Norovirus and Diarrhoea and Vomiting Management Policy ... · PDF fileHampshire Hospitals NHS...

Hampshire Hospitals NHS Foundation Trust – Norovirus and Diarrhoea and Vomiting Management Policy HH(1)/IC/608/13 Due for latest review on March 2016 CHECK THE INTRANET FOR LATEST VERSION

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Norovirus and Diarrhoea and Vomiting Management Policy ‐ HH(1)/IC/608/13

Previous document(s) being replaced Location Policy No Policy NameRHCH CP101 Policy for the management and control of diarrhoea

and vomiting (Norovirus) infections BNHH IC/274/09 Diarrhoea & Vomiting Outbreak Management ProtocolHHFT HH(1)/IC/608/12 Diarrhoea & Vomiting Outbreak Management PolicyDocument Summary This policy provides guidance on the management of outbreaks of vomiting and/or diarrhoea within Hampshire Hospitals NHS Foundation Trust. Norovirus is the most common cause of outbreaks of gastroenteritis within the healthcare setting however there are other causes and this policy will therefore apply to all viral gastroenteritides. This policy should be used by all staff to ensure that patients with suspected infectious diarrhoea and/or vomiting are assessed promptly, isolated and managed accordingly to reduce the risk of transmission to patients, visitors, staff and the healthcare environment and to minimise disruption to essential services. Ownership Author Linda Swanson

Job Title Infection Prevention and Control Nurse Document Type Level Level 1 Trust‐wideRelated Documents Document Details Standard Precautions (incorporating Personal

Protective Equipment) Policy Learning and Development Policy Environmental Cleaning Policy Reporting, Managing and Learning From Incidents Policy (Including the investigation of Serious Incidents Requiring Investigation and Being Open)

Relevant Standards CQC Outcome Outcome 8NHSLA Standard N/A

Equality Impact Assessment

Completed by Equality & Diversity Lead Date Completed 3 June 2013

Final Document Approval Committee Policy Approval GroupDate Approved 24 June 2013

Final Document Ratification

Committee Executive CommitteeDate Ratified 27 June 2013

Authorisation Authoriser Mary EdwardsJob Title Chief Executive OfficerSignature

Date Authorised 28 June 2013Dissemination Target Audience All Trust StaffDissemination and Implementation Plan Action Owner Due by

Publicise detail of new document via Intranet and Midweek message

IPCT and Communication Team

Within 10 w/days of publication

Communication to all Senior Managers to advise publication of policy

BNHH Healthcare Library On publication

The policy will be available on the intranet BNHH Healthcare Library Within 10 w/days of authorisation


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Review Expiry date June 2016Review date March 2016

Document Control – Document AmendmentsVersion No. Details Key amendments to note By whom Date 1 Review of harmonised

HHFT policy New addition of HICPAC 2011 guidance New guidance on de‐isolation of symptomatic patients New guidance on bay/ward closures Addition of staff, visitor, and patient information leaflets Terminal cleaning guidance Addition of isolation priorities Amendment to Diarrhoea and/or Vomiting Risk Assessment Equality Impact Assessment Part 2 – recognition of impact of isolation

Linda Swanson May 2013


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Contents

1. Introduction ........................................................................................................ 5

2. Purpose ............................................................................................................... 6

3. Scope .................................................................................................................. 6

4. Explanation of Terms .......................................................................................... 6

5. Duties ................................................................................................................. 7

6. Incubation Period, Signs/Symptoms and Side Effects ......................................... 8

7. Clinical Treatment of Norovirus .......................................................................... 9

8. Initial Assessment of Patients ........................................................................... 10

9. Testing for Norovirus ........................................................................................ 10

10. Laboratory Results ............................................................................................ 11

11. Infection Prevention and Control Management of Suspected/Confirmed Cases 12

12. Ward/Unit Closure ............................................................................................ 13

13. Isolation Options for the Symptomatic Patient ................................................ 14

14. Symptomatic Staff ............................................................................................ 14

15. Discharging Patients during an Outbreak of Norovirus .................................... 14

16. Defining the Start of a Period of Increased Incidence (PII)/Outbreak .............. 14

17. Actions to be taken during a Period of Increased Incidence (PII) ..................... 15

18. Actions to be taken when an Outbreak is Declared .......................................... 15

19. Terms of Reference of the Outbreak Control Group (OCG) .............................. 16

20. Members of the OCG and their Infection Control responsibilities during an Outbreak ..................................................................................................................... 17

21. Defining the End of an Outbreak/Period of Increased Incidence ..................... 18

22. Actions to be Taken When an Outbreak is Over ............................................... 19

23. Stakeholders Engaged During Consultation ...................................................... 19

24. Dissemination and Implementation ................................................................. 20

25. Training ............................................................................................................. 20

26. Monitoring Compliance with the Document .................................................... 20

27. References ........................................................................................................ 20

28. Associated Documentation ............................................................................... 21


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29. Contributors ..................................................................................................... 21

Appendix A – Equality Impact Assessment ................................................................. 22

Appendix B – Common Infections that Cause Diarrhoea and/or Vomiting and their Management .............................................................................................................. 25

Appendix C – Diarrhoea and Vomiting Risk Assessment Form ................................... 29

Appendix D ‐ Management of the Patient with Diarrhoea and/or Vomiting .............. 31

Appendix E – The Bristol Stool and Bowel Chart ........................................................ 35

Appendix F – Isolation Priorities ................................................................................. 37

Appendix G ‐ Outbreak Control Measures .................................................................. 38

Appendix H – Terminal Cleaning ................................................................................. 42

Appendix I – Staff Information Leaflet on Norovirus .................................................. 43

Appendix J – Patient/Visitor Information Leaflet on Norovirus .................................. 45

Appendix K‐ Discharging Patients during Outbreaks of Norovirus ............................. 49


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1. Introduction

Gastroenteritis is a symptom of infection by many different bacterial, viral and parasitic enteric agents. Vomiting and diarrhoea is often accompanied by other clinical signs and symptoms including fever, dehydration and electrolyte imbalance. The micro‐organisms that cause gastro‐intestinal infection are mainly spread from person to person via the faecal‐oral route. Micro‐organisms transmitted by food (e.g. Salmonella, Escherichia coli (E.coli) can be spread to others by cross‐infection. In outbreaks of food‐borne illness, cross‐infection may cause what are described as secondary cases of infection, occurring several days after the main outbreak. Norovirus (also known as small round structured viruses, Norwalk, or the winter vomiting disease) is a highly infectious virus particularly in enclosed settings such as hospitals, schools, nursing homes and cruise ships. It is more prominent during the winter months, but can occur at any time of year. It is readily spread from person to person through aerosol inhalation and environmental contamination from vomiting and diarrhoea. Norovirus is the commonest cause of outbreaks of infectious gastroenteritis in hospitals, and is estimated to cost the NHS in excess of ￡100 million per annum, affecting approximately 1 million people each year in the UK, and causing major disruption to important and essential services (HICPAC 2011). Recent evidence suggests that implementation of robust infection prevention and control strategies may help to prevent prolonged ward/departmental closures, reduce disruption to essential services, reduce transmission of the infection and maximise the organisations ability to deliver appropriate care to patients safely and effectively (Norovirus Working Party 2011). It is essential that infection control is seen as an organisational responsibility and priority, that adequate isolation facilities and resources are provided, and that appropriate infection control staff and support services are available. Organisational preparedness is therefore essential in the management of Norovirus. Larger clinical units with a higher throughput of patients have been demonstrated as having increased rates of gastroenteritis. It is therefore essential that every opportunity is taken within plans for new builds and renovations to maximise the ability to control outbreaks with the provision of easily segregated clinical areas, bays with doors, and adequate provision of single en‐suite accommodation (Norovirus Working Party 2011). For further information regarding common infections that cause diarrhoea and/or vomiting and their management please see Appendix B.


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2. Purpose

To provide Trust staff with guidance for effective management of patients suffering from gastroenteritis and the prevention of transmission to other patients, staff, visitors and contamination of the environment.

3. Scope

This policy and procedure will be applied fairly and consistently to all employees and service users regardless of their protected characteristics as defined by the Equality Act 2010 namely, age, disability, gender reassignment, race, religion or belief, gender, sexual orientation, marriage or civil partnership, pregnancy and maternity. For employees this policy also applies irrespective of length of service, whether full or part‐time or employed under a permanent or a fixed‐term contract, irrespective of job role or seniority within the organisation. Where an employee or service user has difficulty in communicating, whether verbally or in writing, arrangements will be put in place as necessary to ensure that the processes to be followed are understood and that the individual is not disadvantaged during the application of this policy. In line with the Equality Act 2010, the Trust will make reasonable adjustments to the processes to be followed where not doing so would disadvantage an individual with a disability during the application of this policy. This policy complements professional and ethical guidelines and the Nursing and Midwifery Council (NMC) Code of Professional Conduct (NMC 2008).

4. Explanation of Terms

Enteric agents – Intestinal Gastroenteritis – Inflammation of the gastrointestinal tract involving both the stomach and the small intestine resulting in some combination of diarrhoea, vomiting abdominal pain, and stomach cramps Gastroenteritides – organisms that may cause gastroenteritis Micro‐organism – an organism of microscopic size

Norovirus – a very small contagious virus which causes the stomach or intestines or both to get inflamed (acute gastroenteritis) leading to symptoms of stomach pain, nausea, and diarrhea and vomiting.

