Care Home Template. Guidelines for the Management of outbreaks of Norovirus

Transcription

1 Care Home Template Guidelines for the Management of outbreaks of Norovirus Title: Procedural Document Type: Reference: Version: Ratified by: Date ratified: Freedom of Information: Name of originator/author: Name of responsible team: Review Frequency: Review date: Target audience: Guidelines for the management of outbreaks of Norovirus Guidelines This document can be released 2 Years All Staff

2 Contents 1.0 Purpose Rationale Scope and disclaimer Implementation, Education and Audit Policy Compliance General Good Practice Points Incident reporting Duties and Responsibilities Core Guidance Introduction Signs and Symptoms Transmission Diagnosis Area Management Communication References... 8 Appendix Increased Daily Cleaning Schedule... 9 Appendix 2 Stool Chart Appendix 3 Norovirus Resident Checklist Appendix 4 Terminal Clean Checklist Appendix 5 Visitor Poster Appendix 6 Hand washing poster Page 2 of 17

3 1.0 Purpose This policy has been developed to provide a practical document to equip all healthcare staff with the necessary information on the recognition, management and treatment of outbreaks of Norovirus. 1.1 Rationale The prevention and control of Norovirus is essential for the business continuity of the organisation and the population of Cornwall 1.2 Scope and disclaimer This policy is for use by (insert staff groups here) 1.3 Implementation, Education and Audit Policy Compliance Implementation will be through the (insert systems here e.g. IPC Committee, IPC Link group, Team Leaders, Matrons, Sisters and Managers.) Education and Management of Norovirus will be embedded in mandatory update training for IPC, and supporting Policies. Audit will take place using Infection Prevention Society Audit Tools and Hand Hygiene Audits and the results discussed at (name forum here e.g.ipc Committee.) There will also be monitoring of policy compliance through individual outbreak meetings and management. 2.0 General Good Practice Points Every case of unexplained Vomiting and Diarrhea (V&D) should be isolated immediately and (insert key title here) informed Every case of unexplained diarrhea (D) should have a stool specimen sent at the earliest possible time A second resident with V&D or D constitutes an outbreak and an outbreak meeting should be held as urgent to ensure all Infection Prevention and Control measures are in place A stool chart and fluid balance chart should be maintained on all symptomatic residents Care should be taken to ensure adequate hydration on all symptomatic residents Enhanced cleaning should always be undertaken when there is a case or cases of V&D. Page 3 of 17

4 2.1 Incident reporting The incident reporting system should be used to report (list as appropriate eg: o Cases of confirmed norovirus o Outbreaks (2 or more residents) o Breaches in safe transfer of residents in or out of hospitals) 3.0 Duties and Responsibilities All staff Have the responsibility to follow policy guidance Have a responsibility to ensure that good practice minimizes the risk of transfer of infection Managers Have the responsibility to ensure local risk assessments are carried out where necessary, e.g. to identify safe practices, including the provision of resources to ensure this is implemented Have the responsibility to ensure training is available and staff has the responsibility to attend such training sessions. Managers have a responsibility to consult with staff to ensure policy compliance (Insert key title) is ultimately responsible for health and safety. Notify outbreaks to the Health Protection Agency Core Guidance 4.1 Introduction Norovirus is a major cause of acute gastroenteritis (vomiting and diarrhoea) in children and adults. The cause of illness, Norovirus (previously known as Norwalk-like or Small Round Structured Virus) was described in 1968 in samples from an elementary school in Norwalk, Ohio. The disease is often termed Winter Vomiting Disease because of the increased prevalence in the winter months; however it can be detected throughout the year. Norovirus is the most common cause of outbreaks of gastro-enteritis in hospitals and can also cause outbreaks in other settings such as schools, nursing homes and cruise ships. Hospital outbreaks often cause major disruption in hospital activity resulting area closures, cancelled admissions and delayed discharges which can significantly reduce clinical activity for the duration of the outbreak. Failure to observe and comply with Infection Control guidelines/policy can lead to further spread of infection and a delay in returning to normal activity. Outbreaks can affect both residents and staff, sometimes with attack rates in excess of 50%. For this reason, staff shortages can be severe, particularly if several areas are involved at the same time. It is therefore essential that Page 4 of 17

