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Management of Viral Vomiting and Diarrhoea

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					             Management of Viral Vomiting and/or Diarrhoea – Document Number: CLI_IGCS_31




    INFECTION PREVENTION & CONTROL POLICY



                  CLI_IGCS_31
   Management of Viral Vomiting and/or Diarrhoea

     Document information (does not change)
       Board Library        Document             Document   Original Document    Assured by        Review
        Reference             type                Subject         Author                            Cycle
                             Policy         Integrated        Infection           Clinical        1 Year
     CLI_IGCS_31                           Governance        Control Lead        Practice
                                                                                   and
                                                                                Governance



      Version Tracking (updated for all subsequent versions)
      Version      Date          Revision Description        Editor                            Status
        1.1      2008.11    Draft for Approval                DJ                                Draft
        1.2     2009.01.26 Safety Forum                       DJ                                Draft
        1.3     2009.03.03 Integrated Governance              DJ                                Draft
        1.4     2009.03.25 Board                              DJ                              Approved



If you require this document in a different format, please telephone the Patient Advice and
    Liaison Service (PALS) based at Trust Head Quarters, Jenner House, Chippenham.
                                     Tel: 01249 468000




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              Management of Viral Vomiting and/or Diarrhoea – Document Number: CLI_IGCS_31



                                                  CONTENTS

1.      INTRODUCTION ………………………………………………….……………….. Page 3

2.      PURPOSE OF THIS POLICY ……………………………………………………… Page 3

3.      SCOPE OF THIS POLICY …………………………………………………………. Page 3

4.      RESPONSIBILITIES ………………………………………………………..……… Page 4

5.      MONITORING AND AUDIT ……………………………………….……………… Page 5

6.      STANDARDS …………………………………………………………..…………… Page 5

7.      STATUTORY REQUIREMENTS ……………………………………….………… Page 5

8.      FACTORS THAT MAY INDICATE AN OUTBREAK IS OCCURRING ……... Page 6

9.      ACTION TO BE TAKEN IN THE EVENT OF A SUSPECTED OUTBREAK .. Page 6

10.     STAFF WITH SYMPTOMS ……………………………………..………………… Page 7

11.     CONTROL MEASURES TO BE IMPLEMENTED IN THE EVENT OF WARD
        CLOSURE ……………...…………………………………………………….…….. Page 7

12.     CORE INFECTION CONTROL PRECAUTIONS ………..…………..………… Page 8

13.     CRITERIA FOR RE-OPENING A WARD                   ………………………………………. Page 9

14.     ACKNOWLEDGEMENT & APPENDICIES ……………………………..……… Page 9

        Appendix 1                  Management Pack for Viral Vomiting & Diarrhoea
        Appendix 2                  Outbreak Record
        Appendix 3                  Information for Service Users and Carers
        Appendix 4                  Flowchart with Contact Information for IC Advice




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               Management of Viral Vomiting and/or Diarrhoea – Document Number: CLI_IGCS_31
1.       Introduction

Throughout the year, but more particularly during the winter months from October to April,
hospitals regularly experience outbreaks of vomiting and/or diarrhoea. In many cases the
aetiology of the outbreak cannot be determined, although most are caused by viruses such as
Rotavirus, Norovius or other small round structured viruses.

At the time of suspecting an outbreak, many service users may have been exposed.
Therefore, control measures are centred on the prevention of spread to other areas.
To assist with the prevention of gastro-enteritis, service users with symptoms suggestive of
viral gastro-enteritis should be cared for in a side room (wherever possible) and the Infection
Control Team (ICT) informed.

This policy defines the process for managing viral vomiting and diarrhoea within the Trust.

All AWP infection prevention and control policies are based on The Health Act Code of
Practice for the Prevention of Health Care Associated Infections, Dept of Health (October
2006). In exceptional circumstances, where a complex situation arises that would not directly
match this legislation, a risk management plan must be in place, taking into account the
diversity and best interests of staff, service users and the public.

