Infection Prevention Policy Policy for the Management of Confirmed or Suspected Infectious Diarrhoea & Vomiting in Acute and Community Wards N.B. Staff should be discouraged from printing this document. This is to avoid the risk of out of date printed versions of the document. The Intranet should be referred to for the current version of the document.
Contents: Aneurin Bevan Health Board 1 EXECUTIVE SUMMARY... 2 1.1 Purpose of the Policy... 2 2 TARGET AUDIENCE... 2 2.1 Implementation...2 3 INTRODUCTION... 2 4 POLICY STATEMENT... 3 5 AIMS... 3 6 OBJECTIVES...3 7 RESPONSIBILITIES... 3 8 INFECTION CONTROL PRECAUTIONS...4 8.1 Prevention of Spread Source Isolation... 4 8.2 Hand hygiene... 5 8.3 Protective Equipment...5 8.4 Environmental Cleaning... 5 8.5 Patient Management... 5 8.6 Patient Movement... 6 8.7 Discharge of patients... 7 9 NOTIFICATION... 7 10 SUSPECTED OUTBREAKS... 7 10.1 Suspected Outbreak Initial Steps... 8 11 STAFF ILLNESS DURING OUTBREAKS...8 12 KEY REFERENCES...9 13 APPENDICES... 10 Appendix 1 Infection Preventionl Standard Operating Procedure... 10 Appendix 2 Infection Prevention Outbreak pack...3 Appendix 3 Viral Gastroenteritis - Summary of Guidance... 24 Appendix 4 -The Bristol Stool Chart....27 1
1 EXECUTIVE SUMMARY 1.1 Purpose of the Policy This policy outlines the approach of the Organisation in the management of individual cases of diarrhoea or vomiting that might be of infectious origin and any outbreak associated with such infections through: Prompt identification of cases Appropriate management Notification Isolation precautions Risk Assessment This policy must be used in conjunction with the Infection Control Manual. 2 TARGET AUDIENCE All Organisation employees clinical and non-clinical. All levels of management. 2.1 Implementation All Divisions must ensure that; Staff have access to this policy Staff have the required resources to comply with this policy in terms of equipment, staffing levels and training. Additional staffing resources may be needed during diarrhoea and vomiting incidents. 3 INTRODUCTION Diarrhoea and vomiting may be caused by many agents, both infective and non-infective. Diarrhoea is the increased frequency of passing a loose stool that would not normally be expected for that person due to an underlying clinical condition or an expected consequence of bowel surgery. Diarrhoea can be acute or chronic. Transmission is by the faecal-oral route. Organisms can be present in the environment and transferred by hands. The following policy gives advice regarding the management of a patient with suspected or confirmed diarrhoea or vomiting caused by infection, particularly suspected Viral gastroenteritis, which is often caused by Noroviruses. It should be used in conjunction with separate policies on Clostridium difficile-associated diarrhoea and Food Poisoning. 2
Outbreaks of viral gastroenteritis and other enteric infections in healthcare premises may result in a considerable morbidity amongst staff and patients. An outbreak is defined as two or more cases of known or suspected infectious gastroenteritis on any acute or community ward, This policy provides guidance for the reporting and management of gastrointestinal infections so that individual cases will be dealt with appropriately, and potential outbreaks recognised promptly. 4 POLICY STATEMENT The Aneurin Bevan Health Board will ensure that any case of gastrointestinal infection is managed appropriately and outbreaks of such infections promptly recognised and brought under control through implementation of this policy. 5 AIMS To provide staff with information on the correct management of gastrointestinal infection in patients and staff. To provide staff with information on factors that influence the risk management of individual cases and outbreak situations. 6 OBJECTIVES State requirements for managing cases of gastrointestinal infections. Clarify roles and responsibilities in the management of individual cases and outbreak situations. State the definition of an outbreak, to aid prompt recognition. Provide employees who have symptoms of gastrointestinal infection and their managers of the correct procedure to follow to prevent spread to others. 7 RESPONSIBILITIES All Healthcare workers have responsibility for implementing this policy. All wards and departments must have access to this policy. The Infection Prevention Committee endorses and communicates this policy Organisationwide and provides advice and support in its implementation The Infection Prevention Team (IPT) has primary responsibility for providing training on the policy where needed. 3
