Guideline for the Management of Patients with Known or Suspected Diarrhoea / Viral Gastroenteritis 1. Introduction 1.1 Patients with diarrhoea pose a risk to other patients from micro-organisms contaminating the environment or equipment. It is important that the management of patients with diarrhoea is prompt and effective at minimising the risk of transmitting hospital acquired infection. 1.2 A useful mnemonic when dealing with patients suspected of infective diarrhoea is SIGHT Suspect that a case may be infective where there is no clear alternative cause for diarrhoea Isolate the patient and contact the infection prevention team whilst determining the cause of the diarrhoea Gloves and aprons must be used for all contact with patients and their environment Hand washing with soap and water before and after all contact with patients and the environment Test stool 1.3 A number of different viruses can cause gastroenteritis. They include viruses such as Norovirus and Rotavirus. 1.4 Viral gastroenteritis has the ability to spread very quickly within a hospital environment. Symptoms usually last for 48-72 hours and are self-limiting. Symptoms may include diarrhoea which is often (but not always) accompanied with severe vomiting. 1.5 There is the possibility of infectivity before acute onset and after symptoms cease. During vomiting there is widespread contamination of the environment. 2. Scope The guidance is aimed for use by all healthcare workers within the University Hospitals of Leicester NHS Trust that care for patients that develop or suffer from symptoms of diarrhoea and/or vomiting that cannot be explained as a symptom of their underlying conditions 3. Guideline Standards Management of Patients with Known or Suspected Infectious Diarrhoea No. Action 1 Source isolation precautions must be implemented as soon as possible but within a maximum time of 4 hours for all affected patients preferably in a single room (See appendix one). If a single room is not available contact the Infection Prevention Team (or on call microbiologist out of hours) for advice. Contact duty manager/bed coordinator to assist with finding a side room on another ward. 2 The infection prevention team must be informed using the electronic notification system of any patient in source isolation (within 4 hours of identifying need to isolate) What to do if you have two or more cases of unexplained diarrhoea and or vomiting or one confirmed case of Viral Gastroenteritis. Isolate patient/s immediately and follow UHL source isolation policy. Doors to single rooms or bays (where available) must be kept closed Inform the Infection Prevention Team (IPT) in office hours or the on call microbiologist (out of hours). Any restrictions to admissions will occur after consultation with the IPT or Microbiologist Guideline for the Management of Patients with Known or Suspected Diarrhoea / Viral Gastroenteritis Page 1 of 10
Management of Patients with Known or Suspected Infectious Diarrhoea No. Action What to do if you have two or more cases of unexplained diarrhoea and or vomiting or one confirmed case of Viral Gastroenteritis. 3 Wherever possible a single room with en-suite facilities should be used for patients with diarrhoea. Where this is not possible a dedicated toilet or commode must be identified. The toilet or commode must be designated and labelled for the individual patient. This must be cleaned with Chlorclean after each use 4 Explain to the patient why they are being moved into a single room or the need for extra precautions. Visitors and relatives must also be informed of the precautions that they need to take in relation to hand hygiene 5 A yellow source isolation card must be placed on the door of the single room or by the patient s bed (Appendix 2) 6 Ensure that a stool chart is commenced if there is not one in progress already. The patient s stool chart and fluid balance chart must be completed accurately. Review laxatives or other treatment that may cause diarrhoea, document reason if cannot be discontinued. This information is vital in making an accurate risk assessment 7 A stool sample must be sent to microbiology do not send formed stools. Specimens can be collected from bed pans or soiled linen, even if contaminated with urine or other matter. Start to make a list of all cases including members of staff, stating the time and date that symptoms started. This should include all episodes of vomiting and or diarrhoea. The patient s stool chart and fluid balance chart must be completed accurately. This information is vital in making an accurate risk assessment (Appendix 3) Send stool samples using virology request forms do not send vomit. Specimens can be collected from bed pans or soiled linen, even if contaminated with urine or other matter. A formed stool can be sent. Tip: 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. If Clostridium difficile (CD) is suspected assess for severity markers and treat accordingly. Refer to CD treatment guidelines on the antimicrobial website; this includes starting treatment upon suspicion of CD (do not wait for laboratory confirmation of CD infection) and reassessing treatment upon receipt of results. 8 Patients must be told of the importance of washing their hands using soap and water after going to the toilet and before meals. Where patients are unable to wash their own hands staff must assist. 9 Staff entering the single room or bed space must wear a plastic apron and disposable gloves. These must be removed in the single room or bed space and hands washed with soap and water. Alcohol hand sanitiser must then be used on leaving the bed space or single room. Protective clothing must be worn when handling excreta or vomit and when in close patient contact. Aprons and gloves must be removed before leaving each patient s zone and hands should be decontaminated immediately. 10 Medicines must be stored in accordance to the Storage and recycling of medication in and from source isolation areas procedure see preventing transmission of infection policy (Preventing Transmission of Infective Agents Policy and Isolation Guidelines Trust Ref B62/2011) 11 Any equipment that is used must be cleaned with Chlorclean (one tablet to one litre of cold water) before it is removed from the single room or bed space. Guideline for the Management of Patients with Known or Suspected Diarrhoea / Viral Gastroenteritis Page 2 of 10
