diarrhoea, nor is the passing of loose, "pasty" stools by breastfed babies (WHO 2013). An outbreak can be defined as two or more epidemiologically linked cases of infection caused by the same microorganism in place and time. In an outbreak situation the numbers of affected individuals may be high. If an outbreak is suspected it is essential to implement appropriate infection control measures immediately to prevent the spread of infection. 4. Duties and Responsibilities Chief Executive Ensure infection control is a core part of clinical governance and patient safety programs. Appoint Director of Infection Prevention and Control Page 3 of 28
Promote compliance with infection control policies in order to ensure low levels of health care associated infection. Awareness of the legal responsibilities to identify, assess and control risk of infection. Director of Infection Prevention and Control Report directly to the Chief Executive and the Executive Team. Oversee infection control policies and their implementation Challenge inappropriate hygiene practice Clinicians and General Practitioners (GPs) omiting and / or diarrhoea can be a feature of many serious illnesses and fear of spreading norovirus must not jeopardize the appropriate management of those conditions in which vomiting and/ or diarrhoea is a non-specific feature. Therefore it is essential for clinicians to assess each symptomatic patient for diagnosis to be made. Minor Injuries Unit (MIU) attendees at North Somerset Community Hospital (NSCH) Patients seen in MIU with symptoms of diarrhoea and / or vomiting, particularly if there is a household history of other cases, should be seen in a single room. Refer to Isolation Policy Inpatients Department at North Somerset Community Hospital Immediately isolate or cohort patients with diarrhoea and/or vomiting. Inform the Infection Prevention and Control Team (IPCT) if an individual patient develops diarrhoea and vomiting for unknown reasons. Inform the IPCT (or on call microbiologist out of hours) if 2 or more cases develop Prompt cleaning and disinfection of patient equipment and areas contaminated by vomit and faeces. Refer to Cleaning Policy for Infected Clinical Areas. Infection Prevention and Control Team Educate staff and raise awareness of measures required at the beginning of the winter season. If the outbreak suggests a point source, epidemiological investigations must be undertaken to identify or exclude a food or water source The Infection Prevention and Control Team (IPCT) will ensure that appropriate staff will be informed by e-mail of a ward closure. Give daily advice in the event of an outbreak. Inform Public Health England of outbreak and give daily updates. Food Handlers Food borne outbreaks have occurred in hospitals therefore kitchen hygiene practices must be reviewed regularly and monitored. Page 4 of 28
Nursing Staff and Allied Health Care Professionals Undertake infection control required to prevent and control an outbreak of infection. 5. Gastrointestinal Infections Norovirus Norovirus is the most common cause of infectious gastroenteritis (diarrhoea and vomiting) in England and Wales. Norovirus is estimated to cost the NHS in excess of 100 million per annum and approximately 3000 people a year are admitted to hospital with norovirus and it is thought to be 16.5% of the 17 million cases of infectious intestinal disease in England per year (HPA et al 2012). The Illness is generally mild and people usually recover fully within 2-3 days. Infections can occur at any age because immunity does not last. Historically known as 'winter vomiting disease', the disease is more prominent during the winter months, but can occur at any time of year. It is also known as small round structured virus (SRS) or Norwalk-like virus. Norovirus is highly infectious and outbreaks are common in semi-closed environments such as hospitals, nursing homes, schools and cruise ships. There is an incubation period of 12-48 hours and the symptoms may last 24-72hrs on average. Individuals who have been symptomatic are infectious for up to 48hrs after the last episode of diarrhoea and or vomiting. Other symptoms may include abdominal cramps and/or nausea, headaches, muscle aches and fever. Recovery is usually quite rapid. Rotavirus Rotavirus is the most common cause of gastroenteritis in infants. Almost every child will have had an infection by the age of five. It has been estimated that approximately 18,000 children are hospitalised annually in England and Wales due to rotavirus-related disease. Once someone has had a rotavirus infection they usually become immune to the virus, so infections in adults are uncommon. Rotavirus can cause severe vomiting, severe diarrhoea, and stomach cramps. These symptoms usually last from 3-8 days. Good hygiene is the most important way of preventing the spread of rotavirus (PHE 2013). Other viral gastroenteritis Outbreaks of gastroenteritis caused by viruses are more common in health care settings. Compared to bacteria, viruses have a much lower infective dose. Adenovirus infections affect young children more frequently than adults. Astroviruses cause diarrhoea, mainly in children under five years old, though infections are sometimes reported in adults. Infection in childhood is believed to give long-lasting immunity. In children the disease is typically mild and does not usually require medical attention. Page 5 of 28