Managers have responsibility to support the IPT by ensuring that staff are able to attend training sessions in response to identified needs. Clinical staff must report any cases of known or suspected infectious gastroenteritis to the Infection Prevention Team or on call Consultant Microbiologist out of hours. The Infection Prevention Nurse(s) will investigate all reported cases to determine the probable source. The local Health Protection Team and Environmental Health Department have responsibility for following up sources within the Community. The Occupational Health Department are responsible for the management of staff with suspected or known food poisoning or other gastrointestinal infection in collaboration with their GP and the Infection Prevention Team. The IPT will feedback any non-compliance with this policy if identified to the relevant Division, via clinical incident form. 8 INFECTION CONTROL PRECAUTIONS 8.1 Prevention of Spread Source Isolation All cases of gastroenteritis must be regarded as potentially infectious until appropriate investigations are completed. Action should be taken as soon as a patient is identified with known or suspected infectious gastroenteritis. In Accident & Emergency and Emergency Assessment Units the patient should be isolated immediately in a single room preferably with ensuite facilities. If no isolation facility is available, patient must be fast tracked through to an isolation room and clerked on the ward. In wards, they should be isolated with strict enteric isolation precautions in a single room with ensuite facilities, or allocated their own commode. The case must be reported immediately to a member of the Infection Prevention Team. For suspected viral gastroenteritis, isolation precautions will be required until the patient has been symptomfree for at least 48 hours and passed a formed stool (or one that is normal for the individual). If sufficient side-rooms are not available for affected patients, where the number of affected patients is small and confined to one area of the ward, e.g. one bay, they must be nursed together as a cohort in an area of the ward, preferably close to toilet facilities and apart from other patients. Occasionally, the Infection Prevention Doctor may advise that the rest of the ward may stay open pending observation of the developing number and nature of cases. If the number of cases increases the Infection Prevention Team will deem the ward closed to admissions. Any decision to breach affected wards must be taken through the agreed escalation process to executive level (see Appendix 1). See the separate Diarrhoea and Vomiting Outbreak Advice Pack (Appendix 2) and the appendix to this policy for further details of infection control precautions. 4
8.2 Hand hygiene Effective hand hygiene must be maintained (Refer to policy for hand hygiene) Contaminated hands are the most common route of transmission of diarrhoea infection. After contact with a patient, completing any task or use of equipment, staff must always wash their hands with liquid soap and water using the approved multi-step technique and dry thoroughly with disposable paper towels. Alcohol gel can be used to reinforce hand washing but must not be relied upon for hand decontamination for diarrhoeal disease because the alcohol does not readily kill spores or viruses. Staff must always ensure that patients are advised to wash their hands after using the toilet/commode and before meals. Immobile patients must be offered soap and a clean bowl of water to wash their hands. 8.3 Protective Equipment Disposable non-powdered latex gloves and a disposable plastic apron must be worn whenever there is exposure or potential exposure to body fluids, contaminated items and linen from a patient with diarrhoea. They must be changed and disposed of as clinical waste after each task or contact and decontaminate hands using soap and water. 8.4 Environmental Cleaning Routine thorough and rigorous decontamination of the environment is essential to prevent transmission of organisms that can cause diarrhoea. When a patient has been identified as having diarrhoea additional cleaning frequency must be implemented. All furniture and equipment that has come in contact with the patient must be decontaminated with 2,000 ppm Actichlor solution. Bedpans containing faeces must be disposed of directly into a macerator or bedpan washer thereby reducing the risk of environmental contamination. Following discharge of the patient, the room and its contents must be decontaminated with Actichlor. Attention must be paid to remove all faecal soiling, and in particular to cleaning of furniture, fittings and horizontal surfaces. Mattresses and pillow covers must be decontaminated with Actichlor. Curtains require changing. 8.5 Patient Management A diarrhoea checklist should be used. The following details should be recorded by ward staff: Patient name Unit number Date of birth 5
Date of onset Time of onset Symptoms Frequency and description (use an accepted stool chart such as the Bristol) Location of patient on ward Faecal specimens taken do not send formed stools Previous & current antibiotic treatment Laxatives and aperients used Stop any laxatives or other treatment that may cause diarrhoea if clinically safe to do so. Ensure that patients with diarrhoea remain hydrated and accurate fluid balance charts are maintained. Stool charts must be commenced to document frequency and consistency of stool. Current antibiotic treatment must be reviewed by the clinician (refer to antibiotic prescribing guidance) subsequent antibiotic treatment should be discussed with the microbiologists and clinicians. Other causes of diarrhoea other than infectious causes should be taken into consideration and diagnostic investigations requested accordingly. Following identification of diarrhoea send a faecal specimen to microbiology requesting microscopy, culture and sensitivity, Clostridium difficile toxin assay. If the patient is suspected of having Clostridium difficile, commence appropriate antibiotic treatment (refer to therapy guidelines in the Clostridium difficile Policy). If the patient is suspected of having Viral Gastroenteritis refer to the specific Viral Gastroenteritis guidelines (see Appendix 3). 