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DOCUMENT CONTROL VERSION 6 Ratified by: Clinical Effectiveness Committee Date ratified: 6 August 2013 Name of Originator / Author Senior Infection Prevention and Control

Nurse Specialist Name of Responsible Committee / Individual

Clinical Effectiveness Committee

Date Issued 9 August 2013 Review Date August 2016 Target Audience All Staff

DIARRHOEA AND/OR VOMITING POLICY FOR PATIENTS & STAFF

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CONTENTS

Section Page 1. INTRODUCTION 4 2. PURPOSE 4 3. SCOPE 4 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 5 4.1 Board of Directors 5 4.2 Chief Executive 5 4.3 Director of Infection Prevention and Control (DIPC) (Deputy 5 Chief Executive/Director of Nursing) 4.4 Infection Prevention and Control Committee 5 4.5 Infection Control Doctors/Consultant Microbiologists 6 4.6 Infection Prevention and Control (IPC) Nurse Specialists 6 4.7 Consultant Medical Staff 7 4.8 Modern Matrons/Service Managers 7 4.9 Staff 7 5. PROCEDURE/IMPLEMENTATION 8 5.1 Procedure for Inpatient areas, Registered Homes and Supported Living Homes 8 5.1.1 Clinical Features 8 5.1.2 Key Points 8 5.1.3 Preventing the spread of infection 9 5.1.4 Reducing the risk of spread of infection to other areas 10 5.1.5 When is the patient/ward clear of infection? 11 5.1.6 Management of affected staff 11 5.1.7 Guidance for visitors 12 5.1.8 What happens if symptoms recur? 12 5.2 Procedure for staff illness unrelated to ward outbreak 12 5.3 Specific procedure for management of outbreaks in nursing and residential homes (LD homes) 13 6. TRAINING IMPLICATIONS 15 7. MONITORING ARRANGEMENTS 15 8. EQUALITY IMPACT ASSESSMENT SCREENING 16 8.1 Privacy, Dignity and Respect 16 8.2 Mental Capacity Act 16 9. LINKS TO ANY ASSOCIATED DOCUMENTS 17 10. REFERENCES 18

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11. APPENDICES Appendix 1 Reporting Information 19 Appendix 2 Patient Discharge 20 Appendix 3 Healthcare Associated Infection Risk Assessment Form 21 Appendix 4 Terminal cleaning 22 Appendix 5 The Bristol Stool Form Scale 23 Appendix 6 Environmental decontamination during an outbreak 24 Appendix 7 Outbreak control measures 25

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1. INTRODUCTION

Small round structured viruses (SRSV’s) are the most common cause of outbreaks of gastroenteritis in hospitals. Norovirus is one such virus and is the predominant organism responsible for diarrhoea and/or vomiting outbreaks in health and social care establishments. Norovirus is estimated to cost the NHS in excess of £100 million per annum (2002-03 figures) in years of high incidence and is responsible for approximately 3000 admissions to hospitals. Out of 17 million cases of infectious intestinal disease occurring in the community, norovirus is considered to be responsible for approximately 16.5% of these.

Whilst norovirus infections are usually associated with relatively mild and short lived symptoms, outbreaks involving patients and staff in hospital and care homes can have a significant impact on the organisations activities, including partial and complete ward closures and delays in admissions and discharge of patients. Therefore it is essential that any case of gastro-intestinal illness is detected early and regarded as potentially infectious.

2. PURPOSE

The aim of this policy is to provide the basic information healthcare staff will require to recognise and take appropriate action required when a patient/s is/are suspected of having viral gastroenteritis. Prompt and effective measures are essential in controlling the spread of infection between patients, staff and visitors. This policy provides guidance based on the principle of minimising disruption to important and essential services as well as maximising the ability of the organisation to deliver appropriate care to patients safely and effectively.