The Sapoviruses cause relatively mild gastroenteritis in children less than five years of age. Bacterial gastroenteritis Infection with Clostridium difficile has now become the most frequent cause of hospital acquired diarrhoea (Damani 2012). Clostridium difficile is an anaerobic bacterium that is present in the gut of up to 3% of healthy adults and 66% of infants. However, Clostridium difficile rarely causes problems in children or healthy adults, as it is kept in check by the normal bacterial population of the intestine. When certain antibiotics disturb the balance of bacteria in the gut, Clostridium difficile can multiply rapidly and produce toxins which cause illness. Clostridium difficile infection ranges from mild to severe diarrhoea to, more unusually, severe inflammation of the bowel (known as pseudomembranous colitis). People who have been treated with broad spectrum antibiotics, people with serious underlying illnesses and the elderly are at greatest risk over 80% of Clostridium difficile infections reported are in people aged over 65 years. Refer to Clostridium difficile Policy Bacteria such as Campylobacter, Salmonella, Clostridium perfringens and Staphylococcus aureus are the most common causes of food poisoning. Norovirus can also be foodborne. All these agents generally result in an illness characterised by diarrhoea and/or vomiting. Most of the organisms that cause food poisoning can also be passed from person-to-person by direct contact. Certain foods, e.g. chicken, are acknowledged as at higher risk of carrying bacterial food poisoning organisms such as Salmonella or Campylobacter. Some causes of food poisoning have incubation periods measured in a few hours (Staphylococcus aureus, Bacillus cereus), however most take days to become apparent e.g. Salmonella, 6hours to 3 days and Campylobacter, 1 to 10 days. 6. Routes of Transmission The routes of transmission for gastrointestinal infections are Airborne-inhalation or ingestion of virus particles when a patient vomits Contact-via the hands Person to person with faecal oral route Ingestion of contaminated food and drink Environmental contamination from faeces or vomit 7. Infection Control Precautions Procedures required by community nurses visiting patients in their own home or a care home Liaise with the patient in their own home or the care home staff before seeing a patient, if the patient has diarrhoea and vomiting consider delaying the visit Page 6 of 28
until the patient is symptom free for 48 hours or see the patient on the last visit of the day to reduce the risk of transmission of infection. Risk assess what may be causing the symptoms, send stool samples for irology and M,C&S if required Use healthcare grade liquid soap and water and disposable paper towels for all hand decontamination, as alcohol gel is not effective against gastrointestinal infections. Do not use cotton towels to dry hands. Hand hygiene wet wipes may be used, as a last resort, if water is not available. Staff must carry PPE such as aprons and gloves with them on visits. Decontaminate all patient equipment with a detergent and disinfectant wipe after each use and between patients. Staff must carry clinical orange waste bags and dispose of waste as infectious waste. Make a referral to North Somerset Council for a clinical waste collection see healthcare waste policy Advise patients in their own home to isolate themselves in their own bedroom to avoid transfer of infection to other family members and care home staff to isolate the patient until they have been 48 hours symptom free. Isolation procedures at North Somerset Community Hospital Isolate the patient in a single room More than one patient with symptoms can be placed in a designated cohort area if infected with same organism. In an outbreak situation, see section 8. Individual patients with diarrhoea and/ or vomiting must be isolated until 48 hours symptom free. Patient transfers between different healthcare organisations Patient transfers must be restricted between different departments and other healthcare providers. If it is necessary on clinical grounds to transfer a patient to another clinical area or healthcare organisation, appropriate