Alert Organisms – Gastroenteritis Page 1 of 19 Version 1.1 September 2019

Infection Prevention and Control Assurance Standard Operating Procedure 26 (IPC SOP 26)

Alert Organisms – Gastroenteritis also known as infective diarrhoea (e.g. Norovirus, Salmonella, and Campylobacter

etc.)

Why we have a procedure?

To ensure employees of the Black Country Partnership NHS Foundation Trust have a standard procedure to follow when caring for patients symptomatic with gastroenteritis (diarrhoea and/or vomiting) to minimise and manage the risks of transmission. The Health and Social Care Act 2008: Code of Practice for the NHS for the Prevention and Control of Healthcare Associated Infections (revised January 2015) stipulates that NHS bodies must, in relation to preventing and controlling the risk of Health Care Associated Infections (HCAI), have in place appropriate core policies/procedures. Implementation of this procedure will contribute to the achievement and compliance with the Act.

What overarching policy the procedure links to?

This procedure is supported by the Infection Prevention and Control Assurance Policy

Which services of the trust does this apply to? Where is it in operation?

Group Inpatients Community Locations

Mental Health Services all

Learning Disabilities Services all

Children and Young People Services all

Who does the procedure apply to?

This document applies to all staff employed by or working on behalf of the Trust caring for patients as part of their role and job description.

When should the procedure be applied?

Effective prevention and control of healthcare associated infection (HCAI) must be embedded

into everyday practice and applied consistently. This procedure must be applied when caring

for patients symptomatic with gastroenteritis (diarrhoea/vomiting).

Additional Information/ Associated Documents

Infection Prevention and Control Assurance Policy

Hand Hygiene Policy

Alert Organisms – Gastroenteritis Page 2 of 19 Version 1.1 September 2019

Infection Prevention and Control Assurance - SOP1: Standard Infection Control Precautions

Infection Prevention and Control Assurance - SOP2: Transmission Based Precautions

Infection Prevention and Control Assurance - SOP3: Surveillance of Infection and Data Collection

Infection Prevention and Control Assurance - SOP4: Reporting Incidents of Infection to Public Health England and/or the Local Authority

Infection Prevention and Control Assurance - SOP5: Management and Recognition of Outbreaks of Communicable Infection/Disease

Infection Prevention and Control Assurance - SOP6: Isolation – Care of Patients in Isolation due to Infection or Disease

Infection Prevention and Control Assurance - SOP7: Decontamination - Cleaning, Disinfection and Sterilisation

Infection Prevention and Control Assurance - SOP9: A-Z of Infections – A Quick Reference Guide

Infection Prevention and Control Assurance - SOP13: Closure of Wards due to an Infection Control Issue

Infection Prevention and Control Assurance - SOP14: Undertaking a Patient Infection Risk Assessment

Aims To reduce the risk of transmission of gastrointestinal infections by ensuring that Trust staff:

Are alert to the risks of individual patients symptomatic with diarrhoea and/or vomiting

Ensure patients with diarrhoea and/or vomiting have appropriate infection prevention and control related care and management, by isolating symptomatic patients promptly to reduce the risks of transmission and promote adherence to standard and transmission based precautions

To aid diagnosis by sending appropriate specimens to the laboratory in a timely manner

To administer appropriate treatment as/when indicated

Inform other healthcare providers of the patients infectious status when any transfers of care are planned either internally within the Trust or to external care providers

Definitions

Cohort Refers to the grouping of patients with the same clinical diagnosis, suspected symptoms or clinical risk category in relation to known or suspected transmissible infection

Diarrhoea Having at least three loose or liquid bowel movements each day (Bristol stool chart type 6 and 7)

Faecal-oral route Means spread of microbes (viruses, bacteria or parasites) from the human or animal stool to your mouth

Gastroenteritis Also known as infectious diarrhoea is inflammation of the gastrointestinal tract that involves the stomach and small intestine. Signs and symptoms include some combination of diarrhoea, vomiting, and abdominal pain. Fever, lack of energy, and dehydration may also occur. This typically lasts less than two weeks

Healthcare Healthcare associated infection (HCAI) refers to infections that occur

Alert Organisms – Gastroenteritis Page 3 of 19 Version 1.1 September 2019

Acquired Infection (HCAI)

as a result of contact with the healthcare system in its widest sense – from care provided in the patient’s own home, to general practice, hospital and nursing home care

Infection The presence of microorganisms on/in the body that is causing an adverse effect or host- response – the person is unwell and has signs and symptoms of an infection

Infection prevention and control

Processes to prevent and reduce to an acceptable minimum the risk of the acquisition of an infection amongst patients, healthcare workers and any others in the healthcare setting

IPCT Infection Prevention and Control Team

Pathogenic A medical term that describes micro-organisms that can cause some kind of disease