3. SCOPE

This policy applies to all staff having contact with patients under the care of the Trust, whether in a direct or indirect patient care role. Adherence to this policy is the responsibility of all staff employed by the Trust, including agency, locum and bank staff contracted by the Trust. This policy should be read in conjunction with other infection prevention and control policies, particularly Hand Hygiene, Standard Infection Prevention and Control Precautions, Waste Management, Decontamination, Cleaning, Collection/Handling and Transportation of Pathology Specimens, Laundry and Management of Blood and Body Fluid Spillages.

This policy should be considered and included in services that are contracted and commissioned by the Trust.

This policy applies to all staff, patients, visitors, contractors and other persons who enter Trust owned or rented buildings or grounds.

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4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES

All staff working on Trust premises, outreach clinics and community settings including Trust employed staff, contractors, agency and locum staff are responsible for adhering to this policy.

4.1 Board of Directors

The Board of Directors are responsible for having policies and procedures in place to support best practice, effective management, service delivery, management of associated risks and meet national and local legislation and/or requirements. 4.2 Chief Executive

The Chief Executive is responsible for establishing and maintaining infection prevention and control arrangements across the organisation, but delegates the responsibilities to the Trust Board and the Director of Infection Prevention and Control. The Director with the lead responsibility is the Deputy Chief Executive and Lead Nurse.

4.3 Director of Infection Prevention and Control (DIPC) (Deputy Chief Executive/Director of Nursing)

The DIPC:

• Reports directly to the Chief Executive and the Board

• Reports identified cases of infections/alert organisms & conditions including outbreaks of infection

• Reports all incidents requiring root cause analysis investigation

• Reports directly to the Chief Executive and assure the Board of Directors on the organisations performance in relation to HCAIs

• Acts on legislation, national policies and guidance ensuring effective policies are in place and audited in relation to infections/alert organisms & conditions

4.4 Infection Prevention and Control Committee

The main duties of the Infection Prevention and Control Committee are:

• To oversee compliance with national standards/targets in relation to the prevention and control of healthcare associated infections (HCAI), including the Health and Social Care Act 2008, NHS Litigation Authority (NHSLA) and the Care Quality Commission.

• To oversee key infection prevention & control issues in regards to:

• Policy development and review • Audit • Education & training • Communication with staff patients and the public • Monitoring of infection control incidents

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• Review of root cause analysis reports, identify lessons learnt, develop and monitor action plans • Ensuring that robust plans for the management of outbreaks of infection are in place and to monitor their effectiveness • Agreeing the annual infection prevention and control

report and work programme prior to its submission to Clinical Governance Committee

• To inform the Clinical Governance Committee of clinical risk issues relating

to the Trust

• To monitor compliance for infection prevention & control training

• To oversee the Trust’s compliance with Essential Standards of Quality and Safety (Outcome 8)

4.5 Infection Control Doctors/Consultant Microbiologists

These are medical microbiologists hosted within the local provider acute Trust whose main duties are to:

• Be available for 24 hour access, arrangements made through local service level agreements

• Provide expert microbiology advice for the management and treatment of micro-organisms including outbreaks of infection

• Advise on antibiotic policy/prescribing and challenge inappropriate practices 4.6 Infection Prevention and Control (IPC) Nurse Specialists

These are employed within RDaSH. Their role is:

• To provide expert professional advice and education on the prevention and control of infection to other professionals, multi-disciplinary groups, patients and carers

• To lead in the investigation of identified cases of infection/alert organisms &

conditions

• To advise on control measures, delegating responsibility to Trust staff as appropriate

• To give advice on complex issues relating to infection prevention and control

and report findings to the DIPC

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4.7 Consultant Medical Staff

The Consultant Medical staff are responsible for the supervision of any junior medical staff assigned to work with them, and as part of this supervision they should be satisfied that junior staff members:

• Read and understand the policy • Adhere to the policy • Are aware of and comply with antibiotic prescribing guidance

4.8 Modern Matrons/Service Managers

All Service Managers and Modern Matrons are responsible for:

• Membership at the Infection Prevention and Control Committee

• Ongoing compliance with this policy within their clinical areas and reporting non-compliance to the DIPC via the IPC team