isolation must be taken by the receiving healthcare organisation, following prior discussion with them and the infection control team. Patients may visit other departments, such as radiology, for clinically important investigations only, provided there has been prior notification and infection control arranged. Non important investigation must be postponed. Patients must not be transferred or discharged to residential homes or nursing homes until 48 hours symptom free. Patients can be discharged to their own homes when able to do so. Hand Hygiene In addition to routine hand hygiene at point of care, hands must be decontaminated with soap and water after patient contact and prior to leaving the patient environment, cohort area or isolation room. Alcohol gel must not be used when in contact with diarrhoea and vomiting. Refer to Hand Hygiene Policy. Page 7 of 28
Protective Clothing Wear single use non-sterile gloves and a plastic apron for contact with a patient s body fluids, handling the patient s clothes, linen and contact with the patient s immediate environment. Disposable aprons and gloves must be removed before leaving the patients isolation room or immediate environment and disposed of as clinical waste. Always wash hands after removing gloves and plastic apron with soap and water and dry hands with disposable paper towels. Linen procedures at North Somerset Community Hospital All linen from affected patients should be placed in an alginate strip red bag, inside an outer white bag. Refer to the Linen Policy Cleaning at North Somerset Community Hospital Clean and decontaminate all items of equipment used between patients after each use. The frequency of routine cleaning should be increased with special emphasis on toilet, sluice and high hand touch surfaces. Use freshly prepared hypochlorite solution (1000 ppm) to disinfect patient equipment and the environment. (i.e. Actichlor Plus ) Any spillages or contamination with faeces and vomit must be dealt with immediately. De-clutter the ward environment to aid cleaning and reduce bio-load of virus on surfaces Remove exposed fruits and other edible items, all unnecessary items from locker tops and tables must be removed. Refer to the Cleaning Policy for Infected Clinical Areas. isitors to North Somerset Community Hospital isitors must be advised of the risk of infection and measures to protect themselves should they wish to visit. Advice can be given using the Norovirus Information leaflet found on the NSCP intranet. Non essential visitors should be discouraged until the patient is 48 hours symptom free It is recommended that visitors who have had vomiting and /or diarrhoea should not visit until 48 hours symptom free. isits by school age children should be discouraged, because of the risk of developing sudden symptoms at school and non-compliance with good hand hygiene technique. Terminally ill patients, vulnerable adults and those for whom visiting is essential part of recovery should be allowed visitors at the discretion of the nurse in charge. isitors must be advised to decontaminate their hands with soap and water prior to and after visiting their relative/friend. isitors are not allowed to sit on patients beds, nor should they use patient toilet facilities. Page 8 of 28
8. Ward Outbreaks of Diarrhoea and omiting at North Somerset Community Hospital An outbreak can be defined as two or more epidemiologically linked cases of infection caused by the same microorganism in place and time (Damani 2012). In the event of an outbreak caused by diarrhoea and vomiting at North Somerset Community Hospital, staff members are required to inform a member of the Infection Prevention and Control Team immediately. A decision to place the ward under restricted access will be made by the IPCT, senior nursing staff at NSCH or an oncall Microbiologist. The ward will be under restricted access to all patient admissions and patient transfers will be cancelled to other health care providers. Patient will be able to be discharged to their own home when able to do so. During out of hours, contact the on call manager. Advice can be obtained also from the on call consultant microbiologist at North Bristol NHS Trust (01179 505050) via the switchboard, who will carry out a risk assessment and advise the ward of further infection control measures to be implemented Actions to be taken by the ward (Key Points can be found in Appendix 4) Immediately inform a member of the Infection Control Team if there are 2 or more patients and/or staff with diarrhoea and/or vomiting. Inform NSCH s Matron or Clinical Lead. Close the ward entrance doors and ensure they remain closed. Place an Infection Control notice on the doors (Appendix 5). A microbiology and virology specimen must be obtained from affected patients. o A