8.6 Patient Movement Symptomatic patients with diarrhoea must not be transferred to other wards in the hospital, except for purposes of isolation or cohort nursing. This decision must be based on a clinical assessment of the patient. Visits to other departments must be kept to a minimum. When this is necessary, either for investigation or treatment, prior arrangements must be made with the manager of that department, so that the Organisation s guidelines can be implemented. Symptomatic patients should be seen at the end of the working session to allow time for adequate cleaning. They should only be sent for when the department is ready to see them; they should not be left in the waiting room/ area with other patients and cleaned accordingly. Patients affected by infectious gastroenteritis should be discouraged from leaving the ward to go to the hospital restaurant. 6
8.7 Discharge of patients Patients with diarrhoea who are still symptomatic should only be discharged if they are medically fit and the Infection Prevention and Control Team informed. It is the responsibility of the patient s clinical team to communicate with the General Practitioner about symptomatic patients who are being discharged into their care. Similarly, it is the responsibility of the ward staff to inform community and district healthcare nurses, social workers, or others attending the patient in their own home, of any patient to be discharged into their care who remains symptomatic. 9 NOTIFICATION The Consultant for Communicable Disease Control (CCDC) must also be informed by the clinician responsible for the patient if food poisoning is suspected this can be done whilst awaiting stool test results. The Contact number for the National Public Health Service (NPHS) is 01495 332219. Official notification forms can be obtained from the NPHS if needed. The Infection Prevention Team will report all outbreaks via HOWIS and to Regional office. 10 SUSPECTED OUTBREAKS The Infection Prevention Nurse will investigate each case of unexplained diarrhoea or vomiting occurring in a patient or member of staff. Two or more linked cases with similar symptoms occurring at the same time must be notified immediately by telephone to the Infection Control Nurse or, if unavailable, to the Consultant Microbiologist. Out of hours, the on-call Consultant Microbiologist must be contacted via the hospital switchboard. When the notifications of gastrointestinal infection amongst staff or patients suggest there is an outbreak, the Infection Prevention Doctor and the Infection Prevention Nurse will be responsible for the management and investigation of the incident, and may request assistance from outside agencies such as the CCDC. If, following assessment by the Infection Prevention Team, it is deemed necessary to advise that the ward is closed to admissions in order to reduce the potential spread of the infection, the Standard Operating Procedure for D&V must be implemented by the IPT (Appendix 1). Decisions made at this time will be communicated to the appropriate departments. Please refer to the Standard Operating Procedure for the designated list of healthcare workers who need to be informed of the closure (Appendix 1). The Major Outbreak Plan may be activated if there is a large number of confirmed, or suspected cases. 7
A serious outbreak of D&V would be classified as three or more wards affected within the Organisation. 10.1 Suspected Outbreak Initial Steps a. isolate affected patients b. advise affected staff see below c. obtain faecal specimens for microbiological analysis bacteriology and virology but do not send formed stool d. institute strict enteric isolation precautions e. if the whole or a major part of one ward is affected, close the ward to admissions, discharges and transfers until further evaluation and institute cohort nursing. 11 STAFF ILLNESS DURING OUTBREAKS Staff ill whilst at work in outbreak situations who develop symptoms of viral gastroenteritis whilst on duty must report to their manager that they are unwell and then phone the Organisation s Occupational Health Department for advice on appropriate management and follow up. A stool specimen should be sent to the microbiology laboratory. Staff must stay off work until they are completely free of symptoms for 48 hours. It is accepted that the nature of the illness need not be disclosed to persons other than the Occupational Health Department if the staff member so wishes. Nevertheless, staff should appreciate that it is helpful in the management of the service for managers and the Infection Prevention Team to be informed. Members of staff suffering from gastrointestinal or food poisoning infection must inform