• Reporting all matters relating to infection prevention and control to the

Deputy Director of Nursing

• Facilitating feedback of information related to surveillance data and identified cases of infection/alert organisms and conditions

• Report confirmed cases of infection/alert organisms and conditions through

the Trust’s IR1 system 4.9 Staff

All staff who have contact with patients within the inpatient services and community must:

• Comply with this policy and related guidance

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5. PROCEDURE/IMPLEMENTATION

5.1 Procedure for Inpatient areas, Registered Homes and Supported Living Homes

5.1.1 Clinical Features

The average incubation period for norovirus infection is 12 – 48 hours. The illness is characterised by a sudden acute onset of:

• Vomiting (may be projectile) • Watery diarrhoea and abdominal cramps • Nausea

Other symptoms such as headache, myalgia, fever and malaise are common. Some or all of the above symptoms may be present. Symptoms last between 1 – 3 days and recovery is usually rapid. Dehydration is the most common complication and the avoidance of, or correction of this is the mainstay of clinical treatment. The elderly and immunosuppressed are particularly vulnerable to the effects of dehydration and should be monitored and treated accordingly. 5.1.2 Key Points

• All patients admitted with or who develop unexplained diarrhoea and/or

vomiting should be nursed in a single room until an infective cause has been discounted. Doors must be kept closed to minimise the risk of the infection spreading. Staff must undertake a risk assessment where this is not possible due to the patient’s care needs and continue to re-evaluate on a shift by shift basis. The Infection Prevention & Control Team (IPCT) must be informed if isolation precautions cannot be implemented.

• Contact the IPCT if there are two or more patients/staff with symptoms of unexplained diarrhoea and/or vomiting. The team can be contacted during office hours. For out of hours advice the on call Consultant Microbiologist can be contacted via the switchboard of the acute hospital in each locality. (Appendix 1)

• Where several patients are affected it may be necessary to cohort nurse (nurse similarly affected individuals in the same bay/area) especially if numbers exceed the availability of single rooms. The IPCT or Consultant Microbiologist (out of hours) will advise on the need to cohort affected patients.

• Staff should review the patients’ records to ascertain if there are any potential contributory factors to the development of symptoms such as the administration of laxatives/aperients, antibiotics or the patients underlying medical condition.

• Stool samples must be obtained from affected individuals and sent to the microbiology laboratory for culture & sensitivity and Clostridium difficile testing. The IPCT will assess the need for specimens to be sent for norovirus testing and will liaise with the laboratories accordingly.

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• Effective hand washing with liquid soap and water is essential to minimise the spread of infection. Antimicrobial hand rubs are not effective in destroying norovirus and should be used in conjunction with hand washing rather than an alternative.

• Excreta/vomit must be dealt with immediately. They must be disposed of and the area decontaminated in accordance with the waste and blood and body fluid spillage policies.

• Staff must instigate and maintain accurate records of individuals affected (both patients and staff). This includes up to date stool/input and output charts, outbreak documentation, nursing records/care plans. Records should state the date of onset of symptoms and the Bristol Stool Chart format should be used to document stool types. (Appendix 5)

5.1.3 Preventing the spread of infection

• The IPCT will provide daily infection control guidance if the ward is affected

by viral gastroenteritis. This guidance will be based on the information provided by the ward staff and it is essential that information provided is accurate and up to date.

• Hand washing with liquid soap and water is essential in the prevention of cross infection and hand decontamination is compulsory before and after contact with all patients, their immediate environment and equipment.

• Personal protective equipment (PPE) must be used when handling faeces and/or vomit, other body fluids and for direct/close patient contact. Disposable aprons and gloves must be removed before leaving the patients room and disposed of as infectious waste. The exception to this is when staff must remove vomit/excreta in bed pans and vomit bowls to sluice areas. In this instance PPE must be removed immediately following disposal in to a sluice hopper/macerator/washer disinfector. Hands must be decontaminated immediately using liquid soap and water.

• There is no evidence to support the use of wearing face masks when caring for patients with suspected viral gastroenteritis. The use of masks may instil a false sense of security and are not a substitute for good infection control/standard precautions. However, face protection should be worn if body fluid splashes are anticipated.