5 cases are detected early and isolated appropriately to prevent spread and major outbreaks. 4.2 Signs and Symptoms The average incubation period for Norovirus associated gastro-enteritis is hours. The illness is characterized by a sudden acute onset of: o Vomiting is the predominant symptom, often projectile, and is seen in 50% of cases. However, clusters can occur where vomiting is infrequent or absent altogether. o Watery diarrhoea and abdominal cramps o Nausea In addition headache, myalgia, fever and malaise are common. Some or all of the above symptoms may be present. Symptoms last between one and three days and recovery is usually rapid. Dehydration is the most common complication and residents may require replacement fluids. 4.3 Transmission Noroviruses are highly contagious with as few as 100 virus particles thought to be sufficient to cause infection. Noroviruses are transmitted primarily through the faecal oral route either by person to person spread or via contaminated food or water. In addition Noroviruses can less frequently be spread via aerosol dissemination of infected particles following vomiting (close proximity). Transmission can also occur through hand transfer of the virus to the oral mucosa following contact with environmental surfaces, fomites and equipment which have been contaminated with either faeces or vomit. 4.4 Diagnosis Norovirus may be suspected clinically in residents and staff with a history of vomiting of sudden onset followed by diarrhoea. During an outbreak several people are commonly affected over a short space of time and cases with typical features may be ascribed to norovirus infection without further testing. Confirmation of norovirus infection depends on a PCR test performed on faecal samples. This is useful in confirming the nature of an outbreak early on, identifying atypical or outlying cases and in determining whether norovirus shedding is occurring in cases of persistent diarrhoea. Samples will usually be requested by the Health Protection Agency or Environmental Health Officer. When an outbreak is suspected, it is imperative to institute infection control measures immediately without waiting for virological confirmation from stool testing. Page 5 of 17

6 4.5. Area Management Any resident admitted with symptoms suggestive of Norovirus must be kept separate from other residents within the limits of safe care of the person. The priority is to ensure that resident care is not compromised and at the same time prevent the spread of the virus to other susceptible residents and prevent a major outbreak Where more than 2 residents are affected the wing or floor should be closed. This decision may be discussed with the The Health Protection Agency There should be no further admissions to the closed area. Doors MUST be kept closed within the limits of safe supervision of residents. Symptomatic residents must have dedicated commodes/toilet facilities. Symptomatic residents should have dedicated equipment eg monitoring equipment. Resident equipment should be cleaned and disinfected (with Actichlor plus) between each resident use. Dedicated staff should be allocated to care for symptomatic residents A poster should be displayed at the entrance of the area advising that there is an outbreak of diarrhoea and vomiting PPE (aprons and gloves) must be used appropriately (single use items) and for each episode of care/treatment/examination on all residents by all staff. Soap and water MUST be used for Hand Hygiene after each resident contact. Alcohol hand gel is not effective against Norovirus and therefore should be removed from use. There should be no transfers to other areas/hospitals from affected area unless there is an urgent clinical need in which case the receiving department must be informed. The resident should have an interhealthcare transfer form completed. Minimal numbers of staff should attend the resident. Aprons and gloves must be worn. All equipment that the resident has come in contact with must be cleaned with Actichlor plus. The resident must not wait in a waiting area with others. The movement of affected residents from one area to another for cohort management is NOT recommended. Non-essential staff must not visit the affected area. Where a wing or floor only is closed, a team of dedicated staff should be allocated to these areas. Staff (nursing, domestic) who are working on affected areas must not be moved to work in other parts of the home. The use of Bank and Agency staff is not advised on affected areas. Page 6 of 17

7 Wherever possible, medical staff should visit the area as their last visit if not req it is preferable that they shower and change clothing prior to attending other areas. Hands must be washed with soap and water before and after each resident contact or contact with their immediate environment. Aprons and gloves must be worn for each resident contact. Bristol Stool and fluid balance charts must be maintained on all affected residents. Anti-emetics or anti-motility agents must not be prescribed Staff who become symptomatic with diarrhoea and /or vomiting must leave the area immediately not return to work until 48 hours symptom free. Area staff must inform domestic services of the situation and advise the use of Antichlor Plus. Increased cleaning of the affected area, particularly toilet facilities, must be implemented. Water jugs must be kept covered to prevent the water from becoming contaminated, washed thoroughly each day in a dish washer, and the water changed at least twice a day. Bowls of fruit and open packets of food, i.e. biscuits, must be removed as they become contaminated as a result of aerosol contamination. An outbreak form for symptomatic residents and Staff should be maintained. This may need to be reviewed by the Health Protection Agency. Visiting to all affected areas should be restricted to those visiting critically or terminally ill residents. In this event visitors should be advised to wash their hands on arrival and on leaving the area. They must be advised not to visit other areas of the home. Residents (eg respite) can be discharged to their own homes if no care agency is involved in post discharge care and the family are fully informed. Rooms, wings or floors may be cleaned and reopened after residents have been asymptomatic for 72 hours on the instruction of the Health Protection Agency (in accordance with the Area Closure Policy). Equipment that can not be decontaminated must be disposed of. The terminal clean must be monitored by (insert key title). The area must not be re-opened until approved by (insert key title here) Page 7 of 17

8 4.6 Communication For the duration of any period of closure the (insert key title eg owner) will be updated on a daily basis of details of which area, the number of empty beds, number of cases to date the last occurrence and the next review date / time. 5. References Health Protection Agency (2007) Guidance for the Management of Norovirus Infection in Cruise Ships. London. HPA Lopman B. et al (2004) Epidemiology and cost of nosocomial gastroenteritis, Avon, England. Emerging Infectious Diseases 10 (10) Lopman B. et al (2004) Clinical manifestation of Norovirus gastroenteritis in healthcare settings. Clinical Infectious Disease. 39 (3) NHS Soutwest (2009) Norovirus Toolkit. PHLS viral gastroenteritis working group (2000) Management of Hospital outbreaks of gastroenteritis due to small round structured viruses. Journal of Hospital Infection. 45(1) Page 8 of 17