Diarrhoea – using the Bristol Stool and Bowel Chart an episode of Type 6 or Type 7 stool (see Appendix E)


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Spores – organisms which are resistant structures capable of surviving for extended periods of time in unfavourable conditions Immunocompromised – a state in which a person’s immune systems ability to fight infection is compromised Terminal Cleaning – a final level of cleaning used in health care environments required to help control the spread of infection. The level of cleaning required to denote the end of an outbreak prior to re‐opening of wards/affected areas Epidemiology – the study of patterns, analysis, cause and effects of disease within a given population Period of Increased Incidence (PII) – defined as two or more cases of hospital acquired infection within 28 days linked by epidemiology e.g. two cases on the same ward, bay or unit Outbreak – defined as two or more cases of hospital acquired infection linked by epidemiology and declared by the DIPC/On call Consultant Microbiologist usually following discussion with the IPCT if further spread of the same infection is suspected e.g. with Norovirus a PII becomes an Outbreak if more than one bay is affected on the same ward

5. Duties Post‐holders Chief Executive Officer (CEO) – The CEO has overall responsibility for the strategic and operational management of the Trust ensuring there are appropriate strategies and policies in place to ensure the Trust continues to work to best practice and complies with all relevant legislation in relation to this policy. Director of Infection Prevention and Control (DIPC) – The DIPC is the Trust Director responsible to the board for the delivery of IPC standards. The DIPC will be responsible for defining the beginning and end of an outbreak. In the absence of the DIPC the outbreak responsibilities will be undertaken by the On Call Consultant Microbiologist.

Director of Nursing/Chief Operating Officer (COO) ‐ The COO will ensure that the Divisional Directors take clinical ownership of the policy. The Chief Operating Officer is responsible for convening the Outbreak Control Group (OCG) as required.

Divisional Operational Directors – The Divisional Operational Directors will ensure that all healthcare workers comply with this policy and that all healthcare workers attend mandatory infection prevention and control training. They are responsible for ensuring adequate facilities and resources are available to adhere to this policy.

Clinical Service Managers/Leads (CSM/CSL) – The CSM/Ls will ensure that a printed copy of this policy is available in all of their areas. They will ensure that all healthcare workers comply with this policy and that all healthcare workers attend mandatory infection prevention and control training.


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All Trust employees – All employees will comply with this policy and inform the Infection Prevention and Control Team about any issues or concerns relating to the policy. All staff will attend mandatory Infection Prevention and Control training annually. Infection control is the responsibility of ALL staff associated with patient care. A high standard of infection control is required on ALL wards and units, although the level of risk may vary. It is an important part of total patient care. Committees/Groups

Infection Prevention and Control Team (IPCT) – The IPCT will act as a resource for information and support. They will provide education in relation to this policy which includes mandatory training. They will monitor the implementation of this policy via audit within clinical areas and be responsible for regularly reviewing and updating it.

Health4Work – Health4Work will act as a resource for information, and support and consult with managers, the Infection Prevention and Control Team and healthcare workers regarding the use of personal protective equipment. They will report positive results to staff members in a timely manner.

Health and Safety – The Health and Safety Team will act as a resource for information, and support and consult with managers, the Infection Prevention and Control Team and healthcare workers regarding the use of personal protective equipment. Site Teams – Site Teams will act as a resource for information and support and consult with managers, the IPCT, Consultant Microbiologists and healthcare workers regarding implementation of this policy.

6. Incubation Period, Signs/Symptoms and Side Effects The period from when you are infected to when you start to show symptoms of Norovirus (known as the incubation period) usually lasts 12‐48 hours. During this time, you may be infectious to other people and will continue to be infectious up to 48 hours after symptoms stop. Although Norovirus can affect anybody, some groups of people pose a higher risk of spread of the infection. These include people who have difficulty in implementing good personal hygiene, staff who may have direct contact with infectious material and are involved in serving food to susceptible patients, and food handlers whose work involves touching unwrapped food to be eaten raw or without further cooking.

The virus is very small and is highly contagious, being easily spread by contact with an infected persons stool/vomit and/or contaminated environment/food/drink. The virus is spread via the faecal – oral route.

The virus is shed in the faeces and/or vomit of an affected person and may live on surfaces or objects touched by that person for several days. From these surfaces the virus may be transferred to another person and ingested. Although Norovirus is not


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technically airborne, inadvertent ingestion may occur in those who are in close proximity to symptomatic infected patients. Signs/Symptoms Norovirus is characterised by often sudden onset of symptoms of vomiting and/or diarrhoea. Some people may also have:

• a raised temperature (over 38C/100.4F) • headaches • stomach cramps • aching limbs

Norovirus is usually self limiting with most people making a full recovery within a couple of days. Immunity to Norovirus is very short lived, typically lasting up to a few weeks, consequently re‐infection is common (HICPAC 2011). Norovirus has no specific cure, and cannot be treated with antibiotics. Side Effects Dehydration is the most notable possible side effect of Norovirus, particularly in those who are elderly, poorly nourished, in the very young, and in those whose illnesses or conditions render them more vulnerable to the effects of dehydration.

Apart from the risk of dehydration, the illness is not generally dangerous and there are usually no long‐lasting effects from having Norovirus, with most people making a full recovery within a couple of days. If diarrhoea persists for 7 days or more, or worsens in nature it is advised that the patient be re‐assessed by clinicians and alternative causes of diarrhoea considered and investigated promptly.

7. Clinical Treatment of Norovirus The mainstay of the clinical treatment of Norovirus is the avoidance or correction of dehydration. These measures are particularly important in the elderly and in those who may have underlying conditions or illnesses which render them more vulnerable to the effects of dehydration. This may be achieved through any standard oral rehydration regime in patients who can tolerate oral fluids, plus or minus the use of rehydration compounds such as Dioralyte ®. For those who cannot tolerate oral fluids or preparations, administration of appropriate fluids either subcutaneously or intravenously is indicated as an early supportive measure (HICPAC 2011). Rehydration should be carried out in the community where possible, with specialist outreach teams established to administer this treatment and thereby avoid admission of the patient to hospital solely for this purpose (HICPAC 2011).


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Use of Anti‐Emetic Drugs These are not recommended routinely although some doctors find them useful. There is no evidence for the efficacy of these drugs in adults and conflicting evidence for their use in children for whom side effects may be an issue. There is also the risk of compromising IPC measures through masking the infectivity of patients. Use of Anti‐Diarrhoeal Drugs These are not recommended routinely but some doctors find them useful in cases where other causes of diarrhoea have been excluded. They can be dangerous in some conditions such as Clostridium difficile, and may also mask the infectivity of patients.

8. Initial Assessment of Patients Careful clinical assessment of the causes of vomiting or diarrhoea is important. Even in an outbreak there will be patients who have diarrhoea and/or vomiting due to other underlying pathologies. An initial assessment of patients with diarrhoea must be undertaken immediately symptoms commence using the Trusts Diarrhoea and/or Vomiting Risk Assessment algorithm. Please see Appendix C.

Any patient admitted with diarrhoea and/or vomiting should be admitted into a single room with en suite facilities to allow for a full assessment of their condition. Any patient who commences diarrhoea and/or vomiting whilst already an inpatient should be transferred into a single room with en suite facilities to allow for a full assessment of their condition. It is the onset of symptoms of diarrhoea and/or vomiting which necessitates the need for isolation of the patient, laboratory results should not be awaited to determine whether isolation is necessary. Please see Appendix D Management of the Patient with Diarrhoea and/or Vomiting

9. Testing for Norovirus If Norovirus is clinically suspected then a member of the Infection Prevention and Control Team (IPCT)/Consultant Microbiologist/Site Team/ should be informed immediately. This will allow for prompt isolation, testing and management of patients and their potential contacts. Laboratory services will be informed by the IPCT/Consultant Microbiologist/Site Team that Norovirus testing will be required. Norovirus can be detected via either stool or vomit samples. Stool samples are the preferred method of detection. Vomit samples should be sent in the absence of diarrhoea and where Norovirus is clinically suspected.


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It is important that consideration is given to the patient’s right to consent or refuse testing for Norovirus. The provision of a clear explanation from nursing/clinical staff as to why testing is required can be beneficial in helping the patient come to an informed decision regarding testing.

A stool sample must be sent immediately symptoms of type 6/7 stools on the Bristol Stool and Bowel Chart (see Appendix E) are present and infection is suspected. Stool samples can still be sent if contaminated by urine or taken from an incontinence pad/sheet as this will not usually affect the results. Anti diarrhoeal medication should not be prescribed to relieve symptoms as this may prolong the period of infectivity. Vomit samples must be sent immediately symptoms of vomiting commence and in the absence of a stool specimen when Norovirus is clinically suspected. It is important that the sample is collected and that staff ensure that the sample has left the clinical area and is transported to the microbiology laboratory as soon as possible to allow for timely results. This is the responsibility of the person collecting the sample. Failure to ensure that the sample has left the clinical area can cause extensive delays in testing and obtaining results, leading to potential operational issues within the Trust and potential disruption to services.

10. Laboratory Results During times of heightened Norovirus activity, and especially during Period of Increased Incidences (PIIs), negative test results will allow lifting of restrictions more rapidly, and enable optimal use of scarce isolation facilities, and a return to normal operational duties. Laboratory testing for Norovirus will be instigated by the IPCT in liaison with the Laboratory Manager and DIPC/Consultant Microbiologist and will be based upon epidemiology of affected patients, increased Norovirus activity within the community/hospital setting, and where patients have been admitted with diarrhoea and/or vomiting where alternative, non‐infectious causes cannot be confidently diagnosed. Collection of samples is paramount in aiding decision making amongst the organisation and enabling timely progression of patient care. Collection of samples is the responsibility of the nurse in charge. Ensuring that sample results are obtained is the responsibility of the requesting/collecting person. A Norovirus result is either positive or negative. It is not necessary to test for clearance of Norovirus. Norovirus clearance is dictated by the absence of clinical symptoms for 48 hours or more.


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During normal office hours results will be telephoned through to the IPCT/Consultant Microbiologist/Site Team/Wards by laboratory staff. It is the receiving person’s responsibility to ensure that these results are communicated to the appropriate people. Out of hours results will be telephoned through to the Site Team/Wards/IPCT/Consultant Microbiologist as appropriate by laboratory staff. It is the receiving person’s responsibility to ensure that these results are communicated to the appropriate people.