• It is essential that environmental cleaning is performed to a high standard and cleanliness is maintained (Appendix 6). Special attention must be paid to toilet and bathroom areas, commodes, all horizontal surfaces and frequent touch surfaces such as door handles, flush handles, sinks, taps and nurse call systems. Chlor-clean is the recommended product to be used throughout the ward/area during the outbreak. Staff must be trained in the use of this type of product and be familiar with the correct preparation, storage and disposal of the product. If Chlor-clean is not available cleaning must be carried out using neutral detergent and warm water followed by disinfection with a product containing 1000 ppm of available chlorine.

• Patient equipment must be thoroughly decontaminated between uses using an appropriate antimicrobial agent. Chlor-clean or Tuffie 5 wipes are acceptable products but manufacturer’s instructions should be followed. If possible, single patient use items should be allocated to affected patients or the use of disposable items is recommended.

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• Linen must be disposed of according to Trust policy. Contaminated linen must be placed in red water soluble bags and secured using the white tie supplied with each bag. Linen must be segregated in to the appropriate laundry bin prior to being sent to the laundry on site at TRH. For areas that launder clothing and linen on site, all contaminated linen must still be segregated, handled and laundered safely and appropriately. The use of red water soluble bags must be utilised to minimise the risk of spread of the infection as well as to reduce risks to the staff involved in the laundry process.

• All waste generated in affected bays/single rooms must be disposed of according to the Trusts waste policy. Waste must be discarded in to the infectious waste stream (orange bags).

• Patients should be encouraged to store personal food and drink items such as fruit, sweets and biscuits inside their lockers. Food stuffs that are exposed may become contaminated with norovirus particles and it will be necessary to discard these items to prevent further symptoms.

• Outbreak control measures are outlined in appendix 7.

5.1.4 Reducing the risk of spread of infection to other areas

• It is the responsibility of the nurse-in-charge to make sure that a notice is displayed at the entrance/exit to indicate that there is infection present on the ward. The notice should state if the ward has been closed and if there are visitor restrictions. Additional signage may be required outside closed bays and side rooms to alert visitors and staff to the risks.

• During periods of increased incidence (PII) the ward may remain open to admissions but with restrictions. This may mean that specific bays are closed to admissions. Admissions/transfers must not be accepted in to closed bays or wards unless approved by the IPCT or Consultant Microbiologist.

• Do not transfer symptomatic patients to other wards within the hospital or to other hospitals or care institutions (nursing, residential homes etc). Refer to appendix 2 for details regarding discharge and transfer.

• If there is a clinical necessity for a patient to be transferred to another ward or hospital advice must be sought from a member of the IPCT unless it is an emergency or out of hours transfer. A risk assessment will be undertaken and the receiving unit must be informed and appropriate precautions taken. Details of the patient’s actual/potential infection risks must be completed on section B of the Healthcare Associated Infection Risk Assessment form (Appendix 3) and also recorded on any transfer documentation sent to the receiving healthcare unit.

• Patients can be discharged to their own home as long as they are medically fit for discharge and do not require nursing or social care at home. Advise them to inform the admitting officer if they are readmitted within 48 hours of discharge.

• Visiting staff such as Physiotherapists, Occupational Therapists and Psychologists should avoid visiting affected wards if possible. However, if they must carry out assessments they should visit the affected ward(s) last or allocate a designated member of staff to visit these areas. Only essential procedures should be carried out on symptomatic patients.

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• Do not transfer staff to other wards or departments. The use of bank and agency staff in outbreak-restricted areas should be kept to a minimum. Such staff must be advised of the risk of norovirus transmission, the necessary precautions that must be adhered to and the importance of reporting any symptoms. Staff 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/day.

• It is recommended that staff are allocated to duties in either affected or non-affected areas of the ward but not both unless unavoidable.

5.1.5 When is the patient/ward clear of infection?

• Patients are usually but not always deemed non-infectious 48 hours after their last episode of diarrhoea or vomiting. However, viral shedding often continues for many days or weeks after symptoms have resolved so the need for continued vigilance and adherence to standard infection control precautions is essential.

