Management of Patients with Diarrhoea Reference No: Version: 1 Ratified by: G_IPC_45 LCHS Trust Board Date Ratified: 12 th January 2016 Name of originator/author: Name of responsible committee/individual: Infection Prevention Team Date issued: January 2016 Review date: Dec 2017 Target audience: Distributed via: Infection Prevention Committee All Staff Website 1 Elaine Baylis, QPM
Version Section/Para/ Appendi Guidance on the Management of Patients with Diarrhoea Version/Description of Amendments Version Control Sheet Date Author/ Amended by 1 New document Sept 2015 L Roberts 2 3 4 5 6 7 8 9 10 Copyright 2015 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be reproduced in whole or in part without the permission of the copyright owner. 2 Elaine Baylis, QPM
Guidance on the Management of Patients with Diarrhoea Guidance Statement Background The purpose of this guidance is to advise on the best practice required around the management of patients with diarrhoea and the standard infection prevention and control precautions required to identify the cause and minimise the risk of healthcare associated infections to patients, visitors and staff in health care settings. Statement This guidance is comprehensive, formally approved and ratified, and disseminated through approved channels. It will be implemented for Lincolnshire Community Health Services NHS Trust. Responsibilities Compliance with the guidance will be the responsibility of all LCHS NHS Trust staff. Training The Infection Prevention Team, Clinical Educators and Education and Workforce Development Team will support/ facilitate any training associated with this guidance. Dissemination Via Website. Resource implication This guidance has been developed in line with the NHS Litigation Authority, Department of Health and Best Evidence guidelines to provide a framework for staff within NHS organisations to ensure the appropriate production, management and review of organisation-wide policies. Elaine Baylis, QPM 3
Guidance on the management of patients with Diarrhoea 1. Introduction... 5 2. Scope of the guidance... 5 2.1. Managers... 5 2.2. The Infection Prevention Team... 5 2.3. Infection Prevention Link Champions / Clinical Educators... 5 2.4. Employees... 5 3. Definition... 6 4. Common causes of diarrhoea... 6 5. Management of patients with diarrhoea... 6 6. Management of patients in community setting... 7 6.1 Management of a patient on a community ward... 7 6.2 Management of a patient in an Intermediate Living Team bed... 7 6.3 Management of a patient in a nursing home/care home/residential home visited by Community team staff... 7 6.4 Management of a patient in their own home visited by community staff... 7 7. Monitoring... 8 8. Training... 8 9. Resources... 8 10. Associated guidelines... 8 11. Best Evidence... 8 Appendi A: Flow chart for the management of patients with Diarrhoea... 9 Appendi B: SIGHT Protocol... 10 Appendi C: Bristol Stool Chart... Error! Bookmark not defined. Appendi D: Bowel Monitoring Form... Error! Bookmark not defined. Appendi E: Equality analysis... 14 4
Guidance on the Management of Patients with Diarrhoea 1. Introduction In the UK, incidences of diarrhoea have a huge impact on the community, through absence from work or the effect on bed capacity in acute and community hospitals and nursing/residential/care homes. The emergence of Clostridium difficile as a clinically and politically significant healthcare associated infection and the impact of Norovirus infections, affecting the functioning of healthcare organisations, require a high degree of suspicion when diarrhoea has developed. Health care staff across the health economy must be aware of what is required to detect the cause, minimise the effect on the patient and prevent the risk of cross infection. This guideline is to be used in conjunction with other LCHS guidelines. G_IPC_36 Management of patients with Clostridium difficile infection in Community G_IPC_33 Management of Viral Gastroenteritis G_IPC_32 Outbreak of Communicable Diseases For Flow Chart see Appendi A For other associated documents see Section 10. 2. Scope of the guidance This guidance is for all staff working within Lincolnshire Community Health Services NHS Trust, both in the community and the community hospitals. 2.1. Managers Managers have the responsibility for the standards of clinical practice by their staff in the health care setting. They must: Ensure all individuals are appropriately trained. Inform new employees of their responsibilities under this guidance. Ensure that all employees within their area of responsibility comply with this guidance. 2.2. The Infection Prevention Team The Infection Prevention Team will: Review the guidance on a bi-annual basis and in response to relevant publications from the Department of Health. Support Managers and Infection Prevention Link Champions with audit of compliance with the guidance. 2.3. Infection Prevention Link Champions / Clinical Educators Infection Prevention Link Champions and Clinical Educators are responsible for supporting the Infection Prevention and Control agenda. They must: Ensure the delivery of education locally. Assist in the environmental and observational audits. 2.4. Employees All employees have a responsibility to abide by this guidance and any decisions arising from the implementation of them. Any decision to vary from this guidance must be fully documented with the associated rationale stated. 5