Risk Assessment A process used to identify any potential hazards and analyse what could happen, and to identify steps to be taken to reduce or minimise the risk

Gastroenteritis can be due to infections by viruses, bacteria, parasites, and fungus but the most common cause is viruses. Norovirus – sometimes known as the winter vomiting bug and is the most common cause of viral gastroenteritis in humans. It affects people of all ages. Norovirus can be spread via several different routes; faecal-oral, vomiting and aerosolisation, and through contaminated food and water. Viruses may be introduced into the hospital environment via any of these routes and propagated by person-to-person spread, whereby hands are contaminated from the environment and virus ingested by mouth. Norovirus infection is characterized by sudden onset of nausea, vomiting, watery diarrhoea, abdominal pain, and in some cases, loss of taste. A person usually develops symptoms of gastroenteritis 12 to 48 hours after being exposed to norovirus. General lethargy, weakness, muscle aches, headaches, and low-grade fevers may occur. The disease is usually self-limiting, and severe illness is rare. Several cases may occur on a ward within hours. Clostridium difficile – is an anaerobic, gram positive spore forming Bacillus that can cause an infection in the gut. Signs and symptoms of Clostridium difficile infection (CDI) range from mild diarrhoea to severe life-threatening inflammation of the colon with watery diarrhoea (with a characteristic odour) and is commonly associated with current or recent antibiotic treatment [See Infection Prevention and Control Assurance - Standard Operating Procedure 20 (IPC SOP 20) - Clostridium Difficile].

Rotavirus – is the most common cause of severe vomiting and diarrhoea among infants and young children, a mild to severe disease characterised by nausea, vomiting, watery diarrhoea, and low-grade fever. Once a child is infected by the virus, there is an incubation period of about two days before symptoms appear. The period of illness is acute. Symptoms often start with vomiting followed by four to eight days of profuse diarrhoea. Dehydration is more common in rotavirus infection than in most of those caused by bacterial pathogens, and is the most common cause of death related to rotavirus infection. There are eight species of

Possible Causes of Gastroenteritis/Diarrhoea

Alert Organisms – Gastroenteritis Page 4 of 19 Version 1.1 September 2019

this virus, referred to as A, B, C, D, E, F, G and H. Rotavirus A, the most common species, causes more than 90% of rotavirus infections in humans.

Shigella – Shigellosis is an infectious disease caused by a group of bacteria called Shigella. Most who are infected with Shigella develop diarrhoea, fever, and stomach cramps starting a day or two after they are exposed to the bacteria. Shigellosis usually resolves in 5 to 7 days. Some people who are infected may have no symptoms at all, but may still pass the Shigella bacteria to others. There are four different species of Shigella: Shigella sonnei, Shigella flexneri, Shigella boydii and Shigella dysenteriae. (Shigella dysenteriae type 1 can cause deadly epidemics). Campylobacter – is characterized by inflammatory, sometimes bloody diarrhoea or dysentery syndrome, mostly including cramps, fever, and pain. The most common routes of transmission are faecal-oral, ingestion of contaminated food or water, and the eating of raw meat. Foods implicated in campylobacteriosis include raw or under-cooked poultry, raw dairy products, and contaminated produce. Symptoms typically last five to seven days, most cases occurring 3 to 5 days after exposure.

Amoebic dysentery - Amoebic dysentery, also called amoebiasis, is caused by a single-celled parasite called Entamoeba histolytica. This form of dysentery is more common abroad in tropical countries. Symptoms can appear as many as 10 days after exposure and infection by the parasite. The common symptoms of amoebic dysentery may include violent diarrhoea, often accompanied with blood and/or mucus visible in the foul-smelling stools, severe colitis, frequent flatulence in which the patient gives off malodorous gas, abdominal bloating, dehydration, severe abdominal cramps and tenderness, slight to severe weight loss, moderate to severe anaemia, moderate fever, mild to severe fatigue and mild chills. The amoebae may be then carried in the blood to the liver resulting in the formation of an abscess that presents the following symptoms: fever, chills, mild to severe explosive diarrhoea, pain in the upper right portion of the abdomen, jaundice, weight loss and hepatomegaly. Symptoms can last from a few days to a few weeks. Untreated, even if symptoms go away, parasites can live in the bowel for months or years.

Giardia lamblia - Giardiasis is an infection of the digestive system caused by tiny parasites called Giardia intestinalis (also known as Giardia lamblia, or Giardia duodenalis). Symptoms of giardiasis are variable; some people have no symptoms but still pass cysts in the stool and are considered carriers of the parasite while others may develop acute or chronic diarrheal illnesses that begin to show symptoms in one to two weeks after swallowing cysts. Symptoms of acute giardiasis are profuse watery diarrhoea that later becomes greasy and foul-smelling with occasional bloating and abdominal cramping. Other symptoms can include: foul-smelling flatulence and belching, nausea, bloating, indigestion, fatigue, dehydration, loss of appetite, weight loss caused by malnutrition. It can affect people of all ages but is most common in young children and their parents. This is because things like nappy changing increase the risk of infection. Treatment for Giardiasis is mainly done by medicines.