the manager that they are unwell. The manager will refer to the Occupational Health Department if the staff member does not wish to do so personally. Staff ill at home who become unwell with symptoms of viral gastroenteritis whilst off duty must telephone their manager in the usual way. It would be helpful to the management of the service if staff state the nature of their illness. Members of staff must endeavour to submit a stool specimen as soon as possible for microbiological testing and be advised to remain off duty for 48 hours after symptoms resolve. If more than one member of staff seems to be suffering from gastrointestinal infection, the manager must contact the Occupational Health Department or Infection Prevention and Control Team. If the stool test yields a transmissible pathogen, the Infection Prevention Nurse or Doctor will liaise with the Occupational Health Department in order to carry out a risk assessment to determine the need for further specimens and the time for return to work. The manager of the employee will need to be advised of the outcome of the risk assessment in order to cover the member of staff s continued absence or other recommendations. Where possible, consent must be obtained from the staff member concerned before disclosing any results to their manager. See the Food Poisoning Policy for further advice. 8
11.1 Staff restriction Ideally, Agency Staff must not work on affected wards. However, Bank Nurses and Nurses from other areas could work on the ward providing, a) They remain rostered to the affected ward for the duration of the outbreak. b) They have 3 days off before working on another ward. Ideally patients should be cared for by staff who have recovered from the virus. The Infection Prevention Team would recommend that staff take breaks on the ward. A designated member of staff can access the restaurant to pick up pre-ordered food for staff. Hotel Services staff working on the affected wards must not subsequently provide cover to un-affected ward areas. Domestic Supervisor to ensure appropriate cover is provided. 12 KEY REFERENCES Chadwick P.R., Beards G. et al., Management of Hospital outbreaks of gastroenteritis due to small round structured viruses, Journal of Hospital Infection, 2000 45, 1-10. Centers for Disease Control and Prevention, Norwalk like viruses: public health consequences and outbreak management. MMWR, 2001; 50 (no. RR-9). Cowden J. Winter Vomiting, Infections due to Norwalk-like viruses are underestimated. British Medical Journal, 2002, 324, 249-250. Farr B.M., Nosocomial Gastrointestinal Tract Infections, (cited in Mayhall C.G., Hospital Epidemiology and Infection Control,1999 2nd Ed, Lippencott Williams and Wilkins, Philadelphia. 9
13 APPENDICES Appendix 1 Infection Control Standard Operating Procedure Infection Prevention & Control Team Standard Operating Procedure Management of Diarrhoea and Vomiting Diarrhoea and vomiting outbreaks (often due to norovirus) seriously impact on the care we give our patients as well as severely disrupting Organisation activity. Evidence suggests that norovirus impacts on the number of patients acquiring Clostridium difficile and emerging evidence suggests that mortality rate increases in the elderly. Regardless of age, norovirus gastroenteritis in hospitalised persons is more severe than in other groups. It is therefore essential that outbreaks are identified early and brought under control as soon as possible. Once an outbreak has been identified a named member of the Infection Prevention (IPT) will close the ward to new admissions. Any decision to breach affected wards must be escalated to executive level by bed management / senior manager. Communication of Ward Closure The following personnel must be informed of the ward closure: Ward Manager or nurse in charge Senior Nurse for the affected ward Senior Manager for the affected ward Bed Management Senior Clinician for the affected ward. Senior Occupational Therapist, Physiotherapist and Social Worker Facilities Manager Head of Hotel Services Senior Radiographer The following personnel will be copied in for information: Director of Nursing Non- Exec Lead for infection Control Community Health Council Chief Nurse Media Officer Occupational Health 10
Ward Closures The reasons for closing wards, affected by D&V, are fourfold: To prevent new patients acquiring the virus, in conjunction with their admitting illness. To bring the outbreak under control in the shortest period of time possible, ensuring normal Organisation activity resumes as soon as possible. To relieve pressure on wards where numerous members of staff may be sick with norovirus. To allow effective cleaning, an essential component in preventing cross infection. Identification of an outbreak Early identification of cases is essential. The IPaC team must be contacted when two or more patients with diarrhoea and/or vomiting have been identified and no other reason can be found for the symptoms, or if any normally fit member of nursing staff or of the public suffers from diarrhoea and/or vomiting while in a ward or public area within the hospital. During normal working hours Monday-Friday, an IPaC nurse will visit