11. Infection Prevention and Control Management of Suspected/Confirmed Cases Isolation of symptomatic cases remains one of the most important and effective infection prevention and control measures in limiting the spread of suspected/confirmed Norovirus. Whilst it is recognised that isolation may have an impact on the psychological wellbeing of a patient, this can be greatly reduced by the provision of timely information detailing the reasons why isolation is necessary, measures being used to manage/treat the infection, and how long isolation nursing is anticipated. This information should be provided verbally by the nursing staff/responsible clinicians/IPCT. Information leaflets should also be provided to both the patients and their relatives, ensuring that confidentiality is maintained at all times . Please see Appendix J ‐ Patient/Visitor Information Leaflet on Norovirus.

The isolation of cases within single rooms and bays as opposed to the early closure of complete wards is now recommended (HICPAC 2011) as it allows flexibility of response and the early terminal cleaning and re‐opening of affected sub‐ward areas. Only when there is evidence of a failure of containment within all available single‐occupancy rooms and bays should whole ward closure be considered. In order to maintain necessary clinical services as much as possible and to reduce interruption to vital services it is recommended that healthcare organisations undertake a local risk‐assessed approach to the closure of entire areas to admissions/transfers during outbreaks. The IPCT/DIPC/Consultant Microbiologist/Clinical Service Manager (CSM) are best placed to undertake this risk assessment. Ward/unit closure is not recommended providing the following criteria can be met: • Symptomatic persons can be physically segregated from the non‐symptomatic

patients into single rooms with en‐suite facilities or cohort bays with doors • Levels of staffing are such that successful cohort nursing can be undertaken to allow

for one group of staff to attend to symptomatic patients only, and another group of staff to attend to asymptomatic patients only

• Staff working in closed and adjacent non‐closed areas have been trained on the

importance of preserving efficient segregation of these areas for patients, staff and visitors.


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12. Ward/Unit Closure Ward/unit closure will be required where there is clear evidence that the outbreak is uncontrolled, with further spread of Norovirus evident despite the introduction of isolation/cohort nursing and the implementation of infection prevention and control measures. This assessment will be made by the IPCT in consultation with the DIPC/Consultant Microbiologist and the CSM of the affected area. Ward closure can only be authorised by the DIPC/Consultant Microbiologist. Closure refers to the restriction of incoming and outgoing personnel, equipment, materials (including patient notes) to an unavoidable minimum. The fewer times that the portal of a closed area is crossed, the less is the risk of transmission of virus and further spread to other areas. Patients should only be transferred for investigations and interventions that cannot be safely delayed. There should be an obvious boundary between open and closed areas to signal to everyone that restricted access is in place. This boundary should consist of doors and high visibility signage. There should be provision of hand‐hygiene facilities at each boundary. These may be mobile units if permanent facilities are not available. All non‐essential personnel should be prohibited from entering the closed area. This includes non‐essential social visitors of patients. Admissions to a closed area should be restricted to patients who are known to have been exposed to Norovirus, whether potentially incubating, symptomatic or recovered. Closed areas should, ideally, be self‐contained with hand washing facilities and en suite toilet facilities. The use of commodes and communal toilets may increase the risk of spread in an outbreak and this should be mitigated by the implementation of an intensive and frequent cleaning schedule.

Dedicated nursing and healthcare staff should be assigned to closed areas for each work

shift. If this is not possible, thorough application of personal IPC measures as described in local policies are essential. These measures include the use of PPE such as plastic aprons, gloves, masks and rigorous attention to hand hygiene with soap and warm water.

Staff should also have access to eye and face protection if there is a risk of a body fluid splash into the face. Staff should be reminded that gloved hands that have been used to clean up spillages of body fluids can themselves be a vehicle for further contamination and that these items should be disposed of as clinical waste (orange waste stream) and the hands cleansed with soap and warm water at the earliest opportunity.


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Please also see Appendix D ‐ Management of the Patient with Diarrhoea and/or Vomiting 13. Isolation Options for the Symptomatic Patient Any patient with suspected/confirmed Norovirus is a high priority for isolation. See Isolation Priorities Table Appendix F. A single room with en suite facilities on the ward which the patient developed symptoms is always the preferred option for isolating the patient suspected/confirmed with Norovirus (Norovirus Working Party 2011). All attempts must be made to ensure that this level of isolation is achievable, including the provision of extra nursing staff if necessary to ensure the safety and well being of the patient being cared for in isolation. Failure to isolate must be recorded as an incident by completing a Datix form. Isolation with standard precautions in place should be maintained for a minimum period of 48 hours following cessation of symptoms. Isolation door should remain closed at all times with clear signage depicting that isolation nursing is in progress. In those patients whom are immunocompromised consideration should be given to extending the period of isolation with standard precautions as these patients are at increased risk of relapse, and can experience protracted episodes of diarrhoea with prolonged viral shedding into the environment. De‐isolation of this patient group should be based upon clinical judgement by the clinicians responsible for the patients care, and the IPCT/DIPC/Consultant Microbiologist (HICPAC 2011).

Please read in conjunction with the Standard Precautions Policy. Please also see Appendix D ‐ Management of the Patient with Diarrhoea and/or Vomiting

14. Symptomatic Staff

Please see Appendix G for staff considerations.

15. Discharging Patients during an Outbreak of Norovirus

Please see Appendix K for Discharging Patients during an Outbreak of Norovirus.

16. Defining the Start of a Period of Increased Incidence (PII)/Outbreak Laboratory confirmation is not always necessary in order to define the start of a PII/outbreak, and definition may be based on clinical presentation of cases. However, laboratory confirmation is invaluable in establishing the cause of outbreak and aiding epidemiological surveillance.


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Prior to the instigation of a full organisational approach to an outbreak, there is often a preliminary period in which a small number of undiagnosed symptomatic patients may or may not herald a Norovirus outbreak. These cases will be managed as a PII which signifies increased surveillance, increased interaction between the IPCT, affected clinical area/s, site team/relevant managers and laboratory services. Defining the start of an outbreak/PII serves two purposes.

• helps to establish trigger points for the activation of organisational responses • helps to establish trigger points for epidemiological surveillance and data collection

An outbreak/PII is defined as two or more cases linked epidemiologically and should trigger both actions above. Declaration of a PII may be either formally or informally made by the DIPC/IPCT via communication of the situation to the relevant managers/site teams and clinicians.

17. Actions to be taken during a Period of Increased Incidence (PII) Even during an outbreak of Norovirus careful assessment of the causes of vomiting and/or diarrhoea should continue as there will be patients who have diarrhoea and/or vomiting due to other underlying pathologies. During a PII of diarrhoea and/or vomiting, affected patients should still be isolated in single rooms, or cohort nursed in bays. At this stage, there is no need to call a formal outbreak control meeting although the IPCT should alert appropriate managers and clinicians to the potential for an outbreak. IPC surveillance, interventions and communications with the ward staff should be intensified during this period. The ward staff in liaison with the IPCT should ensure that faeces/vomitus specimens from active cases are collected without delay and are sent to the laboratory for testing for Norovirus detection, bacterial culture and, if appropriate, Clostridium difficile tests. Microbiological analysis of stool specimens associated with potential outbreaks must be available on a seven days a week basis. The turnaround time for non‐culture analysis to provision of a telephoned or electronically‐transmitted result should be within the same day or, at most, 24 hours in order to minimise bed closures and to aid patient management.

18. Actions to be taken when an Outbreak is Declared Declaration of an outbreak is made at a point in the evolution of a suspected outbreak at which there is a significant risk of IPC demands outstripping available resources and affecting operational ability. The IPCT is best placed to assess when this point is reached


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in any given circumstances in consultation with the DIPC/Consultant Microbiologist, with an outbreak being declared formally by the DIPC/IPCT. For ward/affected area outbreak control measures/actions please see Appendix G Outbreak Control Measures In order to oversee the timely management and instigation of any necessary measures to aid control of the outbreak, an outbreak control group (OCG) will be formed by the DIPC. Membership of the OCG should comprise: • Chief Operating Officer/Director of Nursing (Chair) • DIPC (deputy chair if required) • Infection Prevention and Control Nurse with responsibility for the affected area • Medical Director or designate • Consultant in Communicable Disease Control if required (CCDC) • Consultant(s) from the affected area(s) • Senior nurse(s) or midwife(s) from the affected area(s) • Divisional Operational Director of affected area(s) (deputy chair if required) • Consultant Microbiologist • Health4Work Doctor/Nurse • Communications representative • Facilities Manager • Site Co‐ordinator/Lead • Head of HR (if required) • Head of Support Services (if required) • Secretarial Assistance • Other representatives may be co‐opted e.g. Pharmacy/Procurement N.B. some members of the group may represent a number of roles.