Verotoxin producing E.coli (VTEC) – Illness is characterised by severe abdominal pain, and cramping and watery diarrhoea that becomes grossly bloody and lasts for 5–10 days. Fever is usually mild or absent. Asymptomatic infection can occur. The incubation period is 2–8 days, with an average of 3–4 days. Ingestion of contaminated food and water, and person-to-person and animal-to-person transmission by the faecal–oral route are responsible for VTEC infection. Undercooked meat, especially ground meat or mince, is a source of infection. Other known food sources have included lettuce, sprouts, salami, unpasteurised milk and fruit juices. The infectious dose necessary to cause disease is thought to be as low as 10 organisms. VTEC is communicable for as long as the organism is present in faeces, which is approximately 1 week in adults and as long as 3 weeks in children.

Alert Organisms – Gastroenteritis Page 5 of 19 Version 1.1 September 2019

Cryptosporidium - Cryptosporidiosis is a disease usually caused by the parasites Cryptosporidium hominis and Cryptosporidium parvum. It is most commonly seen in children aged between 1 and 5 years. People with weak immune systems are likely to be more seriously affected. The most common symptoms are watery diarrhoea, vomiting, stomach pains, and fever which may only last a couple of days, but which can continue for up to three or four weeks. It can affect people with weak immune systems for much longer. Most people with crypto get better with no treatment, but crypto can cause serious problems in people with weak immune systems such as in people with HIV/AIDS.

Salmonella - Different types of the Salmonella bacteria can cause the illness. The two most common types are S. typhimurium and S. enteritidis. Salmonella infection occurs from consumption of raw meats and eggs, contaminated dairy foods such as unpasteurized (raw) milk, or fruits and vegetables contaminated by food handlers. Reptiles, rodents, and birds may be infected with Salmonella. Contact with these animals increases the likelihood of getting the infection. Symptoms include diarrhoea, stomach cramps and sometimes vomiting and fever. On average, it takes from 12 to 72 hours for the symptoms to develop after swallowing an infectious dose of salmonella. Symptoms usually last for four to seven days and most people recover without treatment.

The main symptoms of gastroenteritis are:

Sudden, watery diarrhoea

Nausea (feeling sick)

Vomiting, which can be projectile

A mild fever

Abdominal pain

Some people also have other symptoms, such as a loss of appetite, an upset stomach, lethargy, aching limbs and headaches. The symptoms usually appear up to a day after becoming infected. They typically last less than a week, but can sometimes last longer.

The bacteria/viruses are commonly transmitted by people with unwashed hands. People can get the infection through close contact with infected individuals by sharing their food, drink, or eating utensils or by eating food or drinking beverages that are contaminated with the organism. Noroviruses, in particular, are typically spread through contact with the stool or vomit of infected people and through contaminated water or food especially oysters from contaminated waters.

Viral gastroenteritis in particular is highly contagious, people who no longer have symptoms may still be contagious, since the virus can be found in their stool for up to two weeks after they recover from their illness. Also, people can become infected without having symptoms and can still spread the infection.

Symptoms of Gastroenteritis

Routes of Transmission for Gastroenteritis

Alert Organisms – Gastroenteritis Page 6 of 19 Version 1.1 September 2019

Faeces can be transported to your mouth by:

Hands, by shaking someone’s hands contaminated by faeces, touching surfaces in public toilets, changing nappies or incontinence pads, working in the garden, dealing with cattle or pets

Toys, mostly in small children

Fomites – various objects, including utensils, capable to carry microbes

Food, usually raw fruits or vegetables, contaminated by stool-contaminated hands or house flies

Drinking water, usually from lakes, contaminated by animal stool, swimming pools, contaminated by human faeces, or even tap water in certain countries with low-hygiene habits

Eating faeces, in children, or in a mental disorder called coprophagia Definition of Acute v Chronic Diarrhoea It can be difficult to determine what actually constitutes a “normal” bowel action as this can vary greatly between individuals, but true diarrhoea consists entirely of liquid/water (type 6/7 Bristol Stool Chart. Acute diarrhoea has a sudden onset and typically lasts between 1 – 4 days. Chronic diarrhoea persists longer than 4 weeks and is usually due to an underlying cause. Diarrhoea is considered significant when a patient has more than 3 episodes in 24 hours. However, any case of diarrhoea, which may or may not be accompanied by vomiting, amongst patients or staff should be regarded as potentially infectious and treated as such unless an infectious cause can be confidently excluded.