the ward to assess the situation. The IPaC nurse will advise as to whether the ward should be closed. On occasion, following consultation with the Infection Control Doctor for the site involved, or his/her named deputy, the IPaC nurse may observe the situation and advise that affected patients are isolated and the bays the patients vacated are closed. Bed management will be informed that the ward is closed or under observation. After 24 hours has elapsed, the ward under observation will be reviewed again: If no further cases are identified and the original cases are not now considered to be norovirus the ward will resume normal activity. If no further cases identified and the original cases are still suspected to be norovirus, keep the bays closed for a further 24 hours. If new cases have arisen and the original cases are considered to be norovirus a full outbreak will be declared. The following operating procedure will be put into place. Standard Operating Procedure During normal working hours Monday Friday, the IPaC nurse will visit affected ward/s early each day to assess the outbreak. Outbreak packs can be downloaded from the Intranet by the affected ward/s which can be used for documentation. Accurate information is essential so that the outbreak can be managed effectively. The IPaC nurses will cohort patients affected by D&V when empty beds are available. As there is a high risk of breaching, the empty bays will be deep cleaned and curtains changed, although this is not considered best practice when bringing an outbreak under control. Where available, doors to empty clean bays should be closed. 11
Following assessment the appointed IPaC nurse will: Review the affected wards with the designated infection control doctor at 10 am. Attend the 10.30 bed management meeting (10.30 Nevill Hall), this will be an absolute priority within the team. Please note that any change in the time of the meeting must be communicated to the IPaC nurse by bleep. The IPaC nurse will not be picking up e-mails as he/she will be assessing the affected wards. The allocated IPaC nurse will update relevant individuals via email. Due to changing management structures please inform the IPaC Team of any individual who needs to be added to the circulation list. The IPaC nurse will liaise with hotel services to instigate cleaning with 2000 ppm Actichlor Plus. The above procedure will continue until all affected wards have resolved and 72 hours have elapsed since the last symptomatic patient. Please note that the IPaC team are not funded to provide a weekend service. This is being discussed at exec level. In the meantime the IPaC team are providing a goodwill telephone service between 9am and 11 am on a Saturday and a Sunday when three or more wards are affected by an outbreak Organisation wide. References Lopman B.A, Brown D.W.G. et al (2005) Institutional risk factors for outbreaks of nosocomial gastroenteritis: survival analysis of a cohort of hospital units in South-west England, 2002 2003 Journal of Hospital Infection Vol 60 Issue 2,135-143 M. Wilcox and W. Fawley, (2007) Viral gastroenteritis increases the reports of Clostridium difficile infection, Journal of Hospital Infection 66, pp. 395 396. PR Chadwick G.Beards et al (2000) Management of hospital outbreaks of gastro-enteritis due to small round structured viruses Journal of Hospital Infection 45, 1-10 12
Appendix 2 Infection Prevention Team Diarrhoea and Vomiting Outbreak Pack Hospital & Ward 13
CONTENTS PAGE 3 PAGE 4 INTRODUCTION STEPS TO MINIMISE SPREAD OF DIARRHOEA AND VOMITING PAGE 5 - STAFF PAGE 6 - PATIENTS PAGE 7 - VISITORS PAGE 8 PAGE 9 CHECKLIST FOR ADMITTING AND DISCHARGING PATIENTS CASE INCIDENT SHEET PAGE 10 CASE INCIDENT CONTINUATION SHEET PAGE 11 SUGGESTED PROVISION OF STOCK DURING OUTBREAK PAGE 12 RESTRICTION NOTICE (please laminate) PAGE 13 RESTRICTION NOTICE (please laminate) PAGE 14 ACTICHLOR ENVIRONMENTAL DECONTAMINATION 14
INTRODUCTION This pack has been produced by the Infection Prevention Team (IPT) in conjunction with ward staff to assist staff during an outbreak situation. It is not intended to replace the outbreak policy, (available in the Infection Control Manual and also via the Intranet) which should always be followed. The IPT will be in regular contact during the outbreak. We can be contacted via switchboard or on the following extensions. Royal Gwent Hospital & Caerphilly District Miners Hospital 01633 238101/4921 Nevill Hall Hospital 01873 732048/2613 Community Hospitals 07903 324603 / 07903 324597 * Please leave a message on the voice mail if there is no-one available. 15