3. Definition Diarrhoea is defined as an increase in stool liquidity usually accompanied by increased frequency of bowel motion. It can be a life threatening event and requires careful monitoring to prevent complications. Infectious diarrhoea may be caused by numerous bacterial, viral and parasitic enteric microorganisms. It may be accompanied by other symptoms including vomiting, fever, dehydration, electrolyte imbalance and skin ecoriation. Two or more episodes of diarrhoea in a 24 hour period requires investigation and action. Diarrhoea is classified using the Bristol Stool Chart (see Appendi B). 4. Common causes of diarrhoea Norovirus abrupt eplosive onset of profuse watery diarrhoea which may be accompanied by projectile vomiting. Several cases may occur on the ward within hours. (See LCHS guidelines G_IPC_33 Management of Gastro enteritis and G_IPC_32 Outbreak of Communicable diseases.) Clostridium difficile watery diarrhoea with characteristic farmyard/manure smells which is associated with current or recent antibiotics treatment. (See LCHS guidelines G_IPC_ G_IPC_36 Management of patients with C.diff infection in Community.) Other Eamples of causes Rotavirus Salmonella Shigella Campylobacter Amoebic dysentery Giardia lamblia Verotoin producing E.coli Cryptosporidium 5. Management of patients with diarrhoea Implement the SIGHT Protocol (See below and Poster Appendi C) Use D&V Risk assessment and management tool to identify likely cause and action the management. (See Appendi D) S Suspect that a cause may be infective where there is no clear cause for diarrhoea Assess medication, food and fluid intake, previous diagnosis I Isolate the patient and consult with the infection control team while determining the cause of the diarrhoea Patient with diarrhoea must be isolated promptly G Gloves and aprons must be used for all contacts with the patient and their environment PPE must be worn when delivering all episodes of care, dealing with blood and body fluids and cleaning patients equipment and environment 6
H Hand washing with soap and water should be carried out before and after each contact with the patient and the patient s environment Hand must be washed with soap and water. Hand sanitizer does not remove soiling and does not kill C.diff and has limited effect on Norovirus. T Test the stool, by sending specimens immediately Follow local procedures to send samples at weekend and bank holiday 6. Management of patients in community setting 6.1 Management of a patient on a community ward Patient with episodes of diarrhoea follow flow chart, Appendi A, Risk assess using D&V Risk Assessment Tool, Appendi D and SIGHT protocol Appendi C. Inform nurse in charge and IP Team at the earliest opportunity via mobile phone. Out of normal hours, leave message on mobile voice mail. 6.2 Management of a patient in an Intermediate Living Team bed If a patient in the care of ILT develops symptoms, ensure that the flow chart Appendi A, is followed and Risk Assessed using the Risk assessment tool, Appendi D and SIGHT protocol, Appendi C is implemented by the care home. Ensure the care home is aware and following their protocols Inform IP team if diarrhoea continues or if other patients/residents in home develop symptoms. Ensure that the Adult Integrated Team is aware and a risk assessment is undertaken to assess the need and frequency of the visit. 6.3 Management of a patient in a nursing home/care home/residential home visited by Community team staff Ensure the care home is aware and following their protocols. Inform IPC team if diarrhoea continues or if other patients/residents in home develop symptoms. Ensure that the Adult Integrated Team is aware and a risk assessment is undertaken to assess the need and frequency of the visit. 6.4 Management of a patient in their own home visited by community staff Ensure that the patient contacts their GP via telephone. Ensure that all the Adult Integrated Team is are aware and a risk assessment is undertaken to ass ess the need and frequency of the visit. 7
7. Monitoring Minimum requirement to be monitored Process for monitoring e.g. audit Responsible individuals/ group/ committee Compliance Audit Manager/ IP&C Frequency of monitoring/audit Responsible individuals/ group/ committee (multidisciplinary) for review of results Responsible individuals/ group/ committee for development of action plan Responsible individuals/ group/ committee for monitoring of action plan Bi -Annually IPC Committee IPC Committee IPC Committee 8. Training Attendance at training will be monitored by the LCHS Education and Workforce Team who will be responsible for advising service managers and directors of non-attendance on a quarterly basis. Service managers and directors will be responsible for ensuring that staff are available for attendance at Induction and Mandatory training and that non-attendance is followed up. 9. Resources The Health and Social Care Act 2008 Royal College of Nursing: The Management of Diarrhoea in adults 10. Associated guidelines G_IPC_04 Guidelines on the use of Gloves G_IPC_06 Management of Linen G_IPC_07 Infection Control Notification Framework G_IPC_17 Hand washing and use of hand sanitizer G_IPC_19 Management of specimens G_IPC_26 Standard of Infection Prevention and Control Precautions G_IPC_28 Management of patients in isolation G_IPC_31 Blood and Body Spillages G_IPC_32 Outbreak of Communicable Diseases G_IPC_33 Management of Viral Gastroenteritis G_IPC_36 Management of patients with Clostridium difficile infection in Community G_IPC_37 Decontamination Guidelines IC003 Healthcare Waste Policy P_IC_02 Community Hospitals Cleaning Strategy and Operational Cleaning Plan 11. Best Evidence Royal College Of Nursing: Universal Precautions for the control of infection (2000). 20 Cavendish Square, London. Department of Health (1974) Health and Safety at Work Act, London, HMSO Department of Health (2001) Standard principles for preventing hospital acquired infections. Journal of Hospital Infection 2001 (47); 21-37 The Health and Social Care Act (2008) 8