Recognising a Suspected/Confirmed Case Patients with any of the following symptoms:

Vomiting - Two or more episodes of vomiting of a suspected infectious case* occurring within a 24 hour period

Diarrhoea - Two or more loose stools in a 24 hour period*

Diarrhoea and Vomiting - One or more episodes of both symptoms occurring within a 24 hour period*

* Not associated with prescribed drugs or treatments and not associated with reaction to anaesthetic or underlying medical condition or existing illness. In addition to the symptoms above patients may also exhibit nausea, pyrexia, headache and abdominal cramps. A confirmed case:

Patient with symptoms as per suspected case above and with microbiological confirmation

Specimen Collection It is imperative that faecal samples are obtained from all symptomatic cases. This is to enable the IPandC Team to identify the cause of the problem and to rapidly implement the correct control measures to prevent further spread to the rest of the hospital setting.

The date and time the sample was obtained must be recorded in the patient’s records.

The reason for sending the sample must be indicated on the request form

Any recent antibiotic history should also be recorded on the form

Key Recommendations

Alert Organisms – Gastroenteritis Page 7 of 19 Version 1.1 September 2019

Hands must be washed thoroughly with soap and water after specimen collection

Usually there is no requirement to provide clearance samples. Actions to be Taken on Identification of Two or More Cases of Unexplained Diarrhoea and / or Vomiting Careful clinical assessment of the causes of vomiting and diarrhoea is important. Even in the midst of an outbreak there will be patients who have underlying pathologies. Senior nursing staff in conjunction with medical staff and the Infection Prevention and Control Team (using the case definition) should make a decision as to the likely cause. When an outbreak is suspected please refer to Infection Prevention and Control Assurance - Standard Operating Procedure 5 (IPC SOP 5) - Management and Recognition of Outbreaks.

In areas where it can be demonstrated that symptomatic persons can be physically and safely separated from non-symptomatic individuals through cohorting it may not be necessary for the full “closure” or instigation of restrictions on an entire ward

Where cohort nursing is in operation within a bay area personal protective equipment (PPE) should be worn and changed in between caring for each patient and hands must be decontaminated thoroughly with soap and water. PPE should be removed and hands washed prior to leaving the cohort area or single room

Where there is more than a single case a list should be compiled, including symptomatic members of staff and visitors, stating the symptoms and the date/time that these started. This information is vital in assisting the IPandC team to undertake accurate risk assessment when they visit the ward (This form can be found in Infection Prevention and Control Assurance - Standard Operating Procedure 5 (IPC SOP 5) - Management and Recognition of Outbreaks - Appendix 2).

Further cases should be added to the list as/when they occur and these will be monitored and documented during the IPandC team daily review

In situations where additional cases occur in locations other than the initial cohort bay

or side rooms in wards that are not fully “closed” the IPandC team needs to be informed immediately (or on call manager out of hours), as risk assessment may indicate the need to progress to a full ward closure restrictions

Symptomatic patients are required to be clear of all symptoms for 48 hours prior to being deemed fully recovered and isolation restrictions lifted – seek advice from the IPandC Team

Visitors Visitors may contribute to the on-going spread of gastrointestinal infections. Visitors where

possible should be discouraged but not prevented from attending the wards that are closed or have restrictions in place due to gastrointestinal infections. This applies especially to the elderly, immunocompromised or the very young, in whom infections may be more severe. It is strongly advised that anyone with symptoms should not be allowed to visit. (Information for patients and carers can be seen in Appendix 2 and 3).

Alert Organisms – Gastroenteritis Page 8 of 19 Version 1.1 September 2019

Personal Protective Equipment (PPE) for Care of Patients with Gastrointestinal Illness

PPE Entry to isolation room or close patient contact

Hand Hygiene

Gloves

Plastic apron

Long-sleeved gown X

Surgical face mask X

Eye protection Risk assessment (risk of aerosol/splash)

N.B. Hand hygiene MUST always take place after removal of personal protective equipment.

Alert Organisms – Gastroenteritis Page 9 of 19 Version 1.1 September 2019

Key Observations Each patient should be reviewed daily by the medical team to review the observations made by the nursing team. Clinical vital signs e.g. temperature, pulse, respirations and blood pressure should be observed and recorded regularly (at least twice daily), for all patients symptomatic with gastrointestinal illness, to monitor for clinical signs of infection/sepsis/deterioration until the patient has been symptom free for at least 48 hours. In addition frequency of diarrhoea and vomiting must be recorded on stool charts (the Trust standard stool chart can be found in Infection Prevention and Control Assurance - Standard Operating Procedure 20 (IPC SOP 20) - Clostridium Difficile - Appendix 1). Any concerns must be brought to the attention of the Nurse-in-Charge and the medical team. Clinical Treatment

Dehydration - The mainstay of clinical treatment is the avoidance or correction of dehydration which may be achieved through any standard oral rehydration regimen if tolerated. For those who are unable to take oral fluids then intravenous or sub-cut administration of appropriate fluids may be indicated. These measures are particularly important in the elderly and those with underlying conditions or illnesses