• Further stool specimens are not required to check if virus has cleared. • Wards that have been closed or have had closed bays/rooms may only be

re-opened after consultation with the IPCT. Usually the ward/bay can be opened when the last patient with symptoms has had no diarrhoea or vomiting for 48 hours. A thorough terminal clean of the ward/bay (environment and equipment) including curtain changes must take place prior to beds being re-opened (Appendix 4).

5.16 Management of affected staff

• Staff are often affected during an outbreak of viral gastroenteritis. • Staff should be immediately excluded from work if they are experiencing

symptoms of diarrhoea and/or vomiting. In some outbreak situations staff may be required to provide stool samples to the Occupational Health Provider to assist in the identification of specific organisms. The IPCT will advise if this is necessary.

• All staff should be excluded from work immediately until they have been symptom free for 48 hours.

• Staff in the groups identified below should be excluded from work immediately while they have symptoms and for a further 48 hours after passing the first normal stool: Staff whose work involves touching unwrapped foods that are to be

consumed raw or without further cooking Those who are employed directly in the production and preparation of

foodstuffs Those undertaking maintenance work or repairing equipment in food

handling areas Enforcement officers and visitors to food handling areas Health care staff who have direct contact, or contact through serving

food, with patients Food handlers should refer to the Food Hygiene Policy for further

guidance.

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Staff should not consume food or drink at the nurses’ station or in clinical areas during an outbreak of viral gastroenteritis. Any exposed food and drink is likely to have been contaminated and may cause infection

N.B Healthcare workers who do not have food handling duties, or who are not based in a clinical/patient accessible area may return to work once symptoms have stopped, but without the requirement to be symptom free for 48 hours. The decision to let them return to work is the managers’ responsibility and must be made following careful risk assessment to ensure the risk of cross infection is eliminated.

5.1.7 Guidance for visitors

• Visitors may contribute to an outbreak of viral gastroenteritis and should be advised to refrain from visiting if they are symptomatic or have not been free of symptoms for 48 hours.

• Elderly visitors, immuno-compromised individuals and young children may be more susceptible to infection and should be advised to refrain from visiting during the outbreak.

• Visitors must be informed of the risk of contracting the infection and given advice in the form of leaflets.

• Visitors should be encouraged to decontaminate their hands using liquid soap and water and then alcohol hand gel prior to and after visiting their relative/friend.

• Visitors should be discouraged from sitting on beds, eating and drinking in affected areas, nor should they use patient toilets.

• Non-essential visitors such as newspaper vendors, hairdressers, mobile libraries and similar should not be allowed on to an outbreak restricted area until the outbreak is declared over and terminal cleaning has been completed.

5.1.8 What happens if symptoms recur?

• Contact a member of the IPCT immediately for a further risk assessment.

5.2 Procedure for Staff Illness Unrelated to Ward Outbreak

This policy applies to those individuals with diarrhoea that is likely to have been caused by a virus, bacteria or food poisoning. Staff with chronic symptoms of diarrhoea as a result of a medical condition such as Irritable Bowel Syndrome, Ulcerative Colitis, intolerance to gluten etc should not require exclusion from work unless they experience marked changes in symptoms.

Staff are responsible for reporting any episodes of diarrhoea and/or vomiting to their immediate Manager and/or Supervisor. Staff should also report to their manager or supervisor if they have suffered with diarrhoea or vomiting whilst on holiday. Any health care worker who develops symptoms of diarrhoea and /or vomiting on duty should leave work immediately and their manager should contact the Occupational Health Provider.

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Any staff with symptoms of diarrhoea and/or vomiting lasting for more than 3 days

should seek advice and treatment from their General Practitioner.

All staff should be excluded from work immediately until they have been symptom free for 48 hours.

5.3 Specific procedure for management of outbreaks in nursing and residential homes (LD homes)

The basic principles of infection prevention and control apply to care homes in exactly the same way as to hospital settings; however there are differences in the detailed approach to the management of outbreaks which are a consequence of the different environment.