STEPS TO MINIMISE SPREAD OF DIARRHOEA & VOMITING In the event of a bed crisis any decision to admit to an affected ward must be discussed between the Consultant Microbiologist and the Senior Nurse for the hospital (out of hours contact via hospital switch). All personnel (including relatives and visitors) must apply alcohol hand gel when entering and leaving the ward. Gloves and aprons must be worn by healthcare personnel and not visitors when having contact with affected patients. Hands must be washed with soap and water when protective clothing is removed. Staff Only essential staff to visit ward, to reduce the risk of infection spreading to other areas, wards and departments. Ideally, Agency Staff must not work on affected wards. However, Bank Nurses and Nurses from other areas could work on the ward providing, a) They remain rostered to the affected ward for the duration of the outbreak. b) They have their 3 days off before working on another ward (incubation period is 72 hours from exposure) Where possible, cohort nurse affected patients. Avoid staff cross cover between affected and non-affected patients. Ideally post affected staff to nurse affected patients. The IPT would recommend that staff take their breaks on the ward. Local arrangements to be made regarding this. Hotel Services staff working on the affected wards must not provide cover to un-affected ward areas. Domestic Supervisor to ensure appropriate cover is provided. Staff with symptoms to remain off duty until 48 hours symptom free. A specimen must be submitted either via the Occupational Health Department or their GP even if only symptoms of vomiting. Food handlers should always contact Occupational Health. Notify next of kin by phone of visiting restrictions during the outbreak of d&v. Visiting is severely restricted and limited to two persons per bed. 16
Patients The patient s clinician must be consulted before admission to an affected ward. Observe patients for symptoms of diarrhoea and/or vomiting also note any other symptoms such as nausea, malaise, myalgia, and pyrexia and record them accordingly. Ensure patient is recorded on the Incident Sheet. Inform Clinician of affected patients so they can be reviewed. Some patients may require fluid replacement. Stool samples must be sent from all symptomatic patients and staff as soon as possible. If symptoms of vomiting only still send diarrhoea stool sample to exclude bacterial cause. Patients at particular risk due to their underlying condition ideally should not be admitted to an affected ward. Avoid unnecessary movement of patients and staff to and from ward. If a patient requires an investigation, the patient s clinician must decide if it is urgent or non-urgent. Those patients who require urgent investigations must be allowed to attend the department e.g. x-ray etc. Contact the IPT for advice if required. The patient should be fast tracked through preferably at the end of the session. Staff should not wear gloves & aprons during the transportation. Gloves and aprons are to be removed before leaving the ward and hands washed accordingly. New personal protective equipment (PPE) should be donned within the visiting department if staff are having patient contact. Again, PPE is to be removed within the department and hands washed prior to transporting patient back to the ward. This is relevant for all staff including portering staff. Gloves and aprons should be worn by all staff for patient contact except during transport to other departments as described above. Linen from symptomatic patients should be placed in an alginate (soluble) bag and tie. Place into a red infected linen bag and tie with yellow hazard tape. Continue this procedure until the patient is 48 hours symptom free. Any spillage of vomit must be cleaned with blue roll followed by Actichlor solution 2000 ppm. Faeces must be dealt with immediately and the area disinfected with Actichlor 10,000ppm solution. 17
Patients should not be discharged to other wards, Hospitals or Nursing homes without consulting the microbiologist. Inform the Infection Prevention Team of any new cases. Leave a message on the answer phone if necessary. 18
Visitors Visiting is severely restricted and limited to two persons per bed. All visitors should be made aware of the need to decontaminate hands before and after visiting. The frail and elderly should refrain from visiting unless urgent until outbreak is over. It is advised that children should not visit the ward during an outbreak. Visitors and relatives should be advised not to visit the ward if they have symptoms of diarrhoea and/or vomiting or if members of their immediate family have symptoms. (NB in special circumstances, contact the Infection Prevention and Control Team). If any relatives or visitors complain of symptoms, they must be advised to consult their own GP. Symptomatic relatives or visitors must also be recorded on the Case Incident Sheet. 19
CHECKLIST FOR ADMITTING/DISCHARGING PATIENTS ( ) IN EACH BOX Responsibility Patient admission/discharge has been sanctioned by the Consultant Microbiologist/Infection Control Doctor. Senior Nurse Hotel Services have cleaned bay/ward. Nurse in Charge/Domestic Supervisor Curtains have been changed. Nurse in Charge/Domestic Supervisor Clinical equipment e.g. drip stands, commodes, wheel chairs etc. have been cleaned by nursing staff. Nurse in Charge There are sufficient staff on duty to cope with influx of admissions to reopened bay/ward. Senior Nurse Date & Time Ward 72-hours symptom free: In cases of outbreak on the ward please could ALL STAFF tick the boxes if a patient has had symptoms of diarrhoea or vomiting during their shift. Please add patient s name to the list if they develop diarrhoea or vomiting. Send a stool sample to the Pathology Laboratory for culture and sensitivity. 20