19. Terms of Reference of the Outbreak Control Group (OCG) Once an outbreak has been identified the functions of the OCG are: • To agree on a working case definition for outbreak management • To agree and co‐ordinate policy decisions on the investigation and control of the

outbreak and to ensure they are implemented • To take all necessary steps to ensure optimal continuing clinical care of all patients

(affected or unaffected) during the outbreak • To take all necessary steps to ensure the well being and safety of staff involved • To assess the resource implications of outbreak management, and how these will be

met e.g. additional supplies and clerical staff • To agree arrangements for providing information to patients relatives and visitors if

required (Appendix J) • To meet on a regular basis as considered necessary by the DIPC/IPCT to review

progress on outbreak investigation and control


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• To define the end of the outbreak and evaluate its management • To inform the Risk and Compliance Manager • To prepare a report for submission to the Trust Infection Prevention and Control

Committee and Divisional Governance Board as necessary

20. Members of the OCG and their Infection Control responsibilities during an Outbreak Infection Prevention and Control Team

• Identify possible PII/outbreak and report to DIPC/Consultant Microbiologist

• Identify an Infection Prevention and Control Nurse to provide leadership at ward level, co‐ordinate outbreak management, and ensure that consistency of advice is provided throughout the outbreak

• Institute outbreak control measures • Ensure the provision of bay/ward signage • Advise on Trust wide signage required • Monitor that outbreak control measures are consistently

implemented • Collect relevant patient/staff information from ward/clinics

or other affected areas and keep an up to date electronic record of affected areas/patients

• Collect all laboratory information • Collate and continually review evidence to confirm incident

and plot its course, reporting this to the DIPC and OCG • Enlist the assistance of the Health4Work staff if required for

the co‐ordination of staff screening if deemed necessary • Report to DIPC • Monitor and advise ward staff on the care of patients

DIPC

• Define the beginning and end of an outbreak • Co‐ordinate all control measures • Inform and liaise with: • Clinicians in affected area • Ward manager • Divisional Operational Director • Medical director • CCDC • Chief Executive • Discuss with Divisional Directors whether a Serious Incident

Requiring Investigation (SIRI) is required in accordance with the Reporting, Managing and Learning From Incidents Policy (Including the investigation of Serious Incidents Requiring Investigation and Being Open)

Chief Operating Officer

• Convene Outbreak Control Group • Chair outbreak meetings • Advise OCG on current status of outbreak • Advise OCG on infection control procedures


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CCDC • Consult with the DIPC and help to institute the Trust Infectious Incident and Outbreak Plan

• Advise the OCG on further epidemiological aspects of outbreak investigation

• Inform and liaise with the Local Authority Environmental Health Department as necessary

• Inform Director of Public Health Medicine as necessary • Inform CDSC as necessary • Liaise with Risk Management • Be available for consultation during the outbreak

Clinical Consultant

• Advise OCG on aspects relating to clinical care of patients • Relay OCG instructions to medical team involved

Keep medical staffing requirements under review Consultant Microbiologist

• Advise OCG on further microbiological aspects of the investigation

• Arrange for microbiological analysis of specimens and report results to OCG

• Advise on the beginning and end of an outbreak Communications Department

• To provide robust local communication channels between agencies both internally and externally

• To provide timely communication to external agencies such as General Practitioners (GP) surgeries, ambulance control and local press to limit admissions from the community where possible

• To provide timely communication to the general public regarding restrictions in visiting

Senior nursing/midwifery manager of affected wards/areas

• Ensure that information from the OCG is communicated to ward level in a timely manner

• Ensure that the affected ward/area is using the electronic data collection method for collating data on affected patients/staff on a daily basis

• Identify any supportive measures that may be required by the ward/area during the outbreak

All meetings of the OCG will have clear agendas; minutes and action notes will be produced. Members of the IPCT will be responsible for providing status reports at each meeting for OCG deliberation. Where an outbreak involves the community, the CCDC may take the lead role.

21. Defining the End of an Outbreak/Period of Increased Incidence The end of an outbreak is defined as either: • 48 hours after the resolution of vomiting and/or diarrhoea in the last known active

case. This is also the point at which terminal cleaning will have been completed. An


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outbreak cannot be declared over until terminal cleaning of the affected area has been completed in whole. Please see Appendix H Terminal Cleaning.

• For epidemiological surveillance the end of an outbreak is defined as no new cases

recognised within the previous 7 days. There is often a small number of patients who may persist with symptoms of Norovirus. It is advisable to segregate those patients within the ward/area in order to facilitate a return to normal activity. This can be achieved by moving symptomatic patients into single rooms with en‐suite facilities or cohort nursing in a bay with doors. Terminal cleaning of a ward should commence once any symptomatic patient is successfully isolated.

22. Actions to be Taken When an Outbreak is Over It is the completion of terminal cleaning that serves as the definition of the end of the outbreak for IPC purposes. There is often uncertainty at this early stage, with a small number of patients experiencing protracted episodes of symptoms (especially diarrhoea) and it may be difficult to ascribe those symptoms to Norovirus with any confidence. Such patients should be placed in single‐occupancy rooms if possible and terminal cleaning of bays and general ward areas may then proceed. The IPCT should inform the wider managerial team and the local health protection organisations of the successful completion of terminal cleaning and unrestricted activity may then resume. Vigilance should be maintained during the immediate period following the recommencement of unrestricted activity because there is a risk of re‐emergence of the outbreak at that time.

23. Stakeholders Engaged During Consultation Stakeholder Date of

ConsultationInfection Prevention and Control (Lead Infection Prevention & Control Nurse)

20/05/2013

Health and Safety (Health and Safety Advisor) 24/05/2013 Safeguarding (Trust Safeguarding Lead) 24/05/2013 Information Governance (Information Governance Manager) 24/05/2013 Assistant Risk and Compliance Manager (Risk and Compliance) 24/05/2013 Divisional Directors and Divisional Directors (Operational) 24/05/2013 Equality and Diversity Lead (Equality & Diversity) 24/05/2013 Infection Prevention and Control Committee 24/05/2013 Consultant Microbiologists 24/05/2013


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Stakeholder Date of Consultation

Clinical Service Managers/Leads 24/05/2013 Operational Service Managers 24/05/2013 Facilities Manager 24/05/2013 Laboratory Manager 24/05/2013

24. Dissemination and Implementation

Action(s) Owner Publicise detail of new document via Intranet and Midweek message

IPCT and Communication Team

Communication to all Senior Managers to advise publication of policy

BNHH Healthcare Library

The policy will be available on the intranet BNHH Healthcare Library

25. Training Individuals in the Trust should receive annual infection prevention and control training to ensure they are aware of their responsibilities. Education and Training will be provided in accordance with the Trust Training Needs Analysis (Learning and Development Policy).

26. Monitoring Compliance with the Document

NHSLA Minimum requirements

Requirement Reviewed by

Method of Monitoring

Frequency of Review

Committee where Monitoring is Reported to

A. Effectiveness of policy

Infection Prevention and Control Team

Audit of outbreak Annual Infection Prevention and Control Committee

27. References MacCannell T, Umscheid CA, Agarwal RK, Lee I, Kuntz G,and Stevenson KB, 2011. Guideline on the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings. HICPAC Guideline. Infection Control Hospital Epidemiology. 2011 October; 32(10). pp: 939‐969. Norovirus Working Party, 2011. Guidelines for the Management of Norovirus


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Outbreaks in Acute and Community Health and Social Care Settings. HPA. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317131639453 (Accessed on 17/05/2013).

Guidance from other organisations Centres for Disease Control and Prevention, 2011. Updated Norovirus Outbreak Management and Disease Prevention Guidelines. CDC. http://www.cdc.gov/mmwr/pdf/rr/rr6003.pdf (Accessed on 01/05/2013).

28. Associated Documentation Standard Precautions (incorporating Personal Protective Equipment) Policy Environmental Cleaning Policy Learning and Development Policy Reporting, Managing and Learning from Incidents Policy (Including the investigation of Serious Incidents Requiring Investigation and Being Open)

29. Contributors

Contributor Job Title Contributor Name

Infection Prevention and Control Nurse Linda Swanson


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Appendix A – Equality Impact Assessment PART 1 To be completed by the document owner Document Title: Norovirus and Diarrhoea and Vomiting Management Policy

Yes/No Comments

1. Could the application of this document have a detrimental equality impact on individuals with any of the following protected characteristics? (See Note 1)

Age No

Disability No

Gender reassignment No

Race No

Religion or belief No

Sex No

Sexual orientation No

Marriage & civil partnership No

Pregnancy and maternity No

2. If you have identified any potential detrimental impact, do you consider this to be valid, justifiable and lawful? If so, please explain your reasoning.

Yes It is recognised that isolation may have an adverse psychological impact on a person and may affect their freedom of liberty. However isolation is still considered the most effective measure in limiting the spread of infectious diseases/ organisms and is therefore considered a necessary intervention

3. If you have answered ‘no’ to question 2, has the policy been amended to remove or reduce any potential detriment?


of 49

Yes/No Comments

• If you answer ‘yes’, please summarise the changes made

• If you answer ‘no’. please explain why not

4. Based on the answers to questions 1 – 3 do you consider that a detailed equality analysis is needed?

No

NAME: Linda Swanson JOB TITLE: Infection Prevention and Control Nurse DATE: 17/05/2013


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PART 2 To be completed by the Trust’s Equality and Diversity Lead Brief Summary of potential impact of this document and whether sufficient consideration has been given to the Equality Duty Isolation of a patient might not always be in line with the individual’s (or family’s) wishes, and could be impacted on their freedom of movement and contact with other patients. The significant risk of not isolating when required to do so, outweighs this potential risk and the policy recognises this. Clear explanation as to why a patient must be isolated will form the basis of any and all discussions with the patient and their relatives. Consent for testing is implied in the policy but not explicit – potential impact on a patient’s right to consent or refusal considered.

Yes/No Comments

1. Is this document recommended for publication without amendment?

Yes

2. Is this document recommended for publication but with recommended amendments? Please specify.

Yes

Reference to consent and also information provided when isolation required

3. Is this document not recommended for publication without amendments being made? Please specify?

4. Is it recommended that this document requires a more detailed equality analysis to be undertaken prior to publication?

No

5. Specify with which, if any, individuals and groups you have consulted in reaching your decision.

CSMs /Infection control nurses

NAME: Zena Ludick JOB TITLE: Operations Director, Surgery DATE: 03/06/2013 Note 1 Under the terms of the Equality Act 2010’s public sector Equality Duty, the Trust has a legal responsibility to think about the following three aims of the Equality Duty as part of our decision making and policy development.

• Eliminate unlawful discrimination, harassment and victimisation; • Advance equality of opportunity between people who share a protected characteristic and people

who do not share it; and • Foster good relations between people who share a protected characteristic and people who do not

share it.


