General Practice Template Guidelines for the Management of cases & outbreaks of Norovirus Title: Procedural Document Type: Reference: Version: Ratified by: Date ratified: Freedom of Information: Name of originator/author: Name of responsible team: Review Frequency: Review date: Target audience: Guidelines for the management of outbreaks of Norovirus Guidelines This document can be released 2 Years All Staff
Contents 1.0 Purpose...3 1.1 Rationale...3 1.2 Scope and disclaimer...3 1.3 Implementation, Education and Audit Policy Compliance...3 2.0 General Good Practice Points...3 2.1 Incident reporting...4 3.0 Duties and Responsibilities...4 4. 0 Core Guidance...5 4.1 Introduction...5 4.2 Signs and Symptoms...5 4.3 Transmission...6 4.4 Diagnosis...6 4.5. Reducing risks in General Practice settings...6 4.6 Home visits...7 4.7 Admitting cases to hospital...7 5. References...8 Appendix 1...9 Increased Daily Cleaning Schedule...9 Appendix 2 Stool Chart...10 Appendix 3 Hand washing poster...11 Appendix 4...12 PATIENT INTER HEALTHCARE TRANSFER/DISCHARGE INFORMATION FORM... 12 Page 2 of 14
1.0 Purpose This policy has been developed to provide a practical document to equip all healthcare staff with the necessary information on the recognition, management and treatment of cases & outbreaks of Norovirus. 1.1 Rationale The prevention and control of Norovirus is essential for the business continuity of healthcare settings and the population of Cornwall 1.2 Scope and disclaimer This policy is for use by (insert staff groups here) 1.3 Implementation, Education and Audit Policy Compliance Implementation will be through the (insert systems here e.g. IPC Forum, IPC Link ) Education and Management of Norovirus will be embedded in (insert local system here) Audit will take place using Infection Prevention Society Audit Tools and Hand Hygiene Audits and the results discussed at (name forum here e.g.ipc Committee.) 2.0 General Good Practice Points Cases should be managed in their home or care home wherever possible and not admitted to acute or community hospital without urgent clinical need. Every case of unexplained Vomiting and Diarrhea (V&D) should be separated from other patients if attending the surgery is unavoidable. Every case of unexplained diarrhea (D) should have a stool specimen sent at the earliest possible time A second case with V&D or D within a household, care home or hospital constitutes an outbreak. Page 3 of 14
In hospitals and care homes an outbreak meeting should be held as urgent to ensure all Infection Prevention and Control measures are in place A stool chart and fluid balance chart should be maintained on all symptomatic patients in care homes and hospitals. Staff who become symptomatic with diarrhoea and /or vomiting must leave the area immediately not return to work until 48 hours symptom free. 2.1 Incident reporting The incident reporting system should be used to report (list as appropriate eg: o Breaches in safe transfer of patients in or out of hospitals) 3.0 Duties and Responsibilities All staff Have the responsibility to follow policy guidance Have a responsibility to ensure that good practice minimizes the risk of transfer of infection Managers Have the responsibility to ensure local risk assessments are carried out where necessary, e.g. to identify safe practices, including the provision of resources to ensure this is implemented Have the responsibility to ensure training is available and staff have the responsibility to attend such training sessions. Managers have a responsibility to consult with staff to ensure policy compliance (Insert key title) is ultimately responsible for health and safety. Page 4 of 14