Appendi A: Flow chart for the management of patients with Diarrhoea Two or more episodes of diarrhoea S I G H T Use D&V Risk Assessment and Management Tool to assess diarrhoea (See Appendi D) C.difficile Gastro-enteritis Other Follow C.difficile guidelines Follow Gastro-enteritis guidelines Investigate further Two or more cases linked in time or place follow Outbreak procedures Seek advice from IP team 9
Appendi B: Bristol Stool Chart 10
Appendi C: SIGHT Protocol 11
Appendi D: D&V Risk Assessment and Management Tool PATIENTS NAME NHS NUMBER DIARRHOEA & VOMITING ASSESSMENT & MANAGEMENT TOOL Definition of diarrhoea is more than two episodes of type 6 or 7 stool (Bristol Stool Scale) in 24 hours. DOB WARD: DATE: DATE OF PATIENT S ADMISSION: NURSE S NAME: GP: CONSIDER THE FOLLOWING CAUSES & COMPLETE FORM AS RELEVANT Clostridium Difficile Yes No Infective Gastroenteritis, e.g. Norovirus or Food Poisoning History of antibiotics in last 3 months Watery diarrhoea (type 6 or 7 on the Bristol (either as current in-patient, previous inpatient Stool Scale) (> one episode in 24 hours) or from GP). Nausea 2 episodes of diarrhoea in the last 24 hours Vomiting Date(s): Projectile Vomiting Visitor, family, or other patients or staff with Type: diarrhoea & vomiting Yes No Date of Onset/ Occurrence Medical/Drug Cause Relevant Medical History Yes No Is patient constipated with overflow? Diverticular disease/colitis/chrons Irritable Bowel Syndrome Detoing Hypoglycaemia/Hyperglycaemia Other, e.g. supplementary feeds or tube feeds (state) Relevant Surgical History Temperature Recent Anaesthetic Colour and smell of diarrhoea indicative of Headaches and aching limbs Bowel/gastric surgery Clostridium difficile (green, slimy and foul Eating normally Other smelling Previous Clostridium difficile Toin result in last Change in diet Drug Therapy 3 months Symptoms lasting > 3 days Laatives/Enema Previous Clostridium difficile GDH positive Symptoms < 12 hours NSAIDs Action if Norovirus/Food Poisoning Suspected Iron Salts Action if Clostridium Difficile Suspected Colchicine SIGHT protocol SIGHT protocol Anti-Parkinsonian Consult management of Patient with Diarrhoea G_IPC_045 and Bowel monitoring chart Chemotherapy C. diff guidelines G_IPC_36 on intranet If Norovirus likely, close bay and cohort nurse. Inform On Call Duty Manger Withdrawal drugs Bowel monitoring Chart IP Team can authorise Norovirus in normal hours. On Call Manager can request PPI s Faeces specimen: (include onset of symptoms date, antibiotic Norovirus testing through On Call Consultant Microbiologist at weekends and Bank Statins history and state probable C. diff). Stools contaminated by Holidays. urine can still be tested. Inform IP Team via mobile (Mon to Fri 8.30 a.m. to 5 p.m.), leave message on mobile Other voice mail if outside these hours. Action Sent: Y/N Date: Result: Consult Management of Gastroenteritis G_IPC_33 and Management of Outbreak of Start Stool Chart Inform On Call Manager *If patient is in a bay, transfer to side room (state) Communicable Diseases G_IPC_32 Inform GP/ANP Inform IP Team Isolate Inform other staff e.g. housekeeping 12
Appendi E: Bowel Monitoring Form Commenced on Patient Details or Addressograph Date Time Colour Amount Bristol Blood Mucous Specimen Result Signature Scale to lab Name DOB NHS Number Ward Patients normal bowel pattern Amount Guide SMALL ¼ of bedpan / pad MEDIUM ½ of bedpan / pad LARGE most of bedpan / pad 13
Appendi F: Equality analysis A. B. C. D. Briefly give an outline of the key objectives of the policy; what it s intended outcome is and who the intended beneficiaries are epected to be Does the policy have an impact on patients, carers or staff, or the wider community that we have links with? Please give details Is there is any evidence that the policy\service relates to an area with known inequalities? Please give details Will/Does the implementation of the policy\service result in different impacts for protected characteristics? The purpose of this guidance is to provide the staff of the organisation with guidelines for the management of patients with Diarrhoea. Impacts on all patients, visitors and staff in respect of providing a timely diagnosis and safe effective practice to prevent the spread of infection. None Known Disability Seual Orientation Se Gender Reassignment Race Marriage/Civil Partnership Maternity/Pregnancy Age Religion or Belief Carers Yes If you have answered Yes to any of the questions then you are required to carry out a full Equality Analysis which should be approved by the Equality and Human Rights Lead please go to section 2 The above named policy has been considered and does not require a full equality analysis Equality Analysis Carried out by: Lynne Roberts Date: 18.11.15 No 14