stool sample taken from a patient within 3 days of admission should be sent for Microscopy, Culture & Sensitivity (MC&S) and another for virology. o After 3 days of admission samples must be sent for Clostridium difficile testing only and another for virology. (Laboratories only accept samples testing for M, C & S in the first 3 days of admission as it would be unlikely that the diarrhoea and vomiting was due to food poisoning after 3 days of admission in a hospital setting). o omit samples may be sent for virology; however this is generally only useful from the initial or second vomit, as viral counts are highest in these. o Commence a stool chart on all patients with diarrhoea and complete the outbreak daily record sheet (Appendix 3). Information required by the infection control team will include the following which must be recorded on the outbreak daily record sheet (Appendix 3) and be available to the IPCN each morning for review: Page 9 of 28
o The names of patients, staff members, visitors affected. o For each patient/member of staff/visitor the date and time of onset and the symptoms. o For each patient, any treatment e.g. antibiotics, laxatives, NG feeds etc., he/she is receiving, and any confirmed microbiology results e.g. Clostridium difficile. o The dates any specimen have been taken and the results. o Information about food brought in from outside the hospital eaten by the affected patients during the 48 hours prior to onset. Staffing Dedicated nursing, healthcare assistants and cleaning staff must be assigned to closed areas for each work shift. If this is not possible, thorough application of personal IPC measures as described in the standard for infection control policy are essential. These measures include the use of PPE such as plastic aprons, gloves 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 members who have worked in an affected area may work in other areas if they have no symptoms of infection but not during the same shift. Symptomatic members of staff who become ill while on duty must inform their line manager and the nurse in charge. They must leave the clinical area and must not return to work until they have been symptom free for 48 hours. The nurse in charge must inform the housekeepers to ensure that enhanced cleaning takes place where the member of staff had symptoms. Staff must not eat and drink in patient areas. Other healthcare workers such as therapists must be wherever possible dedicated to the affected ward during the outbreak. When this is not possible affected wards must be visited after unaffected wards. Bank & Agency staff. 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 that must be adhered to, and the importance of reporting any symptoms. Staff members who have worked in an affected area may work in other areas if they have no symptoms of infection but not during the same shift. The Agency must be informed of the outbreak. Staff must be reminded of the importance of keeping their work areas clean and uncluttered. Good practice would be to take personal responsibility for cleaning desk areas on a regular basis in offices and de-clutter ward areas on a daily basis. isitors Non-essential visitors, especially children and the elderly should be discouraged from visiting. See section 7. Ward re-opening at the end of the outbreak The ward will be re-opened when: Page 10 of 28
There has been 48hours after the resolution of vomiting and/or diarrhoea in the last known case and at least 72hours after the initial onset of the last new case. This is also the point at which outbreak deep cleaning has been completed. Often, there are a small number of patients with persistent symptoms and it is advisable to segregate those patients in order to facilitate a return to normal activity. Symptomatic patients may be moved into single rooms or otherwise within a cohort away from the area to be cleaned. There is thought to be little risk of prolonged airborne persistence of virus and terminal cleaning of an area such as a ward can commence immediately after removal of symptomatic patients (HPA 2012). If there is a need to reopen the ward before this time, this must be discussed with the Infection Prevention & Control Team, Operational Manager or Director Approval sought. Further stool specimens are NOT required to check if virus has cleared. Laboratory detection of virus is of no use in defining the end of an outbreak because viral shedding often continues for many days or weeks after symptom resolution. A thorough outbreak deep clean (which includes environment and all equipment) must be carried out prior to the opening of the ward and the deep clean must be checked by a member of the Infection Prevention & Control Team, Matron or Clinical Lead prior to the ward being declared open (See Cleaning Policy