All Trust infection prevention and control policies will have completed an Equality Impact
Assessment during their development.


2.       Purpose of this policy

The purpose of this policy is to:
    Promptly identify and manage any outbreak of viral vomiting and/or diarrhoea infection

          Quickly identify the source, method of spread and causative organisms responsible for
           the outbreak.

          Prevent further spread of the organisms through implementation of appropriate
           measures and restrictions

          Ensure all individuals, departments and any outside agencies likely to be involved in
           the outbreak have a clear understanding of their roles, and are fully informed and kept
           up to date with regard to progress in the management of an outbreak

          Ensure the prompt dissemination of information in relation to the outbreak, thus
           ensuring the rapid mobilisation of resources


3.       Scope of this policy

This policy applies across all Trust facilities, to all healthcare staff and students. It will apply
to all areas and staff where there may be an actual or potential outbreak of viral vomiting
and/or diarrhoea.

Staff are responsible for compliance with this policy.

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               Management of Viral Vomiting and/or Diarrhoea – Document Number: CLI_IGCS_31
The policy allows for local provision of additional information, but no separate or additional
policy for local areas is permitted or supported.


                                FLOWCHART FOR THE USE OF THIS POLICY


                             Management of Viral Vomiting and/or Diarrhoea


                     Are you involved in work activities involving service user care?



                    Yes                                                             No


              Need to read*                                           Need to be aware the policy
              the full policy                                       exists but not required to have
                                                                     full knowledge of its contents


*Information can also be supplied verbally, face to face or using tapes


Definitions:

D&V              Diarrhoea and Vomiting
ICT              Infection Control Team
DIPC             Director of Infection Prevention and Control



4.       Responsibilities

The Trust Integrated Governance Committee is mandated by the Board to ensure the
successful adoption and implementation of this policy.

Board Directors, SBU Directors, Service and Clinical Directors and Line Managers are
responsible for:
    Ensuring that all staff know how to access Trust-wide policy from the Board Library and
     that changes to Trust-wide policy and new policies are brought to the attention of all
     relevant staff.
    Ensuring that Trust policies, procedures and protocols are implemented across their
     operational areas of responsibility.

Individual staff members are responsible for:

         Working within the provisions of approved Trustwide policies and their associated
          procedures and protocols. Failure to observe and implement policy and their related
          procedures and protocols is addressed through performance management mechanisms
          training or, where appropriate, the Trusts Disciplinary Procedures.
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                   Management of Viral Vomiting and/or Diarrhoea – Document Number: CLI_IGCS_31



             Ensuring that all staff have access to up-to-date copies of all policies, either via the
              Trusts’ Library, Intranet or in hard copy provided within the team base.


5.           Monitoring and Audit

The Trust Integrated Governance Committee is mandated by the Board to ensure the
successful adoption and implementation of this policy. Board Directors, SBU Directors,
Service and Clinical Directors and Line Managers are responsible for:

              Ensuring that all staff know how to access Trust-wide policy from the Board library, that
               changes to Trust-wide policy and new policies are brought to the attention of all
               relevant staff.

              Ensuring that Trust policies, procedures, and protocols are implemented across their
               operational areas of responsibility. Individual staff members have a personal duty to
               work within the provisions of approved trust-wide policies and their associated
               procedures and protocols. Failure to observe and implement policy and their related
               procedures and protocols is addressed through performance management
               mechanisms, training or where appropriate, the trusts disciplinary procedures.

              Ensuring that all staff have access to up to date copies of all policies either via the
               trusts intranet or in hard copy provided within the team base.


6.           Standards

The policy will be assessed against Standards For Better Health C4a, C4c, C21 and The
Health Act Code of Practice for the Prevention of Health Care Associated Infections, Dept of
Health (October 2006).