Common Infections that Cause Diarrhoea and/or Vomiting and their Management – v.1 of 49 Authorised by: Policy Approval Group Date 24/06/13

Appendix B – Common Infections that Cause Diarrhoea and/or Vomiting and their Management This list is not exhaustive but gives examples of micro‐organisms which cause gastro‐intestinal infections. All cases of diarrhoea and/or vomiting should be reported to the Infection Prevention and Control Nurse. Disease and/or infective agent and clinical features

Transmission Guidance and Isolation

Small round structured virus (diarrhoea and/or vomiting) Norovirus

• Faecal oral (hand to mouth following direct contact with faeces and/or vomit).

• Secondary faecal oral spread from infected cases.

• Indirect spread after environmental contamination by vomitis.

• Droplet from aerosols from vomit.

• Contact with contaminated gloves, shared clinical equipment and the environment.

• Unwashed Healthcare Worker’s hands.

• Isolate for 48 hours from the last episode of diarrhoea and/or vomiting.

• Staff members who are symptomatic should stay at home for 48 hours from the last episode of diarrhoea and/or vomiting.

• Collect stool specimens ASAP for Norovirus testing.

• Staff stool specimens should be sent via Health4Work or their GP.

Rotavirus • As above • As above Hepatitis A • Faecal oral which

includes patient to patient spread.

• Infected food handlers with poor personal hygiene.

• Contaminated water and food especially shellfish.

• Contaminated drugs and needle sharing equipment in illicit drug users.

• Isolate for one week after the onset of jaundice or in the absence of jaundice until 10 days after the onset of first symptoms.

• Report cases to the local Public Health England Centre (PHE)

Hepatitis E • Faecal oral person to person spread.

• Isolate for 48 hours from the last episode of diarrhoea



• Contaminated water and food.

• Observe strict hand hygiene.

• Report to the local PHE Centre

Escherichia coli (E.coli) gastroenteritis Causing diarrhoea and vomiting

• Ingestion of contaminated food and/ or water.

• Faecal oral. Contaminated hands of infected cases.

• Contaminated equipment.


• Collect food history. • Notify the local PHE

Centre

Campylobacter (symptoms include profuse diarrhoea malaise, abdominal pain and sometimes vomiting)

• Undercooked meat especially poultry.

• Cross contamination from raw to cooked food.

• Food contaminated by unwashed hands and contaminated utensils.

• Person to person spread can occur.


• Collect food history. • Affected persons should

not prepare or handle food for others until symptom free for at least 48 hours.

• Report all cases to PHE Centre

Salmonella (vomiting, diarrhoea and fever)

• Ingestion of contaminated cooked food by raw food or inadequate cooking temperatures.

• Eggs, red and white meats, dairy products.

• Faecal oral spread.


• Food handlers should not return to work until cleared by Health4Work.

• Report to PHE Centre.

Typhoid fever (Salmonella typhi) The infectious period lasts as long as bacilli are present in stool.

• Ingestion of food and water contaminated by faeces.

• Faecal oral person to person spread.

• Unwashed hands of asymptomatic carriers.

• Isolation precautions for duration of illness and until stools are normal.

• Antibiotic therapy guidance from microbiologist.

• Obtain travel history. • Exclude affected food

handlers until cleared by PHE

• Exclude HCWS who are not food handlers until 3 negative stool specimens taken at 2 week intervals,



commencing 2 weeks after completion of antibiotics.

• Report to PHE Centre.

Cryptosporidiosis gastroenteritis (Protozoan parasite‐causes watery or mucoid diarrhoea)

• Ingestion of contaminated water, food and milk.

• Faecal oral spread. • Aerosol or droplet

spread can occur. • Sexual partners

• Isolation precautions for the duration of illness.

Staphylococcus aureus • Ingestion of food containing staphylococcal enterotoxin, the source can be from HCW hand.

• Contaminated food stored at ambient temperature.

• Standard precautions (person to person spread does not occur)

Bacillus cereus • Contaminated food stored at ambient temperature.

• As above

Diarrhoea (unknown cause) • Faecal oral person to person spread.

• Stool and isolation precautions for 48 hours post symptoms.

Giardiasis (A protozoan parasite that causes diarrhoea and cramps)

• Faecal oral spread of the cysts and by ingestion of the cysts from contaminated food and water.


• Report to the local PHE Centre

• Antibiotic therapy should be guided by a microbiologist.

• Consider testing all household contacts.

Gastroenteritis • Faecal oral route.

• Stool and isolation precautions for 48 hours post symptoms

Cholera Vibrio cholera (Cases are normally admitted to an infectious diseases unit)

• Faecal oral spread. • Contaminated water

and uncooked seafood.

• Stool precautions and isolation for the duration of illness and following two consecutive negative stools taken at 24‐48 hour intervals.



Shigella including bacillary dysentery

• Faecal oral route. • Contaminated food. • Highly infectious

organism

• Stool and isolation precautions for 48 hours from the last episode of diarrhoea

• Clinicians should report to the local PHE Centre

Clostridium difficile (A gram‐positive anaerobic bacillus that produces toxins). Clinical manifestations include abdominal pain, fever and profuse foul smelling diarrhoea.

• Diarrhoeal infection is usually triggered by the use of antibiotics.

• Direct patient to patient spread by faecal oral route.

• Unwashed hands of healthcare workers (HCW)

• Transferred on contaminated equipment (including healthcare equipment).

• Contaminated environment.

• Lack of prudent antibiotic prescribing.

• Isolate with stool precautions until asymptomatic for 72 hours and until stools are normal.

• Collect stool samples for C.difficile toxins.

• Treat with oral antibiotics as recommended by a microbiologist.

• Use Actichlor Plus ® disinfection to reduce spores in the environment.

• Clean room/bay three times daily

• Mandatory reporting to PHE for all cases aged 2+ years that meet the reporting criteria

Clostridium perfringens (A2 strains can survive normal cooking)

• Ingestion of contaminated food (e.g. undercooked minced beef).

• Inadequately reheated food and food kept warm at temperatures 43‐45 C.


• Report to the local PHE Centre.


Diarrhoea and Vomiting Risk Assessment Form – v.1 of 49 Authorised by: Policy Approval Group Date 24/06/13

Appendix C – Diarrhoea and Vomiting Risk Assessment Form

Patient ID Label Diarrhoea and/or Vomiting Risk AssessmentDraw a line showing the route through the flow chart taken and circle the final outcome box enter date/time/ward

and signature in spaces provided. Place this document in patient’s notes as part of the medical record

Ask: does the patient usually suffer from: • Colitis • Diverticulitis • Irritable bowel syndrome • Take laxatives

No Yes

Urgent nursing assessment required Consider overflow/constipation/diet related e.g. enteral feeding/ high fibre diet. Assessment outcome: …………………………………………………….. ….……………………………………………………………………………………………………..

Is this normal bowel habit for the patient (ask!)?

If still unexplained diarrhoea +/‐ vomiting potentially infectious:

• Isolate in side room as a priority. Send stool sample‐ that this has been done follow up

• Obtain prompt medical review. Seek Gastroenterologist advice with diagnosis if necessary

Laboratory confirmed diagnosis of C.difficile/Norovirus/Campylobacter/Salmonella/Shigella? • If C.difficile ‐ commence C.difficile care plan immediately. • Patients to remain in isolation until 48 hours clear of symptoms unless C.difficile positive when patients must remain in isolation until discharge. • All may be considered for Isolation Ward transfer.

Unlikely to be infectious Isolation not usually required unless for purposes of patient dignity

No Yes

Ward: Date: Time: Signature:


Diarrhoea and Vomiting Risk Assessment Form – v.1 of 49 Authorised by: Policy Approval Group Date 24/06/13

Diarrhoea and/or Vomiting Risk Assessment Patient Name: Hospital Number: 1. Date and time of onset of

symptoms:

2. Diarrhoea (explosive, liquid, stools, no warning):

3. Vomiting (more than one episode continued retching):

4. Has patient had antibiotics? If so, what and when?

5. Has patient had laxatives/ aperients? If so, what and when?

6. Does patient have pre‐existing medical condition which might pre‐dispose them to loose stools? If so, what?

7. Is this the patient’s normal bowel habit?

8. Is the patient feverish, pyrexial?

9. Specimen obtained/date sent:

10. If no specimen obtained list reason:

11. Has the patient been exposed to symptomatic patients/family/ staff/visitors?

12. Position on ward? 6 or 4 bed bay/side room, bed space number:

13. Are any other family members affected?

14. Has the patient been reviewed by medical team to exclude other causes?

15. Is the patient receiving naso‐gastric feeding TPN?

16. Decision taken to isolate?

PLEASE USE IN CONJUNCTION WITH FLOWCHART OVERLEAF


Management of Patient with Diarrhoea and Vomiting– v.1 of 49 Authorised by: Policy Approval Group Date 24/06/13

Appendix D ‐ Management of the Patient with Diarrhoea and/or Vomiting The creation of short term Norovirus isolation wards is not recommended because, unless these wards are part of the routine configuration of the hospital, there may be an unacceptable safety risk to patients as a result of suboptimal management of their other medical conditions. The routine transfer of patients into an isolation ward does not prevent or even reduce the continuing outbreak on the original wards. Also, Norovirus illness is of short duration. Individual Case in a Ward Bay Any patient admitted to hospital with diarrhoea and/or vomiting and any patient whom develops diarrhoea and/or vomiting whilst an in‐patient must be assessed promptly by nursing staff/clinicians to attempt to identify the cause of the diarrhoea and/or vomiting. See Appendix G Diarrhoea Algorithm. Norovirus should be suspected if: • There is confirmed/suspected Norovirus within the community and/or the

hospital • The patients close household contacts/family members have the same symptoms

or have recently had the same symptoms • The patient has been in contact with any other individuals (either in the

workplace, school etc) who had symptoms of diarrhoea and/or vomiting • Other people in contact with the patient develop the same symptoms e.g. other

patients/staff members If Norovirus is clinically suspected please follow guidance below Individual Case of Suspected/Confirmed Norovirus in a Ward Bay. If the patient has diarrhoea of unknown origin i.e. is not on laxatives; not considered part of an underlying condition, or where there is uncertainty in assessment then they need to be isolated in a single room with ensuite facilities. See Appendix G Diarrhoea Algorithm It is the onset of diarrhoea and/or vomiting which determines that the patient should be isolated. Do not wait for a positive diagnosis of a named bacteria or virus before deciding to isolate a symptomatic patient. Prompt action can prevent transmission to other patients and prevent bay/ ward closure. If en‐suite facilities are not available the isolation room must have a designated commode/ toilet for the use of that patient only. An isolation sign must be placed on the door to inform all entrants that isolation precautions are required. The need for isolation and precautions required must be explained to the patient and relatives ensuring that confidentiality is maintained at all times.