for Infected Clinical Areas) Actions to be taken by the IPCT The Infection Prevention and Control Team will inform key personnel if an outbreak of viral gastroenteritis is suspected and beds/wards are to be closed. The IPCT will liaise with North Somerset Community Hospital s Matron/Clinical Lead/Ward Sister every day. The IPCT will email the following personnel daily to update them on the outbreak situation. Email Contacts Chief Executive Director of Infection Prevention and Control Director of Operations Hospital Manager Public Health England The IPCT will provide daily infection control advice if the ward is affected by viral gastroenteritis. If the ward is closed over a weekend or Bank Holiday, written advice will be given to the on call manager as to the status of the outbreak and when a deep clean may be instigated. The Infection Control Record (Appendix 2) will be completed by the IPCT on each visit or phone call to ward staff documenting the progress of the outbreak. Page 11 of 28
9. Re-occurrence of symptoms Please contact a member of the Infection Prevention & Control Team for further advice on the clinical management. 10. Monitoring of Compliance Where shortfalls are identified by the IPCT, the ward sister, matron and clinical lead for North Somerset Community Hospital will ensure that improvement programmes are agreed and put in place to improve compliance in the form of an outbreak report. Any shortfall that is identified, by the IPCT, will have an action plan put in place by the Infection Control Forum and extra education will be given at North Somerset Community Hospital training sessions, statutory mandatory training for clinical staff and infection control link practitioner training days. 11. Training All NSCP staff will receive training in infection control as part of statutory & mandatory training and local induction ongoing per team as per NSCP training matrix. Clinical staff will receive an annual update in infection control, which will include management of diarrhoea and vomiting, as per NSCP training matrix Non clinical staff will receive updates in infection control issues, including management of diarrhoea and vomiting as per NSCP training matrix. Infection Prevention and Control must be discussed at staff appraisals and objectives set within Personal Development plans in line with the requirements of NICE Quality Standard (NICE (National Institute for Health and Care Excellence) 2016). 12. References Chadwick et al (2000) Report of the Public Health Laboratory iral Gastro Enteritis Working Group, Management of Hospital outbreaks of Gastro-enteritis due to small round structured viruses. Journal of Hospital Infection (2000) 45: 1-10 Damani N (2012) Manual of Infection Prevention and Control (3 rd Ed). Oxford. Oxford University Press HPA; British Infection Association; Healthcare Infection Society; Infection Prevention Society; National Concern for Healthcare Infections; NHS Confederation (2012) Guidelines for the management of Norovirus outbreaks in acute and community health and social settings. Accessed 27/05/16 at Page 12 of 28
https://www.gov.uk/government/publications/norovirus-managing-outbreaks-in-acuteand-community-health-and-social-care-settings NICE (2016) Healthcare Associated Infections. Accessed 31/5/16 at https://www.nice.org.uk/guidance/qs113 PHE (Public Health England) 2013 Rotavirus. Accessed 27/5/16 at https://www.gov.uk/government/collections/rotavirus-guidance-data-and-analysis PHLS Advisory Committee (2004) Preventing person to person spread following gastrointestinal infections: guidelines for public health and environmental health officers. Communicable Disease and Public Health ol. 7(4) P362-384. Accessed 27/05/16 at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/33684 1/guidance_on_preventing_person-to-person_infections_4_04.pdf World Health Organisation (WHO) (2013) Diarrhoeal disease. Accessed 2/6/2016 http://www.who.int/mediacentre/factsheets/fs330/en/ 13. Appendices Page 13 of 28
Appendix 1 Information provided by the PHLS Advisory Committee on Gastrointestinal Infections 2004 Organism Amoebic dysentery Bacillus species food poisoning Campylobacter Cholera Clostridium botulinumbotulism Clostridium difficile Clostridium perfringens food poisoning Cryptosporidiosis Cyclosporiasis Control of human source notifiable notifiable notifiable notifiable notifiable. Person to person spread does not occur N/A notifiable. Person to person spread does not occur notifiable notifiable (Chadwick et al 2000) Cases Contacts Exclusions Microbiological clearance until treatment complete admit to an Infectious diseases unit Hospital admission imperative... and antibiotic treatment Screen household contacts No action required Clinical surveillance Clinical surveillance for 5 days No action required Monitor susceptible individuals No action required Clinical surveillance No action required 48 hours after first normal stool. 48 hours after first normal stool 48 hours after first normal stool 48 hours after first normal stool 48 hours after first normal stool 48 hours after first normal stool 48 hours after first normal stool. Cases should avoid using swimming pools for two weeks. 48 hours after first normal stool One stool obtained one week after end of treatment. Two negative stools 24 hrs apart Page 14 of 28