Anti-emetic - These are not recommended routinely there is no current evidence for the efficacy of these drugs in adults and conflicting evidence for their use with paediatric patients for whom side effects may be an issue. There is also the risk of compromising IPandC measures through masking the infectivity of patients

Anti-diarrheal drugs - These are not recommended routinely as there is the risk of compromising IPandC measures through masking the infectivity of patients

Cleaning

Ensure the rooms of patients with gastrointestinal infections are prioritised for frequent cleaning (at least daily) with a focus on frequently touched surfaces and equipment in the immediate vicinity of the patient

Keep the environment clean and clutter free

Use disposable cloths for cleaning and discard immediately after use

Clinical equipment should as far as possible be allocated to the individual patient

Re-usable equipment MUST be decontaminated after patient use and between each patient

See Infection Prevention and Control Assurance - Standard Operating Procedure 7 (IPC SOP 7) - Decontamination, for more information. Environmental cleaning is vitally important in preventing the spread of infection. The cleaning regime incudes the standard daily clean followed by disinfection with 1,000ppm chlorine solution to all surfaces and frequent touch points.

N.B When a patient with a gastrointestinal infection is transferred/discharged the room/bed space must have a terminal deep clean undertaken before its re-use – this includes replacing

curtains. Contact the Estates and Facilities Helpdesk to arrange on 0121 612 8010 or ext.: 8010

Discontinuation of Precautions Providing symptoms are no longer present, isolation can usually be discontinued 48hrs after the last episode of diarrhoea and/or vomiting, however this may vary dependant on the causative organism. The Infection Prevention Team should be contacted for advice in these situations. On discontinuation of precautions a thorough isolation clean should be carried out using detergent and hot water followed by a 1,000PPM chlorine solution.

Alert Organisms – Gastroenteritis Page 10 of 19 Version 1.1 September 2019

Staff The main focus is based on the principle of minimising the disruption to important and essential services and maximising the ability of the Trust to deliver appropriate care to patients safely and effectively.

All staff must understand the significance and potential consequences of gastrointestinal illness within the Trust and ensure they are aware of and apply the appropriate infection prevention and precautions interventions when caring for patients with suspected / confirmed gastroenteritis

Staff must be able to identify the symptoms early in order to prevent transmission and outbreaks occurring and must be able to appropriately manage outbreaks of gastrointestinal infections as/when they do occur

All staff caring for patients with a known or suspected gastrointestinal infection must use standard and transmission based precautions to reduce the risk of further acquisition and transmission of infection [See Infection Prevention and Control Assurance - Standard Operating Procedure 1 (IPC SOP 1) - Standard Precautions and Infection Prevention and Control Assurance - Standard Operating Procedure 2 (IPC SOP 2) - Transmission Based Precautions]

Staff Exclusion Rule

All staffs who are taken ill at work with either diarrhoea and / or vomiting should be sent home immediately without completing their shift. It is the individual’s responsibility to communicate to colleagues that the bathroom / toilet area requires immediate decontamination before use by other staff members. This is to prevent spread to other members of staff on the ward

Staff should be excluded from the workplace for 48 hours after all symptoms of diarrhoea and/or vomiting have ceased. The period of exclusion is to prevent further transmission to the workplace environment due to potential continued viral shedding which can occur up to 48 hours after symptoms have ceased. Staff and students working

within the Trust are to be advised that this exclusion is mandatory. For further advice on an individual basis please contact the IPCT or Occupational Health

The submission of a stool sample by staff is also a requirement if the reason for staff sickness is diarrhoea and vomiting. Samples should be submitted via the Occupational Health Department or G/P

Advice and guidance can be sought from the IPCT or Occupational Health team should this situation arise

Good communication is essential to ensure a safe transfer of patients with gastrointestinal infections.

Transfers out - If a symptomatic patient is to be transferred to another hospital or other care provider, the receiving ward/department/care-home should be notified prior to the transfer taking place – this is the responsibility of the Nurse-in-Charge. When transferring to another hospital the IPCT will liaise with the receiving Trusts infection prevention and control team [See Infection Prevention and Control Assurance - Standard Operating Procedure 16 (IPC SOP 16) - Sharing Information with other Health and Social Care Providers].

Discharge/Transfer of Patients with Gastrointestinal Infections

Alert Organisms – Gastroenteritis Page 11 of 19 Version 1.1 September 2019

Transfers between wards – Patients with gastrointestinal infections must only be transferred to another area due to clinical necessity. If these patients are transferred within the Trust, the receiving area must be fully aware of the precautions necessary prior to transfer. The patient must not be transferred until the receiving area is prepared. In addition the IPCT must also be informed of the planned transfer PRIOR to the transfer taking place so that appropriate information and advice can be given.