Management of Patients with Known or Suspected Infectious Diarrhoea No. Action What to do if you have two or more cases of unexplained diarrhoea and or vomiting or one confirmed case of Viral Gastroenteritis. 12 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 they can maintain the necessary precautions. The patient s bed must not be transported to other areas until it has been thoroughly cleaned. Alternately patients need to be transported on a trolley. 13 Decontamination of all vomit or faecal spillage is vital to ensure microorganisms are removed. Wearing PPE remove spillages with paper towels and decontaminate area with Chlorclean. Discard all waste into orange bags. 14 Enhanced cleaning in affected side room/bay: 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 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 system, telephones, door handles/ push plates, sinks and taps 15 A restricted access notice is placed at the entrance/exits to the ward (Appendix 4). Initiate responsible visiting (visitors asked not to visit if they have symptoms). Reduce unnecessary visitors to the Trust, two visitors only per patient immediate family or close friends and restricted visiting hours. 16 Do not accept admissions while restrictions are in place 17 When there is more than one case confined to a single bay on one ward the affected bay to be closed to admissions. Dedicated staff to be assigned to affected bay/s so that admissions can continue to the rest of the ward. 18 Patients can be discharged to their own homes if they are clinically stable. 19 Patients that have been asymptomatic for 48 hours and formed stools can go to the discharge lounge whilst waiting for transport. No transfers out from ward except for urgent clinical needs (e.g. ITU) or patients own home (NOT nursing/care home) Patients can be discharged to their own home as long as they are asymptomatic. Advise them to inform the hospital if readmission occurs within 48 hours of their discharge. Patients from restricted wards should not be placed in a discharge lounge whilst waiting for transport. 20 Visiting staff e.g. Physiotherapists, Occupational Therapists, Phlebotomists and Pharmacists should still continue their service to the ward. If possible, the affected ward(s) should be the last to be visited. 21 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. 22 Suspected cases not confined to single bay on one or more wards, convene Out break meetings and establish actions to reduce impact on bed capacity. Infection Prevention to communicate the details of ward closers to the bed meetings Guideline for the Management of Patients with Known or Suspected Diarrhoea / Viral Gastroenteritis Page 3 of 10
Management of Patients with Known or Suspected Infectious Diarrhoea No. Action What to do if you have two or more cases of unexplained diarrhoea and or vomiting or one confirmed case of Viral Gastroenteritis. 23 3-5 wards restricted. Daily out break control meetings. Infection prevention to provide clinical details. CMG s to provide details of empty beds on each ward. 5 or more wards restricted. Consider cohorting of closed wards 24 Patients to remain in source isolation in a side room until they have been asymptomatic for 48 hours and have had formed stools. A clearance stool specimen is not required. Viral particles can still be excreted for 48 hours after the symptoms have stopped. Patients can be classed as non-infectious 48 hours after their last bout of vomiting or diarrhoea. 25 If a ward has restrictions due to viral gastroenteritis the ward can usually lift the restrictions 48 hours after the last patient has had any symptoms and post infection cleaning has taken place. The Infection Prevention Team must be involved in deciding whether the ward can be reopened. 26 All affected areas to be Hydrogen peroxide fogged. If hydrogen peroxide fogging is not possible all affected areas should be thoroughly cleaned with Chlorclean. Curtains must be changed. Once this has been completed source isolation can cease. 27 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 hours has elapsed from their last symptom, unless otherwise advised by Infection Prevention Team. 28 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. 29 Visitors should be encouraged to clean their hands with soap and water on leaving the isolated side room/bay/ward. 4. Education and Training 4.1 Posters are available from the infection prevention team to raise awareness of infective diarrhoea management. 4.2 Education on the principles and practices for preventing transmission should begin during all healthcare professional s pre-registration training in the health professions and is a prerequisite for anyone who comes into contact with patients, the patient environment or equipment. 4.3 Training in infection prevention is included on Trust Induction for all new staff with annual mandatory infection prevention updates in accordance with Department of Health requirements. 5. Monitoring and Audit Criteria Key Performance Indicator Method of Assessment Frequency Lead Feedback given at the time to ward and CMG. Reported as part of outbreak report to commissioners. This will occur within the Serious Untoward Incident timescales following identification of an outbreak. The Serious Untoward Incident Policy is available on Insite documents Report completed and shared with each CMG giving COHORT audit completed wherever patients are being cohorted Source isolation precautions. The source isolation audit At time of outbreak Infection Prevention Infection Prevention Team Infection Prevention Guideline for the Management of Patients with Known or Suspected Diarrhoea / Viral Gastroenteritis Page 4 of 10