7.           Statutory Requirements

The Employer
Section 2 of the Health and Safety at Work Act (1974) states that “it should be the duty of
every employer to ensure, so far as reasonably practicable, the health, safety and welfare at
work of all his/her employees”. The employer is required to provide appropriate information
and instruction, normally in the form of a policy, together with appropriate safety equipment,
training and supervision to ensure their employees are protected at work.

The Employee
Employees also have duties under Sections 7 and 8 of the Health and Safety at Work Act,
1974 and Reg. 14 of the Management of Health and Safety at Work regulations 1999. They
must comply with any safety policies or procedures put in place to protect their health.
Employees must protect their own Health and Safety. Employees also have a duty to ensure
that their actions do not harm the Health and Safety of others when managing clinical areas
with diarrhoea and vomiting.


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                 Management of Viral Vomiting and/or Diarrhoea – Document Number: CLI_IGCS_31




8.       Factors that may indicate that an outbreak is occurring

             Generally both staff and service users can be affected (two or more staff members, or
              two or more service users over a 48 hour period)

             Duration of illness is between 12 and 60 hours

             Vomiting can occur in more than 50% of cases

             There is an incubation period of 15 – 48 hours

             Other symptoms include headache, malaise, and low-grade fever none of which are
              associated with other causes such as laxatives or antibiotics.

Effective communication is essential during an outbreak.


9.       Action to be taken in the event of a suspected outbreak

See Appendix 1 for general guidelines – Management Pack

Action to be taken by the nurse in charge:
    Immediately inform the Infection Control Team responsible for your area (Appendix 5).

Have ready the following information:
   The number of service users and staff affected

            For each service user/member of staff the date of onset and the type of symptoms

            For each service user, any treatment e.g. antibiotics, laxatives he/she is receiving, and
             any confirmed micro biology results e.g. Clostridium Difficile

            The date any specimen was taken, and any known results

            Food eaten by the service user 48 hours prior to onset, including any food brought from
             outside the hospital. (if this is known)

Responses from the ICT:
  A. That the ward/bay/area will be under observation. Follow standard infection control
     precautions and contact the ICT if more service users or staff are affected.
  B. That the ward/bay/area must be closed to admissions, discharges or transfers.

Inform:
    The AWP Infection Control Team
    Ward Manager / Nurse in Charge
    Modern Matron
    Senior Nurse for the site
    SBU Clinical Director
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              Management of Viral Vomiting and/or Diarrhoea – Document Number: CLI_IGCS_31
       SBU Director
       Hotel Services Manager / Housekeeping Supervisor
       Support Services Business Manager
       Infection Control Link Practitioner
       Other wards on the site
       Consultant Psychiatrist and Medical Staff responsible for the Clinical Area

The AWP ICT will advise the CEO, Nurse Director, Medical Director and Health Protection
Agency, and make a decision where necessary in liaison with the DIPC and Microbiologist if
an outbreak meeting is appropriate. See policy for Major Outbreaks of Communicable
Infection, including Outbreak Plan.

The Management Pack for “Management of Viral Vomiting and Diarrhoea” will provide all of
the necessary clinical actions to be taken. Appendix 1.


10. Staff with symptoms

Members of staff who become symptomatic while on duty should inform their manager and
contact the Occupational Health Service. They must leave the clinical area and MUST NOT
return to work until they have been symptom free for 48 hours.

Catering staff must seek Occupational Health Service advice regarding return to duty. Staff
must send specimens for testing via their General Practitioner.


11. Control Measures to be implemented in the event of ward closure

Infection Control Notice to be placed on the door at entrance to ward/clinical area

Ward Closure
A decision to close the ward will be made in collaboration with a member of the Infection
Control Team. The ward is closed to admissions discharges and transfers. A documented
risk assessment should be undertaken. Should exceptional circumstances arise a decision
made to admit a service user to a closed ward.