• Any resident with possible infectious diarrhoea and/or vomiting should be

segregated from other asymptomatic residents. If an affected resident shares a room and there are vacant rooms available, temporary use of that room should be utilised to segregate residents.

• If room sharing residents cannot be segregated they must be segregated together and rigorous IPC procedures including increased cleaning frequencies must be applied.

• Symptomatic residents should be advised not to visit communal areas including shared toilets and bathrooms until they have been symptom free for 48h.

• If possible, affected residents should be provided with sole use of a designated toilet or commode until asymptomatic for 48h.

• The manager of the home should inform the local health protection organisation of the suspected outbreak and the IPCT. They should also notify the General Practitioners of the affected residents and ensure they have sufficient specimen containers in which to collect stool samples for microscopy, culture and sensitivity, norovirus and C.difficile testing.

• There are specific difficulties associated with the management of residents with dementia, however these residents should be supported but encouraged to remain in their own rooms or within a limited area of the care home.

• Terminal cleaning must take place once affected residents have been symptom free for 48h. Sometimes there may be a small number of residents who may have persistent symptoms and it may be difficult to ascribe those symptoms to norovirus with any confidence. Such cases should remain in their rooms until they are either 48h symptom free or an alternative non-infectious cause is suspected/identified.

• The general principles of IPC apply to care homes and hospitals. The Department of Health is producing a guidance document ‘Care home resource on infection prevention and control’ and staff following Trust policy should read this in conjunction with the DH document.

• Care homes often have carpeted floors and soft furnishings. Consideration should be given at the point of purchase to the ability to successfully clean and decontaminate such items. Cleaning methods such as steam cleaning should be used during outbreaks and in terminal cleaning schedules.

• Hand washing by staff must occur before and after care giving and as per WHO 5 moments initiative. The use of residents’ hand washing facilities is acceptable; however all staff must only use liquid soap and paper towels for hand washing.

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• All used linen poses an infection risk. Personal protective equipment (PPE) such as plastic aprons and disposable gloves should be worn for handling contaminated clothing and linen. Linen should be removed from a resident’s bed with care and placed in an appropriate bag. Used linen must never be placed on the floor.

• Staff should refer to new DH guidance Choice Framework for local Policy and Procedures 01 – 04: Decontamination of linen for health and social care (2012).

• Although it may not be practical to display notices regarding the infection status of individuals rooms, staff must ensure colleagues, outside contractors and visitors are aware of any outbreak and the precautions necessary to reduce cross infection. Guidance for visitors in section 5.2 should be adhered to.

• Discharges and transfers to other organisations – see Appendix 2 for guidelines.

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6. TRAINING IMPLICATIONS

Diarrhoea and/or vomiting policy for patients & staff Staff groups requiring training

How often should this be undertaken

Length of training

Delivery method

Training delivered by whom

Where are the records of attendance held?

All staff At local induction

At local induction for new starters. Existing staff reminded as new policy issued through Team Brief

Managers ICP link champions in clinical areas

Electronic Staff Record system (ESR)

7. MONITORING ARRANGEMENTS

Area for Monitoring

How Who By Reported To Frequency

Outbreaks Incidents Modern Matron Infection Prevention and Control Specialist Nurse

As and when

Incidents Own audits Infection Prevention and Control Specialist Nurse

Infection Prevention and Control Committee

As and when

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8. EQUALITY IMPACT ASSESSMENT SCREENING The completed Equality Impact Assessment for this Policy has been published on the Equality and Diversity webpage of the RDaSH website click here. 8.1 Privacy, Dignity and Respect The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all patients with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

Indicate how this will be met Consideration needs to be taken into account for the patient who is symptomatic but also for other patients nearby. Privacy curtains should be used if the patient is in a bay area. If the patient is in a single room ensure the door is closed, if safe to do so. If the patient is in a bay area they may need transferring in to a single room if practicable.