Key Performance Indicator Method of Assessment Frequency Lead compliance score and identifying areas of noncompliance. CMGs required to put measures in place to improve compliance. includes compliance with the isolation elements of this guideline. Team Quarterly Team Compliance reported to commissioners as part of quality schedule Compliance with 4 hours to isolation monitored using electronic notification system. Infection Prevention Team Quarterly Infection Prevention Team 6. Legal Liability Guideline Statement Guidelines or Procedures issued and approved by the Trust are considered to represent best practice. Staff may only exceptionally depart from any relevant Trust guidelines or Procedures and always only providing that such departure is confined to the specific needs of individual circumstances. In healthcare delivery such departure shall only be undertaken where, in the judgement of the responsible healthcare professional it is fully appropriate and justifiable - such decision to be fully recorded in the patient s note 7. Supporting Documents and Key References Public Health England (2013) Updated Guidance on the Management and Treatment of Clostridium Difficile Infection. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/321891/clostri dium_difficile_management_and_treatment.pdf UHL Cleaning and Decontamination Policy ID: UHLSP-600-5610 UHL Infection Prevention Policy ID: UHLSP-600-5697 UHL Personal Protective Equipment policy ID: 5770111895 UHL Preventing transmission of infection policy ID: UHLSP-600-5749 WHO (2009) Guidelines on Hand Hygiene in Health Care First Global Patient Safety Challenge- Clean Care is Safer Care. Available from http://www.who.int/en Public Health England (2012) Guidance for managing Norovirus outbreaks in acute and community health and social care settings. Available from; https://www.gov.uk/government/publications/norovirus-managing-outbreaks-in-acute-and-communityhealth-and-social-care-settings 8. Key Words Clostridium difficile, Viral gastroenteritis, Diarrhoea, Vomiting DEVELOPMENT AND APPROVAL RECORD FOR THIS DOCUMENT Author / Lead Officer: Elizabeth Collins Job Title: Lead Nurse Infection Prevention Leslene Edwards, Elizabeth Hoyle Infection Prevention Liaison Sister Approved by: Policy and Guideline Committee Date Originally Approved: 2004 Latest Approval Date: 16 th October 2015 Next Review Date: October 2018 Version Number: 3 Details of Changes made during review: This version incorporates and supersedes the previous stand alone Viral Gastroenteritis Management Guidelines (B3/2012). No changes were made to guidelines Guideline for the Management of Patients with Known or Suspected Diarrhoea / Viral Gastroenteritis Page 5 of 10
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Appendix 1 Patient has Diarrhoea? Type 6 or 7 stool: Bristol stool chart Yes Is this linked to their condition, bowel surgery or medication such as laxatives, suppositories or enemas or analgesia? No Monitor and ensure a stool chart completed Take source isolation precautions and monitor Isolate patient in a side room Yes Further Episode of Diarrhoea Within 4 Hours No Move patient into side room if not already in one. Ensure a stool chart completed Discontinue Isolation Precautions Send stool / faecal specimens: for MC&S and C diff testing, and virology for Norovirus testing NB: Stool specimens can be obtained from, sheets or the floor if necessary; it is imperative that specimens are sent as soon as possible from all patients. Inform medical staff Inform Infection Prevention Team or out of hours Microbiologist on call if a suspected outbreak Inform Duty Manager If Clostridium difficile is suspected assess inflammatory markers and treat accordingly: Refer to Clostridium difficile treatment guidelines on the antimicrobial website. If suspected Norovirus, refer to Norovirus guidelines on in-site. Guideline for the Management of Patients with Known or Suspected Diarrhoea / Viral Gastroenteritis Page 7 of 10
Appendix 2 All Staff If entering an isolation area you SOURCE ISOLATION MUST: Clean hands Visitors Please see staff in charge before entering this isolation area Wear Gloves Wear an apron Consider a MASK - Refer to Mask Flow Chart Clean your hands before and after contact with the patient and after Wear gloves and apron if providing personal care Before leaving isolation area you MUST: Remove protective clothing Wash hands with soap and water On leaving the area use hand sanitiser Guideline for the Management of Patients with Known or Suspected Diarrhoea / Viral Gastroenteritis Page 8 of 10
Appendix 3 D&V Ward OUTBREAK Date Reported: Ward: Hospital: Name Bay/Bed No. Symptoms D V Start Date Spec sent date Result Relevant drug therapy or medical condition Progress on subsequent days Date Date Date Date Date Date Date D V D V D V D V D V D V D V Number of empty beds Guideline for the Management of Patients with Known or Suspected Diarrhoea / Viral Gastroenteritis Page 9 of 10
Appendix 4 ACCESS TO THIS WARD RESTRICTED IS YOUR VISIT ESSENTIAL? IF IT IS, PLEASE SPEAK TO THE NURSE IN-CHARGE WASH YOUR HANDS WITH SOAP AND WATER BEFORE LEAVING THIS AREA Guideline for the Management of Patients with Known or Suspected Diarrhoea / Viral Gastroenteritis Page 10 of 10