Discharges to other wards departments hospitals, nursing or residential homes or the
service users own home
Service users on an affected ward must not be transferred to other wards/departments,
hospitals or nursing and residential homes unless they are 72 hours symptom free. In
exceptional circumstances, discharge or transfer should only occur following discussion with a
member of the Infection Control Team.

Discharge to the service users own home is acceptable providing the service user and their
carers agree and are given advice on the management of symptoms should they occur.
If any member of a care team is required to visit the service user at home, the
appropriateness of the home discharge and follow up arrangements must be discussed with
the Infection Control Team.

Transfer of service users to departments for procedures/appointments


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              Management of Viral Vomiting and/or Diarrhoea – Document Number: CLI_IGCS_31
During an outbreak, there may be exceptional circumstances when service users may require
tests, appointments and procedures outside of the affected ward. A risk assessment should
be performed which takes into account the following:

       Whether the service user involved has any symptoms
       The urgency of the test and procedure
       Whether appropriate precautions can be taken by the receiving department

If a service user is to have a test/procedure, the receiving department must be informed in
advance, and if possible seen at the end of the clinic list. Enteric precautions identified in
Section 12 of this policy must be adhered to.

Staff (including temporary staff e.g. NHSP and agency)
    Staff should not be moved from the affected ward to other wards, unless they have
        been off duty for at least 48 hours and are asymptomatic.
    Staff should only be moved into the affected area from other areas/wards in
        exceptional circumstances, in liaison and discussion with the Infection Control Team.
    Under no circumstances should staff eat and drink in service user areas. Staff
        movement away from the affected area should be kept to a minimum.
    Allied Health Professionals, non-clinical staff and other staff not based on the ward
        should discuss their visits with the ward staff nurse in charge and Infection Control
        Team, and should ideally visit the affected area at the end of the day if an outbreak is
        known.

Visitors
    Visitors to the ward should be advised of the risks associated by contact with infected
       serviced users.
    Children should not visit, except in exceptional circumstances.
    All visitors should decontaminate their hands with alcohol hand rub for 30 seconds, or
       soap and water, before and after visiting the ward.
    Information leaflets in relation to viral infections and precautions should be available to
       service users and visitors. Available on AWP intranet. Home page. Infection control
       leaflets.

Communication
   The responsible Infection Control Team will make contact with the ward affected on a
    daily basis or as otherwise advised.
   It is essential the outbreak chart is completed following each separate symptom and
    this record is readily available to provide an update to the IC Team each time the ward
    is contacted.
   Service users who have been infected should not take part in cooking activities in the
    hospital environment for 48 hours post symptoms.


12. Core Infection Control Precautions

Enteric Infection Control Procedures
The key to the prevention of transmission of the virus within the clinical area is the effective
decontamination of the environment and equipment and appropriate handling of infected
items.

During an outbreak, attention must be given to the following:
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              Management of Viral Vomiting and/or Diarrhoea – Document Number: CLI_IGCS_31

     Hands
      Decontamination of the hands is the most important means of prevention of spread.
      Before and after attending service users, hands must be de-contaminated meticulously
      with soap and water. Alcohol hand rub, or soap and water, must also be used on
      entering and exiting wards.

     Protective Clothing
      Gloves and aprons should be worn in accordance with the Universal Precautions Policy

     Linen
      All linen from infected service users should be placed in an alginate / water soluble bag,
      inside an outer red bag. Check Linen policy for local infected / foul linen management
      as AWP have a variety of Laundry contracts and the process may vary. Sufficient
      supplies of alginate bags should be available.

     Cleaning
      o Equipment must be cleaned between service user use with detergent and water.
      o Particular attention must be given to cleaning commodes.
      o Spillages of vomit or faeces must be immediately cleaned up using detergent and
         water. Then follow spillages information.
      o Particular attention must be given to cleaning of toilet and bathroom areas. These
         areas must be regularly checked and enhanced cleaning is required if soiling occurs.
         Cleaning services will use Achticlor plus on a daily basis to disinfect surfaces and
         during terminal cleaning. This may vary dependant on local contracts. It is essential
         a chlorine releasing solution 1000ppm is used.
      o Refer to Disinfection Policy IC09.