Where do I go for further advice or information?

Infection Prevention and Control Team

Physical Health Matron Your Service Manager, Matron, General Manager, Head of Nursing, Group Director Your Group Governance Staff

Training Staff may receive training in relation to this procedure, where it is identified in their appraisal as part of the specific development needs for their role and responsibilities. Please refer to the Trust’s Mandatory and Risk Management Training Needs Analysis for further details on training requirements, target audiences and update frequencies. Monitoring / Review of this Procedure In the event of planned change in the process(es) described within this document or an incident involving the described process(es) within the review cycle, this SOP will be reviewed and revised as necessary to maintain its accuracy and effectiveness.

Equality Impact Assessment Please refer to overarching policy

Data Protection Act and Freedom of Information Act Please refer to overarching policy

Alert Organisms – Gastroenteritis Page 12 of 19 Version 1.1 September 2019

Infection Prevention and Control Precautions Overview Patient Placement

Isolate symptomatic patients in a single room with en-suite facilities

Restrict patient movement and exclude from all communal therapies

Keep isolation room door closed as far as possible ensuring patient safety at all times

Patients

All affected patients should be commenced on a Bristol Stool Chart [chart can be found in Infection Prevention and Control Assurance - Standard Operating Procedure 20 (IPC SOP 20) - Clostridium difficile- Appendix 1]

Send specimens to the lab for diagnostic investigations e.g. culture, norovirus and C. difficile testing as required. Only stool recognised as Bristol Stool Chart type 6 and 7 will be tested. The date and time the sample was obtained must be recorded

Provide adequate opportunity to allow patients to decontaminate their hands at regular intervals particularly after visiting the toilet and prior to consuming food and drinks

Provide patients with relevant information and the control measures they should follow to minimise cross-infection (see Appendix 3)

Advise on restricted visiting and visitors visiting at their own personal risk

Hand Hygiene

Adequate facilities for hand hygiene must be provided for patients, staff and visitors

Hand wash basins should be accessible and regularly restocked with liquid soap and paper towels

N.B. hand sanitising gels may not be effective therefore use of soap and water is advised when caring for patients symptomatic with diarrhoea and/or vomiting

Personal Protective Equipment (PPE)

Use gloves and apron as indicated to prevent transmission between patients [see Infection Prevention and Control Assurance - Standard Operating Procedure 1 (IPC SOP 1) - Standard precautions]

PPE must be used when handling excreta or vomit and when in close patient contact

PPE must be removed and hands washed before leaving the isolation room/cohort area

PPE must be changed and hands washed before moving from one patient to another

Consider use of facial protection if there is a risk of body substances contaminating the face of the healthcare worker

Environment

It is essential that environmental cleaning is carried out to a high standard and cleanliness maintained paying particular attention to frequent touch points

Intensify cleaning ensuring affected areas are cleaned with the appropriate chemicals e.g. chlorine 1,000 PPM solution [See Infection Prevention and Control Assurance - Standard Operating Procedure 7 (IPC SOP 7) - Decontamination]

Decontaminate equipment after each use

Do not leave exposed foods out on the open ward, kitchen or staff areas e.g. communal fruit bowl, open biscuits etc.

Appendix 1

Alert Organisms – Gastroenteritis Page 13 of 19 Version 1.1 September 2019

Deal with spillages immediately – clean and disinfect all faecal and vomit spillages [See Infection Prevention and Control Assurance - Standard Operating Procedure 7 (IPC SOP 7) - Decontamination])

Linen

Used and soiled linen from affected patients should be bagged into Alginate (red water soluble bags) before placing into the linen bag and treated as infected linen. If laundry is to be taken home by relatives place contaminated laundry into the orange and white patient laundry bag (see information in the Gastroenteritis – information for patients and carers in Appendix 2 and 3)

Bed linen should be changed daily as a minimum for all affected patients

Beds not in use should not be remade until the ward is ‘re-opened’ and mattresses and bed frames have been thoroughly cleaned to minimise the risk of contamination of bedding

Healthcare Workers

Ensure all staff are aware of the necessary control measures

Allocate staff where possible to care for affected OR non-affected patients to reduce the risks of transmission

Prevent non-essential staff visiting the ward

Ensure affected staff refrain from work until they are 48 hours clear of all symptoms

Equipment

All shared equipment MUST be thoroughly decontaminated after every use to prevent person-to-person spread

Use single patient use equipment whenever possible [See Infection Prevention and Control Assurance - Standard Operating Procedure 7 (IPC SOP 7) - Decontamination]

Continuous Monitoring and Communication

Maintain an up-to-date record of all patients with symptoms and the number of staff affected

Monitor all affected patients for signs of dehydration and correct as necessary

Communicate with the multidisciplinary team/managers and infection prevention and control on a daily basis