D&V OUTBREAK Ward/Dept.. Date Name Consultant Bay Diagnosis Medication Comment D=diarrhoea V=vomiting d&v = both Date: 21
SUGGESTED PROVISION OF STOCK DURING OUTBREAK (Based on 30-bedded acute ward) The Infection Prevention Team would recommend that additional supplies be ordered for the duration of the outbreak. Item Recommended Quantity Supplier Gastroenteritis Information WAG Leaflets 30 Infection Control Nurses. Alcohol Hand Gel 10 sachets Pharmacy Actichlor Tablets (1.7g) 2 packets Pharmacy Alginate Linen Bags (water soluble) 3 packets Stores/ Procurement Red plastic infected linen bags 3 rolls/packs Stores/ Procurement Bed Linen, sheets, pillowcases etc. As required Linen Room/Laundry Aprons At least 3 boxes Stores/ Procurement *Latex Gloves At least 3 boxes Stores/ Procurement Yellow hazard tape (for sealing neck of 3 rolls Stationery Stores/ infected linen bags) Linen Room Patient alginate bags 3 rolls Stores/ Procurement * Nitrile gloves are available for staff with known latex allergy or for contact with affected patients with known latex allergy. 22
ABHB/Infection Control/0141 Management of confirmed or suspected infectious diarrhoea and vomiting in acute and community wards ** NOTICE TO VISITORS ** This ward currently has a high incidence of diarrhoea & vomiting Visiting is severely restricted & limited to 2 persons per bed. Frail elderly people & children should not visit unless urgent. Visitors who have had recent symptoms or diarrhoea & vomiting should not visit If you require further information, please contact the Infection Prevention Team Nevill Hall 01873 732048 Royal Gwent Hospital 01633 238101 Status: Issue 2 Issue date: November 2012 Approved by: Infection Prevention Committee Review date: November 2014 Expiry date: November 2015 Page 23
ABHB/Infection Control/0141 Management of confirmed or suspected infectious diarrhoea and vomiting in acute and community wards ActiCHLOR A P P L I C A T I O N O F S O D I U M D I C H L O R O I S O C Y A N U R A T E D I S I N F E C T A N T Required concentration of Dilution 1.7g Additional Advice 13.1.1 USE available chlorine. Tablets Environmental Cleaning Environmental Decontamination Blood & Body Spillage Not Applicable Not Applicable Detergent and water for all hard surfaces and mattresses. 2000PPM (0.1%) 10,000PPM (1%) 2 tablet in 1-litre of cold water 1 tablet in 100ml of cold water Clean area initially with detergent and water then disinfect. Use measuring bottle to obtain accurate concentration. Contain spill with paper towel and apply made up disinfectant solution 1%. OR 10 tablets in 1-litre of cold water. DO S DON TS Always use correct dilutions & cold water Do not take internally Always wear gloves Do not mix with acids Store in a dry, secure place Do not mix with cationic detergents Replace lid after use Do not submerge animal fibres (e.g. wool or silk) as this will inactivate the chlorine Keep out of reach of children Do not mix with urine and vomit When in contact with the above agents, disposable gloves must be worn. Status: Issue 2 Issue date: November 2012 Approved by: Infection Prevention Committee Review date: November 2014 Expiry date: November 2015 Page 24
ABHB/Infection Control/0141 Management of confirmed or suspected infectious diarrhoea and vomiting in acute and community wards Appendix 3 Viral Gastroenteritis Summary of Guidance Viral Gastroenteritis has the ability to spread very quickly within a hospital environment. Symptoms are usually self limiting. There is the possibility of infectivity before acute onset and after symptoms cease. During vomiting there is widespread contamination of the environment and due to its high infectivity it also common for staff to experience symptoms. 1. What to do if you have two or more cases of unexplained diarrhoea and or vomiting or one confirmed case of Viral Gastroenteritis. Isolate patients immediately and follow the source isolation policy. Inform the Infection Prevention Team (in office hours) or the on call microbiologist (out of hours) if there are two or more known or suspected cases. Any restrictions to admissions will occur after consultation with the team. The Infection Prevention Team will email to all departments within the affected Organisation site about necessary restrictions. Send stool samples using microbiology request forms do not send formed stools. Complete all forms and labelling of pots prior to obtaining the specimen and wash your hands thoroughly afterwards. This will help to prevent cross contamination from your hands to the surrounding environment. Start to make a list of all cases including members of staff, stating the date that symptoms started. This information is vital in making an accurate risk assessment. 2. How to prevent spread in the ward environment. Hand Hygiene must be carried out with soap and water before and after contact with all patients and their immediate environment. Protective clothing must be worn when handling excreta or vomit and when in close patient contact. Aprons and gloves must be removed before leaving the patient s environment and hands should be decontaminated immediately. There is no evidence to support the use of masks. Decontamination of all vomit or faecal spillage is vital to ensure viral particles are killed. Environmental cleaning: It is essential that this is carried out to a high standard and cleanliness is maintained. The ward must be physically cleaned and disinfected at least once a day with Actichlor solution (two tablet to one litre of water). Special attention must be given to toilet and bathroom areas, commodes, all horizontal surfaces and frequent touch surfaces such as the nurses station, nurse call Status: Issue 2 Issue date: November 2012 Approved by: Infection Prevention Committee Review date: November 2014 Expiry date: November 2015 Page 25