De‐isolation is usually possible once the patient has ceased symptoms of diarrhoea and/or vomiting for 48 hours. If Norovirus is suspected the isolation room will require terminal cleaning including the use of HPV cleaning prior to being released back into the bed stock. Individual Case of Suspected/Confirmed Norovirus in a Ward Bay A single room with en suite facilities is always the preferred option for isolating the patient suspected/confirmed with Norovirus (Norovirus Working Party 2011). All attempts must be made to ensure that this level of isolation is achievable, including the provision of extra nursing staff if necessary to ensure the safety and well being of the patient being cared for in isolation. Failure to isolate must be recorded as an incident by completing a Datix form. Where Norovirus is suspected and in order to restrict potential transmission throughout various wards/departments within the hospital all attempts must be made to accommodate the symptomatic patient in an en‐suite room on the ward on which they initially commenced symptoms. In order to accommodate this it may be necessary to transfer those non exposed, unaffected patients occupying the wards en‐suite rooms to other ward isolation rooms. The nature of the patient transfer must be communicated by the nurse in charge of the transferring ward to the nurse in charge of the receiving ward/area so that they may take any necessary precautions. The Site Co‐ordinator/ IPCT/Duty Consultant Microbiologist must be consulted where patient moves off of an area suspected to have Norovirus is identified as necessary. The period of isolation will extend until the patient has ceased symptoms of diarrhoea and/or vomiting for 48 hours or more and a terminal clean has been performed. See Appendix E Terminal Cleaning. During the isolation period it is advised that a minimum of twice daily cleaning of high touch surfaces is carried out using an Actichlor Plus ® solution at a strength of 1000 ppm. See Appendix F Daily Housekeeping Management of Norovirus Isolation Areas. In order to reduce the environmental load of Norovirus spores and prevent re‐infection of the patient, it is advised that all efforts are made to deep clean the patients environment with an Actichlor Plus ® solution at a strength of 1000 ppm once the patient has been asymptomatic for 48 hours or more. Once the patient is discharged from that environment terminal cleaning will be required prior to releasing the room for any further patient occupation. See Appendix E Terminal Cleaning. If the patient suspected/confirmed with Norovirus is deemed too clinically unstable to move by the responsible clinician then a risk assessment to keep the patient in a bay/open unit must be performed by the clinicians, the IPCT, the Clinical Service Lead



(CSL) for the area and the ward manager. In this situation the bay will be closed to further admissions/transfers except urgent clinical transfers. Patients may be discharged home from the closed bay. Patients may not be discharged to other care settings from the closed bay until all affected patients are clear of symptoms for 48 hours or more, and the whole bay has had a terminal clean. See Appendix E Terminal Cleaning. During the isolation period it is advised that a minimum of twice daily cleaning of high touch surfaces is carried out using an Actichlor Plus ® solution at a strength of 1000 ppm. See Appendix F Daily Housekeeping Management of Norovirus Isolation Areas. The bay may only be de‐isolated and released for further patient occupation/transfer once all affected patients are clear of symptoms for 48 hours or more, and the whole bay has had a terminal clean. See Appendix E Terminal Cleaning. Two or More Cases in a Ward Bay If ward accommodation allows all symptomatic patients should be nursed in single rooms with en suite facilities. All attempts must be made to ensure that this level of isolation is achievable as a priority. In order to restrict potential transmission throughout various wards/departments within the hospital, single room isolation should be on the ward where the patient/s initially commence symptoms. In order to accommodate this it may be necessary to transfer those non exposed, unaffected patients occupying the wards en‐suite rooms to other ward isolation rooms. The nature of the patient transfer must be communicated by the nurse in charge of the transferring ward to the nurse in charge of the receiving ward/area so that they may take any necessary precautions. The Site Co‐ordinator/IPCT/Duty Consultant Microbiologist must be consulted where patient moves off ward are identified as necessary. If single room isolation is not achievable then the bay must be closed to admissions/transfers except urgent clinical transfers, when the suspected/confirmed infectious nature of the patient/s must be clearly communicated to the nurse in charge of the receiving ward/area to enable necessary precautions to be instigated. Patients may be discharged home from the closed bay. Patients may not be discharged to other care settings from the closed bay until all affected patients are clear of symptoms for 48 hours or more, and the whole bay has had a terminal clean. In order to expedite discharge to other care facilities such as nursing/residential homes consideration may be give to transferring a non symptomatic contact patient from an affected bay into a single isolation room providing this isolation room is on the same



ward. Once the patient has been successfully isolated and has developed no symptoms within a 48 hour period the patient may then be discharged to the care facility, providing that the whole ward has not closed in the interim. Clinical Procedures/Investigations

Where Norovirus is suspected/confirmed and in order to restrict potential transmission throughout various wards/departments within the hospital only clinically necessary/ urgent off ward investigations should occur.

Where possible all attempts must be made to carry out investigations on the ward, but necessary urgent clinical procedures/investigations should not be delayed for those suspected/confirmed of Norovirus. Where urgent off ward procedures are required the following criteria must be met: • Where possible the suspected/confirmed patient should be 48 hours clear of

symptoms of Norovirus. Where the patient is coming from a closed affected bay/ward even if they are asymptomatic they should be treated as if a positive case.

• The nurse in charge of the receiving area should be informed of the patient’s suspected/confirmed infectious status by the nurse in charge of the patient’s care so that any necessary measures may be taken.

• The patient should be put last on the procedure list allowing for the theatre/ procedure room to be cleaned thoroughly afterwards.

• The patient should not be left in any waiting areas but should be called down for the procedure and taken into the theatre/procedure room directly upon transfer. They should be recovered in the theatre/procedure room and then transferred directly back to the ward.

• Theatre staff must wear personal protective equipment whilst tending to the patient.

• The theatre/procedure room must be deep cleaned with a 1:1000 ppm Actichlor plus solution following the procedure providing the patient has not had any symptoms of diarrhoea and/or vomiting whilst having the procedure. If the patient has had any symptoms of diarrhoea and/or vomiting whilst in the procedure room, the deep clean must be followed by an HPV clean.

See Appendix H for Terminal Cleaning See Appendix K for Discharging Patients during Norovirus Outbreaks


The Bristol Stool and Bowel Chart – v.1 of 49 Authorised by: Policy Approval Group Date 24/06/13

Appendix E – The Bristol Stool and Bowel Chart

Tick box according to stool type

Patient Name:

Hospital No:

NHS No:

Date:

Type 1

Type 2

Type 3

Type 4

Type 5

Type 6

Type 7

Time

Signature

Type 1 and 2 Suggest constipation Refer to trained nurse Consider starting of reviewing laxative treatment

Type 3 and 4 Suggest normal stool

Type 5 and 6 Suggest loose stool Refer to trained nurse Consider reducing or withholding laxatives

Type 7 Suggest loose stool Refer to trained nurse Consider obtaining specimen

Comments


The Bristol Stool and Bowel Chart – v.1 of 49 Authorised by: Policy Approval Group Date 24/06/13

Tick box according to stool type

Designed and implemented by Staff Nurse Daly E1, NHHT. Supported by an educational grant from Norgine Ltd MO/05/0537 April 2005. Adapted for HHFT November 2012.HH(1)/IC/573/12 Clostridium difficile Infection (CD): Prevention, Treatment and Control Appendix C Bristol Stool Chart

Date:

Type 1

Type 2

Type 3

Type 4

Type 5

Type 6

Type 7

Time

Signature

Designed and implemented by Staff Nurse Daly E1, NHHT. Supported by an educational grant from Norgine Ltd MO/05/0537 April 2005. Adapted for HHFT November 2012. HH(1)/IC/573/12 Clostridium difficile Infection (CD): Prevention, Treatment and Control Appendix C Bristol Stool Chart


Isolation Priorities – v.1 of 49 Authorised by: Policy Approval Group Date 24/06/13

Appendix F – Isolation Priorities

HIGH Do not remove from isolation without prior discussion with duty Microbiologist/IPCT

MEDIUM LOW

• Diarrhoea and/or vomiting of unknown origin

• Suspected/confirmed Norovirus

• Suspected/confirmed C.difficile

• Suspected/confirmed Pulmonary TB including MDRTB. Possible MDRTB must be discussed immediately with the duty microbiologist

• Suspected/confirmed Chicken pox/ Shingles/ Measles

• MRSA in sputum/ exudating wound/MRSA skin shedder/high Mupricin resistance/ MRSA 16 or 18

• E.coli 0157/Shigella/ Salmonella

• Norwegian scabies • Pandemic influenza • Viral haemorrhagic fever

– possible cases must be discussed with the duty microbiologist immediately

• Invasive Group A Strep

• ESBL/AMPC/Acinetobacter • GRE • RSV/Influenza • Mumps • Meningitis with cough

(isolation for 24 hours IVABX)

• Strep A/Strep G on high risk areas (isolation for first 24 hours of IVABX)

• Open weeping TB lesions to skin

• MRSA 15 or 16 post full screen and on Mupiricin

• Meningitis (undiagnosed or meningococcal) no cough

• Strep A/G (after 24 hours IVABX)

• Scabies (isolate until first treatment completed)

NB: MRSA 16 & 18 strains can be more resistant to antibiotics and also resistant to Mupricin 5 and 200, due to the resistancy of the strain these patients cannot be placed in an open bay or with any other MRSA positive patient.