Organism Escherichia coli-other than ero cytotoxinproducing Giardiasis Hepatitis A Listeriosis Marine biotoxins Non-cholera Noroviruses Control of human source N/A notifiable notifiable as viral hepatitis notifiable as food poisoning. Person to person spread does not occur except during neonatal period notifiable as food poisoning. Person to person spread does not occur notifiable as food poisoning notifiable as food Cases Contacts Exclusions Microbiological clearance and antibiotic treatment Admission to hospital and antibiotic treatment poisoning Rotavirus N/A Salmonellosis notifiable as food poisoning (Chadwick et al 2000) Clinical surveillance Screening household contacts may be required accination of house hold contacts if index case identified within one week Clinical surveillance Clinical surveillance Clinical surveillance Clinical surveillance Clinical surveillance Clinical surveillance 48 hours after first normal stool 48 hours after first normal stool 7 days after onset of symptoms 48 hours after first normal stool 48 hours after first normal stool 48 hours after first normal stool Page 15 of 28
Organism Shigellosis Staphylococcus aureus food poisoning Typhoid and paratyphoid infections (enteric fever) Yersiniosis Control of human source Clinical dysentery is notifiable. notifiable as food poisoning. Person to person spread does not occur notifiable notifiable as food poisoning (Chadwick et al 2000) Cases Contacts Exclusions Microbiological clearance. Isolation in hospital is advisable Screened microbiologically Clinical surveillance Faecal specimens should be taken from all contacts in the month prior to the cases disease onset Clinical surveillance Microbiological clearance 48 hours after first normal stool Until microbiological clearance 48 hours after first normal stool Two negative faecal specimens taken 48 hrs apart Seek advice from Health Protection Agency Page 16 of 28
Appendix 2 Infection Control Record Diarrhoea and omiting Outbreak (IPCT to complete) Ward Ext... Date / time ward closed. Organism confirmed. Relevant persons informed: Ward Closed Ward Open Matron & Clinical Lead Hospital Manager and Ex. Team Housekeepers Outbreak E-mail sent to PHE Inform Communication Team IPCN visit details & advice given Date Signature Page 17 of 28
Outbreak Record Continuation Sheet Date Signature Page 18 of 28
Appendix 3 Outbreak Daily Record Sheet Form to be completed continuously and up to date for IPCN liaison from 8a.m. Ward. Ext No Item No Pt s Bed Location Adm Date Onset date Pt Name and Hospital Number Relevant Notes Specimen Sent Result 1 Bed Medical D or? C.diff 2 Bed Medical D or? C.diff 3 Bed Medical D or? C.diff 4 Bed Medical D or? C.diff 5 Bed Medical D or? C.diff 6 Bed Medical D or? C.diff 7 Bed Medical D or? C.diff 8 Bed Medical D or? C.diff 9 Bed Medical D or? C.diff 10 Bed Medical D or? C.diff 19
11 Bed Medical D or? C.diff 12 Bed Medical D or? C.diff 13 Bed Medical D or? C.diff 14 Bed Medical D or? C.diff 15 Bed Medical D or? C.diff 16 Bed Medical D or? C.diff 17 Bed Medical D or? C.diff 18 Bed Medical D or? C.diff 19 Bed Medical D or? C.diff 20 Bed Medical D or? C.diff Page 20 of 28
21 TIME - - - - - - - - - - 1 D TIME - - - - - - - - - - 2 D TIME - - - - - - - - - - 3 D TIME - - - - - - - - - - 4 D TIME - - - - - - - - - - 5 D TIME - - - - - - - - - - 6 D TIME - - - - - - - - - - 7 D TIME - - - - - - - - - - 8 D TIME - - - - - - - - - - 9 D TIME - - - - - - - - - - 10 D
Page 22 of 28 TIME - - - - - - - - - - 11 D TIME - - - - - - - - - - 12 D TIME - - - - - - - - - - 13 D TIME - - - - - - - - - - 14 D TIME - - - - - - - - - - 15 D TIME - - - - - - - - - - 16 D TIME - - - - - - - - - - 17 D TIME - - - - - - - - - - 18 D TIME - - - - - - - - - - 19 D TIME - - - - - - - - - - 20 D
Staff Name Job D?? Date Onset Date last worked Return to work Specime n date Result Relative/ isitor Name Pt connected with D?? Date Onset Date last visited Specimen date Result Comments: Page 23 of 28