13. Criteria for re-opening a ward:

The ward will be opened when:
 There have been no new cases in service users of staff for a period of at least 72 hours.
 Service Users have been asymptomatic for 72 hours
 The ward has undergone a deep clean of all areas, and curtains have been changed. (NB
   This should ONLY be undertaken after discussion and advice with the Infection Control
   Team)
 It is essential the Hotel Service Manager is advised daily on the outbreak situation to
   ensure they are prepared for completing the deep clean. During the deep clean nursing
   staff will need to be available to ensure the housekeeping staff have uninterrupted access
   to all areas.


14. Acknowledgements and Appendices

Report of the Public Health Laboratory Viral Gastro Enteritis Working Group, Management of
Hospital Outbreaks of gastroenteritis due to small round structured viruses. Journal of
Hospital Infection (2000) 45: 1 – 10

Acknowledgement to:
Royal United Hospital NHS Trust and North Bristol NHS Trust.

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              Management of Viral Vomiting and/or Diarrhoea – Document Number: CLI_IGCS_31
Appendices:
     Appendix 1                     Management Pack for Viral Vomiting and Diarrhoea
     Appendix 2                     Outbreak Record
     Appendix 3                     Information for Service Users and Carers
     Appendix 4                     Flowchart with Contact Information for IC Advice




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             Management of Viral Vomiting and/or Diarrhoea – Document Number: CLI_IGCS_31
       APPENDIX 1




       Management Pack – For the Outbreak of D&V (Diarrhoea & Vomiting) and suspected
       Norovirus




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                                               Management of Viral Vomiting and/or Diarrhoea – Document Number: CLI_IGCS_31
APPENDIX 2
INFECTION CONTROL DIARRHOEA & VOMITING OUTBREAK INFORMATION. Record following each separate episode of D & or V
Ward: …………………………        Site : ………………………Date Closed: …………………………                                                                 Date Opened: …………………………
PLEASE MARK EACH EPISODE OF DIARRHOEA & or VOMITING as //////
  Service User Name     Onset   Bay/    Date Spec      Result           Comments
                        Date    Rm        Sent         -ve or   (Laxatives, NG feed)   D      V      D    V      D     V    D   V       D   V   D   V      D    V      D   V   D     V
                                                        +ve




 Bed state – number of empty beds

         1.1. Number symptomatic
 Staff                 Symp     Onset   Spec       Resolved     Staff                  Symp       Onset   Spec       Resolved   Staff               Symp       Onset   Spec    Resolved
           Management of Viral Vomiting and/or Diarrhoea – Document Number: CLI_IGCS_31

   APPENDIX 3

                INFORMATION FOR SERVICE USERS, RELATIVES & CARERS
                        VIRUSES CAUSING DIARRHOEA AND VOMITING
    The viruses referred to within this leaflet are:
                                     Small round structured viruses (e.g. Norwalk/Norovirus)
                                     Rotavirus
Introduction
This leaflet aims to provide the reader with information about the following:

      What is a small round structured virus (SRSV)
      What is rotavirus?
      How are these viruses spread
      How will this affect my family and friends?
      Further information
      How will this affect me?

What is small round structured virus?
SRSV is a virus that can cause mild to moderate symptoms of diarrhoea and vomiting.
Symptoms also include nausea, abdominal pain, headache and a general feeling of being
unwell. The symptoms usually last for 24 – 48 hours. This type of infection is more common
during the winter months or early springtime and is commonly reported within the community
during these months.

What is rotavirus?
Rotavirus is a virus, which mainly affects infants and young children. Symptoms are similar to
SRSV but may last for 4 – 6 days.