Outbreak Control Measures – v.1 of 49 Authorised by: Policy Approval Group Date 24/06/13

Appendix G ‐ Outbreak Control Measures Ward

• Close affected bay(s) to admissions and transfers • Keep doors to single‐occupancy room(s) and bay(s) closed at all times • 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 • Commence data collection of all patients within the ward/bay highlighting those

whom are symptomatic • Ensure that provision of necessary ward stock levels are adequate • Prepare for reopening by planning the earliest date for a terminal clean • Ensure that all affected patients are closely monitored for signs of dehydration

Ward Managers

• Ensure all staff are aware of the Norovirus situation and how Norovirus is transmitted

• Ensure that staff information leaflets (Appendix I) are available in staff rest areas • Ensure all staff are aware of the work exclusion policy and the need to go off duty at

first symptoms • Ensure that all staff are aware that they will be required to send in a sample of

either diarrhoea or vomit for testing for Norovirus with results to be directed to Health4Work

• Ensure that a responsible person is charged with daily data collection of all patients within the ward/area – identifying all ward patients but clearly defining patients who are symptomatic. The responsible person should send the data collection sheet electronically to the IPCT and CSM no later than 10 am daily to allow for decision making by the outbreak control group

• Allocate staff to duties in either affected or non‐affected areas of the ward but not both unless completely unavoidable (e.g. therapists)

• Ensure that there is provision of information leaflets for all affected patients and visitors with advice on the outbreak and the control measures they should adopt

• Advise visitors of the personal risk and how they might reduce this risk • Ensure that visitors are aware that they should not visit if they have signs/symptoms

of Norovirus until they are at least 48 hours clear of symptoms • Maintain an up to date record of all staff with symptoms, liaising with Health4Work

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

Hand Hygiene

• Ensure adequate provision of hand hygiene facilities including soap, paper towels, disposal bins.

• Alcohol gel is ineffective in killing Norovirus – soap and water is the recommended product of choice

• Ensure that hand hygiene is performed upon removal of any PPE worn



• Ensure that hand hygiene continues to be performed using the 5 Moments for Hand Hygiene approach

• Encourage and assist patients with hand hygiene

Personal Protective Equipment (PPE) • Use gloves and apron for contact with the affected patient and/or their

environment • Ensure that gloves and aprons are single patient use only and are changed between

each and every patient and between clean and dirty tasks • Use a standard surgical mask when cleaning up any bodily fluids/disposing of bodily

fluids • Use eye shields/goggles where there is a risk of splashing to the eyes/face • Dispose of any PPE into the clinical (orange) waste stream

Environment

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

• Discourage communal foods e.g. boxes of biscuits/chocolates unless individually wrapped as many hands will access them

• Ensure that the environment is kept completely de‐cluttered to enable adequate cleaning

• Ensure that clinical areas are not over‐stocked as this may lead to large stock losses during the terminal cleaning phase

• Effective cleaning and removal of organic soiling using an Actichlor Plus ® 1:1000 ppm solution prior to disinfection is essential

• Ensure that all cleaning is carried out using an Actichlor Plus ® 1:1000 ppm solution. Do not use detergent wipes alone as they are ineffective in killing Norovirus spores.

• Intensify cleaning to twice daily using an Actichlor Plus ® 1:1000 ppm solution, ensuring affected areas are cleaned and disinfected.

• Toilets used by affected patients must be included in cleaning regimes • Decontaminate frequently‐touched surfaces with an Actichlor Plus ® 1:1000 ppm

solution • Ensure that domestic staff wear appropriate PPE and follow standard infection

control precautions. • Use dedicated domestic staff where possible and avoid transfer of domestic staff to

other areas unless they have been 48 hours clear of contact with an affected area and have not developed symptoms themselves

• On a ward with closed rooms clean from unaffected to affected areas, and within affected areas from least likely‐contaminated areas to most highly contaminated areas

• Use disposable cleaning cloths • Dedicate reusable cleaning equipment to affected areas and thoroughly

decontaminate between uses e.g. mop handles and buckets • Pay particular attention to frequently touched surfaces such as bed tables, door

handles, toilet flush handles and taps



• National and local colour coding for PPE and cleaning equipment should be adhered to, in order to avoid cross contamination

Equipment

• Use single‐patient use equipment wherever possible • Segregate equipment where possible to ensure no cross over of equipment

between affected/unaffected areas wherever possible • Decontaminate all patient equipment immediately after use with an Actichlor Plus®

1:1000 ppm solution • Ensure that clean utility room equipment cupboard doors are kept closed to reduce

the risk of environmental contamination and the need to dispose of multiple stock loads during the terminal cleaning phase

Linen

• All linen should be discarded into the red soluble bags (alginate) and then placed into clear/white plastic bags

• Linen should be cleared away in a timely manner by portering staff and not allowed to accumulate

• All patient linen should be changed on a daily basis • Linen should be bagged immediately in the patient care area and not left on

flooring/chairs/lockers etc • When making beds care should be taken not to shake out sheets thereby causing

dissemination of any spores • Linen should only be carried bagged, never loose • Extra provision of linen may be required during an outbreak and it is the wards

responsibility to request extra provision Spillages

• Ensure that gloves, aprons and masks are worn as standard, plus the addition of goggles/eye protection if risk of splashing to eyes/mucous membranes.

• Clean up spillages immediately • Remove debris with paper towels disposed of into clinical waste stream, and then

decontaminate the area with an Actichlor Plus ® 1:10,000 ppm solution • Discard all PPE into the clinical waste stream and wash hands with soap and water

Staff Considerations Exclusion of symptomatic staff It is recommended that affected staff members are excluded from work until they have been symptom free for 48h. Bank and agency staff The use of these in outbreak‐restricted areas should be kept to a minimum. Such staff working in affected areas should be advised of the risk of Norovirus transmission, the specific precautions that must be adhered to, and the importance of reporting any symptoms. 48 hours should be allowed before transferring staff who have worked in an affected area to other unaffected areas providing they are symptom free themselves.



Visitor/Visiting Considerations The visitor who has Norovirus is a transmission risk and the visitor who does not have Norovirus is at risk of contracting it during a visit. The first is an obvious infection prevention and control hazard but the second is usually not. Restrictions on visiting are mainly intended to assist in outbreak control. Local decision by the outbreak management group should determine any visiting restrictions required. Visitors who have Vomiting and/or Diarrhoea Visitors who are symptomatic should not visit until at least 48h after the resolution of their last symptoms. All Other, Non‐infected Visitors Visits by children of school age should be discouraged for the duration of an outbreak because of the risk of sudden symptoms developing without warning in school. Adult visitors should be warned of the risk of contracting Norovirus and given advice in the form of an information leaflet. They should be discouraged from visiting other patients outside the outbreak restricted area unless the closed area is visited last. Extenuating Circumstances Visitors should be allowed in extenuating circumstances on the decision of the ward manager. Terminally ill patients, children, vulnerable adults and those for whom visiting is an essential part of recovery should be allowed visitors at the discretion of the ward manager. Clinical and social judgment needs to be applied sensitively and compassionately whilst recognising the duty of care for the health and well being of all patients, staff and visitors. Those who have travelled a long distance, taken time off work, or in other ways have been significantly inconvenienced, may be allowed to visit patients on outbreak restricted areas provided that they observe IPC measures. Non‐essential visitors. Visits from newspaper vendors, hairdressers, mobile libraries and similar should not be allowed within an outbreak restricted area until the outbreak is declared over and terminal cleaning successfully completed. However, provision of reading materials such as newspapers can be an important part of recovery and can be provided to patients in other ways which do not jeopardise outbreak control. Used reading materials should be disposed of as clinical waste and should not be shared between patients Contractors Appropriate instructions should be given to contractors before they enter a closed area. However, only work that cannot be postponed until after re‐opening of the closed area should be allowed. Please see Appendix I for Staff Information Leaflet on Norovirus Please see Appendix J for Visitor Information Leaflet on Norovirus


Terminal Cleaning – v.1 of 49 Authorised by: Policy Approval Group Date 24/06/13

Appendix H – Terminal Cleaning

• Terminal cleaning is a pre‐requisite to ward/bay/single room re‐opening and return to normal bed stock.

• The IPCT, CSM and Ward Manager will advise the Domestic Manager/Supervisor that terminal cleaning will be required and the proposed date.

• Terminal cleaning will involve a whole ward/departmental approach • It is recommended that unused disposable patient care items within the patient

area are discarded • Boxes of open gloves inside single rooms/bays‐ discard whole box and contents • Boxes of open gloves outside of single rooms/bays – discard the first 5 layers of

gloves and clean the outside packaging with the Actichlor Plus ® 1:1000 ppm solution

• Open packs of wipes etc‐ discard the entire pack • Medical equipment – discard of any equipment in packaging which cannot be

cleaned without breaching the sterility of the product • Discard of paper notices – laminated wipeable notices may be kept • Remove window and privacy curtains and send for laundering • Remove all linen – including unused linen‐ and send for laundering • Decontaminate all equipment –including beds/lockers/tables/ monitoring

equipment/commodes/toilet seats using the Actichlor Plus ® 1:1000 ppm solution • Steam clean any soft upholstery • Complete terminal cleaning by cleaning all ward areas including dirty utility, clean

utility, offices, patient areas with a Hydrogen Peroxide Vapour (HPV) cleaning system.