4. 0 Core Guidance 4.1 Introduction Norovirus is a major cause of acute gastroenteritis (vomiting and diarrhoea) in children and adults. The cause of illness, Norovirus (previously known as Norwalk-like or Small Round Structured Virus) was described in 1968 in samples from an elementary school in Norwalk, Ohio. The disease is often termed Winter Vomiting Disease because of the increased prevalence in the winter months; however it can be detected throughout the year. Norovirus is the most common cause of outbreaks of gastro-enteritis in hospitals and can also cause outbreaks in other settings such as schools, nursing homes and cruise ships. Hospital outbreaks often cause major disruption in hospital activity resulting area closures, cancelled admissions and delayed discharges which can significantly reduce clinical activity for the duration of the outbreak. Failure to observe and comply with Infection Control guidelines/policy can lead to further spread of infection and a delay in returning to normal activity. Outbreaks can affect both patients and staff, sometimes with attack rates in excess of 50% (in homes or hospitals). For this reason, staff shortages can be severe, particularly if several areas are involved at the same time. It is therefore essential that cases are detected early and managed appropriately to prevent spread and major outbreaks across the health community. 4.2 Signs and Symptoms The average incubation period for Norovirus associated gastro-enteritis is 12-48 hours. The illness is characterized by a sudden acute onset of: o Vomiting is the predominant symptom, often projectile, and is seen in 50% of cases. However clusters can occur where vomiting is infrequent or absent altogether. o Watery diarrhoea and abdominal cramps o Nausea In addition headache, myalgia, fever and malaise are common. Some or all of the above symptoms may be present. Symptoms last between one and three days and recovery is usually rapid. Dehydration is the most common complication and some patients may require replacement fluids. Page 5 of 14
4.3 Transmission Noroviruses are highly contagious with as few as 100 virus particles thought to be sufficient to cause infection. Noroviruses are transmitted primarily through the faecal oral route either by person to person spread or via contaminated food or water. In addition Noroviruses can less frequently be spread via aerosol dissemination of infected particles following vomiting (close proximity). Transmission can also occur through hand transfer of the virus to the oral mucosa following contact with environmental surfaces, fomites and equipment which have been contaminated with either faeces or vomit. 4.4 Diagnosis Norovirus may be suspected clinically in patients and staff with a history of vomiting of sudden onset followed by diarrhoea. During an outbreak several people are commonly affected over a short space of time and cases with typical features may be ascribed to norovirus infection without further testing. Confirmation of norovirus infection depends on a PCR test performed on faecal samples. This is useful in confirming the nature of an outbreak early on, identifying atypical or outlying cases and in determining whether norovirus shedding is occurring in cases of persistent diarrhoea. When an outbreak is suspected, it is imperative to institute infection control measures immediately without waiting for virological confirmation from stool testing. 4.5. Reducing risks in General Practice settings Consider use of poster displayed at the entrance of the area advising that there is an outbreak of diarrhoea and vomiting in the community if appropriate. Affected patients should not attend the surgery if this can be avoided. Anyone attending with symptoms suggestive of Norovirus should be kept separate from others within the limits of safe care of the person & have dedicated toilet facilities if this is possible if not use enhanced cleaning of toilets used by those with symptoms. Equipment should be cleaned and disinfected (with Actichlor plus) after use on patient with Noro symptoms. Page 6 of 14