Appendix 4 Key Points for North Somerset Community Hospital Key points Transfer any symptomatic patient to a single room or group together, with separate facilities and designated staff Ring IPCT if two or more cases of unexpected sudden vomiting on (Julia Bloomfield 07554 224732) (Suzanne Golding-Ellis 01275 885383 or 07867832808 (Out of hours contact an on-call microbiologist via Switchboard at North Bristol NHS Trust) Decontaminate hands with soap and water only. Do not use alcohol gel. Wear aprons and gloves when caring for symptomatic patients, wash hands with soap and water after removal Obtain specimens of diarrhoea or vomit ASAP from patient as possible, including staff Send specimens for IROLOGY and M, C & S on a microbiology request form or on ICE in the first 3 days of admission. Once patients are 72 hours post admission send specimens for C.difficile only on a microbiology form and irology request on ICE. Clean up spillages promptly using a solution of hypochlorite 1000ppm according to manufactures guidance (Actichlor plus ) wearing protective clothing Ensure commodes are cleaned thoroughly between each patient episode using Actichlor plus DISCARD all uncovered food and drink from work stations and bed side tables. Do not transfer patients to residential or nursing homes during an outbreak. Patients that are asymptomatic can be transported to other healthcare departments for investigations, but should go on the end of the list. Symptomatic patients must only go for urgent investigations where the benefit outweighs the risk. Liaise with the relevant department. Patients that are asymptomatic and are able to be discharged home are encouraged to do so, providing the family / carer is willing to receive them. Advise the Ambulance Service if a patient being transported has come from an area that has an outbreak and whether they are symptomatic. Please try to avoid ambulance transportation whilst patients are symptomatic, where possible. IPCT will liaise with the hospital manager and executive team regarding closure and reopening of beds Ward to remain closed until 48hrs have elapsed since last symptomatic case and ward outbreak deep clean completed Affected staff must leave work immediately and stay off until 48 hrs after last symptoms. Page 24 of 28
Appendix 5 Outbreak Notification Poster for Ward Entrances Infection Prevention & Control DO NOT ENTER Diarrhoea and omiting Outbreak Please see Nurse in Charge before entering 25
Appendix 6 Equality Impact Assessment Equality Impact Assessment Section 1: Initial Assessment Policy Author Date of Assessment Julia Bloomfield July 2016 Title of Policy The Management of Diarrhoea and omiting Policy Is this a new or existing policy? Replaces existing policy 1. Briefly describe the aims, objectives and purpose of the Policy / Guidance Document: To provide a clear course of action for staff in the event of an outbreak of Diarrhoea and omiting and plans to reduce spreading the virus. 2. Who is intended to benefit from the proposed process and in what way? All patients and staff, to ensure a healthy care and working environment and to protect the vulnerable from further illness. 3. Who are the main stakeholders in relation to this Policy/Guidance? Patients and Staff 4. Are there concerns that the Policy/Guidance does, or could have, a differential impact due to any of the equality areas? (Y/N delete as appropriate) Age Disability Gender reassignment Marriage and Civil Partnership Pregnancy and Maternity Race Religion or Belief Sex Sexual orientation N N N N N N N N N 5. What existing evidence (either presumed or otherwise) do you have for this? 26
Applicable to all equally 6. Based on the answers given in questions 4 & 5 is there potential for an adverse Impact in this policy/guidance? No 7. Can this adverse impact be justified? N/A If you have not identified adverse impact or you can justify the adverse impact, finish here. If you have identified adverse impact that cannot be justified, please continue to Section 2 Section 2: Full Impact Assessment 8. What experts/relevant groups have you approached to explore their views on the issues? Please list the relevant group/experts, how they were consulted and when. Relevant groups/experts How were the views of these groups obtained? Date contacted 9. Please explain in detail the views of these groups/experts on the issues involved: 10. Taking into account the views of the groups/experts and the available evidence, what are the risks associated with the policy, weighed against the benefits of the policy if it were to stay as it is: Risks Benefits If you have found that the risks outweigh the benefits you need to review the policy further and put together an implementation plan which clearly sets out any actions you have identified as a result of undertaking the EIA. These may include actions that need to be carried out before the EIA can be completed or longer-term actions that will be carried out as part of the policy or development. Page 27 of 28
11. Monitoring arrangements and scheduled date to review the policy and Equality Impact Assessment: Review Date Page 28 of 28