Please read in conjunction with the Cleaning Standards Policy


Staff Information Leaflet on Norovirus – v.1 of 49 Authorised by: Policy Approval Group Date 24/06/13

Appendix I – Staff Information Leaflet on Norovirus

Norovirus‐ What Staff Need to Know

Norovirus is the most common cause of infectious diarrhoea and vomiting in England and Wales. It is a mild illness which people generally recover from in 2‐3 days. There are no long term ill effects from the illness, and once you have had Norovirus you may be immune to catching it again for up to a few weeks. It can cause symptoms of diarrhoea and/or vomiting, but some people may be asymptomatic carriers of the virus, i.e. they may have and be excreting the virus but do not know it. Why is Norovirus a problem? Norovirus is very contagious and the symptoms can be particularly unpleasant for people who are already unwell and therefore vulnerable to infection. It may dehydrate them and increase their length of stay in hospital. It may also infect our staff which can result in operational issues for our hospital. In otherwise fit and healthy people it is a very self limiting illness and does not require hospital treatment. The best treatment for Norovirus is to stay at home, and try not to visit areas such as hospitals and nursing homes to limit the spread of the virus. Make sure you drink plenty of fluids so that you do not become dehydrated. If you are worried please contact your GP for advice. How can I catch Norovirus? Norovirus is spread primarily via the faecal/oral route, either by consuming faecally contaminated food/water, or from direct person to person contact. Good evidence exists to show that there can also be transmission via aerosol of vomitus, which presumably results in droplets contaminating surfaces or the oral mucosa and being swallowed. There is no evidence to suggest that infection can occur through the respiratory system. Norovirus is very contagious and it does not take a lot of particles of the virus to be ingested to catch it. How can I help to prevent the spread of Norovirus? The most effective measures we can all take to help reduce the risk of catching and spreading Norovirus include the following:

• Gloves and aprons are no longer necessary in corridor areas of wards but please ensure that you wear these upon entering a bay/room that is affected, and that you change these between each and every patient contact and wash your hands following their removal


Staff Information Leaflet on Norovirus – v.1 of 49 Authorised by: Policy Approval Group Date 24/06/13

• If you are advised to wear scrubs then please ensure that you change these before exiting the ward especially whilst visiting the restaurant/public areas

• On wards/areas where staff have been put into scrubs, visiting staff members (e.g.

phlebotomists/therapy staff/visiting clinicians) do not need to change into scrubs unless their visit is anticipated to be an hour or longer

• Please limit your visits to any other areas within the hospital – the fewer times that

the portal of a closed area is crossed, the less the risk of transmission of virus and further spread to other areas

• When dealing with an episode of diarrhoea and/or vomiting (i.e. cleaning up after a

symptomatic patient) please wear a standard face mask along with your gloves and apron. Please also use eye protection if any splashing is anticipated. Please remember that all items of personal protective equipment are single use items and therefore must be changed in between each patient.

• Wash your hands before and after any patient contact, and after every visit to the

toilet, and before eating and drinking.

• Do not consume food and drink on the ward area

• Ensure that visitors are discouraged from visiting if they have had symptoms of Norovirus or have been in contact with anyone else with symptoms for at least 48 hours.

• Ensure that visitors are encouraged to bring in only food gifts which are or can be

covered, or are single wrapped, and it is advisable that only fruit which can either be peeled or washed is brought in.

• Please do not keep communal boxes of chocolates/biscuits etc on the ward areas

which are affected, as many hands will access them.

• Ensure that visitors to the hospital do not sit on the beds.

• We ask that all visitors and staff wear aprons and gloves upon entering a bay/room that is affected by Norovirus, and that they remove their aprons and gloves before leaving the affected area and wash their hands with soap and warm water. If you need to carry bodily fluids to the dirty utility room it is advisable to change into clean aprons/gloves to do so.

• If you are a member of staff who experiences Norovirus symptoms then you should

report this to your line manager, and you must send in a stool sample or a sample of vomitus with results to go to Health4Work. You must not return to work until 48 hours after your last episode of diarrhoea or vomiting.


Patient/Visitor Information Leaflet on Norovirus – v.1 of 49 Authorised by: Policy Approval Group Date 24/06/13

Appendix J – Patient/Visitor Information Leaflet on Norovirus

Infection Prevention and Control Team

Norovirus

Information for patients, relatives and carers

This booklet has been provided to help answer some of the questions you may have about Norovirus. What is Norovirus? Norovirus is one of the most common stomach bugs in the UK affecting people of all ages. Norovirus may also be known as small round structured viruses (SRSV) or Norwalk‐like viruses. Between 600,000 and 1 million people in the UK catch Norovirus every year. You may have also heard it referred to as the winter vomiting bug because the illness is more common in winter. However, the virus can be caught at any time of the year.

Norovirus is highly contagious especially in enclosed settings such as schools, hospitals, nursing homes and cruise ships. The period from when you are infected to when you start to show symptoms (known as the incubation period) usually lasts from 12 to 48 hours. During this time, you may be infectious to other people.

Although having Norovirus can be an unpleasant experience, it is not generally dangerous and most people make a full recovery within a couple of days, without having to see a doctor. What are the symptoms of Norovirus? The virus causes symptoms of vomiting and/or diarrhoea, which are often sudden in nature.

Some people may also have: • a raised temperature (over 38°C/100.4°F) • headaches • stomach cramps • aching limbs Symptoms usually appear one to two days after you become infected but they can start sooner. As the virus is usually short lived most people make a full recovery within a couple of days. Norovirus has no specific cure; the best thing to do with Norovirus is to allow it to run its course. Norovirus cannot be treated with antibiotics.



Apart from the risk of dehydration, the illness is not generally dangerous and there are usually no long‐lasting effects from having Norovirus. However, it can be pretty unpleasant while you have it. Dehydration One of the main risks from Norovirus is dehydration from your body losing water and salts from vomiting and diarrhoea. The first sign of dehydration is thirst. Other symptoms are: • dizziness or lightheadedness • headache • tiredness • dry mouth, lips and eyes • dark, concentrated urine • passing only small amounts of urine (fewer than three or four times a day)

Mild dehydration is common and can be easily reversed by making sure you have plenty to drink. Severe dehydration is more of a risk in the very young and the elderly and it is important to seek medical advice if you think that you may have symptoms of severe dehydration, these include: • severe thirst • dry, wrinkled skin • an inability to urinate • irritability • sunken eyes • a weak pulse • a rapid heartbeat • cold hands and feet • seizures How is Norovirus diagnosed? Norovirus is diagnosed by having a sample of your stool tested in a laboratory. However, this is not always necessary as diagnosis can be made from your clinical symptoms and treatment is the same for most causes of stomach bugs. If you have a sudden episode of vomiting and diarrhoea, it is likely that you have Norovirus. What should I do if I have Norovirus? If you have Norovirus, you can ease your symptoms by: • Drinking plenty of water to avoid dehydration • Taking paracetamol (if tolerated) for any fever or aches and pains • If you feel like eating, eat foods that are easy to digest • Staying at home. Do not go to the doctor, because Norovirus is contagious and there is

nothing the doctor can do while you have it. You may also infect other people by going to your surgery

• Contacting your GP by telephone to seek advice if your symptoms last longer than a few days or if you already have a serious illness



Extra care should be taken to prevent babies and small children who have symptoms from dehydrating, by giving them plenty of fluids. Babies and young children can still drink milk. Try not to worry if you are pregnant and you get Norovirus ‐ there is no known risk to your unborn child. How can I avoid infecting other people? The virus is easily spread by contact with an infected person. You can also catch it through contaminated food or drink or by touching contaminated surfaces or objects. Outbreaks in busy places such as hospitals, nursing homes and schools are common because the virus can survive for several days on surfaces or objects touched by an infected person. If you have Norovirus, you may continue to be infectious for a short period after symptoms stop, therefore you should avoid food preparation and direct contact with other people for at least 48 hours after your symptoms have gone, and you should also not return to work/school etc until you have been clear of symptoms for at least 48 hours. You should also not visit friends or relatives in a healthcare setting unless you have been clear of symptoms for at least 48 hours. The following measures should help prevent the virus from spreading further: 1. Wash your hands frequently using soap and water (alcohol hand cleansers are not

effective against Norovirus) before preparing or serving food and eating meals; and after contact with a sick person and their surroundings (sick room, bedding, clothing and equipment); going to the toilet and/or assisting a sick person to go to the toilet; leaving the area where the person has vomited or had diarrhoea.

2. Do not share towels and flannels 3. Clean up any bodily fluid spills immediately – flush down the toilet if possible and then

wash the affected area with detergent and hot water followed by disinfection with a bleach based solution diluted according to manufacturers instructions and taking care not to mix different types of chemicals as the fumes may be dangerous (always ensure that chemicals are stored safely away from children)

4. Once cleaned, the area should be rinsed with clean water and allowed to dry 5. Launder affected linen on as hot a wash cycle as possible ensuring that any solids

remaining on linen is first disposed of into the toilet Further information

Public Health England www.gov.uk/phe NHS Direct www.nhsdirect.nhs.uk NHS Choices www.nhs.uk



If you have any queries or concerns about your condition, please do not hesitate to speak to the nurses and doctors looking after you. Infection Prevention and Control Team

• Andover War Memorial Hospital Telephone: 01962 825156

• Basingstoke and North Hampshire Hospital Telephone: 01256 486774

• Royal Hampshire County Hospital Telephone: 01962 825156 www.hampshirehospitals.nhs.uk Infection Prevention and Control Team March, 2013 Review March, 2014 FCS/ 026/ 2013 © Hampshire Hospitals NHS Foundation Trust


Discharging patients during Outbreaks of Norovirus – v.1 of 49 Authorised by: Policy Approval Group Date 24/06/13

Appendix K‐ Discharging Patients during Outbreaks of Norovirus

Patients should be discharged from hospital as soon as their health permits.

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 Norovirus providing they are able to manage their symptoms Discharge to Nursing/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 48 hours. 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 individual’s 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 This should be delayed where possible until the patient has been asymptomatic for at least 48 hours. Discharge or Transfer to Other Hospitals Urgent transfers to other hospitals will need an individual risk assessment to be carried out by the responsible clinician, the IPCT/DIPC/Consultant Microbiologist/the receiving hospital. A patient’s clinical condition should not be compromised by infection status, however it is important to manage the risk effectively.

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