8.2 Mental Capacity Act Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible.

Indicate how this will be met

All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1)

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9. LINKS TO ANY ASSOCIATED DOCUMENTS

The following are all available under Clinical Policies, Infection Control, RDaSH Intranet:

- Infection Control Policy for the Surveillance, Prevention and

Management of Infection - Infectious Diseases in Day Nurseries Policy - Hand Hygiene Policy - Standard Infection, Prevention and Control Precautions Policy - Trust Cleaning Policy - Policy for Collection, Handling and Transportation of Pathology

Specimens

- Laundry Policy

- Management of Blood and Body Fluid Spillages - Decontamination Policy

Waste Policy, Health & Safety Policies, RDaSH Intranet Incident Reporting Policy, Health & Safety Policies, RDaSH Intranet

Terminal Clean procedure, RDaSH IPC Intranet site

Other linked documents are:

• Department of Health 2007 Essential Steps to Safe Clean Care:

Reducing the Healthcare Associated Infections.

• Department of Health 2004, A Matron’s Charter: An Action Plan for Cleaner Hospitals.

• Public Health (Infectious Diseases) Regulations 1988 outlines additional diseases which are reportable and outlines management arrangements.

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10. REFERENCES PHLS (1995) The prevention of human transmission of gastrointestinal

infections, infestations, and bacterial infestations. Communicable Disease Report, Vol 5, No 11. 1995.

Department of Health (1995). Food Handlers Fitness to Work. Guidance for Food Businesses, Enforcement Officers and Health Professionals. Prepared by an expert Working Group convened by The Department of Health.

Health Protection Agency (2007). Health Protection Agency Network for the Detection and Characterisation of Norovirus, Newsletter 1, July 2007.

Department of Health (2010) The Health and Social Care Act: 2008 Code of Practice for health and adult social care on the prevention and control of infections and related guidance. London. Crown Copyright

Regulation (EC) No 852/2004 of the European Parliament and of the Council on the hygiene of foodstuffs. Annex II Chapter VIII paragraphs 1 & 2. Guidelines for the management of norovirus outbreaks in acute and community health and social care settings. Norovirus Working Party (2012). Choice Framework for local Policy and Procedures 01 – 04: Decontamination of linen for health and social care. DH 2012.

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APPENDIX 1

REPORTING INFORMATION

During office hours: Report two or more patients with unexpected diarrhoea and/or vomiting to the Infection Prevention and Control Team on 01302 796237.

Out of Office hours: If two or more patients present with symptoms outside office hours, contact the on call Consultant Microbiologist for advice for your area as detailed below: Rotherham Contact Rotherham District General Hospital switchboard 01709 820000 and ask to speak to the on call Consultant Microbiologist. Doncaster Contact the on call Consultant Microbiologist via DRI switch board 01302 366666. N & NELincs Contact the on call Consultant Microbiologist via DRI switch board 01302 366666. Additional contact numbers: Public Health England (local contact) 0114 3211177

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APPENDIX 2 Patient discharge

• Discharge to own home: This can take place at any time irrespective of the stage of the

patient’s norovirus illness. It is not necessary to delay the discharge of symptomatic

patients or those who may be incubating the illness.

• Discharge to nursing or residential homes: Discharge to a home known not to be

affected by an outbreak of vomiting and/or diarrhoea should not occur until the patient has

been asymptomatic for at least 48h. However, discharge to a home known to be affected

by an outbreak at the time of discharge should not be delayed providing the home can

safely meet the individuals care needs. Those who have been exposed but asymptomatic

patients may be discharged only on the advice of the local health protection organisation

and IPCT. These recommendations should be formally agreed between hospitals and

homes in a discharge policy.

• Discharge or transfer to other hospitals or community based institutions (e.g.

prisons): This should be delayed until the patient has been asymptomatic for at least 48h.

Urgent transfers to other hospitals or within hospitals need an individual risk assessment.

Norovirus guidelines 2012

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APPENDIX 3

This form must be ordered from the print room and not photocopied. The order code is on the bottom of the form.