9 Appendix 1 Increased Daily Cleaning Schedule ALL DAMP DUSTING/MOPPING TO BE UNDERTAKEN USING A CHLORINE BASED DISINFECTANT EG ACTICHLOR PLUS INSERT FREQUENCIES THAT REPRESENT AN INCREASE TO THE NORMAL ROUTINE Bin run (? times daily) Empty and reline all bins Bathroom/Showers (? cleans daily) High dust and clean wall/vertical surfaces up to 6 feet (1) Damp dust all other surfaces including all fixtures, fittings and furniture Wipe over bin and empty if necessary Clean, shine and remove smears on mirrors/internal glass Clean bath and surrounds Clean basins and surrounds Replenish supplies if necessary Dust control and damp mop floor area Toilets (?cleans daily) High dust and clean wall/vertical surfaces up to 6 feet (1) Damp dust all other surfaces including all fixtures, fittings and furniture Wipe over bin and empty if necessary Clean, shine and remove smears on mirrors/internal glass Clean basins and surrounds Clean toilet and surrounds Replenish supplies if necessary Dust control and damp mop floor area Sluice (? cleans daily) High dust and clean wall/vertical surfaces up to 6 feet (1) Damp dust all other surfaces including all fixtures, fittings and furniture Wipe over bin and empty if necessary Clean, shine and remove smears on mirrors/internal glass Clean basins and surrounds Replenish supplies if necessary Dust control and damp mop floor area Page 9 of 17

10 Affected Residents Rooms (2 cleans daily) High dust and clean wall/vertical surfaces up to 6 feet (1) Wipe over bin and empty if necessary Clean window sills, radiators plus fixtures and fittings Clean, shine and remove smears on mirrors/internal glass Damp dust each individual bedspace (lamp, TV, horizontal surfaces, bed frame, locker, table, chair) Clean basin and surrounds Clean toilet and surrounds Replenish supplies if necessary Dust control and damp mop floor area Lounge ((? cleans daily) High dust and clean wall/vertical surfaces up to 6 feet (1) Wipe over bin and empty if necessary Clean window sills, radiators plus fixtures and fittings Clean, shine and remove smears on mirrors/internal glass Dust control and damp mop floor area Page 10 of 17

11 Appendix 2 Stool Chart Page 11 of 17

12 Appendix 3 Norovirus Resident Checklist Information the Health Protection Agency may require on each resident to assist in the assessment of suspected viral gastro-enteritis. 1 Date and time of onset of symptoms 2 Diarrhoea (explosive, offensive, no warning, Bristol stool type?) 3 Vomiting (more than one episode, continued retching) 4 Has the residents had antibiotics? If so please list. 5 Had the resident had aperients? 6 Does the resident have a pre-existing medical condition which might predispose them to loose stools? 7 Is this the resident s normal bowel habit? 8 Is the resident feverish, pyrexial? 9 Has a specimen been obtained? Date sent? 10 Has the resident been exposed to symptomatic relatives/ residents/ staff etc? 11 Which room is the resident occupying? 12 Are any visitors affected? 13 Has the resident been reviewed by the GP to exclude any other clinical cause? 14 Is the resident receiving naso-gastric feed/tpn 15 Is the resident constipated and could this be overflow? 16 Is the resident on any medications which may predispose them to loose stools? Page 12 of 17

13 Appendix 4 Terminal Clean Checklist A terminal clean will take place when the outbreak has ended. Actichlor Plus should be used to clean with. All areas should be cleaned and be monitored by (enter key title) The following chart should be used and signed as approved once all cleaning has taken place. Bay/Side Room/Area Cleaned by Checked by Alcohol Hand Rub Dispenser Bed Bed lights Ceiling vents Chair Curtains (changed) Door Door handle Hand towel dispenser Internal glazing Lockers Low level dusting Mirrors Resident hand books Resident name plate Resident notes folder Sink Soap dispenser Switches Tables Televisions Wall vents Waste bins Window ledges Toilets/Bathrooms Ceiling vents Door Door handles Hand towel dispenser Internal glazing Low level dusting Mirror Page 13 of 17

14 Sink Soap dispenser Switches Toilet Wall vents Waste bins Window ledges Sluice area Ceiling vents Door Door handles Hand towel dispenser Internal glazing Low level dusting Mirror Sink Soap dispenser Switches Toilet Wall vents Waste bins Window ledges Equipment Commodes Hoists Obs Machine Cleaning approved by:. Signed: Date:.. Page 14 of 17

15 Appendix 5 Visitor Poster ATTENTION SICKNESS OUTBREAK NOTICE TO VISITORS There is currently an outbreak of diarrhoea and/or vomiting. To minimise the risk of it spreading, please do not enter unless your visit is essential. For further information please contact Page 15 of 17

16 Appendix 6 Hand washing poster ATTENTION SICKNESS OUTBREAK HAND WASHING There is currently an outbreak of diarrhoea and/ or vomiting. For the duration of this outbreak please do not use the alcohol gel *use soap and water to wash hands* For further information please contact Page 16 of 17

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