Alert Organisms – Gastroenteritis Page 14 of 19 Version 1.1 September 2019

Special Instructions for Visitors and Relatives

Visitors should be advised not to visit if they have symptoms of gastroenteritis or have had recent contact with a person with diarrhoea and / or vomiting. This includes recent visits to other wards or departments affected for example with norovirus

Visitors where possible should be discouraged but not prevented from attending the

wards that are “closed” / have restrictions in place due to outbreak of gastrointestinal illness. This applies especially to the elderly, immunocompromised or the very young, in which infections may be more severe

Visitors should be encouraged to decontaminate their hands on entering and leaving the ward by either hand washing (using liquid soap and water)

If clothing from symptomatic patients is returned to relatives or carers for laundering, they should be given verbal instruction on how to safely launder the items in the home setting (see below)

Soiled and contaminated clothing should be presented to relatives in an orange and white water soluble bag (these are specific laundry bags compatible with domestic washing machines). Instructions for use:

o Put the sealed white and orange patient laundry bag directly into the washing machine. Do not take the clothes out of the white and orange bag, soak the clothes or wash them by hand

o After placing the laundry bag into the washing machine, wash your hands thoroughly with soap and warm water

o Wash the white and orange bag separately from all other laundry you may have, don’t overload the machine

o Use biological washing powder/liquid and wash the clothes using a 60°C wash

o The bag has a soluble tape and central seam, which will dissolve during the wash cycle. Remove the bag after washing and place into your household waste

o Dry laundry as soon as possible. Tumble drying at high temperatures (if fabrics permit) will have a further hygienic effect or alternately air dry on a clothes line and iron

The Patient and Visitor Information Leaflet “Gastroenteritis – information for patients and carers” (appendix 3) should be given and made available to all patients and visitors to the ward

Appendix 2

Alert Organisms – Gastroenteritis Page 15 of 19 Version 1.1 September 2019

Clostridium difficile Information for patients and carers

What about my laundry? Patient’s clothes will be given to your relatives to take home inside a white and orange patient laundry bag. Where this is not possible it may be possible to use the hospital laundry. The Infection Prevention and Control Nurse will be able to advise. The risk of infection when washing patient clothes at home is low. Why have I been isolated in my room? In order to reduce the risk of spreading the infection to other vulnerable patients you will be asked to stay in your room for a few days and the staff looking after you will need to wear protective clothing (gloves and apron) to reduce the risk of them spreading the infection to themselves and others. What about antibiotics? Antibiotics are not usually advised if you are normally in good health. Your immune system can usually clear the infection. Antibiotics do not kill germs which are viruses. Sometimes antibiotics may be prescribed if you become more unwell, your symptoms are due to a bacterial infection or if you already have an underlying chronic illness

INFECTION PREVENTION AND

CONTROL

Gastroenteritis

Information for patients and carers

Proud to be clean,

it’s everyone’s business!

If you require further advice or information, please contact the Trust’s Infection Prevention and Control Team or a member of the

ward/department staff.

Appendix 3

Infection prevention & control is everyone’s responsibility Patients and visitors all have an important role to play in preventing

the spread of infection

Visitors with symptoms of gastroenteritis (diarrhoea & vomiting) are advised NOT to visit the hospital until they have been symptom

free for at least 48 hours

Alert Organisms – Gastroenteritis Page 16 of 19 Version 1.1 September 2019

If you are at home then it’s best to stay in until you are feeling better. There is not always specific treatment, so you have to let the illness run its course. You do not normally need to see your GP as it should get better on its own and visiting the surgery can put others at risk.

Get medical advice if you have:

symptoms of severe dehydration such as persistent dizziness, only passing small amounts of urine or no urine at all

you have bloody diarrhoea,

you are vomiting constantly and are unable to keep any fluids down

you have a fever over 38°C

your symptoms haven’t started to improve after a few days

in the last few weeks you have returned from a part of the world with poor sanitation or you have a serious underlying medical condition.

Your Doctor/GP may suggest sending off a sample of your poo to a laboratory to check what’s causing your symptoms.

What can I do to help ease the symptoms?

Drink plenty of fluids to avoid dehydration – you need to drink more than usual to replace the fluids lost from vomiting and diarrhoea. Water is best but you can also try fruit juice and soup.

Take paracetamol for any fever or aches and pains

Get plenty of rest

If you feel like eating, try small amounts of plain foods such as soup, rice, pasta and bread.

Use special rehydration drinks made from sachets bought from your local pharmacy if you have any of the signs of dehydration (dry mouth, dark urine)

Can I spread the infection to others?

Gastroenteritis can spread vary easily, so you should wash your hands regularly while you are ill and always after visiting the toilet or preparing your food/drinks. Stay off work/school/college or university until at least 48 hours after your symptoms have cleared to reduce the risk of passing it on to others. Also avoid preparing/handling food for others for the same time period.