How are these viruses spread?
These viruses are spread by contact with faeces, vomit or contamination in the environment.
They may also be spread in the air following an episode of diarrhoea and vomiting.

How will this affect me?
Although these infections are usually short lived, people may still spread the infection for up to
48 hours after the symptoms have stopped. For this reason, discharge to a residential or
nursing home may be stopped until we are sure that there is no risk of further spread. This is
also the reason why we are sometimes closed to admissions until all staff and service users
have recovered.

How will this affect my family and friends?
Although affected wards may remain open to visitors, it is advisable to avid visiting with the
very young and older people, as they may became more unwell than others if they contact the
virus. Visitors should try to avoid visiting any person in hospital with symptoms until 2 days of
symptoms have passed. Visitors should also not visit the ward if they have symptoms of
diarrhoea and vomiting, until two days after the symptoms gave settled. In an attempt to
control the spread of infection, visitors are advised not to visit other wards within the hospital
after visiting an infected service user or ward. Visitors should always wash their hands with
soap and water or in the case of visibly clean hands on leaving the affected ward.

Further Information
We hope that this general information is useful. Please ask a member of staff if there is any
additional information you would like.
                 Management of Viral Vomiting and/or Diarrhoea – Document Number: CLI_IGCS_31

  APPENDIX 4

                                      INFECTION PREVENTION & CONTROL ADVICE for
                  AWP Inpatient Sites – All Inpatient Wards covered by local District General Hospitals (DGH)
                                                 Infection Control Teams (ICTs)
                                          Advice needed on Infection Prevention &    ------------         Infection Control Link Practitioner located
                                                 Control (IP&C) situations                                           on all Inpatient sites


                                  All inpatient sites will have a hard copy of, or access to IP&C Policies provided by their local
                                  District General Hospital Infection Control Team and should be referred to in the first instance.


                            If relevant information needed cannot be resolved following local District General Hospital policies/guidance

                                     OFFICE HOURS                                                              OUT OF OFFICE HOURS

                                                                                                        Can this wait until office hours?
             Contact relevant local District General Hospital Infection
                          Control Team – details below
                                                                                                     YES
                                                                                                                                             NO
                                                                                             Follow guidelines for
                                                                                                                                   Contact responsible
                                                                                                 Office Hours
                                                                                                                                 Service Level Manager &
          B&NES …Royal United Hospital … 01225 825450                                                                           advise of situation and any
          NORTH BRISTOL TRUST                                                                                                    actions taken to resolve.
                     Frenchay …………. 0117 9701212 Ext 3441
                     Southmead ………. 0117 9505050 Ext 3425                           Service Level Manager will make decision whether to contact local DGH
          SALISBURY ……………………….. 01722 429089                                                   (for urgent advice not available in local policies)
          SWINDON …………………………. 01793 604550
          UBHT BRISTOL …………………… 0117 9283868
                                                                                                  YES                                        NO
          WESTON-SUPER-MARE ………… 01934 881142
                                                                                        SLM to contact relevant                     Follow guidelines for
                                                                                        District General Hospital                       Office Hours
                                                                                     reception/switchboard & ask to
                                                                                         speak with the on-call
                                                                                              Microbiologist


                                                                                          Bath Royal United Hospital ..................... 01225 428331
                                                                                          Bristol Royal Infirmary …………………… 0117 9230000
                                                                                          Frenchay Hospital ……………………….. 0117 9701212
                  AWP Infection Control Team                                              Southmead Hospital ……………………... 0117 9505050
        Diane Jepson – Director – Mob: 07990 517684                                       Salisbury District General Hospital …….. 01722 336262
   Ian Russell – Infection Control Nurse - Mob: 07824 626216                              Swindon Great Western Hospital ………. 01793 604020
            Jill Baker – PA – Office: 0117 3784457                                        Weston General Hospital (WSM) ………. 01934 636363
IC/SLA/General Contact Advice Chart – Oct 07

				
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