PPE (aprons and gloves) must be used appropriately (single use items) and for each episode of care/treatment/examination on all affected patients by all staff Soap and water MUST be used for Hand Hygiene after each patient contact. Alcohol hand gel is not effective against Norovirus and therefore should be removed from use. 4.6 Home visits Home visits to those with symptoms suggestive of Norovirus should be scheduled after other visits if possible. Shower and change clothes before seeing other patients. Soap and water MUST be used for Hand Hygiene after each patient contact. Alcohol hand gel is not effective against Norovirus. Wipes eg Clinnell may be used where soap and water is not available but hands should be washed with soap and water at the earliest opportunity. PPE (aprons and gloves) must be used appropriately. 4.7 Admitting cases to hospital Admission to hospital should only be considered following thorough assessment of clinical need. Consider the use of hospital at home services (or equivalent) where appropriate. Usual indications for admission would be severe dehydration, uncertain diagnosis or other condition needing urgent specialist attention. Discuss admission with Acute GP service on MAU or MAU Consultant to enable appropriate triage of admission to isolation facility. Interhealthcare transfer forms MUST be used when admitting any patient with an infection. The movement of affected residents from care homes is NOT recommended as a measure to reduce transmission in the home. Care homes have a version of this guidance as well as Health Protection guidance to advise on outbreak control. Page 7 of 14
5. References Health Protection Agency (2007) Guidance for the Management of Norovirus Infection in Cruise Ships. London. HPA Lopman B. et al (2004) Epidemiology and cost of nosocomial gastroenteritis, Avon, England. Emerging Infectious Diseases 10 (10) 1827. Lopman B. et al (2004) Clinical manifestation of Norovirus gastroenteritis in healthcare settings. Clinical Infectious Disease. 39 (3) 318-24 NHS Soutwest (2009) Norovirus Toolkit. PHLS viral gastroenteritis working group (2000) Management of Hospital outbreaks of gastroenteritis due to small round structured viruses. Journal of Hospital Infection. 45(1) 1 10. Page 8 of 14
Appendix 1 Increased Daily Cleaning Schedule ALL DAMP DUSTING/MOPPING TO BE UNDERTAKEN USING A CHLORINE BASED DISINFECTANT EG ACTICHLOR PLUS INSERT FREQUENCIES THAT REPRESENT AN INCREASE TO THE NORMAL ROUTINE Toilets (?cleans daily) High dust and clean wall/vertical surfaces up to 6 feet (1) Damp dust all other surfaces including all fixtures, fittings and furniture Wipe over bin and empty if necessary Clean, shine and remove smears on mirrors/internal glass Clean basins and surrounds Clean toilet and surrounds Replenish supplies if necessary Dust control and damp mop floor area Sluice (? cleans daily) High dust and clean wall/vertical surfaces up to 6 feet (1) Damp dust all other surfaces including all fixtures, fittings and furniture Wipe over bin and empty if necessary Clean, shine and remove smears on mirrors/internal glass Clean basins and surrounds Replenish supplies if necessary Dust control and damp mop floor area Page 9 of 14
Appendix 2 Stool Chart Page 10 of 14
Appendix 3 Hand washing poster ATTENTION SICKNESS OUTBREAK HAND WASHING There is currently an outbreak of diarrhoea and/ or vomiting. For the duration of this outbreak please do not use the alcohol gel *use soap and water to wash hands* For further information please contact ----------------------------------------------------- Page 11 of 14