What is gastroenteritis? When you have gastroenteritis your stomach and intestines are irritated and inflamed. It affects people of all ages but is particularly common in young children. This is typically caused by a viral or bacterial infection. What are the symptoms of gastroenteritis?

The symptoms are:

Sudden watery diarrhoea

Nausea (feeling sick)

Vomiting which can be projectile

Abdominal cramps

A mild fever Some people may have other symptoms such as loss of appetite, aching limbs and headache.

How did I get gastroenteritis?

The bugs that cause gastroenteritis can spread very easily from person-to-person. You can catch the infection if small particles of vomit or poo from an infected person get into your mouth, such as through:

Close contact with someone who has gastroenteritis

Touching contaminated surfaces or objects

Consuming contaminated food or water

Unwashed hands after going to the toilet or changing nappies The commonest cause of gastroenteritis is a virus – the main types are Norovirus and Rotavirus. Rotavirus is the world’s most common cause of diarrhoea in infants and young children, cases in adults are usually caused by Norovirus or bacterial food poisoning. The symptoms usually appear up to a day after becoming infected and typically last less than a week, but can sometimes last longer.

What to do if you have gastroenteritis The best thing to do is stay in your room if you are in hospital – the nurses will advise you what to do Good hand hygiene is the most important way to prevent the

spread of gastrointestinal infections. Posters at the hand wash sinks show the best way to wash your hands

Alert Organisms – Gastroenteritis Page 17 of 19 Version 1.1 September 2019

Guidance for Staff - How should I assess an adult with gastroenteritis?

Assess the severity of the illness.

Ask about:

Frequency and consistency of stools.

The presence of blood in stools.

Frequency of vomiting.

Ability to eat and drink.

Perform an appropriate examination:

Check temperature, blood pressure, and heart and respiratory rates.

Assess for abdominal tenderness.

Assess for features of dehydration

Investigate potential causes or contributing factors.

Ask about:

Recent contact with someone with acute diarrhoea and/or vomiting.

Exposure to a known source of enteric infection (possibly contaminated water or food).

Recent travel abroad.

Recent antibiotics or hospital admission within the last 8 weeks — suspect infection with Clostridium difficile.

Use of drugs such as proton-pump inhibitors and metformin.

Assess personal risk factors, such as:

Age — elderly people are at greater risk of serious dehydration and complications.

Pregnancy — pregnant women are at greater risk of dehydration and complications.

Comorbidities — people who are immunocompromised or have co-existing medical conditions (for example renal impairment, inflammatory bowel disease, diabetes mellitus, or connective tissue disorders) are at greater risk of more severe disease and complications

Review medications:

Certain medications (for example diuretics and angiotensin-converting enzyme inhibitors) can exacerbate dehydration and renal failure. Be aware that the efficacy of certain medications (for example warfarin, anticonvulsants, and the oral contraceptive pill) may be affected by severe diarrhoea

When should I send a stool sample for analysis?

Stool cultures are usually not necessary for most adults who present with acute, watery

diarrhoea. Send a stool specimen if:

Appendix 4

Alert Organisms – Gastroenteritis Page 18 of 19 Version 1.1 September 2019

There is uncertainty about the diagnosis of gastroenteritis.

The person is systemically unwell.

There is blood or pus in the stool.

The person is immunocompromised.

There is a history of recent hospitalization and/or antibiotic treatment.

Diarrhoea occurs after foreign travel to anywhere other than Western Europe, North

America, Australia, or New Zealand.

Diarrhoea is persistent and giardiasis is suspected.

Seek advice from the Infection Prevention & Control Team & local health protection unit

in the following circumstances, as samples may be required:

Suspected public health hazard, for example diarrhoea in food handlers, healthcare

workers, or elderly residents in care homes.

Outbreaks of diarrhoea in the family or community, when isolating the organism may

help pinpoint the source of the outbreak.

Contacts of people infected with certain organisms, for example Escherichia coli O157,

where there may be serious clinical sequelae to an infection.

Alert Organisms – Gastroenteritis Page 19 of 19 Version 1.1 September 2019

Standard Operating Procedure Details

Review and Amendment History

Version Date Description of Change

1.1 Sept 2019 Document reviewed as planned. Appendix 4 added

1.0 July 2016 New Procedure established to supplement Infection Control Assurance Policy

Unique Identifier for this SOP is BCPFT-COI-POL-05-26

State if SOP is New or Revised Revised

Policy Category Control of Infection

Executive Director whose portfolio this SOP comes under

Executive Director of Nursing, AHPs and Governance

Policy Lead/Author Job titles only

Infection Prevention and Control Team

Committee/Group Responsible for Approval of this SOP

Infection Prevention and Control Committee

Month/year consultation process completed

October 2019

Month/year SOP was approved October 2019

Next review due October 2022

Disclosure Status ‘B’ can be disclosed to patients and the public