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APPENDIX 4 Terminal cleaning

1. Discard unused disposable patient care items

2. If items cannot be appropriately cleaned, consider discarding these items

3. Remove window and privacy curtains avoiding unnecessary agitation and send for

laundering

4. Remove bed linen and any unused linen and send for laundering

5. Decontaminate all equipment in accordance with manufacturers instructions/Trust

Decontamination Policy

6. Thoroughly decontaminate all surfaces using Chlor-clean or alternatively, clean with

neutral detergent followed by disinfection with a chlorine releasing agent 1000ppm

7. Steam cleaning of upholstered furniture is recommended

The terminal clean procedure and checklist can be accessed on the Trust IPC intranet site.

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The Bristol Stool Form Scale APPENDIX 5

Type 1

Separate hard lumps like nuts (hard to pass) Type 2

Sausage-shaped but lumpy Type 3

Like a sausage but cracks on the surface Type 4

Like a sausage or snake, smooth and soft Type 5

Soft blobs with clear-cut edges (easily passed) Type 6

Fluffy pieces with ragged edges, a mushy stool Type 7

Watery, no solids pieces, entirely liquid Reference: Heaton.K.W., Radvan J., Cripps H. et al (1992) Defecation frequency and timing and stool form in the general population: a prospective study. GUT. 33: 818 - 824.

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APPENDIX 6 Environmental decontamination during an outbreak

• Increase frequency of cleaning using dedicated domestic staff where possible and avoiding

transfer of domestic staff to other areas

• Clean from unaffected to affected areas and within affected areas from least likely

contaminated areas to most highly contaminated areas

• Use disposable cleaning materials including mops and cloths

• Dedicate reusable cleaning equipment to affected areas and thoroughly decontaminate

between uses e.g. mop handles and buckets

• Use Chlor-clean wherever possible to disinfect surfaces

• Pay particular attention to frequently touched surfaces such as bed tables, door handles,

toilet flush handles and taps

• Cleaning staff and other staff who undertake cleaning duties should follow standard

infection control precautions and wear appropriate PPE

• National and local colour coding for PPE and cleaning equipment should be adhered to in

order to avoid cross contamination

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APPENDIX 7

Outbreak control measures (text based on Health Protection Scotland guidelines) Ward

• Close affected bay(s) to admissions and transfers • Keep doors to side room(s) and bay(s) closed • Place signage on the door(s) informing all visitors of the closed status and restricting visits

to essential staff and essential social visitors only • Place patients within the ward for the optimal safety of all patients • Prepare for reopening by planning the earliest date for a terminal clean

Staff

• Ensure all staff are aware of the norovirus situation and how the infection is transmitted • Ensure all staff are aware of the work exclusion policy and the need to go off duty at first

symptoms • Allocate staff to duties in either affected or unaffected areas of the ward but not both unless

avoidable Patient & Relative information

• Provide all affected patients and visitors with information on the outbreak and the control measures they should adopt

• Advise visitors of the personal risk and how they might reduce this risk Continuous monitoring and communications

• Maintain an up to date record of all patients and staff with symptoms • Monitor all affected patients for signs of dehydration and correct as necessary • Maintain a regular briefing to the organisational management, public health organisation

and media office Personal Protective Equipment (PPE)

• Use gloves and aprons to prevent personal contamination with faeces and vomitus • Consider use of face protection with a mask only if there is a risk of droplets or aerosols

Hand hygiene

• Use liquid soap and warm water as per WHO 5 moments • Encourage and assist patients with hand hygiene

Environment

• Remove exposed foods, e.g. fruit bowls, and prohibit eating and drinking by staff within clinical areas

• Intensify cleaning ensuring affected areas are cleaned and disinfected. Toilets used by affected patients must be included

• Decontaminate frequently touched surfaces with detergent and disinfectant containing 1000ppm available chlorine

Equipment

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• Use single patient use equipment where possible • Decontaminate all other equipment immediately after use

Linen

• Treat all linen generated from patients with symptoms as contaminated. Use of water soluble bags indicated to segregate linen safely

Spillages

• Ensure all body fluid spillages are removed immediately. Follow Trust policy