Appendix 4 PATIENT INTER HEALTHCARE TRANSFER/DISCHARGE INFORMATION FORM (To be used for all patient transfers and discharges between any healthcare settings) PATIENT NAME: D.O.B:..././. CR. NO: ADDRESS: HOSPITAL:. CONSULTANT:. GP:. GP SURGERY: NHS NO: WARD: DATE ADMITTED:../../. DATE FORM COMPLETED:../../. Name of transferring/discharging facility: (e.g. hospital, ward, care home, own home)... Name of receiving facility: (e.g. hospital, ward, care home, own home).... Name & designation of clinician responsible for decision:. Person completing this form: Print name:. Signature:... Designation:... Main contact (NOK/main carer):.. Telephone number:... Relationship:... Informed of Discharge/Transfer YES/NO (Please circle) If NO, specify reason:... MEDICAL: DIAGNOSIS:. IS THE PATIENT AWARE OF DIAGNOSIS? YES NO (Please circle) RELEVANT PAST MEDICAL HISTORY:.. MOBILITY: YES NO ADDITIONAL INFORMATION e.g. ASSISTANCE / SUPERVISION / TRANSFERS WITH EQUIPMENT? TRANSFERS WITH 1 or 2? Stipulate number of carers required: TRANSFERS INDEPENDENTLY? MOBILISES WITH EQUIPMENT? MOBILISES WITH 1 or 2? Stipulate number of carers required: MOBILISES INDEPENDENTLY? HAS BARIATRIC NEEDS? PERSONAL CARE: YES NO ADDITIONAL INFORMATION SELF-CARING? ASSISTANCE REQUIRED? TISSUE VIABILITY: YES NO ADDITIONAL INFORMATION e.g. AREA(s) AFFECTED SKIN INTACT? EQUIPMENT INSITU? EQUIPMENT REQUIRED? Inc dressings WATERLOW SCORE DATE 0F ASSESSMENT or REVIEW / / NUTRITIONAL STATUS: YES NO ADDITIONAL INFORMATION NORMAL DIET / FLUIDS? SWALLOW PROBLEMS? SUPPLEMENTS REQUIRED? IS PATIENT SELF MEDICATING? MEDICATION SUPPLIED? KNOWN ALLERGIES? Page 12 of 14
OTHER: ADDITIONAL INFORMATION SPEECH SIGHT HEARING BREATHING CONTINENCE YES NO YES NO ADDITIONAL INFORMATION Continent of URINE? Catheter in situ? Continent of FAECES? COGNITION YES NO ADDITIONAL INFORMATION HISTORY /INTENTION OF SELF HARM? ORIENTATION/TIME/ PLACE /PERSON? WANDERS / AGGRESSIVE? (verbally/physically) N.B This is a double sided form-please ensure both sides are completed at the time of transfer/discharge Patient name: CR No. SOCIAL INFORMATION: ADDITIONAL INFORMATION LIVES ALONE OR WITH? KEY WORKER in COMMUNITY TYPE OF DWELLING: Tick if patient has: COMMUNITY NURSES COMMUNITY MATRON DASC (SS) INVOLVEMENT INFECTION CONTROL: YES NO IS THE PATIENT AN INFECTION RISK? IS THE INFECTION CONTROL TEAM AWARE OF THE TRANSFER/DISCHARGE? IS SWAST/TRANSPORT SERVICE BOOKED AWARE OF THE TRANSFER/DISCHARGE? Please tick most appropriate box below and give confirmed or suspected organism Confirmed risk Name of organism: Confirmed risk Name of organism: HAS THE PATIENT BEEN EXPOSED TO OTHERS WITH INFECTION? e.g. D&V If patient has diarrhoeal illness, record bowel history for the last week based on the Bristol Stool Form Scale: IF A DIARRHOEAL ILLNESS, IS IT THOUGHT TO BE OF AN INFECTIOUS NATURE? HAS THE PATIENT BEEN SCREENED FOR MRSA? IF YES ENSURE RESULT IS RECORDED IN RELEVANT SPECIMEN RESULTS TABLE BELOW IF DIAGNOSED AS MRSA+ HAS DECOLONISATION COMMENCED? IF YES, RECORD DATE COMMENCED HERE:././. FURTHER SCREEN DATE(S) HERE: / / / / / RELEVANT SPECIMEN RESULTS (Including admission screens-mrsa, glycopeptide-resistant enterococcus SPP, C. Difficile, multi-resistant Acinetodactor SPP) and treatment information, including antimicrobial therapy) SPECIMEN DATE RESULT TREATMENT IS THE PATIENT AWARE OF DIAGNOSIS OF INFECTION? DOES THE PATIENT REQUIRE ISOLATION? OTHER RELEVANT INFORMATION RE INFECTIOUS STATUS: NOTE: Should the patient require isolation please telephone the receiving unit in advance IF YOU REQUIRE FURTHER ADVICE CONTACT YOUR INFECTION CONTROL TEAM Page 13 of 14
NURSE PATIENT VALUABLES: Is the patient able to take responsibility for their cash/valuables? If YES follow discharge procedure If NO do they need to be transferred to a hospital safe at next destination? If YES have you notified General Office of patient transfer/discharge? OVERALL RECOMMENDATIONS: SUMMARY/KEY INFORMATION FOR FUTURE PATIENT MANAGEMENT: INCLUDE ADMISSION AVOIDANCE CONTINGENCY PLAN FOR TRANSFERS FROM HOSPITAL SETTINGS When FAXing ensure both sides are copied & patient name and NHS number recorded Note: Infection Control section covers all fields of the DoH 2007: Essential Steps to safe, clean care Inter-healthcare infection control transfer form Page 14 of 14