ABHB/Infection Control/0141 Management of confirmed or suspected infectious diarrhoea and vomiting in acute and community wards system, telephones, door handles, door push plates, sinks and taps 3. Preventing spread to the rest of the hospital environment. A notice is placed at the entrance/exits to the ward. Do not accept admissions while restrictions are in place unless authorised to do so. Patients can be discharged to their own home as long as they are asymptomatic. Advise them to inform the admitting officer if readmission occurs within 72 hrs of their discharge. Patients from restricted wards should not be placed in a discharge lounge whilst waiting for transport. Do not transfer symptomatic or asymptomatic patients to other wards within the hospital or to other institutions (e.g. other hospitals or nursing and residential homes) for the duration of the ward restriction. If clinical need requires transfer, for example to ICU or theatres then ensure that both infection control and the receiving unit are aware of the situation and that a risk assessment has been performed. Do not send symptomatic patients to other departments unless it is unavoidable. If an investigation is required, inform the receiving department who can take the necessary precautions. Senior personnel from Professions Allied to Medicine must be informed of the ward closure by the IPT to ensure service provision is reviewed. Visiting staff e.g. Physiotherapists, Occupational Therapists, Phlebotomists should still continue their service to the ward but staff deployment must minimise multi-ward working. If possible, the affected ward(s) should be the last to be visited. Do not transfer staff to other wards/departments. Where possible bank staff should be discouraged from working on other wards if recently worked on a restricted ward. 4. When is the patient/ward clear of infection? Viral particles can still be excreted for at least 48 hrs after the symptoms have stopped. Patients can be pragmatically classed as non-infectious if over 48 hrs have elapsed since their last bout of vomiting or diarrhoea & passing a normal stool A clearance stool specimen is not required. During ward restrictions due to Viral Gastroenteritis the ward can usually reopen 72 hrs after the last patient has had any uncontrolled symptoms without contaminating the environment. This takes into account the period of infectivity 48hours plus the typical incubation period for any newly infected individual. N.B. Infection Control must be involved in deciding whether the ward can reopen. Status: Issue 2 Issue date: November 2012 Approved by: Infection Prevention Committee Review date: November 2014 Expiry date: November 2015 Page 26
ABHB/Infection Control/0141 Management of confirmed or suspected infectious diarrhoea and vomiting in acute and community wards All areas must be thoroughly cleaned with Actichlor, once restrictions have been lifted. 5. What about the staff? Staff should be immediately excluded from work if they have symptoms of Viral Gastroenteritis, such as diarrhoea and or vomiting. Staff should not return to work until 48 hrs has elapsed from their last symptom, unless otherwise advised by Infection Control. Staff should not eat or drink at the nurses station during an outbreak of Viral Gastroenteritis, e.g. avoid open boxes of chocolates or biscuits on the desk these may have become contaminated. 6. What about visitors? Visitors should be advised not to visit if they are symptomatic or have had recent contact with someone who has had diarrhoea and/or vomiting. Visitors should be restricted and the very old, young and immunocompromised discouraged from visiting. Visitors should cleanse their hands with soap and water followed by gel before and after patient contact and on leaving the ward. 7. What happens if symptoms recur? Try and isolate the patient. Contact Infection Control immediately. If staff have symptoms that recur they should be excluded from work and should not return until 48 hours have elapsed from their last symptom. Status: Issue 2 Issue date: November 2012 Approved by: Infection Prevention Committee Review date: November 2014 Expiry date: November 2015 Page 27
ABHB/Infection Control/0141 Management of confirmed or suspected infectious diarrhoea and vomiting in acute and community wards Appendix 4 The Bristol Stool Form Scale Status: Issue 2 Issue date: November 2012 Approved by: Infection Prevention Committee Review date: November 2014 Expiry date: November 2015 Page 28